HomeMy WebLinkAbout020-1418-40-000 (2)
.iii-•II_u Lepane I l:rnlnp:::r nL'
PRIVATE SEWAGE SYSTEM St. Croix
`.alety arc Budo ^u L -
INSPECTION REPORT a:} >enTnl No
GENERAL INFORMATION 1A-TACN TO DERM:T'' ;,a,e Plan IC No 606988
Pc-scnal alrormaaoa You praalne ma'y u.. _fza to' scccn'::ury o-1P...... =ms Law. s. 2 ::d i 11;111
°culn: Hdctf:. Nao¢ ^ry VIII;l;,l iown:mq: I'ar:e lax Nc
Fredrick and Joy Berg TOWN OF HUDSON 020-1418 40-000
CHI f+N C.n': Insp. 3" Elnv Bbl L-=_cnpac" eCbnM lperdRa^~eAd;:p tic
20.29.19.2652
TANK INFORMATION ELEVATION DATA
TYPE MANl1FAC-0RF% CAPA;:I IY tilA: IDN US 11 C
:x.'uuc Cv.•rzi . /cb
Alt. BIV CoJpn.
"lerauor Bldg. sew 07,
-1pl3ina S'.Ht lnw
9 7• ~
TANK SETBACK INFORMATION SL':HI OUtlei
9f. •7
TANK T6 P71. V,~::LL ULLIG. 'Gent to At, lctake ROAD D1 Inlel
SeCnr. Bnllnm ~
Iiosmy t s r I Icadc14dar. 7591• Qct
1
At::aNOn Dlst r'nx: 7.35 jq. Q
/
Haldrtrg Bot. System O ' 73_
PUMP/SIPHON INFORMATION =inal Grade
ManUfacklrer -le and
,Cove' /C~
6c'm
Tr)H Fnetlon _oss Syslem -.eac - - - TDh F-
Rtt: emain It eng ld Dlr.. tc. ill-el
SOIL ABSORPTION SYSTEM
BE.D:TRENCH Adt^ Lenglf v fx 'arv.:ne,: PITDIMENSIONS Nc O`Pir- Ircadr ]r.: .r.,mtl .-,np:h
DIMENSIONS T 7Z J~~1+1
SETBACK SYSTEM TO Flt ULrIG 'JdLLL LAKE:STRCANI LEACHING Ida^ufacurcr.~ 1-i
INFORMATION CHAMBER OR i'/PC /Svstc ^ /V UNII •dccc Nu+I rsa
DISTRIBUTION SYSTEM F +M! ILA V
h"'o' hi.: n. 1:'Id Drstribaor . Ilne Sat Id, i;>a:.mp 4ent c t aa
PiP!`ISl \ U~
Lc'atr GIe ~ 1 rnglh ~ ❑ia Spaanc
SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only
Leptr _I h+pch : or w. -eoln o' xr -tetlea.'i:oooetl w. 1AWCtleo
Bec Ire ch censer Rt<vT r:9i pope-OpSill _
ves Nn `i Nn
~r
COMMENTS: ;1nGUde none dk ;aerK4 J.r clesr.Sers ~ns preserH. te.t,t ~ Inspecuoc zt. Inspection #2.
Location: •L.4 'o7RF\ I N GIN AIVt_' nJa C
1.) WI bm Description= l
z'; lJ s(vcrlength
= 'y 64, \S 1, a T[) Ct ~)F~ '
^J
amount of cove, =y"
Foa~,l` 5
Ilan rrvislon Required' Yet _ No
)SC, 01al:'Wc lo• andllmna'. Information V o ✓7
16
Late In:Fpclofs gnatur C¢a N~
D-br'L (4,' 819(I
"Y=2'•4 r. r---w.--.- Industry Smite Divmw county
1400 E Washington Aver 51 C Rr, iX
P.O. Box 7162
r, Sm4ry Permit NwsDer (to be dild in by Co )
Madiso4 WI 53707--1162
1\ ww ~ _ O
Sanitary P rift Application SmkTnnmerimNeanhu
Ina xndaroe wide SPS 39311(2) W-., Adm- C'ak, sutsnissiat of Nis rpm o ! `i N
is required prim in obtaining a aininuy pcmeL Note' Applicationlurrsa for snmbwrrd POW1S submitted In Prajan Address (ifdiff than emilmg addrR)
the IRpeMSCnt of Safety and Pmfession:4 Semmes Perxmma in4xmation you pmnide may be fm secondary
PurPORM m acmrdarcc viidr Ilre Ptivac law, s. 15.07 I m Stns.
L Application Information- Pleaoe Print All labrtiation - (S•i n~El 1/1/1CtA, sa..~,
rr hrr y (N m 's Name - Parcel d
j /~~I'r ICS L CY Lj )"Lt~! czc tyts•yC-CCC
Pm(temY Owner's Mailing Address - Pinin"L.ocation ao,ay .)-t.2 seZ
Yk11 Wr fJ4 ~Atic Oovrtp
Cony, Site Zip Cade Phone Number
R. Type of Baslding (ckeek aY that apply) l.a dg T X'r N; R I / . E ov
Sal I or 2 Famih Dwelling - Number offio& Stmdrisoon Nana
BI 7kE C LEA!
❑ Public Comvsccial - Describe Use ~a rAe
❑City of
CSuteOwned - DtabcUse ``sI~ CS'MNum6a ❑ Vdlaycol'_
3 ~ I "7 L F~7 S - 91 Town of l l u ns[
IIL Type of Permit: (Ckxk only one box oa line A. Compkte lime B if appkmbk)
JR00 Nesv S)smm p Replamnrnt System ❑ lteaomantllkam Tank
g RN'CAI Permn Renewal O Permit Revision ❑ Charge of Phember 1 ❑ Permtl Tasafa m New V
clone Expliation
,1~sVL7' of PO~YI'S SvuemtComtaneni/Davice: (Clerk aB HatiaoNV1) - _
1° n°n'Prsaasad Io'GTOUOO ❑ Psemawed hi-cwmwA ❑ A14;n& ❑ MouW > 24 in ofacbble mil ❑ Maud <24 m or u e`RN'c sod
Nwding Tarok Oda:r Disprxsal Conputeo(oWlan) ❑PrcueamnenlM oe(explan)_ ~ . w~Kn.(dL rG
V. Dis
Design rutUrreal " at Am Information:
Design Flow (gpd) Design SjAW"jon
Distend Ar
m RoWW (sf) Am System Elevation
VL Task Info Toni itof M,nufscMV
lpm Crallorn Ureic C
No.'r.W yx¢
v...:® Taolo C l: c 9 a
3
'z 5L
Vit. Responsibility S4@ateat- I. Me aade sgee4 a a ' 'li for installation *(the t'OW rS Aawr en tW afmded pinm
Plumber 's trasrx (Pan) 14 umber Rumum Phone Number
Plumber's Addos (S heet. ry'S Zip Cork)
YS [ I7 tZl UcK ~ALi
~V~T,IIT. CoJ n /D _artmoi UM Oaly
L)4CpPraved Parent Fee Dam lssund e !swing tent Si
teem fm Rasul S r a 7~ O
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4s pef ntlr 3gesre't• FI . t V ilu •ItJf .
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M per wise b l co& l CMmav'r?
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In-Ground Gravity Plan PAGE 1 OF 4
Index & Cover Sheet
Con porwO A wXW Design Refrericm
version 2.0, SBD-10705-P (N.01I01, P_ 10/12)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments:Enc
;
_TNFtL-wTcR secs E ' FLCiv' POWTS Application for Review
Soil Evaluation Repor & Side M
/GPT t c Tfw K /+r Kgr-Ae&Tr
IAZAIW'T
Project Name / Description
Owner tame(s): .r Kt DKti _jr - ,
Phone:
Owner Address: /Ye I/ c fi t: C , c P t D sc ,v v_:, 2Ip:
Project Addnaw
GovL Lot , 1/40f ` _1/4, Section , c
T l~t N R f 1 EQor WEE
7ownsiHp _(!rQ; ~.e county- 57 CKDtx
Project Pawcef IDS r <i / i ` - . Clr
Designer Information
DeslWwr Ham. AI ARV -~l 41U e iq~_r Phone: '2)5 ~_-12M21
De8&Ww Address: Z,s Lt 9'1 Kw& ~~THtI C+ r L)A a
s ~ LJI ziP:
'Ewell: ~u't.-of(~t.-sF-erdei pswv) n CO ~ou+fooK c'o,ti - ..y.yr`w,v.•.a~_'v.K.'q~.n`•-';a,,,
stamp.
Remarks:
° 1lup
Signature: Date: e-vI $
an~itaEntamcopy.
Plot Plan Page ---'of
y
PROPERTY OWNER ! -'=ufocK ~Tcv 'Ll. j~cl2C IN 40 FT.
(except where noted)
Legal Description: LL7 ~d$ I LX-L~ 7hE va%yt~TrIbr„r/9 ` backhoepit
'SEC, t0 7Gy A.` Rj j,1 TL'lL,, ' ^f li 1.4
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In-Ground Gravity Plan PAGE 1 OF 4
Index & Cover Sheet
CoaWswe Marmral Design Reftw"w
version 20, SBD-10705-P (N.01MI, k 10/12)
Pg 1 crf 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attactrlnenfs: E ures:
r,t--neATcR sPccs- E-z r l-cty POWTS lication for Review
Soil Evaluation Report & Site M
SFP71C TANK AaK FMEA7T
~r,,~vc.-r0/,~~r--_ ~EUri~c:•Tpc~/ Dt~~
Project Name / Description
owner wrne(s): f KU)KW K = ly , o BEY . Phone:
Owner Address: YO I u,x" ZIP:.
p io/ (p
• •ojectAddress: (:~>A/vie
GovL Lot: - w' 1/4 of /„t 114, Section_ Lt N-R__U__E-]Or yyn
Township county 57- . C R0/x
Project Parcel m s
Designer Information
Designer Name:./ LM keec-r<Ptwne: ?15
DesigrwrAddress: Z8~197 K,Ue,Q2rHU2s ~l In ,z ,.rr
E-mail: h0l tw'Jes - Z*:
License Number. 1959-067 Remarks: A1W
,
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A 1839 K
IdVB Y FA
40/ C
signature. Date:
~PY
Plot Plan Page ' of y
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PROPERTY OWNER: 1" 40 FT.
except where noted)
Legal Description: IT Lt.. "y backhoe pit
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• Aiwavs clean and free of fines
• Bundles are quick to install, saving costs on heavy machinery and labor
• Modular construction allows configurations to match trench dimensions for most system shapes and sizes
• Engineered for optimal storage and absorption efficiencies
• Ability to contour along sloped sites and around trees or landscaping
• Lightweight system is perfect for repairs and tight job sites
• Easily hand-carried into position reducing time and labor
• 5' or 10' lengths with simple snap, internal couplers
• Easier cleanup at the job site with the elimination of stone
• Manufactured from recycled materials rather than a mined natural re.SO rite
• A wide variety of diameters and configurations to meet any installation professional's needs
• Approved in many jurisdictions with an increased efficiency rating, reducing drainfield size
• Backed by the leader in the ensite wastewater industry
EZ
h, INFILTRATOR
For technical assistance, installation instructions or customer service, call Infiltrator Systems at 800.689.7759.
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Morixontai Systems
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uFt3 1 u24 GEG 1235V. GEC) 1203T-GEO
-GEO 1203V-GEO 14fi2~i_GF o i 303T-GEO
m A e.c: yr A~..ent •AI ~n n.!,- nv, i "'Y'u J'.:.,:P tl,. mnr•x! of uund.es. '
arc ; w-. I a4~ t.
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INFILTRATOR
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C; Saybrook. cf ;;6475
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800.689.7759
www.ezfiowlp.cam
www.infiltratorsvstems.com
Eor technical assistance, installation instructions or ct;st,mer srl ;;ill 4
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SAFETY AND BUILDINGS DIVISION
Plumbing Product Review
j X r~ p ~;t P.O. Box 2658
s $ ICI Madison, Wisconsin 53701-2658
TTY: Cornet Through Relay
'AOt1sy,~n~~.`% Scott Walker, Governor
Dave Ross, Secretary
October 11, 2013
INFILTRATOR SYSTEMS INC.
GOVERNMENT AFFAIRS DEPARTMENT
4 BUSINESS PARK RD
PO BOX 768
OLD SAYBROOK CT 06475
Re: Description: LEACHING SYSTEM, POLYSTYRENE AGGREGATE
Manufacturer: INFILTRATOR SYSTEMS INC.
Product Name: EZFLOW DRAINAGE SYSTEMS
Model Number(s): EZ1203H (3-12" bundles with pipe in center bundle in 5 ft. or 10 ft. length).
EZ1203HP (3-12" bundles with pipe in each bundle in 5 ft. or 10 ft. length).
FZ1201P (1-12" bundle with pipe in 5 ft. or 10 ft. lengths), EZ1201A (1-12" bundle
containing aggregate only).
EZ0701 A (1-7" bundle containing polystyrene aggregate only in 5 ft. or 10 It. lengths).
EZ1203H-GEO (1-12" bundle with non-woven geotextile fabric installed at 180 degrees on
the upper side of the bundle, pipe in 5 ft. or 10 ft. lengths).
(EISA of EZ1203 H, EZ1203H-GEO or EZ1203HP in 5 ft. lengths = 25.0 sq. ft./product,
EISA of EZ1203 H; EZ1203H-GEO; EZ1203HP in 10 ft. lengths = 50.0 sq. ft /product,
Width = 36 inches, Height = 12 inches, Max. depth of bury , 8 ft.).
Product File No: 20130145
The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance
with chapters SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin
Statutes.
The Department hereby issues an alternate approval to s. SPS 383.44(4)(a)t.a.; 384.30(6)(k) based on the
Wisconsin Statutes and the Wisconsin Administrative Code. This alternate approval Is valid until the end of
October 2018.
This alternate approval supersedes the approval issued on 4/10/2012 under product file number 20120139.
This aftemate approval letter shall be incorporated with your previously approved plans and/or specifications
approved under product file number 20120139.
This alternate approval is contingent upon compliance with the following stipulation(s):
• This product must be installed in accordance with the manufacturers printed instructions, product approval, and
plan approval. If there is a conflict between the manufacturer's instructions and the product approval and/or plan
approval, the product approval and/or plan approval will take precedence.
• When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must receive wastewater having a BOD5 value less than or
equal to 220 mg/L, a TSS value less than or equal to 150 mg/L and a FOG value less than or equal to 30 mg/L
on a monthly average.
• When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must be installed in individual excavations that create a
dispersal cell that is horizontally separated from other dispersal cells in other excavations by at least 3 feet. The
3-foot measurement is measured between the closest outside edges of the product listed in the regarding block
of the product approval fetter.
SBD-10564-E IN. 10197) File Ret: 13014502-DOC
INFILTRATOR SYSTEMS INC
Page 2
October 11, 2013
Product File No: 20130145
• When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must be installed in a dispersal system, which has the top of the
dispersal cell at or below original grade of insitu soil.
• This product must have geolextile fabric that meets requirements of s. SIPS 384.30 (6) (g), Wis. Adm. Code,
installed directly on top of the product and extending down along the sides of the product to a point at least
6 inches from the bottom of the product.
• This product may be installed in dispersal cells in place of stone aggregate specified in approved POWTS
Component Manuals or Department approved systems. When the distribution cell is not sized based on the
EISA rating, the dispersal cell area must be equal to or greater than the area required for stone aggregate.
• This product may be installed at a depth that exceeds the maximum depth stated in the regarding block of this
approval, when the manufacturer provides in writing that the proposed installation depth is acceptable for the
individual installation.
• The following stipulations apply only to the EZ1203H-GEO, 1 12 in. and 3-12 in. bundles with non-woven
geotextile fabric installed at 180 degrees on the upper side of the bundle, pipe in 5 ft. or 10 ft. lengths:
1. When installing EZ1203H-GEO in 5 ft. or 10 ft. lengths, the product must be installed with the geotextile fabric
facing upward.
2. When installing the 3-12 in. bundles, trenches must be excavated no wider than 42 in.. with a 36 to 40 in.
trench width preferred. (Although EZ1203H-GEO is not, to date, recognized in the EZFLOW Mound Component
Manual.)
3. Geotextile fabric meeting the requirements of s. SPS 384.30 (6) (g), installed directly on top of the product
and extending down along the sides of the product to a point at least 6 inches from the bottom of the product.
When installing model EZ1203H-GEO, the fabric width shall be at least 5 ft. wide.
4. When installing the 3-12 in. bundles, bands used in transport must remain intact during installation.
5. Pipe connectors are necessary for the transition between differing pipe materials (e.g., polyethylene
corrugated piping and PVC pipe), meeting s. SPS 384.40, and must be used to assure piping does not separate
during construction and backfilling. (Example: Include pipe connector such as AC-VCOUPLER-4 for both
Schedule 40 and 3034 PVC 4 in. pipe.)
• For gravity distribution of wastewater, the distribution cell piping shall meet the following conditions:
1. The cell units (bundles) shall be 12 inches in diameter 1 inch.
2. The cell units (bundles) shall be manufactured in 5 and 10-foot lenqth sections, 2 inches.
3. The 4-inch pipe within the bundle shall be certified as complying with ASTM F 405, Standard Specifications
for Corrugated Polyethylene (PE) Tubing and fittings.
4. The 4-inch pipe shall he offset from the center towards the top of the bundle whereby 5 to 6 inches of
aggregate is located between the bottom of the pipe and the bottom of the bundle, and 2 inches of aggregate is
located between the top of the pipe and the top of the bundle.
5. The 4-inch pipe shall be connected by an internal coupling device to allow continuous connection from one
bundle section to the next.
6. The end-to-end gap distance between pipe containing bundle sections, as measured from the straps fixing
the netting to the pipe or from the face edges of aggregate on adjoining bundles, shall be no greater than
3 inches.
7. The header or manifold pipe connected to the 4-inch pipe within the bundle shall be at least 6 inches above
the infiltrative surface of the distribution cell, or the 4-inch pipe within the bundle shall be connected to the
header or manifold pipe using an adapter that raises the invert to at least 6 inches above the infiltrative surface.
• The EISA rating reduction may be used in dispersal cells less than 36 inches in width.
1. The maximum excavation width of the dispersal cell is 42 inches for a 33 to 36 inch bundle.
INFILTRATOR SYSTEMS INC
Page 3
October 11, 2013
Product File No: 20130145
• Otherwise as permitted in this Alternate Approval, the stipulations of the In-Ground Soil Absorption Componcnt
Manual for Private Onsite Wastewater Treatment Systems (Version 2.0) October 2012, [SBD-10705-P (N. 01/01;
R. 10/12)1 apply.
• A ropy of the manufacturers' installation instructions shall be onsite and available at the time of installation.
• A copy of this aRemate approval shall be onsite and available at the time of installation.
• Additional information is included as attachment(s) to this letter; see attachment A.
In granting this alternate approval the Division of Industry Services reserves the right to require changes or additions
should conditions arise making necessary for code compliance. Nothing in this review shall relieve the manufacturer
of the responsibility for designing a safe component into the built environment.
The department is in no way endorsing this product or any advertising, and is not responsible for any situation which
may result from its use.
Sincerely,
Glen A. Jones, M.S.
POWTS Product Reviewer
phone: (608) 267-5265
fax: (608) 267-9723
email: glen.jones@wi.gov
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatina Limits:
Design Flow = e> gpd; BODs 5 220 mgL4; TSS 150 mgL4; FOG 5 30 mg:'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, e(c.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i. e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump recycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms. etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tankts) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturers specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name cfindrvidualorcompany : GF~TrEAj-ch'F Plane: ,IJ-%-~/ ~E <<'0
rrF
Local government unit ~ Y b6V7LGLp j. iPhone: /1
Local government unit address: " - ZIP:
Any detective par of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continaencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a predetemnined area of suitable soils.
System Abartdorunent
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
■
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERS1 UP CERTIFICATION FORM
r. L..
Mailing Address l G 'r:r_ J i .Ati
Property Address
(Verification required from Plaranng & "Coning Department for new construction)
City/Slate Parcel Identification Number t, p
LEGAI. DESCRIPTION
Property Location _ _ J6 A , Sec. , It T _N R r7 W, Town of t (U C~ e
Subdivision Plat: 7N_ "';4 r. f.1 Lot #
Certified Survey Map # Volume Page #
Warranty Deed # (before 2007)Volume Page #
Spec house 13yesU6 Lot lines identifiablegymono
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature f iflre to handle wastes Proper
maintenance consists of pumping out the septic Lank every three years or sooner, if needed, by a licuhsed pumper. What you put into
the system can affect the function of the septic tank as a trcahnmt stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St Croix County Sanitary Ordinance.
The property owner agrees to submit to St Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site:
wastewater deposal system is in proper operating condition and/or (2) after inspection and pumping (if necescary~ the septic tank is
less than M full of sludge.
Uwe, the undersigned have read the above requ ncments and agree to maintain the private sewage disposal system with the
standards set forth, he aarh, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained roust be completed and returned to the St Croix
County Planning & 'Long Department within 30 days of the three year expiration date
Uwe certity that all stafnmwnts on Luis form are true to the best of my/our knowledge. Uwe am/ate the owner(s) of ire
property described above, by virtue of a w?rrmdy deed recorded in Register of Deeds Office.
Number of bedwoms
SIGNA OF AP I (S) DATE
"`Any information that is msrcptesmtrd may result in the sanitary permit being revoked by the Planning & "Zoning Department ••a
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed
(REV. 04/12)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
'this is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address)_ _y located
at: _ ° . 1/4, _ „r„ %4, Section .3. Town -z/ N, Ranged W,
Town of ; 1 u c~~y St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes_ No__ .
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: / -5L':
Construction: Prefab Concrete Steel Other
Manufacturer (if known): Go c _ cir:
Age ofTank (if kown): zrCy
Permit nu known) 5y ;3y
( teens Plumber Signature) (Print Name)
(Title) (License Number) MP/NiPRS
111Z '7f/LU(~'
(Date)
Form to be completed by licensed plumber (Dept of Satety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
T -
This is to certify' that 1 have inspected the existing septic and%or dose tank
presently serving the following residence:
(Street address) located
at: ~ ~J '/4, c- '''A. Section Town =r N, Ranee W",
Town of St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No_
(if no, skip next line.)
Approximate volume or length of time: _ gallons minutes
'l'ank Capacity:
Construction: Prefab Concrete x__ Steel Other .
Manufacturer (if known):
Age of Tank (if own): zr t-q
Permit nu
(.icens'd Plumber Signature] (Print Name)
(Title) (License Number) MP.1NIPRS__,
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 1 1 _i Wisconsin Administrative Code)
Rev. 2,'2012
X I a,I U PRIVATE SEWAGE SYSTEM `n°°I' St. Croix
INSPECTION REPORT
453434 U
GENERAL INFORMATION (ATTACH TO PERMJT)
Steve Plan ID No'
Persaul inlor,etkx, Yw pvuide may :tE used for secondary purposes fPrivary Lax. 5.15 04 I';{m,j
Part Hpreei s Name Cry Village X roxnsn p Parcel Tax No.
Sienna Corp Hudson Townshi 020.1418-40-000
CST 614 Ex, _ BM Elev NIBMOwsmobox; _ SBUpMTOWrypg„gyMpp NO
20.29.19.2652
TANK INFO MATION fLb o' EVATION DATA
, TYPE MANUFACTURE - CAPACITY STATION BS HI FS ELEV.
:.Sept: r, Benchmark
l J 'l (2 so
Dosing Alt. BM
i.waPwl Bldg. Sewer
5. '
Holcir,g SVHt Inlet
TANK SETBACK INFORMATION SuHt Outlet
TirNK TO WL WELL BLDG. Vent W AirMi,. ROAD of Inlet
Srq>hc / r Of Bolton
-!s
f;cs rig Header/Man. I
Aeral'An Dist. Pipe , 0 r
.o `3SSD
Holding Sot. System D 7140
g 9 D cft- 6,0
Final Grade -
PUMPI IPH_ON INFORMATION D f 97• $"I r
Manta-turw Demand St Cover t
GPM 03.E 3-5D w •D
Model NUmU - `4 a 1-0 V., f
7DN Lih 7"on LOSS System Head TDH Ft
i
ForcegaIm Length Die ow tower / I i4 ve e- t1o r
ABSORPTION SYSTEM S
ENC %V011. ! No T,V, 4 PR DIMENSIONS No Ol Pits Inside Da Liquid Depth
dIMEN NS f 1 g r
SETBACK SYSTEM TO Pit BLDG WELL LAKE/SIR= LEACHING Manuf .1 e.
INFORMATION r CHAMBER OR
Rro Sppys~:~err~rr
Vv✓ 01 ~~0~/ UNIT kkbei Nu,n
DISTRIBUTION SYSTEM (a
HeadwNlanitdd I l Jistiioulion x Hole Sim x HOIe Specvq VpN :u Av make
~r-gu+_ _ Oa _ te.,]It~~~ SPaanp )
SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only
Pali Orm Dept Over 1 1 xx DFoh of xz Sce SodOM xx Muicheo
dwl~ imx7, Lerner BedRrend, E,57os Topsal
Yes No Yea No
COMMENTS: (Include code discrepancies, persons present. etc.) Inspection p1:[t_Q Inspection W1:_
Location: 464 Wren Ln Unknown (S~WI114 ~NE 114 20 T29N R19W) The Glen Lot 58 Parcel No: 20.29.~52
1-) Alt BM Description = ST v~.fe C.Ct+<f,
2.) Bldg sewer length = I 0r
- amoun/tI of e~r = t n ~cL
y_,.~1 <{c4 e~r, QfJ6~ ~"I" .eiL u
3) N Y( lC o ~JC 5s: If 6e
na#+3.Q.ln.- ..8vc4dC 3 d + b.-2w,.r c~.[swtil4ers , `.RQ t'° O
:If Sian reviSlon Rcguued? vas Y No 34 ~--ta+~'r 0
Jse other sloe for additional information. I
W°+~"' rees~Pa.
~U.n,,IT'tplR.ve ~._.1 iu !•O++-I(t~erMOw.WtY-CMrf/~j.0 r~J 1c 5
J'~ Xi rr /
End Connection Lateral Layout Diagram
' -i=Turn-up7-valv-eo-cearmt plug
orifice located at C r
OfifI point ri
X.T_
p
/ L terals & III rnI of PVC Sch 40 Per SPS Table 3$0.30 51
N,.mber of Laterals, j44 Orifice Diameter 0 156 in
Latc••al Diameter \ in Orifice Spacirg (X) 2.10 If
I -Ill. al I ength (P) Orifices per Lateral 22
Lateral End(L) ft Orifice Density 665 It'7or.+ce
Ll Spacing (S} h Manifold length 3.25 11
at Flow Rate gpm Manifold Diameter 1 50 in; Iem Flow Rate gpm Forcemain Velocity 2.42 Igsec
Dose Tank Information
\rr
tS,- 11. ai,e n;. i.nlna -
' I'n up 1 4, l ien r5
' Hrnpiil-I la,p.• _,1- Pimp of , e'oxlc'+I'1+
83 C~
I
II t11k ple'.31ipr 111
I7:JJuu unJ:, :n,L A~ CC
CII^'ICnSion Inches Gallon. Wieser Concrete. Products. Inc
:`142 364.20 Cu .cif• 650.00 1
B 200 34-00 Volume 17.00 gylnnra
2 81 478
204
04
D I 12 l)D
'oral 38.24 6r .00
Fi,kcr Manufar.!wer _S I Tech Filter
°r er Modet Number 1- 1 W ii16
HI3rm Manufach i SJE Rhombus
A;arm Model mber A3 -ank Alert
Fv7p M, ufaclurer Zoeller com_pan}_
Pump, ode[ Number I_ _ 102:
I'I. mp Must Deliver 23.69 gpm at 20.84 It TDM
G. 1te S.v lchrx cu•aain ng 11000ry rnnv net hp us°C in Ihla s,rB?.nn
Project V CHAe__. Ss2 I'LLI_N A C[Iv F.ige4 u' 1D
Wnconsn Deparbrlent of Cormle,ce' SOIL EVALUATION REPORT 1129
Papa 1 of .1
Cruls..~n of Safely and Buildings in accordance sale Comm 85. Ws. Adm. Cade S" Sal Service
oaf amdtle aw plan cn paper na Iroe tlm an v t! .cne. n sve Nan mwt Corny St. Croon
rrlude W env Irrxted W vernal end IwnortN relerenra Pont (em). d.I and
pwe,Y skge. scde a dmmeom, Mdn attar, and halm ad delanre to Inarval wad. Parcel 1.0
Please print alt fn/o~ap0a --t pending
r{yKng nbrrtrorw POldo my lv u>d 'Aa6Cra Fkmwildr%> r5ol;t)(mH R~ Dalaa u ~3
f Property Owner 71-
6 p" Location ]
Sienna Corporation l 1,d SW iH NE 1M S 20 T 29 N R 19 W
PraPerty Owners NatYng Address a! Block a Subd. Name Or CSMt
4940 VMtng Dr. Suds BOB na The Glen
' Cay ErQ.+74 Stale [w C Ptlrne Cdy 'Village Town Nearest Road
MN 55435 952835-2806 Hudson Donvn Rd.
I! New Comlrmlm Use of
Resrowillai I Number of bodrooms 4 Code oemred desgn flow rate 600 GPD
. RePkcerrwrd - Po Ill; or cGnmwrcel - Descnbe
owentmash Petedoutwasth
Flood plain ekvatwn, If applk:ahle na
General cvaneraa
are recarmnerdebaa. System elmlim 94 1211. Wenches spaced an depth to code 6.58e bebw gladei'a U 3
2 djI S*Af' aqol.va.-d LWAJ
- J Boring 0 BarYq
Pd Ground Surface Nev. 100-70 n Depth to arwng raclo 115 rn
Sol 49Paraaen RaW~
Inrvm Cepur Domvenl Gobr Redw 0.~notan 7MM Stmmee Co mewc Oandary Ko OPW
-Etas I 'E11112
1 0-33 10yr32 none ad 2msbk mfr 9w 2f .5 9
2 1 0yr414 none M 2msbk mfr Ca na 4 6
3 ` 115 7.5yr4/4 none C~ Call mvfr na fill 07 1.2
f F
L--- 3
.F-21 string a
fd Pa Ground Surface eiev 100.70 tL rMpth to Wntng facto 115 n
norv:s, Oc9dt le ;I Cobr Redoal rltxm Teoaa Structure Corolla e
Bouroary Rocb
-E1
t 0-33 1orw none nM "E
i sd 2madc mfr gw 1c .5 .9
9
2 33-52 10yr4/4 none VIII 2msbk mfr ca 1f .4 6
` 3 52-6_7 7.5yr4/4 none , 1e( l~ t0Y" 059 mvh cs ne --I 1.6
lj 4 87.1151 7.5yr4/4 noon till mvff na net J 12
~s 170 (19
'Effluent el=BOD; 30 < 220maiLad TSS>30<I5 Meal- •EII 02-800 <30
mqL and d
CST Nana (Please prvq Slgneture. CST ST Num uear
Dal1d J- Steel 248958
~ SIeN Sal Service Dale Evaluation Conducted Telephone Numbs
1564 CR GG. New Riohnions, W 154017 91132002 715 246-5085
1
Property ovrrief Sienna Corporation Parcel to a Oondlr4
Page 7 or 3
Borfn 0 fiamB
Pit Ground Surface eiev 99.30 m Depth w tmitirp facer 115 n AppiiatwRmt,
Ifordm Depth Dwrant Colr Redor Dmnpron Textac suvelue Comaterur 60 Mfy Rn CPDdP
•Ena1 'EHa'1
1 G-42 10yr3l2 none SII 2msbk raft gw 1 f 5 9
2 4= $z 10yr414 none sid 2msbk mfr to na 4 6
3 67-115 7.5yr4/4 none Is CS9 mvfr na na .7 12
~~f,o~.o sys ~em~ -Im w,.e O. 7 ✓ s ;-Z 6j, _ a~r~~- en.Rd .e,i o tx,,~ 0, Y r.
N
" J -skse~C, ~v Syr trn ,c G d~"
-M
L~I was
Pit Ground Surface elev. R Depth to limning factor in.
Ilwm Depth DOrmera Coo, Reds D9[+eeon lexose ";uwm Cppad n Sca A mRre
outlery Rom GPDO D/M
'Effat •EM2
r
I Boring a , 6onrg
Pn Ground S;mace elev IF Depth to twang factor in. ~ R
Hnnrm Depth Cmi.C 1, Redox Dcacrpxm lean a WitWe Cometafm (kxridary Roth, GPDA'
'Effat 'Erta2
v
' Eflluenl at . DCD f 3G <;2G nryl aW 755 •:rp 15~ mgrL ' Enluent T2 = _W mgfL
' 8OD<<;tp rrq'L and TSS
The Drpanrnrnt nr ('onu~k-ra is :~n equal ~ygrodunay scrvicc pnrvider and anPb~er. If you coed asiatafroo M aeoeu eervitta nr
a
Property Owner Sienna Corporabon Parcel ID• pending Page 2 d 3
gerpg Ir "I Bon q
10 Pd Ground Surface elev 99.30 n. Depth to Imiing factor 115 in ~ Hde
Ho,¢on 0" Donwwd Cob, Redox orxrVI texture Stan" Commence Boundary Rota GPD~1l'
•Erta1 •Efm
1 0'42 1Dyr3/2 none sa 2msbk mfr pw 1f 5 .9
2 4 10yr414 none siG 2msbk mfr cs no .4 6
3 67-115 7.5yr414 none Is Os9 mvfr na na .7 12
/ SyS r v }O tti4 O• 1 {Or sizin1 - pti nt - CdUi2d a.Q.r4 D, l4 to
4 7e1 " J {O r 1 Sk tQ~al~ v sys Fps ^ 4. ~cr
❑ BMW • Baring
_j Pit Ground Surface eiev. ft Death to limning factor in Re1e
Ho,¢on fle; : I OW a an Cabr Redw Oewxpoon Tpdua Slrradue Coieefenrc
Boundary Raga GPD/tY
•Effa1 •Elktn
❑ Soong K Soong
_A Pa Ground Surface wev h. Depth 10 soxoxg factor in, Sol Ap*abon Role
Harmn Oegh Domren Cabr RoAox [lescryton Textua Sow r Consonance Doudary Hoot' OPOM
'Effa1 'EfPt2
Effluent R1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mglL . EMhreru 92 = 000 % 5 JO s and TSS <,Ts
"he he (kPanmenl o(('ummna u an oquul opMylunity srviar. p,vaidcr em1 mpMycr. if you nand assistance a nassistance 41 x~ servigVL
ces or
Mound System Management Plan
Pursuant to SPS 383.54, Wis. Adm. Code
1 General
This system shall be elated in accordance with SPS 382-84 Wis, Adm. Code, and shag maintained in accordance with tW component
manuals [Synergy Syste L LC., Geomat Mound Component Manual versiun 1, 2017, Pressure Dlstiitnnion Component Manual Ver, 2.0
SBD-10706 P (N. 01101) at SSWMP Publication 9.6 (OV81)] and local or stale rules pertaining to system maintenance and maintenance
reporting.
Septic and pump tank a , hdonment shag be in accordance with SPS 383.33, Wis. Adm. Code when the tanks are no longer
used as POWTS componen .
Septic or pump tank man risers, access risers and covers should be inspected for writer tightness and soundness Access ape gs
used for service and assassin a shag be sealed watertight upon the completion of service. Any opening deemed unsound, defe - . or
subject to failure must be rep c. Exposed access openings greater than 8-inches in diameter shat be secured by an effecbv ocking
device to prevent accidental i un uthorized entry into a tank or component.
Septic Tank
The septic tam shall be amtam . by an individual certified to service septic tanks under s. 281.48, Slats. The intents of the septic tank
shall be disposed of in actor ante wi NR 113, Wis. Adm. Code. The operating condition of the septic tank and at fitter shall be assessed
at least once every 3 years b inspecho
The outlet filler shag be leaned as n cessary to ensure proper operation. The fitter cartridge should no a removed unless provisions
are made to retain solids in a tank that in slough off the filter when removed from its enclosure. If the er is equipped with an alarm, the
fitter shall the serviced if the a arm is activate continuously. Intermittent filter alarms may indicate surge ows or an impending rxmbnuous
alarm
The septic tank shat haw its contents rem ved when the volume of skalge and scum in the to exceeds 113 the liquid volume of the
tank. If the contents of the to k are not remove t the time of a triennial assessment, maintena a personnel shall advise the owner as to
when the next service needs to be performed to inter less than maximum scum and sludg accumulation in the lank.
The addition of biological or chemical additives o enhance septic tank performance is nerally not raquired. However, if such products
are used they shall be appro ed for septic tank use the Wisconsin Department of Co erce.
Pump Tank
The dosing (pump) tank . all be inspected at least on every 3 years. All s - ches, alarms. and pumps shall be tested to verify proper
operation. If an effluent filters installed within the tank it all be inspected at serviced as necessary. If the force main has a weep hole, it
should be noted if it is functio al during pump operation, an if not, it shout a cleaned.
*-No one should over r a septic or dose fank since angerou gases maybe present that could cause deadii
our and P re Distribution Svster0
No trees or shrubs should be planted on the mound. Plantiay ba made arounc the mound's perimeter, and the mound shag be
seeded and mulched as net ssary to prevent erosion and to p vii some protection from Bost penetration. Traffic (other than for vegetative
snow compaction in the winter will prompenetra . Cold we er installations (October-February) dictate that the mound be heavily
maintenance) on the mound not recogimpendinghydratAic since soil mpacti may hinder aerator of the infiltrative surface within the mound and
mulched as protection from freezing.
Influent quality into the Mond systet ex ed 220 mg1L BODs 150 mi TSS, and 30 mg4 FOG for septic tank effluent w 30
mgrL BOD., 30 mg1L TSS, 11 mg1L FO4 1100 mL for highly tree d effluent Influent flow may not exceed maximum design flow
specrhed in the permit for fill InstallatioThe presaurc distribution ~ystem is with a flushing point at the end f each lateral, and R is recommended that each lateral be
flushed of accumulated solids at least o3 years. When a pressure test performed it should be compared to the initial test when the
system was installed to deter nine if onclogging has occurred and if orifice clea ng is required to maintain equal distribution within the
dispersal cell
Observation pees within bi disp ll be checked for effluent ponding. P ing levels shall be reported to the owner, and any
levels above 4 inches considered an ng hydraulic failure requiring additional, ore frequent montonng.
Continency Plan
if the septic /wia o is components become defective the tank or component shag b repaired or replaced to keep the system In
proper operatin.
II the dosing , pump controls. alarm or related wiring becomes defective the defe component(s) shall be immediately
repaired m repcomponent of the same or equal performance If the mount fails to a ccept wastewater or begins to discharge wastewater to the grousurface, R will be repaired or replaced
in Rs' present lcreasing basal area if toe leakage occurs or by removing biologically clogge absorption and dispersal media, and
refuted pipng, g said components as deemed necessary to bring the system mlo proper oper brig condition.
See Page 6 for the name and telephone number of your local POWTS regulator and service rovider.
Project; MICHAEL J & KATHLEEN A. COVE Page 7 of 10
~o...crtx.
Satery arxfn.",i-9 pt,;g.y~ . PRIVATE SEWAGE SYSTEM St. Croix
INSPECTION REPORT 5annan PermitNO
GENERAL INFORMATION (ATTACH TO PERMJT) 453434 0
r'ersgral inler!n01Cn jCV prPH]e maY be used 1cc secoN x 51.10 Ran ID No
%Y PuryoseS (Privary Lsw 5.15, W ;11,'mr
tf lxm4 Hnkiet'S Name CM 'Jibun X Tomm~ V Perw Ta< NV:
Sienna Cor Hudson Town-hi 020-141840-000
Ics*akl Eye _ nn. eMFka+ sm Dewrokor
S•r SBCLx/immrNange'Map NO.
20.29.19.2652
TANK INFO MATION
I E ~ ''LF'~-'~ ('~•J EVATION DATA
ivP hAANUFACTUREr CAPACITY STATION BS HI FS ELEV
!Septic
!2 5-b BenchmRit
Dosing
Alt Bkl
Aeial;o
Bltlg. Sewer
IHpI`Ci~g C. Pr
SUHI Inlet .J C
(,,3 q~./P
TANK SETBACK INFORMATION Stmt outlet /I
TANK 70 PIL b' b • $11
WELL BLDG. Vent ro qk ~nlake ROAD Lit inlet
'Septic _
" f s 3 ' DI Bottom
Dosing
Heaaer/Man.
AeraeOn S JV
' Dist, Pipe , D r
Holding . O 4 s- Sa
sot. System D 60
8. D
PUMP/ IPHON INFORMATION Final Grade l
1
k7analadwer
GPMand S COVe
3 7 r
r~ lb
Mnde)Numb - . QD ,O
TDH Lift 6C11011 Loss System Head TDH FI ' 4 W ( i
ro,. in Length L]of Oisr io W.
SORPTION SYSTEM
N s tYylh ( 9! pro Trendies N. J
IfiIE f Z WT DtMEN910NS flWog InaCp De. LquiC DexO
1
FORNIA NTION Lt SV$TEkI TO PIL BLDG YELL
I
NFORMAKE.rSTRFAM LEACHING Manurav
Ty;*O(SI *,,A. CH
~ AMBER OR
L/ 8 I ~Q UNIT g06MN
DISTRIBUTION SYSTEM y L
~Ylese«r.o.eanirdO Diu d,kon
11 Pi Ia, x /kilo Sze x Hole Spacing Vent to Air Inlake
_pia
SOIL COVER1n~- ~S r
X Prpesurc Systems Only xx mound or AU-Grads Systems Only
r; C.ar oern O.vr ra DnMn of
~•=':'icxh Corner endrtraw FCpSZ zx SeedlxUSoddeO xz MUldleC
. loci on _ _ '
Ye Nn Yes NO 1
COMMENTS: (Irldude code d+screlwOeS. persons present, etc) Inspection g1:~(1~ Inspection A2:__ _
Lewtion: 464 Wren Ln Unknown (SW 114 NE 114 20 T29N R19W) The Glen Lot 56
Parcel No: 20.29 19 y
Au BM Oesvlpaa, = 5T- k^•L4•+..~-eQR. te~t~ (.v .,~•ko b . ~ z
/T r `
?.)Bitlg semrleng(h= {tor
- amoun/t of c er - 1 f
3J t3e.1..~1n,o.c > 2 1- e.. 5sx (
1.~.0. .(flr-~Ow(~. 30+ /~~QnMrc-fb,,.ke's MU u~ o-
PWn mvision Rep~ered'+ O Yes NO A--A7C1`
Use oLner Side for adduionai mnxn iton
$]l~U/R.a9~• j ate ' 1n+~ei
/KK ,P~PM,xCtb ST wlow > CWV (3-0' ~ SSq~ C No J) I
~ts-~,
"vr
J' n
.,1
J t
I qrV!- SL~
t f
At
tvb
F 33t
Ya v °II
A.'
~d
o0°v