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HomeMy WebLinkAbout030-2133-05-000 Wisconsir, Department ofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix .Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 506283 0 GENERAL INFORMATION 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: Vander Vorst, Garth & Jennifer St. Joseph, Town of 030 - 2133 -05 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: (}cj (V\ , GST 3Q.30.19.2005 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , ,^- � 1 f Benchmark F l Dosing t4 f� Alt. B �� s 4. 94s Bldg. Sewer 7. 4 71 � Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet \ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet .` Septic � / / Dt Bottom 7g A)A, z > z' -" ! • • Z Dosing - /t , ! >Z, / Header /Man. — „q Aeration — Dist. Pipe .7 ( / ,Z Holding Bot. System ! �n r PUMP /SIPHON INFORMATION Final Grade 3.71 9 7. ( / Manufacturer Demand St Covp; � 9 V 3 Zo�,l GPM C'i I W � Model Number 13 �1 ?� / t �� / TDH Li fer Friction Los 7 System Head TDH Ft ( tD % •/ �3•al /) 55S Forcemain Length Dia. si Dist. to Well SOIL A BSORPTION SYS BEDITRENCH Width Length ! No. Of Trenches PIT DIMENSIONS No. Of Pit_ Inside Dia. Liquid Depth ( DIMENSIONS 1l -7 Q e '\ SETBACK SYSTEM TO / P/L B WELL LAKE /STREAM LEACHING Manufacturer: - �• INFORMATION Type tem: CHAMBER OR 75 C A A UNIT Model Number: �- DISTRIBUTION SYSTEM Header /Manifold ! Distribution I x Hole Spacing � I T Air Intake P J / S Pe(s) t � O Length (G Dia ' 1 1-e l ngth �z- Dia Spacing __ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over ! Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center l , Bed/Trench Edges Topsoil 6 ><es L] No s ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / a 7 Inspection #2: 1 I Location: 1383 31st Street Houlton, WI 54082 (NW 1/4 NW 1/4 30 T30N R19W) Deer Me Lot 5 Parcel No: .30.19.2005 D escription = • ftYG� Lev C� �' ►c�k�1�. Z 1.) Alt BM / flow � 2.) Bldg sewer length = '7 (� S O +ti / �L - amount of cover = G• �` Plan revision Required? ❑Yes No O�, �( lO Use other side for additional information. SBD -6710 (R.3/97) Date insepctor's Soture Cert. No. commerce.wi.gov Safety and Build' 's Divis County o J 201 W. Washington Ave., BOX �' o C� /�o /1 Madison, W 1 53707 -7 Sanitary Permit Number (to be filled in by Co.) Department of Commerce V U 2-5 Sanitary Permit Applic tlon State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm Code, submission of this ' orat to the a propr ue$ v' mental / unit is required prior to obtaining a sanitary permit. Note: Application tixms A� tyte�w edL�TS are Project Address (if different than mailing add ss) submitted to the Department of Commerce. Personal information you rovide may he used for secondary �urwses in accordance with the Privac Law, s. 15.04(I)(m), Stats. �- OA4S 1. A lication Information - Please Print All lnformatio Property Owner's Name Parcel # ,I L e 00 r on fe a3Q --x'13 Property Owner's Mailing Address Property Location 1 Vc( �`/ Govt. Lot C'i" /'l ZipCoddee�/ Phone Number � Section one) h w � T .3� N; R le EorW 11. Type of Building (check all that apply) Lot # f�l Subdivision Name o: mil 2 Fay Dwelling - Number of Bedrooms � '" � .(e'er 4etnd41WS ❑ PublicYCommeicial -- Describe Use _ �Q� ❑ Cite of CSM Number C1 Village of ❑State Owned - Describe l se Gj l 1 Town of o 1 JL 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. XNew System t Y ❑ Replacement System ❑Treatment /Holding Tank Replacement Only El Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. El Permit Renewal C] Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System /Com onent/Device: Check all that appl D o ❑ Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ,Mound > 24 in. ofsuitable soil ❑ Mound < 24 in. of suitable soil , ❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design f (gpd) / Design Soil Applicatiow(gpdst) Dispersal Required (s Dispersal At Proposed ( System Elevation / O n Ij t A D 9• ✓ VL Tank Into Capacity in Total # of Manufacturer v Gallons Gallons Units ti J V. p V New Tanks Existing Tanks ` / /" t //•'�� CG L / 4 CJ v H n s C7 4 Septic 0, Weill ir+enk _ Jl —� Dostag Chamber V11. Responsibility Statement- 1, the undersigned, assume re nObility for insta ation of the POWTS shown on the •attach , plans. Plumber's Name (Print) Plumber's Sigm nn' C MP /MPRS Number Busine�Phone Number Plumber's Address (Sheet, City, State, Zip Code) Am Y VIII. County/ a artment U e Onl Permit Fee Date sue Issuing *ent Signature approved ❑ prov $ =Given Reason forDenial 07 IX. Condi §tReasons for Disapproval 3) t (� y u t 1. Septic tank,-effluent finer and I I _ - {� — �.3'„`� s v dispersal cell must all be s / makftilW k as per management plan provided bypktmbw. Ow 2. All setback requirements must b0i m*tt b*d J Nto !'tom g J Attach to complete plans for the s7stem and submit to the Court I v only on paper not less than 8 112 x I I inches in size SBD -6398 (R. 01/07) Valid thru 01/09 -ale: 1" age 2 of -� 1 " t • �3aAl >g 4/0 open \OilH I i n ( �re, i Q I All, y� I Cep \ I 4 J ' i S 50 rr, L e l IL .\ i / C f 1 1. Will meet' all Comm. 83 setback requirem is 2. Septic Tank / '�ay nk Gallons Dog Ta_&LGallons Nfg. Wieser Concrete / Products 3. Benchmark #1 Elevation 100.0 Description of- 7_ T OC— W OOe 0<7- / t&ll' Q Benchmark #2 Elevatio Description of- 4. Other- age { L NORTH .�0 � i kor ! e l JJ Qa e v, �a�' ^S� _ ©den C i a I � I e w of C(.)I "L?e- fi "OTL3 1. Will meet all Comm. 83 setback requirements / &O 2. Septic Tank Gallons Doke Tank_ Gallons Ffg. Wieser Concrete Products 3. Benchmark #1 Elevation 100 .0 Description of- �p� e3c wood (O<7`_ wela i Benchmark #2 Elevation /�L Descx tion of p 4. Other- RECEIVED JUL 2 0 2007 PAGE 1 OF S SAFEWWage System Plan Index PLAN I. D. NO. PROJECT TYPE CALLON MOUND o PROP. OWNER — q r r ADDRESS P . d %� /� �T D o �x o ,�; a � PROJ. LOCATION -- COUNTY S7• CrolX TOWNSHIP LEGAL DESC . �y . L "_'� . SEC. 21 , T,;?�) N , R &W i lan in accordance with Mound Component Manual ST. - "D-10691 -P (N. 0101) Version 2.0 and Pressure Distribution Manual S ?'D- 10706- -p (N. 01/01) Version 2.0 PAGE ONE INDEX SHEET PAGE TWO PLOT PLAN PAGE THREE CROSS SECTION & PLAN VIEW PAGE FOUR LATERAL DISTRIBUTION PIPE PAGE FIVE PUMP/SIPHON TANK PAGE SIX PUMP CURVE PAGE SEVEN MANAGEMENT PLAN PAGE EIGHT ( t r DESIGNER Dennis Hewitt 'CREDENTIAL NUMBER 221483 ADDRESS W2062 HIGHWAY 10 MAIDEN ROCK, WISCONSIN 54 250 - 83 0 7_ TELEPHONE 715-64 -468_ DATE SIGNATURE �Aq alry -NED OF COME rtY �s LSPONDENC • Safety and Buildings c 4003 N KINNEY COULEE RD commerce.wi.gov LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 i s c o n s i n www.commerce.wi.gov /sb/ www.wisconsin.gov Department of Commerce Jim Doyle, Governor ctw 1 Mary P. Burke, Secretary July 30, 2007 CUST ID No. 221483 ATTN.• POWTS Inspector DENNIS L HEWITT ZONING OFFICE HEWITT EXCAVATING INCORPORATED ST CROIX COUNTY SPIA W2062 US HWY 10 1101 CARMICHAEL RD MAIDEN ROCK WI 54750 -8307 HUDSON WI 54016 CONDITIONAL APPROVAL Identi ficati ©n Numbers PLAN APPROVAL EXPIRES: 07/30/2009 Transaction ID No. 1423739 SITE: Site ID No. 728323 Garth & Jennifer Vander Vorst Pease refer to both idbntificad numbers, County Road V. above, in all corres ondence withthe a enc Town of Saint Joseph St Croix County NWIA, NWl /4, S30, T30N, R19W Lot: 5, Subdivision: Deer Meadows FOR: Description: Mound / Four Bedroom / Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1143862 Maintenance required; 600 GPD Flow rate; 24 in Soil minim depth to limiting factor from original grade; System: Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 101), Pressure Distribution Component Manual - Version 2.0, SBD - 10706 -P (N.01 101); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per 6.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. r • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. C ondi • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption APF area. chs. NR 811 & 812c DEMP WREN • A Sanitary Pen must be obtained from the county where this project is located in accordance with the Of requirements of Sec. 145.135 and 145.19, Wis. Stats. SEE CORFU • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat DENNIS L HEWITT Page 2 7/30/2007 • Comm 83.22(7) A copy of the approved plans specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 u' Fee Received $ 175.00 Balance Due $ 0.00 Charles L Bratz POWTS Reviewer II, Integrated Services WiS1MART: code: 7633' (608)789-7893, 7:45 am - 4:30 pm Monday - Friday charles.bratz @wisconsin.gov cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544, Friday, 7:00 A.M. To 3:30 P.M. r !age 3 of 8 Ground Contour��// Elevation 'S�o Synthetic Covering System Elevation q Distribution Pipe Medium Sand �... Topsoil F a FE „ % Slope CELL Of ; � Force Main Plowed 2 Aggregate From Pump Layer D „ Cross Section Of A Mound System F to 6 6 ,. � LINEAR LOADING RATE �, GPD/LN F- A Ft. H _ DESIGN LOADING RATE �GPD�SQ FT- Ft. t3 � _1 _ FT 1 .1s� Ft. .... BASAL AREA NEEDED Ft. BASAL AREA AVAILABLE. _L4 Fr K Ft. 1 Ft. Force Main W - Ft. L ` Observation Pipe w �.--- - f - --- --- --- --- - -- -- - - - - -- -- _. - - -- _ - -_-»l Distribution Cell Of Pipe Aggregate t Observation Pipe Lateral Clean -Outs Plan View Of Mound ¢ LATERAL Absorption Area I a 4 of 8 Perforated pipe Detail lean -Gut End View Perforoleo T PVC P pe t�p'a n ° t -4 tti o Moles Loca On Bottom. a S Are Equal Spaced ' Access Box s v PVC Force Main i i Q PVC P Manifold e R _ Distribution / /)4147 e44 71ee S _ Pipe X 7 10� InchP- Lost Mole Should Be Nest To End turn— � Distribution Pip Layout Hole Diameter _1 Inch Lateral Inches) Manifold Inches �--� Force Main Inches T �f # of holes /pipe Invert Elevation of Lateralsy Ft. Graph 6 SYSTFN EIRtIATTON Minimum Lateral Diameter Based on O rm a Spacing 0lurrun orinas 350 325 300 275 250 '- — -- - - - - --- - -- _ - -. -- _- _ __. _. - - --- - -- Y O 4 200 r 3' e 175 J � 150 • J 125 . - - --- �-- --- --- - - -_._ - - - ___ - - -- - 2• 100 75 1 -tn• 1•va• 50 -- -- -- -- --- -- _.. - - - - --- -_. _ 25 3/4' 0 25 3 35 45 5 a Page 5 Of 8 COMhINATION SEPTIC TANK /PUMP CHAMBER 4" CI Vcnc Pipe «;cn (NO Scale) Approvca Cap. 15' .Approved Locking Manhole Cover From duil.3ing� With Warning Label Attached n Weatherproof Approved Junction Box Vent Cap 1. Minim.- fi" Min 4" Minimum Gr ' quick Disconnect 16" Minimum i i 1 /•i" Deep Hol i Baffle t I Approved Joint "" � A C I. Pipe � /V p Extending 3' Alarm dr Filter B I Approved Joy Onto Solid Soil On 6; w /C.I. Pipe or PVC I C Extenaing 3' Q j'� + Onto Solid S PUMP'OFF ELEV. 61. i 6 or PVC D Ccnc. Bloc 3" of Bedding Under Tank--/ Lateral Volume a0�',,�y &" 464 ��'-% Gal Min. Dose. (5 X Lat. Vol.) Gal Max. Dose (20% of DWF) 120 Gal oxba ck IpUO �'� I ' Y' �G3 ql � Cal Fl Noce: Pump and Alarm Are On Separate Circuits � � Gal Max. Dose W /Flowback Tank Manufacturer WIESER CONCRETE PRODUCTS Tank Size - Septic/ Pump: 1200 806 Gallons Alarm Manufacturer: S. J. ELECTRO � /, Gallons Model Number: 101 RICH WATER- Capacities: flinches or Gallons • B 2 inches or Pump Manufacturer: � r • C i nches or Gallons + D inches or Gallons Model Number: Minimum Discharge ate: Total,*.- inches or Gallons s � kifaf / t - 'Iff �nce Between Pump Off and Distribution Pipe: Feet Minimum Required Supply Pressure: .........................+ �� ,Fee • .e // Feet of Force Main x Feet. 00 + _Friction Factor /1 ��!�' et Inch Diameter Force M ain Head•...= / Feet Total Dynamic / °-/ Internal Tank Dimensions: Gal. /Inch Liquid Depth Page 6 of 8 t HEAD CAPACITY CURVE MODEL "98" r� 30 25 20 5 10 5 GALLONS 10 20 30 40 50 60 70 8C 80 160 240 0 FLOW PER MINUTE Table 6 FRICTION LOSS (FOOT /100 FEET) M PLASTIC PIPE' Flow in Nominal Pipe Size GPM 3/4 1 1 -I /4 1 - I5 1 2 1 - 3 1 4 6 1 2 3 3.24 4 5.52 S 234 6 11.68 2.88 Velocities in this area 7 15.53 3.83 arc below 2 feet per second 8' 19.89 4.91 9 24.73 6.10 10 30.05 7.41 2.50, 11 35.84 8.84 2.99 12 42.10 10.39 3.51 13 48.12 12.04 4.07 14 56.00 13.81 4.66 1.92 Is 63.62 15.69 5.30 2.18 16 71.69 17.68 3.97 2.46 17 80.20 19.71 6.68 2.7S 18 21.99 7.42 3.06 19 24.30 8.21 3.38 20 26.72 9.02 3.72 40.38 13.63 5.62 " 30 56.57 19.10 7.87 1.94 " a� �� � `- 35 25.41 10.46 .58 a.3 /OAS 33 h7 " rQ 0 32.53 13.40 3.30 45 40.45 16.66 4.11 SO 49.1 S 20.24 4.99 60 28.36 7.00 0.97 70 37.72 9.31 1.29 80 11.91 1.66 90 Velceities in this area 14.81 2.06 100 exceed 10 feet per second, which is 18.00 2.50 0.62 125 too g" for 27.20 3.78 0.93 150 various flow rates and 5.30 1.31 175 pipe diameter 7.05 1.74 200 9.02 2.23 It 250 13.64 3.36 0.47 300 4.71 A66 POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owne S ep t ic Tank Capa city 4&C gal ❑ N A Permit # Septic Tank Manufacturer r- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model _ ❑ NA Number of Commercial Units ® NA Pump Tank Capacity 711 gal ❑ NA Estimated flow (average) Pump Tank Manufacturer �. ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer LO r- ❑ NA Soil Application Rate gal /day /ft2 Pump Model ❑ NA • InfluentlEffluent Quality Monthly average Pretreatment Unit NA ❑ Sand /Gravel Filter ❑ Peat Filter i Grease FOG <30 m /L Fats, Oil G as (FOG) - mg /L Biochemical Ox ❑Mechanical Aeration ❑Wetland Oxygen Demand (BOD) <220 m /L Y9 5 mg /L Tot al Suspended Solids (TSS) <150 mg /L ❑ Disinfection ❑Other. Manufacturer Pretreated Effluent Quality OK NA Monthly average ** Dispersal Cell(s) Biochemical Oxygen Demand (BOD <_30 mg /L ❑ In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) <_30 mg /L ❑ At - grade X Mound Fecal Coliform (geometric mean) <10 cfu /100m1 1 ❑ Drip - line ❑ Other: Maximum Effluent Particle Size % inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months ,K year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one -third (% of tank volume Inspect dispersal cell(s) At least once every ❑months year(s) (Maximum 3 yrs.) Clean effluent filter At least once every ❑ months 64 year(s) Inspect pump, pump controls & alarm At least once every ❑ months 0 year(s) ❑ NA Flush laterals and pressure test At least once every ❑months year(s) ❑ NA Other: At least once every ❑ months ❑ year(s) J4 NA Other: At least once every ❑ months ❑ year(s) jet 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 ( % 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A service report shat b p of an I e provided to the local regulatory authority within 10 days of completion y service event. START UP AND OPERATION: For new construction, prior r to use of the POWTS check treatment tank(s) for the presence 1 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. i t 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 poor 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 PO WTS: antibiotics, p 9 baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; Y es; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat napkins; tampons; and water softener brine. � sanitary na p pesticides; s scraps; medications, oil; painting products; pestic de Y P ABANDONEMENT: 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 safety abandoned in compliance with ch. 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 POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement 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 evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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> > 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 E' Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Agency a Phone Phone This document was dratted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the non;rnum regidrements of ch romm 83.22(2)(b)(11(d) &M and 83.54(1). !2) & (3), Wisconsin Administrative Code. Use of this document does not Or Ma/ Ws P � Wisconsin Department of Commerce SOIL VALUATION REPORT Page of Division of Safety and Buildings Adm. Code in accordance with Comm 85, Wis. --- County Attach complete site plan on paper not less than 8 1/2 x 1 r t include, but not limited to: vertical and horizontal referen point (13 direction and Parcel I.D.� percent slope, scale or dimensions , north arrow, and to tion and distance to nearest roa o9d - of 1 - 6Y - - 6W Please print all informs on. AUG O 2 Zda� Reese d by Dat G Personal information you provide may be used for secondary pu oses�P (3) (m}). ; Z Prop erty Owner Property Loca on 114 ��// 114 S T N R/ E (or W Govt. Lot A " _V Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# vav - �x 8�� y cit State Zip Code Phone Number El City E] Village Ud Town Nearest Road Ca h 0. New Construction Use: Residential ! Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: ZOe - Flood Plain elevation if applicable - ' Parent material l nn ,,,/ - r ^ General comments /P.sk dr ,- f sut ldk ro r 1?74U�T(� [I�'D��Oh c ell t�/�/ and recommendations: u e C& " L /r e(ed 2 � S 1 m14 /47OV s2�'7 ❑ Boring # iBorng ❑ � Pit Ground surface elev. GrL ft. Depth to limiting factor a� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Ef GPD/ftZEff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - 1 /CI f'' t�- s pb S Boring Boring # l ® v� Pit Ground surface elev. CYO ft. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots IEff#1 I * in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. S ' Effluent #1 = BOO > 30 < 220 mglL and TSS >30 < 150 mglL " Effluent 2 = BO s < 30 mg /L and TSS < 30 mg/L CST Name (Please Print) Signature - CST N m . act: 4-15�WA- - I Date Evaluation Conducted Telephone Number Address le �✓ SBD -R330 (R07 /00) Property Owner A OII W IKLM �-- Parcel ID # J Page C of Boring # 121 [] Boring / pit Ground surface elev. /'r* y ft. Depth to limiting factor __ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 fy ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 El Boring # Ground surface elev. ft. Depth to limiting factor in. F ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots I GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 ' Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L 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. 560.8330 (R.07 /00) 1 L,U'i PLAN • -�� r SCALE 1" _ l' "1' • �'A Cr i o i ' " h'P?CI;:� 1sl:1ICHMAftK 1f:L1 +.VA'!'1U"" _ (� 1'M #1 +jC �U DESCHII lON Ulu N1 ��a L -2 BM #2 I W,6 DESCRIPTION OF #2 OF woo, t X a PvS1 LEGEND - -- A = BM (BENMARK) O= SOIL BORINGS p -5 �= WELL. Ak��. NO H MCI • I ` .4,. WTIP lot ;� - � ,� ��� , � ►'fit � l --- - - - - -_ '� - - - -- v� L oT lc) d C ) o �Ui_- y 6 - 71-zj�z 17 p ?_21483 7 ____ _ .._ Wizconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page � of in accordance with Comm 85, Wis. Adm. Code • Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County S include, but not limited to: vertical and horizontal reference point (BM), direction and C, percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. �•'�M�tlu G Please print all information. Revie ed by DatQ j Personal information you provide may be use ors I ` ,a)~'jRacy La . s. 15.04 (1) (m)). tr Property Owner I Property Location 1/4 S � T 30 N R l E(o W) . Name or CSM# Property Owner's Mailing Address Lot # Block # Subd 1 t`1 zZp 5 r S Clty State Zip Code Ptwh _ r El 5400 b� y �6 S (] Village Town Nearest Road U (-1 ® New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate 4 b GPD ❑ Replacement El Public or commercial - Describe: Parent material L,) L� g Flood Plain elevation if applicable Iy ft General comments ! and recommendations: 1^� �U1vp w/ 'x (� ' 1� CNZL [Y-1Uwl 6 0 E - SPA RLL - Oh1'tUv \Z. �l�V . ol Boring # [] Boring ® r � Pit Ground surface elev. i -0 ft, Depth to limiting factor 3 Z. in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Applic ahon Rate i in. Munsell : pu. Sz. Cont. Color Gr. Sz. Sh. •Eff# . Eff#2 l0`i I °D �b 3 11 o,v AJ U Boring # 1C ❑� Boring c� tbl Pit Ground surface elev. - I 13 t . 0 ft. Depth to limiting factor 3 s in, Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Sort ApG cation Rate In_ Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 1 0 -s -8 Z 12.3 S I h,4 2 3 b 3 3s -stt L/ SLl sL 13 2 Effluent #1 = SOD > 30 < 220 mg/L and TSS >30 < 150 mg& • Effluent #2 = SOD, 30 m — s _ 9n and TSS < 30 mg/L CST Name (Please Print) Si na CST Number Arthur L,.-Wegerer (Z)� �10Z S 220254 e q � - . - Address W e g e r e r Soil Testing & Design S e r v i c e Date Evaluation Conducted Telephone Number 421 N. Main St. River r'alls, [7I 54022 b - � 6- O 715 -425 -0165 • Property Owner G�1 Parcel ID # IN 3 �� Page of F a - 1 Boring # ❑ Boring Pit Ground surface elev. C A�. a ft. Depth to limiting factor 3 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 1 - tiu\-I tz7) ti 13 Z l o Y 2 3tb ew 1- S . g 3 ��� 1oy 2316 si I Z rn sb h '4 3o -S Z 10.1 iZ S! 3 0-1 a S ` 2 313 s i 1 C� rrt `� Z ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I •Eff#1 •Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L Uie 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. S8D.8330 (R.6J00) PLOT PLAIT Page 3 of 3 ✓ Scale 1' - rn k�_ loo.o'Or� 10 rrstc_, 3LY DZ A v p\,A P t PsE. W/ LAI i N 0 4 1 92 J / 1 s_ x..48. o s $o`rSoM DF C-ELL. tTL,�38.5 �• LM3 i I � I i ,ar• �ZDl�OS� —D'3 715 -425 -0165 220254 03 -1 CST Signature ure g Date Telephone. Ito. CST P1o• Job P10. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND V //�'� OWNERSHIP CERTIFICATION FORM OwnerBuyer C mr e -- i �r' N f��Q e r' Mailing Address -i n '60Y ew /"l fJ0�0h 0 &/ I Q�� L - �- S eer /I2 5 3 ,9, 5� ' Property Address d ���y (Verification required from Planning & Zoning Department for new construction.) (� , City /State ZV W . Parcel Identification Number x SZ ,E LEGAL DESCRIPTION Property Location - 1 /4 , 1 /4 , Sec. T L?�N R_/,'�' W, Town of Subdivision pPl' l ! / E?aW K , Lot # - . Certified Survey Map # .�T�,�1f , Volume , Page # Warranty Deed # fj rl ff , Volume , Page # Spec house yes (9> Lot lines identifiable <0 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 §Comm. 83.52(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 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 Planning & Zoning Department within 30 days of the three year expiration date. Itwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedro T IGNATURE OF APPLICANTS) 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. OS/05) DOCUMENT No. STATE BAR OF WISCONSIN FORM 1 -1982 WARRANTY DEED 8 5 5 1 5 9 1 855159 KATHLEEN H. WALSH Stuart __T,__- Gre.�n - -_ n REGISTER OF DEE This Deed, made between ..__.. - __________- ST. CROIX CO., WI WI Laurie__A,,__Green_,__husband_. and-_ wifS :_---- _- ___ _____ ___ _____ ______ RECEIVED FOR RECORD -- --- --- ' ----- --- -• - - -- ------- ----- - ---- - - - - - - ---------- .-- -------- --- ------------- -- ---------- ---- - ---- -- 07/06/2007 11:20AM - - - -- - -'- - - -- ----- ---- - - - - --- ---------------------------•-•-- ----- --- ----- ----- --- --- - -- - -- Grantor. WARRANTY DEED and ... - Gah._ y_ nc3grVQrst- _and__7ennfer__VanderVorstl- EXEMPT • II ', husband__ and__ wi fe__as_ -- marital_ ------------- REC FEE: 11.00 P- ropex- ty-------- - - - - -- ------- - - - - -- ------ - -- - - - - -- --- - - - - -- TRANS FEE: 309.00 ------ - - - --- -------- - ------ •------- ---- • -- -- -- - ---- •---- --- -•- - - -- -- .................. Grantee, PAGES: 1 WitneSseth, That the said Grantor, for a valuable consideration ..... ................. 1�6TURN 7 conveys to Grantee the following described real estate in --------- County, State of Wisconsin: Lot 5, Deer Meadows in the Town of St. Joseph, St. Croix County, Wisconsin Tax Parcel No 030 - 21 - 05 -00_ i This _ 1S --- --- --------------- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And -------- - --- --- - - ------------------------- --------- ----- ........ --- ---------------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this .. - -••- ... 22nd day of ._......... un e- -• - - -• '•--- • - -- -- •--- - - - - -- •2007-_.. --- -- -- -- -•- ----- -----•- --- ...... �C - --- --- ------ ------ (SEAL) ` ----------•-- -•------ -- ---- •----------•----- --------• ------ •$tLl > t._T ...Cz>;B n . -- - --• - ------- - -- - -- ------ (SEAL) _. ✓➢.:_:! - ----- (SEAL) Laurie A. Green --- -- --•- -- .... ..• ............................ ----•----- •--- •--- •-- -••-- -•-- -.._.. -.... AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN so. --------- _---------------------------------------------------------------------- __County. _ authenticated this ___..._.day of ........................... Personally came before me this _ ------- of - _ - June_________ ___ __ ________ ______ -2 0 Q ____ the above named -- -- -- --- ------ -- ---- -- - --- -- ----------- -------------------------------------- -------------------- .---- -- -- ---- ----- - ----- TITLE: MEMBER STATE BAR OF WISCONSIN (If not. -- --•- -- ---- •----- r °•--.. authorized by § 706.06, Wis. Stats.) to ma )e1dkSAQfRANKL1 h "e ted the forego dtibt THIS INSTRUMENT WAS DRAFTED BY CMnMkWro XP Jan31,2010 David M. Newberg, Po Box 206 --- ----- • - - - -- --- - -- -- --- -- - °-- -- -•..... Stillwater, MN 55082 a •- --- ---- ...........•... '°--•-•--------------- - -- --- -- -- ----------- - ------------ -- Nota Public - --- ---- -- -- - ---- -- --------------- County, Win. (Signatures may be authenticated or acknowledged. Both My ommission is ermanent. (If not, state expiration are not necessary.) date: `Namea of persons aienlne in any capacity should be typed or printed below their eIgnatures. WARRANTY DEED STATE BAR OF WISCONSIN •- - - - -_- ^• - - Q � 74' TYP \ 8' THCK 0 i I POURED CONC, STEPPED AS NOTED f FOUNDATION STEPPED TO f FULL WALKOUT r , ---------- — --------- . 1 r 1 i tr i i 2-8 SET+ ---------------- \ --- -------- -------- ---------------- ----------------------- 1 1 1 ll 1 1 j I , I 1 4 ^0 FAN UTILITY t FUTURE BEDROOM 4-0 ' 14 -6 X 10 -0 1 ; 1 j 1 1 I , 4 1/ 2 ^ L PI JOISTS 1 , I � 1 � - 1 a ; ' ------ - - - - -- 1 I , '2-8 1 OSD 2 -8 OS° ' 2 -g r I ' 1 2 -6 i I 1 1 b ; I UP 14R ----------- ------- lit "lliti" ------ I I n y i 14' -liY yl 10 1 1 9 1/2' LPI JOISTS i 2 -8 r 2 -9 i i 18' O.G. � I /' O50 b I FUTURE FAMILY ROOM +— i 19 -8 X 13-4 9 1/2' LPI JOISTS IS ; 18' O.C. � I I 1 , I - ---- - --- -- -- ---- ----- ---- - -- - - -- - -- -- - — - ----------------- --------------- - - -- 0 , 1 1 FOUNDATION STEPPED TO 1 FULL WALKOUT I � 5 r Y -fC g -Y i! 8' 1I t -6 74' 8-0 POURED WALL STEPPED TO 4 -0 POURED WALL WITH 2.6 KNEE -WALL ABOVE NPLAT: L 5 21.3 ;•rt v i E...I O CA N CO � O � p II Nc6 � Z •�� m p Z I V) CD Ln \ � N � r j 0 w W 00 Q Q It °- �� �� U \ I N � Q cn In N Q 00 \ I- r- S' t` O � m N O O / J O rM Z ti m W \ O I �� rro" z N 011 W 4 cn O LL U) \ � o U) a r7 N 0 u in M a o " L o cV N O `� z w w O N o N � \pss8 W z M M m / n� �6� O) o 01) N Z X� � N � pi lot N . 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