HomeMy WebLinkAbout020-1001-00-000�::a a:`nd o".Id F.
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PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
St Cri
a e... N. 600281
Pi T. N. 020.1001-00-000
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19
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that 1 have inspected the existing septic and/or dose tank
presently serving the following residence
(Sneetaddress) �V S� .(�{ -L r�� y ' located
at �xJ y4, j� /, Section /)7 , Town Z/ N, Range_19 W,
Town of /-}i,./�.� I , 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 system9 YesNo
(if no, skip next line ) _ _
Approximate volume or length of time _gallons minutes
Tank Capacity
Construction. Prefab Concrete X Steel Other
Manufacturer(ifknown): �Air<r.ta
Age of Tank (if known):
Permit number (if known)
C Cr 11J
(License lumber 1 azure) (Prot Name)
(Title) (License Number) MP/MPRS
�11 h7
Date
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s 145.(H6, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev.2/2011
PAGE OF
In -Ground Gravity Plan
Index & Cover Sheet
Component Manua Deogn Reremnces
Vegan 20, sB01070S (N DIMI, R. 10112)
Pg 1 of 4
Index & Cover Sheet
Pg2of4
Plot Plan
Pg 3 of 4
Dispersal Area Cross -Section & Plan View
Pg4 of
Management Plan
Altachments:
Enclosures:
Ic R � slzc�
POWrS Application for Review
,Y *s..�
Soil Evaluation Re ort85ite Map
Project Name / Description
Owner Name(s):
Z�R XA T
1d V JAf44me:
r}wmrAooleo:
ICSF 4L2D nJ fiAKS nR
iianxn
Lp: &yDlj[
Pralicl Aooresa:
/s+mci
Govt W1:_
uu- 114of NE1/4,Secbon
DI ,T
YI N-R_L�' E❑orW®
Tovmah1p;- iurAMu,l
county:
-X CdtLlx
Project Parcel to
s: Cd=-lory- LO-COC
Designer Information
Designer Name: llane Jr. iluerLrtr Paorla 7L5 ;':(. rl7.s
Deslgner^dd g ;2S' 9i KA's:IATNw,i$ 6'4 DASKLKy w ➢P: -0a
Eanell: Ii�l45tndes a. odlmK eam
License Number. J 6 x1 CC l
Remarks:
Signature: 2 >vi:C ,zF.�- [
.ate
Y
1ls OhYH •(\'IS{1 P. � � 921a'Jy
hJl za*,t old told
%oilJN°K/�MLS
Yew ? I
IN-GRODND GRAVItt DISPERSAL AREA ✓ LIM
UnRarm ElavaOan Trenches with Oulcm StandaN-W Cnemlwrs ,,,,,,,,d,
}fi Trench(down-sizingcrad1l) y_0_0_0
L vWWmww. U 9
� uawv
ww, TYPIC.RL TRENCH
CR SECTICNVEw
si
IN, Scald
wm.�_�
�° 9ra kmn, auurnyN [bnrvfyi MN'sNw, u' TYPICµ TRENCH
mow• RANwEN
INusule)
A-100
4L::-� -I
-------� ----.v .-
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m
_
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INSTALL PER TRENCH
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Z VwVw,AWoeeeTWEiCA- W9 r /1 AN'Va�
&C,03,af _ 0.7 LR = asz n - f.�
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PAGE 4 OF
In -ground Gravity Management Plan
IMPORTANT
Too owner of this Iin-ground gravely system shall the lawyer for ns uspetual operation and maroYdanes puRuarAb
requirements W SPS 382 beef, Who Admm Cade Pursuant to SPS 3N.52(2), Wipe Admin Cale, the system shell
be wlBldent a human healm hacard d net malrealned m amddanre wolf this approved management plan
Furthermore , all nspaiwn and marntenanre apparent stall be Pormensd by a regYUred POWB Maintainer In
expresses whir SPS M352(3) Was Armin Cape
Maslmum DYcetsel Area Oceretlna LMIB:
Design Flow/VC% gPdi BOD65220ml T8,35160ml F00530nal
Inspection Closi [ INSPECT EVERY 3 YEARS
¢ or"use
o age of System
fears if a drops, paper complaints, etc)
mechanical Paris en I, a, ppmpc valwe, SMxnee fleas, etc)
maenad fuel (r e, leaks, breaks, common, etc)
vibes w4ume in mostrouxic treatment tanks) and any 0elnbubdn apputeoance(s)(I a, tltaurphon/drop byes)
method or improper use (re, exchadmg design espai prohibited a wMN ,Nc)
• extent G pending In dlommuhm esll poor to smeng
o druing rnaguYribes -d applicable it a, pumprechcling, Peat switch senses efc)
el¢MWI wmponmis- rappleabk (Le, wrung, mnnetlwns swdcbes, controls, borers, alarms, ate )
o dlsinbutrm kteral or lateral denim Pluggng (measure lateral drelal Pressure -pointers to bases speuSmepr)
e sprat enchants M a muse or saw2e trial are structures W
Malnterrenca Checklist MAINTAIN EVERY 3 YEARS (or when necadi
in Sepft and dine tanks shall be tamped by acertified Seplege wmosng opemlorlicensed under s 281 Q Wla
State when Mevolumem si rn Matanys) eaceds oneArlN (113) Me Imuml volume of Me tenk(s) or
asregulredbylocalordlranes depasalNconlema Mall bepurwanl to NR 113, Wow Adorn CM¢
o Effluent Opens shall IS IrspacYd every 3 years and shall be deanatl when newssary to assume any
accumulMM ships according to manufacturers spectral A servnng penal well always be grafter than 12
months
Sysdm maintenance reports shall be automated W the Paper local government unit in amordance with
SPS W3.55 Wild. Admen Cale Report any commkinu meant fallure or maMundern ta.
Name N abandoned or company ADUAP�TcD SEP11CT!)Sfl4tliT/C�Zt).Phone 71,i-7L3-fi 7
Local eo+emmem r.Nr S U1Wk lbu CT1' YOMMVJalTV nE vcvPhore'e�/$-3yb -`/6 �a
L llgwwnmentonitmdmY 1-IunsaUr orris i> —ZIP 5HD/6
Any defeslow pan of this system shall be mpalted replaced, or removed pualuam W SPS 383 st (1), wdc Admen
Cate Repandr r¢plac¢ment of Y physical ouor m urn oflthe P Wmpanaybshall Amply wits SP3 383, he r Admen Cate
No orMucr gr h brat 3l or Vocc:Areed Cop n of the POVRS may be used unless approver by the repayment m
accordance with 5P53eG. Wisp heroin Lod¢
In the avant that anyfailad treatment mmpnn¢nt of IN, POWfS snot be repaired it Ce mepo dpursuant to
a Plan submdtad to the appmenare apencyfo- remewaM approval AfNNrn rmunddi"malxm nentmaybe
abandoned add replsass by a codemnplylm imperial compenenl in a Preoperational area of suitable Souls.
SVNm AbaMonment
If use of this POWTS rs discontinued, R shall de aMMoned in wooMenot with SPS 38333 Wise Admm Cale
lid � 0 24.60
`$C
i
iSECTION A —A
J
1lc 002S 00 --�� ERMANENT FOAMED —IN �
POLYURETHANE GASKET
4
THIS AREA MAY BE FILLED WITH
CONCRETE FOR ADDITIONAL WEIGHT
t
3 10
4.50
Material: Copolymer Polypropylene
Color: Green
Drainage and
Septic Products
PART
T,I Tic. Inc
TELEIRRME' 147550.1011
1200 FaC, ,t
T FREE: 1413382 nice
PART
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F" w2 Ss0.EfN
24" RISER LID
24 - RISL - GREEN
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c 12.00
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SECTION A -A \#
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Material;Copolymer Polypropylene
13.00 Imo— -�_ Color:
Green
Drainage and Septic Products
TO-na. Im. TEtH w 502se0Jm2
1MO Fn Omm -- - TOLL FREE' W 302 T009
NAME:
24 X 12 RISER
24 X 12 • Rig - GREEN
The Only Septic Tank Filter You II Ever Need
roe.
The lifetim ter
The I, fen me fi'ter is the Most eflloem: low maintenance eff-uent filter on them a met rated 35M Gi With flea
filtenng capacity of other fItare IIIme fIter Is the best value for your dollar The unique plate design elle
sods Inside the cartridge virtually eliminating mamterance Cleaning is made easy through thee] I Mina tron of
Wnroen dates. nahng tie tarn mein and replace mlmmal Cu, unique durable construction and patented I
wtmade moral o'tne difield -he are[me Ereisavailable In 1/8', 1/15' 1/32' and Vol filtmboc SIZE
< In addition, our distributors buying directly from he manufacturer allows them to get our product to theme
reasmable occe ® hint mmmm vno Qualify
Single -Piece Filter Case
Made of high quality materials. thesrngle-plece
Men case conmme noglae or sensors. pried no
r,n...rn,Ver.mrglmrn� OnmrsmuINIMI( nrer much 8/2220/7
LiOZ/ZZ/8 dyd ap0-NUM-agdae/woo olpall9awnyq/fdlty
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flex
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Pod on ether end of are W rk4 standard Chamber
APPROVED..
EMW tNmem cl mm
II I66S���tEl@� r�?3i� �Ili41)11�
IEFfEcmg lEN31111
Pal EmGp
FROMVIEW SIDE VIEW M)IJIM
Typo) Tmcll New
I—x�ruon_
40
34-W z53-L, 12'w
86d mm r 1341i mm R 305 mm)
E el Ul
48- 1219 mm)
lacer Hall
3" r203 mm)
Stan, Lap¢IV
43 gal (183 L)
ll Haight
8'J203 mm)
TITTER; Porax,,I
Irv. u.ww.,..m.
neaxertnew�nee Sram�m¢awnnryon�nlq immnw n
ra Nca gwmaN
And
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o so Iti
Weaker wrwmadsg+dtsam
• 'a The Ormun Through Relay
co, nr" And wi broader
0.1 ill Andrei
s
SWember262013 (RevLsed Nwembar 13 MID,
INFILTRATOR SYSTEMS INC
GOVERNMENT AFFAIRS DEPARTMENT
a SUSINESS PARK RO
PO BO%T66
OLD SAYBROOK CT 06475
Re Decorous LEACHING CHAMBER
Menanica er INFILTRATOR SYSTEMS INC
Product Name. QUICK A STANDARDW
Model Numberp) OUICK<STANDARD W
(EISAforchambersvainorenthoulacre osud R/chamber EISAtorendcaps.SA
60sg X'puroI Andcam, Lawn9lerlglh M chamber - a 0 fit laying le at end caps
1011 WEm•N inches Haght. 12 school, Mal daplh of bury -B IF, FOR BED
INSTALLATIONS. All DEPTH OF WRY 13 REDUCED TO ae IN qxn ismard area-
9 6d ON it member 35 sin H,cast of end caps)
Product File No 20130191
The specRicalons and or plans for this pfumbfng product have been reviewed and baseball to been For ance
with adapters SPS 3821Mough 390 Wisconsin Admfmslra0ve Code, and Chapters 105 and 160. Wisconsin
Statutes
The DepMmerll haddyIssues an alferreb amws to a. BPS 3fl] At Stan A 384 5 t Won the Wisconsin
Stables and the Wisconsin Administrative Code The 8""e "feet is "Rd uMll the chi of Bplambr
MIS
This approval supersedes the approval issued on IsidrM9 under product fie cancer 2O070551.
This approval alter mat be Incorporated with our Wwfbusty approved titans anabr medical approwed under
webuct fire damear 2o70551
This ememare appwet 6 consultant upon compeanee wrlh me foddering shpuWhonfa)
• This Awl must NrnitNled in xmrdama with the manulanuders pushed rueful wwudmprWal.and
plan approval If Thom n e comficl bmwean the consu lurm i minsual and Me pl ii windows] arM/m pion
appoval, the product approval and/or plan approval will lake precedence
• Wrom this prWucl canceller a dowasal call mat is cfml dacM bn the EISA rating scroll the bararCng
block Ol me prWcl atimbi ON, Nr WM must rxerve wazerfu r havag a B005 valve answered 3o add
220 mph add a T55 value be on 30 add ISO mi
• When this product Is installed In a Recall cell that s steed based on me EISA rating elated in the regarding
block of the product approval earn, this product must he Instalbd in occasional excavations mat create a row of
chambers that are horizontally anuamled from other rows in other subproblems by al least 3 feet The 3 teat
measurement is measured confirm the closest butsde edge$ of the leaching cliamgers
Vbh� thin product 11 mdaled m a of 111 Ball that rc eras sagas on the full rating slated in the r99,mong
dttlt of me pmtluclapproval letler the electrical call hcgn or allow at bast prior of commit in the
chasms"thi baunow ofvasu water,,, in, drar,ri mat dnchmpasnto Oe chamare
SOD 105yrrN 1ald For 130TY020(fp
s
SWember262013 (RevLsed Nwembar 13 MID,
INFILTRATOR SYSTEMS INC
GOVERNMENT AFFAIRS DEPARTMENT
a SUSINESS PARK RO
PO BO%T66
OLD SAYBROOK CT 06475
Re Decorous LEACHING CHAMBER
Menanica er INFILTRATOR SYSTEMS INC
Product Name. QUICK A STANDARDW
Model Numberp) OUICK<STANDARD W
(EISAforchambersvainorenthoulacre osud R/chamber EISAtorendcaps.SA
60sg X'puroI Andcam, Lawn9lerlglh M chamber - a 0 fit laying le at end caps
1011 WEm•N inches Haght. 12 school, Mal daplh of bury -B IF, FOR BED
INSTALLATIONS. All DEPTH OF WRY 13 REDUCED TO ae IN qxn ismard area-
9 6d ON it member 35 sin H,cast of end caps)
Product File No 20130191
The specRicalons and or plans for this pfumbfng product have been reviewed and baseball to been For ance
with adapters SPS 3821Mough 390 Wisconsin Admfmslra0ve Code, and Chapters 105 and 160. Wisconsin
Statutes
The DepMmerll haddyIssues an alferreb amws to a. BPS 3fl] At Stan A 384 5 t Won the Wisconsin
Stables and the Wisconsin Administrative Code The 8""e "feet is "Rd uMll the chi of Bplambr
MIS
This approval supersedes the approval issued on IsidrM9 under product fie cancer 2O070551.
This approval alter mat be Incorporated with our Wwfbusty approved titans anabr medical approwed under
webuct fire damear 2o70551
This ememare appwet 6 consultant upon compeanee wrlh me foddering shpuWhonfa)
• This Awl must NrnitNled in xmrdama with the manulanuders pushed rueful wwudmprWal.and
plan approval If Thom n e comficl bmwean the consu lurm i minsual and Me pl ii windows] arM/m pion
appoval, the product approval and/or plan approval will lake precedence
• Wrom this prWucl canceller a dowasal call mat is cfml dacM bn the EISA rating scroll the bararCng
block Ol me prWcl atimbi ON, Nr WM must rxerve wazerfu r havag a B005 valve answered 3o add
220 mph add a T55 value be on 30 add ISO mi
• When this product Is installed In a Recall cell that s steed based on me EISA rating elated in the regarding
block of the product approval earn, this product must he Instalbd in occasional excavations mat create a row of
chambers that are horizontally anuamled from other rows in other subproblems by al least 3 feet The 3 teat
measurement is measured confirm the closest butsde edge$ of the leaching cliamgers
Vbh� thin product 11 mdaled m a of 111 Ball that rc eras sagas on the full rating slated in the r99,mong
dttlt of me pmtluclapproval letler the electrical call hcgn or allow at bast prior of commit in the
chasms"thi baunow ofvasu water,,, in, drar,ri mat dnchmpasnto Oe chamare
SOD 105yrrN 1ald For 130TY020(fp
Mun�.+K�J'nire�
INFILTRATOR SYSTEMS INC
Paget
September 26 2013
Product Place M13019T
• When Ins product is installed in a distribution cell that Is smed based on the EISA raMg stated in the regarding
dock of the product appoval Inner this product must be Installed in a dlsinblaion system, witch has the tap of
the dtsinbufmn cell at or below orrgnal grade
• When this product is installed next 10 esch other n adiitribution cell that rs NOT szed based on the EISA rating
spied an the regarding pack of fine pmdu t approval leper, the effluent (agartaneen area is bi 0 the length
times the such of the chambered area The use of geotetlik fabric in this type of InstallMmn is optional
• Woen this Tha rs installed wish geote+We ghee on the sides of Pis product in a orsonWOon cell fore a razed
based on are EISA raurg staunch the regarding black M the fount approval under, the gmRNle fapc Must
est all of the following spsskohons
Gcutenule strap be nonwoven
Weight shall be 0 as or/sa ra to 1 5 Di yd
Apparent opening size (AOS) shall he 2630 U S &eve tASTM 0-1)51)
The depadmenl is in no way endorsed this product Or any advenlsray, tnd is not responsible for airy situation wnmh
may result from ds use
Sincerely
Glen A Jorge, MS
POWTS Product fieveiver
phone (608) 267 5265
fax flich 2e7 9723
email glen lorsoff goy
ST.0 OIX COUNTY
SEPTIC 1'ANK MAD TENANCF AGRE6A4NT
AND
OWNERSHIP CERTIFICATION FORM
O.weJ9egg� - lA vt� F r�T k.A M uVAK
Malljng Addles W;;�1=���Gw�.apbzk CfiK''D✓.n +lul>5/G�n1
nOpcny Address i Imlbo�dPn I/Gk.S !A"IVP
fan r W uirM Rom Pla�mine R ]name DePmmml fa now rmmtmml
CLW/Smc A.11si�1 I La Pmael ldemefiaoo Nmnbm UAL—/GC/—CG—eeO
LP Al, 18F.RfRNT80N
Prupalyl.omDm �v' ''%, Ai� ''/.,Src 0 T ey NR I� W, Town of fl tll7✓`�`%
Certified Sarvry Map d
Lmd
Volume / Page% AT
wefr.aty Daedx L!P (hefine2W7)Vohme 23_ 1 pw# HPl
pcbw Q'g 5lra Lot lure r@enfiablevywo"
SYSTEhe MAL NAN , ANM OWNRRf ERIrtI A 1 N
Impmpuutt nrd memmare oryaw awlie.ryxm mwatudl in in Peaulwe rmlme ml,enam w..te. Prop"
Wbupupmmb
Me rynem ban el(eb the fmcaon of de upueWk m n uumvnl slags m the woos digad rys¢m Ounu m k=m
rtspmtlblitiesuepuib�io g$v539152(1)andinCbpb112- Sr.Cmia Cowry9avlarr Ora cc
The pmpny owry sgb m sbout m SL Cmv Cauay PlamwB A ZOM9 DAartmet a umfimnon romy aped by rM1e
andby a rplumbu,lawaMaan plumlu. ruPdNplwbzrore Lvnud pumps rnrhm6 bm(1) me aetim
r& wa rymm la In pmpe, Pe ... y Webb bon W&U,(2)nllvtroepuuonaM partryn0(ifnectzsary 1. lk tt cmks
Iess then 113 We ofdudge
I then empef bane read the above uau ,,,mas Meps le mveram lb, pnve¢>vxpe armosal rys¢m mN tee
aWWmds We Nrb eerury as ssI by dre Dtpe iofwety Mditfimgma Smatxcand Cx DwmmemaN,WJPmvrac
Swmar Wrwnnn Cem canon n.nne reu. esevayenmm mamminGmun ee mmy MeM rewmMmAe St Cmia
Cowry Plvmurg & IDnrnB Depemm vitlim 30 dap of be br¢ Ym epi Moo daR.
Ore vernry Nu ell Nbmuru an Ws( mn to Ne beat of W"w MrWdy. l(m&ebm Ne ewer[) aaA
pmpany dxmbea share. by Vm of a uaumry dead Ned m RegavrofD Mcz
NamE<r oFhe4mame \n1L�
SIGNATURE OF APPLICA (S) DATE
• Any mforwbu d*t emuMumW ary e"'kim Ne awOry perms Mne mwtr by the Pl a ms A Ia'a^9DeRamb ue
maul, mbt 0i 9 Vpll=cb A W=edW u Whed now 0e Reprer ur Dmda Ofeb end a wpy of ue eueaM a yrrf
Adfigm,Qe um meve u Pva
(RN.YNll)
CST QO(7-ayq
%FINED SOIL EVALUATION REPORT P I N 1
na smM mm mrc
57
CROIX
i1a A �o�;o,igi reroie�reom P.w i� oea raol.a-000
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IAMESA CBARBARA, MLINAR IC Lv'—>W;p NE w5 47 f 39 N N 19
H,d... i WI i 54016
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