HomeMy WebLinkAbout026-1141-09-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 4 0725 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
P.C. Collova Builders, Inc. I Richmond Township 026- 1141 -09 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
M • p' 1 IM-0 I I = 0 �— .M • 33.30.18.1013
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
G3 � 6fl0 0.3� /oe.3g Im o
Dosing Alt. BM
Aeration Bldg. Sewer
S• 9 9Y• Y`
Holding
St/Ht Inlet
G•05� If 33'
TANK SETBACK INFORMATION St/Ht Outlet 6.35 .03 f
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ; � 5o t 3 r No I Dt Bottom
Dosing Header /Man. (� • S� q''3 9r
Aeration W Mo .(p q 93.6 9
T w i c Z, • e 3• lli-8'
Holdin Bot. System W 77 . !rt> 2 �g I
E — fl
Final Grade k-- 3•5D
PUMP /SIPHON INFORMATION 5.6� •��
Manufacturer Demand St Cover t l 1
GPM (a T S•`/3�
Model Num r
TDH Lift n Loss System Head T H Ft
Forcemain ength Dist. to We
SOIL A RPTION SYSTEM 0 S
§ffQQTRENCH idth , Length No. Of Trenches PIT IMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM 43. W � C2
SETBACK SYSTEM TO ��77 P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHAMBER OR o0 _ k
Model Number: •0 r�
DISTRIBUTION SYSTEM
Header /Mani Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) V g
Length Dia T L Dia Spacing U
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes 'J No M, Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1:P/ j Inspection #2:
Location: 1169 121st Ave New Richmond, WI 54017 (SW 1/4 SE 1/4 33 T30N R18W) Duck Pond Escape Lot 9 Parcel No: 33.30.18.1013
1.) Alt BM Description = w� r S Y +"� -�•
2.) Bldg sewer length = Iv• D
rl
- amount of cover = E����
Plan revision Required? Yes No
Use other side for additional informatio `. 1 ,l Insepctors Signature J Cert. No. J
SBD -6710 (R.3197) vJ ' 5 LO,n NTn
` 201 W. Washington Ave., P.O. Box 7162
V TA
sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 4lao )-�;—
Sanitary Permit Application state Plan I.D. Number
A
In accord with Comm 83.21, Wis. Adm. Code, personal i rQride� �� fa q LZl �+'
may be used for secondary purposes Privacy Law, 1504 E V E W Project Address (if different mailing address)
I. Application Information - Please Print All Information
APR 1 4 200 �11g1 -tea
Property Owner's Na me Parcel N iLoo Block #
1 2T. CROIX COUN_iY
Property Owner'ss M ailing Address Property Loreto
City, State Zip Code Phone Number
t4 1 J rrcle ire)
II., Type of Building (check all that apply) L T �C� N; R,� E W
>v+�' Subdiv on Name CSM Number
2 Family Dwelling - Number of Bedrooms
❑ Public /Commercial - Describe Use
❑ State Owned - Describe Use — L5 CL // iK / q � ❑City_ ❑Village�e ownship of J
M. Type of Permit: (Check only one box on fine A. Complete line B if applicable) 102/p= 11V
A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ermit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner '7`d 6) — 3/
IV. Ty of POWTS System: (Check all that appl A
on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In-Ground ❑ H olding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter chin Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dfs rsaUTreatment Area Informah . C
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (A) System Elevap
4/6 a 1 33 5�'6 u1 ads
VI. Tank Info Capacity in Total Number ',/ Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Hokting Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersign2j responsibility for installation of the POWTS shown on the attached plans.
Plumber's a me (Print) Plumber' turc MP u ber Business Phone Num r
Plumber; s Addre ss (Street, City, s ® rate C
VIII. RnEtLTgartment Use Onl
itary Approved El Disapproved Per Fee ( ludex Grtdwater Date Issued L Ag Signat mPs)
❑ Owner Given Reason for Denial Surchar s �3
IX. Conditions of Approval/Reasons for Disapproval
Attach complete plans (to the County only) for the system on paper not less than 8142 x 11 inches In size
SBD -6398 (R. 01/03)
Soil k AE d S ��Y stem PLOT PLAN
PROJECT P.C. Colbva Bldrs. Inc. .U.BOX 489 Somerset Wi 54025
SW 1/4 SE 1 /4S 33 /T 30 N/ W TOWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 4/11/03 BEDROOM 3
CONVENTIONAL XXX IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30
BENCHMARK V.R.P. Top of Foundation ASSUME ELEVATION 100° Filter Zabel A -100
❑ BOREHOLE (DWELL IH.R.P. Same as Benchmark
121st Ave SYSTEM ELEVATION 93.4/92.8 4' Below Grade
Plans Designed Using
Conventional Powts to be chmark is top of
Manual Version 2.0 walko t @ .0' c
o3
B oom
H use B.M. # Nt
a
200'
T 7 I
nts
Vent 2%
2 B -1 120%
>6 „ Standard Biodiffuser
of Cover Leaching Chamber 2°10
with 31.1 ft2 of Area 50 e
6' Long 11 "
4 „ Grade at System Elevation 01
B -3
2 -3' X 94'
Cells with >3'
not enough slope Spacing
to establish
contours
Vents
B -2
Cty Rd E 182' Property Line
4� � 90394 Sq. Ft. \ _ — — — — — —
2.08 Ac �� >3
\ \ to \
T
6 -_ - 5 6e; cj? / --
� � O g3 2O1 7/ ,4,j
r ��a
S 00'4617" W
� 42.47' �\ �n
LOT 1
__ __ F � o 1 r 1�
Ft. / r - I 870 s
/ 0 / LOT 8 LOT 9 I `°� \ I �I 2.00 Ac.
o
94754 Sq. Ft. I 9525�� � A
Sq. Ft. 3
2.18 Ac. c•
Q..�/ glglccFF N3 v
ai
N / 0 2 rn I rn
41 C
/ t � ^� 90086\ Sq. Ft.
r 3/ i 2.0� Ac.
' co
rn
16.21'
262.26' �, ` F 23.25'
- - - - - - 241.06 - _ _ ^`� - 17�, 45' - 159.77'
116.99 53 — 107.7T' — — 6S 7 — — — — — -
NTY ROAD E SOUTH LINE OF THE SE 1/4 OF SECTION 33 - N 89'41'(
- _ - - - - N 89'43'55" W 2638.57' _ R.A. 2638„72' - - - -
UNPLATTED LANDS
_NT UTILITY EASEMENTS:
NO POLE OR BURIED CABLES ARE TO BE PLACED SUCH THAT THE INSTALLATI
WOULD DISTURB ANY SURVEY STAKE, OR OBSTRUCT VISION ALONG ANY LOT LIN
STREET LINE, THE DISTURBANCE OF A SURVEY STAKE BY ANYONE IS A VIOLATI IN
OF SECTION 236.32 OF WISCONSIN STATE STATUES. UTILITY EASEMENTS AS HEREI
SET FORTH ARE FOR THE USE OF PUBLIC BODIES AND PRIVATE/PUBLIC UTILITIES
HAVING A RIGHT TO SERVE THE AREA. /
*N /W ystem PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc. .Box 489 Somerset Wi 54025
SW 14 4 SE 1/4s 33 /T 30 OWN Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 4/11/03 BEDROOM 3
CONVENTIONAL XXX IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 65 ABSORPTION AREA 933 # of chambers 30
BENCHMARK V.R.P. Top of Foundation ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
121st Ave SYSTEM ELEVATION 93.4/92.8 4' Below G
t erd 1
Plans Designed Using
Conventional Powts Alternate benchmark is top of
Manual Version 2.0 walkout @ 96.0' o
c, Pro 3
Bedroom
House B.M. #1
a�
a
10 200'
'
T
Vents
Vent 10' 20' B -1
Cno
120/
j „ Standard Biodiffuser
ver Leaching Chamber
with 31.1 ft2 of Area 50 Slo e
, 2%
Long 11 ”
34" Grade at System Elevation B -3 100'
2 -3' X 94'
Cells with >3'
not enough slope Spacing
to establish
contours
Vents
B -2
Cty Rd E 182' Property Line
wisconsin DVW or cormaFce SOIL EVALUATION REPORT Page / of
DivisimaisawandBuldings in awoke with Cam 85. Wis. Adn code � �
anach corroete 8" plan f not less titan 8 W x 11 lrx*res fa size. � oZG / —
lop -
include. but not limited to: vertical and horizontal reference point (W direction aid
se. scale ordimenctrrs, o north arrow. and lour and dish to nearest road Rs
please print an i»formatkrn. s T cko;x coory ry /S j
p � yo u ptoyids may be used for secondary PwP� (may L, 6 .1504 (1) (m)). - -
%'� /1 f Locati /
Pwpedy0Mw Property . C • e / t. L) � I tai 4-A - � �(,/ 4 114 S T - 3,O N R E (
F;R— vownees a BloGc # Name CSW
G
P . O ► C))�
WMIS 0 Cade Ntsnber City Vi6age Town W� Road
l,Svn,Z,QAa I I [
ZrNw Corwtrucilon Residential / Number of bedrooms Cade derived design flow rate . GPo
❑ Replacement ❑ PL6k commercial - Describe: N + - - ft. Parent material 5 . • � 1= Flood Main elevation N app6cabie
General comments f r � r
and woommendetiars: J $ ���tJc CJ
❑ �' JC ear �c3�/� L/
a Pit Grow+d surface elev. ° f R Deem lo wnNi rg factor Sod Rata
tfodaon Depth Dw*vrACdw Redoru Description Texture Structure Carusistaruoe Botrnday Roots
( Munaell Qu. Sz. Cont Cain Gr. Sx. Sh. *Ml 'Ef11112
fl ap LJ
a eodng
p Ground surface elev. I ft Deem l0 �+g m 5oA� Nca6on Rate
iiaimon Depti1 Dominant Color Redooc Description Texture Stuck" Conroe Boundary l� GPM
In. Qa SL Cont. Color Gr. Sr- Sh. *EM
'EM
• f#1= BOD ' 3D.< 2aD +x+9 and Tom' - ' Efkx nt #2 = Ea0m <_ 90 mgll an TSS <_ 30 rngl�
CST Number
L Ad E dmw pare Evahrarion conducted TelePtwrre NrrrVrer
Property owner Parcel ID# D ' Pa of
�n9 # ❑Boring ,
3 Ground surface elev. ft Depth to limiting factor in. Rye
.Pit Soil
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff=
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. •Eff#1 •Eff#2
01 A.1
2
L9 1 7 1
mfg # ❑ Boft
❑ Pit Ground surface elev. ft. Depth to limiting factor tu• Sod Applicalloin Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fE
in. Munsell Ou. Sz. Cont. Color Gr. Sz Sh. •Faf#1 •011#2
F Ong # ❑ Boring
❑ Pit Ground surface elev. ft Depth to Nmiting factor in.
Sol Application Rate
Horizon Depth Dominant Color Redox Description. Texture StnxAur'e Consistence Boundary Roots GPDlff:
In. Munsell OU. Sz. Cont Color Gr. Sz. Sh. •Eff#1 I •Etf#2
Ettiuent #1 = BOD > 30 _< 220 rnWL and TSS >30 150 ng& ' Effluent #2 = BOD, < 30 nvyL and TSS < 30 mg&
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777.
seD433ot1Lfi 0)
Safety and Buildings Division Coun� r /•
201 W. Washington Ave., P.O. Box 7082
N *Isconsin Madison, WI 53707-7082 Sanitary Permit Number (to be filled in by
Department of Commerce (608) 6546 aO -��S
Y PP f
State Plan LD. Num r
San Permit A lication
In accord with Comm 83.2 1, Wis. Adm. Code, pens '
may be used for secondary purposes Privac V Law, R ED Project Address (if different than mailing address)
I. Application Information - Please Print All Informati n / I " � - I - 3)1 � �
MAR 7 2003 P ew R( V.WCktd 60
Propert wn is men Parcel # Lot # i Block #
I [, I ' C X COUNTY
Property er's Mailing Address j Property ) Location
t ^ 14 2 11 1 � &_ %., Section I ` (3 Lj 9q
City, State Zip Code Phone Number
�) �Z i ( (circle o r
II. ype of Building (check all that apply) T
,7 1 or 2 Family Dwelling -Number of Bedrooms
Subdivision NaVie CSM Number
1 �
❑ Public/Commercial - Describe Use ^' 3 X / ✓ r
❑ State Owned - Describe Use ❑City ❑Vi11agpNTownship of
III. peyf Permit: (Check only one box on line A. Complete line B if applicable)
A. w System ys ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System
• C1 Permit Renewal C1 Permit Revision List Previous Permit Number and Date Issued
B
❑ Change of ❑ Permit Transfer to New
Before Expiration Plumber Owner
IV. of POWTS System: Check all that appl 914zi�
Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil El At-Grade 11 Single Pass Sand Filter 11
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
i
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dis ersal/Treatment Area Inform _ Z/
Design Flow (gpd) Design Soil A lication Rate(gpdsl) Dispersal Area Required (so Dispersal Area Proposed (so System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Prefab Site St Fiber Plastic
Gallons Gallons of units Ui Concrete Constructed
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit �
Dosing Chamber
VII. Responsibility Stat ent- I, the undersi a ssume responsibility for installation of the POWTS shown on the attached plans.
Plumbqr' Name (Print) Plumbe ' azure MP/MPR� utrlbe� � � Business Phon �u�
_S ka A LL // y
IJ
Plumber's Address (Street, City, State, Zip )
VIII. Coun /Department Use Onl
pproved ❑Disapproved
Sanitary Permit Fee (includes Groundwater D Issued suing Age t Si a Stamps)
Surcharge Fee) ' 7 2 �� 0 3 �/ C
El Owner Given Reason for Denial !� Q `
IX. Conditions
o�f�Approval/Reasons for Disapproval , / 7T A 41 ->
�f
Attach complete pl (to the Coun only) for the system on pap& not less than gln ill Inches i nUlze
SBD -6398 (R. 08/02)
PLOT N
PROJECT P.C. Collova Bldrs. Inc. AD SS P.O.Box 489 Somerset Wi 54025
SW' 114 SE 1/4s 33 /T 30 N/R 8 W T N Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 2/19/03 BEDROOM 3
CONVENTIONAL xxX IN- GROUND PRE R CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 10 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1212 # of chamber 39
BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION loo Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P Same as Benchmark
SYSTEM ELEVATION 96.8/96.4/96.0 1.5' Below Grade
N
Vent `
f a
Standard Biodiffuser
>6" Plans Designed Using c3,
Leaching Chamber Conventional Powts °
of Cover with 3 1. 1 ft2 of Area
Manual Version 2.0
a r"
� 6' Long
11" �
„ Grade at System Elevation
Please note: further Pro 3
testing will be done Bedroom
on this site House
30'
ST
50'
B -1
0 '
50'
2%
Slope
50'
20 B -3 3 -3' X 82'
10 Cells with >3' B.M. #2
Spacing
B -2
30' 25'
Cty Rd E 182' Property Line
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715 - 246 -5148
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSIiIP CERTIFICATION FORM
nn /� II
t S n1
IJ . � � (� o VA � c� L.
Owner/B g r
Mailing Address
Pro perty Address j o
I Y
(Verification required from Planning Department for new construction)
A
City /State �IojAtchcapn� Parcel Identification Number 02la -,Q9 .aV
LEGAL DESCRIPTION
Property Location Sec` TV i4 -R � W, Town of _ 1
Subdivision E scaD - Q� — T_ot it
Certified Survey Map 4 G 04 �fl Volunie � Page it
Warranty Deed It 9 Volume Page r
Spec house I ❑ no Lot lilies idcutiiiabic yc� J no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to 1Landle , ,vastes. Proper maintenance
consists of pumping out the septic tank every duce years or sooner, if ucedcd 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.
The property owner agrees to submit to St. Croix Zoning Department a cc:tification form, signed by the owner and by a
master plumber, journeyman plumber, restricted nlumbcr or a licensed pumncr verifying that (1) the on-site wastewater disposal system
is in proper operadug condition and/or (2) after inspection and pumping (if necessary), We septic tank is less than 1/3 full of sludge.
Uwe, 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 Commerce 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 Zoning Office within 30
ys of the e year a ndat e.
t a 2 / 17/0 3
SIG14AURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) htowlcdge. I (wc) am (arc) the ovmcr(s) of
e pr p t described above, by v' We of a warranty deed recorded in Register of Deeds Office.
at7
SIGNATuR:.OP XPPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.'• « "'
'* Include with this application; a stamped warranty decd from the Register of Deeds office
a copy of the certified survey map if reference is made in tine warranty decd
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of 7 i
FILE INFORMATION SYSTEM SPECIFICATIONS
I Owner Septic Tank Capacity L900 a l ❑ NA
'f Permit # do —� Septic Tank Manufacturer � E3 NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units NA Pump Tank Capacity al IJC NA
Estimated flow (average) a al /da Pump Tank Manufacturer NA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer NA
Soil Application Rate - al /day /ft2 Pump Model NA
Standard Influent/Effluent Quality M onthly ave r a ge" Pretreatment Unit NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Disper 1 Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD :530 mg /L n- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510` cfu /100m1 �/ [� ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency _
❑ month(s) ( aximum 3 years) ❑ NA
Inspect condition of tank(s) At least once every: Z __3 J9 year(s)
Pump out contents of tank(s) hen combined sludge and scum equals one -third (Y of tan _ ume ❑ NA
Inspect dispersal cell(s) At least once every: Z��j E3 y and l(s) (Maximum 3 years) ❑ NA
❑ month(s) ❑ NA
Clean effluent filter � A At least once every: 1-2— years)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
Flush laterals and pressure test At least once every: 13 year(s) month(s)
earl I(s) ❑ NA
❑ month(s)
Other: At least once every: ❑ year(s) ❑ NA
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) 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 tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, 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 10 days of completion of any service event.
Page y of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. 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
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
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 chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits 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.
• 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 PO S fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant
replace nt system:
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 evalyatios t o establ�h a �u�abl e; replacement Re / placeYstems mu t
comply with the rules in effect at that time. �}� d. - h
❑ A suitable replacement area is not available due to setback and /or soil lithitations. Barring advances in
technology a holding tank may be installed as a last resort to replace the failed POWTS.
Al � ❑ T he site has nn _ *^ •_� " ` - " - -- ` " ""'° ^f tha POWTS a soil and s ite
e . h, "ri + �-- - ^-� ---_� �__� .. ►.� , -1-- -mart araa If nn r°nl -- 1 hle a holdi tank
a be reconstructed in lace following 13 Mound and at -grade soil absorption systems may p 9 removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone _ ZLf'6.— �"� (® Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name t1)'�f� Name
Phone L— & — !L W Phone __) G 4 3Y
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
Ofiisconsin Department of Commerce SOIL EVALUATION REPORT Page --L Of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan mutt
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. d 2
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all info i! I 1 I J
eviewed Date
Personal information you provide may be used for se rpose (Privacy Lgw,, A. 04 (1) (m)). 7 Q
Property Owner jjnr� \�� r Location
P � l /„ / ✓ Goat le t S &U 1/4 S G 1/4 S 3 T �jp N R / g E (or) l�
Property Owners Mailing Address Lo # Block # Subd. Name or CSM#
a /` 7i �u e
R"
b , ��+
City State ip Code h e Number CpUN F1G ❑ Village Town Nearest Road
® New Construction Use: [ja Residential I Number - O or{�s� i Code derived design flow rate y.SOI 6 QQ GPD
❑ Replacement �[[� Public or commercial - Describe:
T
Parent material / Flood Plain elevation if
General comments ft-
s�/,� C � e l4v, 76- &0 � W" 1
and recommendations: WL.A
❑ Boring # Boring
Ground surface elev. �� • (oC� ft. Depth to limiting factor �_ in. Soil Application Rate
9 pit
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef1#2
I b -I z Z S � m �r C S I v-C 5
i z -3 l rsll Z rn st - 4�- c s — 9
3 q
Boring # F] Boring - ...
® Pit Ground surface elev. �g. 4b ft. Depth to limiting factor 77 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
(
6- Id, 2 - 5 2 bk cS I vj� S $
Z 11 -y5 ID r 13 — Sick Zmsbk r\'l�r �S
3 ys r yly L 2rr5 k ,
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L *Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
CST Name (Please Print Si ature CST Number
�C( liY1 �
Address Date Evaluation Conducted Telephone Number
715 -Z1/ 7-
FF�OM P C COLLOUR BURS, INC PHONE NO. : 715 549 5911 Nov. 16 2001 09: MW P1
S t'A I E BAR CF W ISCCVNSIN RJXM I - 19N8 tr i1 13 9
WARRANTY DEED KA THLEEN N. WALSH
REGISTER OF DEEPS
r r St. CRVIX Co., wi
This Deed, made between Kenneth L. Brown and Kathleen B. gum! M FOR 11ECORD
Brown, Ilasbaad end Wifs - -`� 01 -;1i -2001 9:SS Al4
MtWTV DEED
Graator, and P. C Collovs Builders. Inc. EX VT T
CRI CIYT FEE!
CmY CTCt
�diol15FE3 F£E: 820.00
— RECM- M FCCc 10.09
rjnntN.
Granttr, for a valuable considerstioo, eocveys and wvrontt to i
Grantee III* following dtyaribcd real estoto in SL Croix AA p o uj
County, %k of Wisconsin,
teeer�ln Arta
v.em end Iterate Add"=
David 1 EA..
Y'hat port of SS U4 SW 114 and SW 114 SE 1/4 Sac. 33- T30N -V I S :1' described 304 L=ast St.
as Follows: Lou 1, 2 and 3 of Cartitied Surey M-p rxOH41i in Vol. I: of iludton, `Ni 54Ct6
Cortified Survey ?Raps, page 3698 as Tree. No. 607591.
St. Croix County, Wisconsin ozG• rovtD a){xm. USfr t VYG ZUf .
026•iC96.70.000
Psred IuatdtlsattDN Nvnl>es ti'lN)
This 14 not honne:trzd property.
T. (is not)
Exceptions to wamnlies: 2xiRing highways, a .,emcnt, R rights of way of record.
Doitd thin f day of April w. toes -
. Kenneth L. Browit
Kathleen B. grown
AUT11110 TICA TION ACKPtO W LLDGMENT
STATE Of Wisconsin )
Stgaatwett) ) n
3t. Crotx County. )
Ptrroratly came before one this *.F
setneetketed Ili!* , day of April - 1 2001 the above rained
easeth I- Brown had Kat$feen D. Bronx
TITLE: :.! .R OF WISCONSIN �- ro wax, to be the persotr(t) +vbo aeueated the foregoMg
4 ~ ' I .eat and aekimimleaRC the same.
j 4¢G, is. stars.)
.WAS VW r2t) BY . Aflt t(^ avid J. Lrsireen
304 Logs";; HadsotL W1 54016 Notuy INblie, Sate of W}scmtsin
(31V be satheadesud er aeknowiedtrd. Jodi an :net My Commission is pennmsms no st c cxplrauaR mate:
-cssary) 1
'Nuns of Neosho sltalret is vj c shatid be iyp.d or printed bekw thelr,ltneaves
wAMAMTY 1619 STATt BAN Or mItCONSte
nt_r Mw 2 -Mee
INFORMATION I'xvre33MAL7 COMPANY e0t4, OO W. VA WDASS.M7e
r