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HomeMy WebLinkAbout032-2119-10-000Wisconsin Department of Commerce Safety and Building Division GENERAL INFORMATION Personal information you provide may be used for PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) [Privacy Law, s-15.0a (1)(m)I Shannon Nee and Dean Kaufman Jr °TO CST BM Elev: Insp. BM Elev: BM Description:Nn/ TANK INFORMATION LX I TYPE MANUFACTURER �) CAPACITY Septic -, T C1L.— 1 L HoWng I FILJTof �2S TANK SETBACK INFORMATION f ha 11 LOt F s,/ ®L',;AQA=M® e' �M= �= l�� PUMP/SIPHON INFORMATION k + Head SOIL ABSORPTION SYSTEM IF SOMERSET �[M/✓1dA�i Ah 1TION DATA Bldg. Sewer i -i a -i .) BED/TRENCH DIMENSIONS Width 1 /3 Length No. Of Trenches o) Z PIT DIMENSIONS No. Of Pits/ / side Liquid Depth / SETBACK INFORMATION SYSTEM TO P/ BLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT anufacturer Type Of System Cot4cT bNOL- — 6V ' Model Number U)L �/l ujo l mou l ivim o T J I tra SA 1441 Header/Manifold j� ' Length I I Dia 1 Distribution _ Pipe(s) .--—"----- Length Dia Spacing Vent to Air I� ntalk 1 avr� �.vr arc x Pressure Svstems Only xx Mnimd or et-rt.ad. Av.tnm. nnly Depth Over I 1 Bed[Trench Center De th Over Bed[Trench Edges > xx Depth of Topsoil xx Seeded/Sodded _ m Mulched .� 1111 III - -- C Yes ❑ Na O Yes No i COMMENTS: (Include code discrepen/ci/es, persons present, etc.) ' Inspection #(�1(: I ' nC I,n1t�,7cttiQ�n #2: Location: 1993 62ND ST(�,, ,L .II�ST) � 4' 4j� A� ) 1, J ` ��l l" I r S I IA i 1.) Alt BM Description = Jc�li fllll�Ipi c,U� /I r -_ 1 J "IL 1y 2.) Bldg sewer length = .Jl/t t Oct �S` 1 4t Au O jJ,Q/f b t 'b lGwt. - 17VAI,1 t amount of cover = 1 �V r CA f H2'of (cwMUll1 J o Plan revision Required? E-] Yes TiiI�No A I� •/�1t Use other side for additional information. 27 %OZi}� wc-r�tl.� ' ✓'J SBD-6710 (R.3/97) Date Ins tor's Signature Cert. No. 540-0)0ad — ao :4•: �,<<,. ,� IIsIT !� p2 2020 �A� ix County Safety and Btr➢6rtgs Division 1 W.WashirtgOeRt P.o. Box7,6z Mai�ison. 707-7162 _ w1 � somry perm a(m be®led m by Coe 177 9 7 C ev It AppKcah in accordance with S g3.21(2), Wier. Adm. Code, submiss m of this form to the • 1 t is pr or m olmmmg • san cry permit Note: Applicabon forms for o stat POWIS am s bmit ed m the Dcparment of Safety and Professonl Senvies. Personal information you provide may be used for secondary Sloe Tr �•(/1 etim Number jeet cadet ass (ddiPore d WmmdrB add,em) ptuarpossas in a000rdarce with the Privacy Iaw, s 15A9(1 m), Sits / �p L Application Information -Please Print AN Information Property Owar'• Name Parcel p —/ - .,Addt �� >�� d3t.19a IOU 741-1126W,4ZZY Govt. Lat ZA7 V, Session City, Zip Code Phone Number I —Al Q. Type of Bat"09 (cheek all that apply) i.a g 1 or 2 Family Dwelling - Number of Bedrooms subdivision Name ok " ❑ PublwX mmam eid - Desrbe Use sr Blom d ❑ city or ❑Staec Owned -Dcaarbe Use Z ZX64r- ❑ Village of pY TOWn of .riiri%�u!SYc'% _ CSM Number III. Tyapp�te of Permit (Cheek only a# bon an inn A. Complelte Roe B if applinble) y� New System ❑ Replacement Sysem ❑ Tremsent/Holdmg Tank Rcplac®em Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewed ❑ permit Revivm ❑ Chasge arpl tuber ❑ Permit Trmdcrm Now lid Previom permit Number and Date Issued Before Expiation Owner • / von cis ry (/Device• Cheek all that apply) Non-Prcarsiacd EnOromd ❑ Presseiard laGroumd ❑ At -Grade ❑ Moumd> 24 m. of sadidde foal ❑ Moumd <24 m. ofswrable 016u Diapersal CmrPooent (explaia) ❑ Ikviee (eapi•m) r�...r/v V. maYf Area Information: Design Flow( Design Sod Application Dispersal Area Ravi ad (•0 Arca Proposed gya eon nev8°"' 4 VL Taak bite Ca"City in Gat, Tad Crltom a ed Unix Mmt>f caw= B V , h m m — iv U iL New Ta&o Tmka Septic or Holding Tank Lot Dosing aver VIL Stalemeat- I; lies tsdxdped, ream• ear sesla0alioa ottie POWIS ahawa u nee amu elied pls. ZZISI� PI 's NumberBeeme"PhoneNumbrry,Side,Zip Cale) VIEL,ConaftAlliegicarbsesit Use Apprmud Pe i.en Reason limial Permit Fee d -5 •� / 3 Zo Si�torc IR.Coo ij(IjppileRllRessonsforDnappioval �g1� 1.Septic tank, ef�uentfilter and 3� 4(L CM.t,tA.JI dispersal cell must W sqjrvice_d / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained AW toeosplerepfm6r a.eaym a>a eabdtbbe CoanNaM'•a,oWour mess IheaS M. 11 ladeive C/ SBD-6398(R- 11/11) c A Ac.�Cv/✓O'�6�rOeF/'111fx'X•��J�aAQ!-/�j�, 'e;d S ss3i - ORu:�j Gicajg esr,� a�a�s OA A Ac.�Cv/✓O'�6�rOeF/'111fx'X•��J�aAQ!-/�j�, 'e;d S ss3i - ORu:�j Gicajg esr,� a�a�s OA CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: >� Owner's Name: —AAA(/ ✓ ��� Owner's Address: Legal Description: .UPI ,Ak Township:/ «T County: ��11 �a.� -• Subdivision Name: Lot Number -- Parcel ID Number !Z2 - 5)//e-?-//1 Page I Index and title Page 2 Plot Plan Page 3 System Siang & Cross_,%ction Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. License Number - Date: Phone Number Signature Designed pursuant to the In-Gmund Sal Absorption Component Manual for POWrS VetsIon 20 SBD7070 -P (KO7N7 ), Page 1 T i n P4.&) .f �/!✓�-�Ya� sc�,'?G-T.3/may-�/A/�l S/+9iflSAlt" r ..-. . . r - YdH $ 4 Sdh¢dte 40 Q'dd0 PVr- VErt Pipe VA&Veit (.gyp /f -1 ft ChEgnbBr F_ ZLI- ft Syshen Bevzbon ft jL' tt 'l(IN(i�((IIII(IIIII11111II(Iilllifllllllflll(I(111111lIIffflfllllllllflllill;lC�;111111■ i IIIIII�IIIIIIIIIIUIIIIIIIIIII(fill(III!(111lIIIIIIilllllillllill(IIIIIII(Illlli� I(INf ■ , 2 rows Df des eadL tlw Of SKv. PL-525 EFFLUENT FILTER (Cr win Polylok, tric is pleased to add its new commercial fitter to its existing line of quality effluent filters. The PL-525 is rated for over 10,000 GPD igallons per day) making it one of the largest commercial filters in its class. It has 525 linear feet of 1{10 filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effl uent won't leave the tank_ No other fvter on the market can make that claim! PL-525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2.'Remove tank cover and pump tank if necessary. E?� Alarm accessibil"rty 525 linear feet Of 1116' filtration slots Roeepts 47 & 6" SCHD, 40 Pipe--,, U & Patent Noa 6.("SA 0 5.371,640 PL-525 Instal latier?: 3. Do not use plumbing when fitter is removed. Ideal for residential and com- 4. Pull PL-525 out of the housing. 5. Hose off fitter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is property aligned and completely inserted. 7. Replace septic tank cover, mercial waste flows up to 10,000 Gallons Per Day (GPD). Accepts PVC ' extension handle Rated for over 10,000 GPD Gas deflector Automatic shutoff ball when filter is removed 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4' or 6' outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace the septic tank cover. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page —of _ FILE INFORMATION Owner Permit # MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Tank Manufacturer. ❑ NA PfSeptic ❑ Dose ❑ Holding Volume: (gal) Tank Manufacturer. DNA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Vertical Distance Tank Bottom(s) to Service Pad: (it) Horizontal Distance Tank(s) to Service Pad: (ft) Specific servicing mechanics must be provided If vertical is >15 feet or if horizontal Is >150 feet Specific instructions to be provided on back. Effluent Filter Manufacturer. Poy o� ❑NA Effluent Filter Model: Pump Manufacturer: 12 NA Pump Model: Pretreatment Unit Manufacturer. ❑ Mechanical Aeration Elr� Peat Filter y� NA ❑ Disinfection ❑ Welland ❑ Sand/Gravel Fitter ❑ Other. Soil Absorption System 19 In, -Ground (gravity) ❑ In -Ground (pressure) . ❑JNA ❑ At -Grade El Mound El Drip -Line ❑ Other Other. ❑ Service Event Service Frequency Pump out contents of tank(s) .� When combined sludge and scum equals one-third (Ya) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s). (Maximum 3 years) ayear(s) ❑ NA Inspect dispersal cell(s) At least once every: yew )s) (Maximum 3 years) El NA Clean effluent fitter At least once every: ❑ moMh(s) Elyear(.) NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) X� Flush laterals and pressure test At least once every: ❑ month(s) ❑ year(s) J>d NA Other. At least once every: ❑ month(s) ❑ year(s) ❑ NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify anycracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a.failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third ()r,) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent fitters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event GMW-005 (02/115) Page _ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) priorto use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If'the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: D9 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit Issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and baring advances in POWTS technology, a holding tank may be installed as a last resort ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INST ER POWTS MAINTAINER Name / Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone _ This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. page —of — START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process andlor damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Startup or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result In the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline; greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to Insure that the system Is properly and safely abandoned in compliance with s. Comm 83,33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If"the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: I� A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the btomat at the Infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INST LER POWTS MAINTAINER Name Name Phone [Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name � " W Phone Phone This document was drafted by the staffs or the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance wlth sections Comm 8322(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Admrnisfrative Code. l N 4 i PINE CLIFF FIRST ADDITION WGt}EEppT IMTRMXVI/i6MNWt{>H PMTVMSWi6M p 4A WPMT OF Mm 4OF MN 4 d Rtflln K TTµ pri TNVM V SOGAT. M CI®t tOMR. 1I1l;1fI1lpl D S GiR MT' V_ SERW L m..wescm 74ALe I— k0.J_ 1 1 — — — — — _ _ — — — _ _ _ _ _ iMTW i UTq_ w' 41K R 1K x/1/• EVII�AV.� fM'n'[ti w•RM! •nnW M n•ww• T wva iur 21 ! t � L2f.L.FiS IZ Ifriz Il 4 • __ _ ir. � p t611 K iYT I Ei I •[M K: OF 1 22 R :__,--- __----- —_ _____-__ L a Illp wa:w\ OWNERS OWN E4 a wxrx.x or.SptxAl, 03 M. VI NNS µ N LEGEND I / / � f ® ` •- :' wirr 23 ATM,'. ' �'! r 8 4'1 Mr./- B w°nx rvLO}xxlt Nnw <wK+ r Mw nK ]ao Q y • R• iq•.R R. KWXK Ntn mnKr .Nt N rxW .R/MO SNP •lt a.K. 40f tpx[R J. t R!1#RVilm iN to _ iwW / � �' 'jl .............. W 4Nn RIW.. 4U[ �� Ir yll4 Nallr 4R4•r / / �•'% 21 _ i I / I 1 I • % � � Ay F �, Cv�•m� wN vx4. 41K ncvxW-uw WaIK nul Wa4 Y.P 1K [.,Kln R 1�4tOrtx3' V•iP FrNrIP •n• \\�`. ♦ 26 xnr . � NKw a x.oinrtx VINN nl.. Y..n RRMN• Mi. luv W rl. x K, . NAYu •a. ro .wx R maxR• axW Wl n•x KK nwxn 25 N!A KI % UEI K -\y '....... •. ................... ......... 101W lIKR MYV.>MM'1/• \. T .., $•OS'DB"E i]OAD' MR YlT Nn � _— M LDT 8 PLAT OF PINE RIFF x'•�M mtKu]p 4Yax aG tM tM R 11R[t tK ♦ gnNr R i(Ctpl N4R cx�l rpn r KI M va Ir +] xM IO RMMYr4 �• MPwrt Iwxc ti IwKMx ,,• 4 �K.'MtnlOam twnEw Lein a4 K•Nn LWI! 4Kr" ML [bM Ixxaxt IKIY IRM NT•env nMN'S 4Y '»•ry il]'n'N-f I)'u'Ni'Y rwi,es eN.r Nix fr»a•-v v�nry nr.» nw� w• m+v xxr�nv sv ��a wur xn•:rK-v xnwnrt w n• 4Nv nrmvn fx]mwv iY I4SOI INIY w11'n2 3v 9W NY' !b•' 1]]]•' Mir•fY .• MY•V wry rN]' WP]SXY SNIYN'Y bm n>x nfTawY reramv LOT 10 11.M . n Niwi ialil. xa K, 4N.[6. SKu S IT Nttr • I�xRr wxxKl n tw n ol ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State • si'J- Z��' Parcel Identification Number LEGAL DESCRIPTION Property Location � '/4 , ,J�XL'/4 , Sec. �/ , T _ --�LN R / 9 W, Town of Subdivision Plat:'&gewfi= '/`fzAy , Lot Certified Survey Map # Warranty Deed # Spec house ❑yespdto Volume , Page # (before 2007)Volume , Page # Lot lines identifiableJAyes❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment 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 disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, 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 must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on 1�ts form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a 71ranty deed recorded in Register of Deeds Office. Number of be rooms J IG TURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** 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) y Wisconsin Department of Commerce Division of Safety and Buildings Bureau of Integrated Services in Attach complete site plan on paper not less than 8 1/2 x include, but not limited to: vertical and horizontal referei percent slope, scale or dimensions, north arrow, and loc s, APPLICANT INFORMATION - Please print a Personal information you provide may be used for secondary punpos Zip Code Phone L VALUATION nc W Wis. Adm. Code ppr � 7 s in sizdL,At County (BM), direction N �IAce;o crest road. Parcel . . # sT CP 1999 v 3a Page of 1/4 d� 1/4,S�G T ?/ ,N,R iufxlA./lJame wSM# ❑ City„ ❑ Village N Town Nearest 0 New Construction Use: ® Residential / Number of bedrooms —4/— Addition to edsting building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow de" gpd Recommended design loading rate —.7—bed, gpdflt2 . Y trench, gpd/ft2 Absorption area required 13SQ bed, ft2 %{i`J trench, R2 Maximum design loading rate _,Zbed, gpd/f12---.&—_trench, gpd/tt2 Recommended infiltration surface elevation(s) / 1-fIt (as referred to site plan benchmark) Additional design/site considerations _. Parent material 4 /R 4, I'Asi/ Flood plain elevation, if applicable ft S = Suitable for system I Conventional Mound In -Ground Pressure AT -Grade System In Fill Holding Tank U= Unsuitable for system I ® S ❑ U 1A S ❑ U 10 S❑ u ®s ❑ U I EIS O U ❑ S N U Boring # 1,, Ground elev. le-vt• Depth to limiting factor 71/ in. Boring # El Ground elev. //fin Depth to limiting fa_ctQr SOIL REPORT BE ®®®®® mom l / Remarks: _ M1M0 � 1,Y In. Remarks :ST Name PI a Print Signature l/ Telephone No. - 3 4ddrees 41 Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER p PARCEL I.D.# Boring # c Ground elev. Dept to limiting. factor iggin. Ground ;el��jj�� 41ift. Depth to limiting fat }yin. Boring # Ground elev. /4L�0. Depth to limiting factor �t_in. Boring # Ground elev. ft. Page ;zP— of �v Remarks: Remarks: ME ®®®®® Remarks: Depth to limiting factor —in.Remarks: SBD-8330 (R.9/98) PROPERTYOWNER 70 k0m ZM�' ° SOIL DESCRIPTION REPORT Pale�of o(ota2/ PARCEL I.D.# Ground elev. /Aw- Depth to limiting. factor Ground elev,. �ft. Depth to limiting r in. Boring # Cl Ground elev. /fzfh. Depth to limiting factor fit, ln. Boring # 0 Ground elev. tt. 'MFMM�.�� ©G�dL'/���S�I� ■ FM�MMM _MM�MMMMa Remarks: Remarks: Remarks: Depth to 1� limitlng factor In. Remarks: SBD-8330 (R.9t98) 66k e9 i1 sos v ISP/j�-�tYsyr�/c^f•>(�'lp.���� f9�i�N(oi�6%�1 �'�"'�' `200THAVEy NUE \\ I 508.3 " �\ I I� I / 1 I� // I A 1 1 A / W I II �/ — \ I 1 \ 7 m LO 21 �� a I \ I I 1 IT \ 1 I _ I I I LBO = 882.3 I ^ I \ 512.43•. \ \ \ —1 —1 PREPARED FOR: WITTSTOCK BUILDERS PO BOX 395 SOMERSET, WI 54025 SITE ADDRESS: 1993 62ND STREET �I N SCALE: 0 50 100 ELEVATIONS SHOWN ARE NAVD 1988 DATUM. MINIMUM BUILDING SETBACKS: 100'ROAD 10' SIDE MINIMUM, 25' TOTAL 25' REAR I, Douglas J. Zahler, Wisconsin Professional Land Surveyor, hereby certify that this Stake -out Plan was prepared by me or under my direct supervision and is correct to the best of my knowledge and belief. iI Z J IL Z 05 O O Y F LLJ Q C N z QN li x Z) J'3 = =3w Co z_ CL O N OF 1