The URL can be used to link to this page

Home My WebLink About016-1007-50-000isin Department of Commerce PRIVATE SEWAGE SYSTEM It and Building Division INSPECTION REPORT ;ENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] SARA CASSELLIUS Iuounry: St. Croix 016-1007-50-000 U51 BM tlev: Insp. BM Ele¢ 13M Description: r 3 SecrWn/Tovm/Range/Map No: "ID P LOnr re nex+:+I_ 04.30.15.58 TANK INFORMATION ® " �ME MMU I�1M-r��rl� TANK SETBACK INFORMATION I i A' ILIA/ ISM WS ISeptic 1+I Ob 1 1 f 01411 10' 1 15 ` I --- PUMP/SIPHON INFORMATION Manufacturer Demand %evI Js Model Number t TDH 3 2 FriGgn I,gs Syate+d Forcemain Len ptZO` Dlaa r. Dist. totoJWe[ -76 1 SOIL ABSORPTION SYSTEM A STATION ' JS t HI, I FS IU ELEV. Benchmark •3.001 ( 103 Gt 100,0 Alt. BM Bldg. Sewer vF in SU t Inlet rr-. 10f 2 2 nl J SVHt Outlet Dt Inlet Dt Bottom Haan. Bov 0 1'L 2: 3 Dist. Pipe Bot. System _ 9 Phal-Grade 1$ Il .5�1 St Cover 5 I p 1 8• J VQ, 1_ I r , Z .t BEDITRENCH DIMENSIONS Wdth^ I 7! Len6 s No, Of Trenches Z PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO JPIL BLDG WELL LAKE/STREAM LEACHING CHAMBER OR NIT Manufacturj- ( r -/w Type Of SyStem, - COV7 V"L►' lv,4 7�� L / r 1 -/ Model Number: 1 Jr DISTRIBUTION SYSTEM r''r�r+sr--may Header/Manifold LengN Dia Distribution Pipets) x Hole Size x Hole Spacing Vent to Air Intake (� } Do T 4 Length - Dia Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded for Mulched 1 1 Bed/Trench Center / � 0 Bed/Trench Edges � 1 L �� ''') Topsoil —❑'� Yes No COMMENTS: (Include code discrepancies, _persons present, etc.) Location: 1780 295TH S;T� L tbb`� (T ~ dt,I Y`5 1.) Alt SM Description 2.) Bldg sewer length - amount of cover = N 1 ex I$"bf tolec on D'u Plan revision Required? ^, Yes ENO Use other side for additional information. I I 2r9 SBD-6710 (R.3/97) Data tea. l I-n�`}pection#1: („�IZv�1 Inspection#2: pet 5 5VrtLf� VCVN-�5 or Spv{-1• LH� ,12 Insep ofs lgnatur Can. No. C.fflf 0- I?�o i - 4F Safety and Buildings Division County .era-f X #r r� AY 1 S 2020 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707-7162 Sanitary Permit Number (to be fyea in by Co.) qt crotx County Community en ermit Application tate Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Project Address (ifdifferent than mailing address) is required prior to obtaining a sanitary permit Note- Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15. I m , Stets. G' a �R• 1. Application Information - Please Print All Information Property Owner's Name I/ Parcel # f5:W1'V /A` 0/6-/eo7-56-eaa Property Owner's Mailing Address Property Location Uy 3o - JS- e-Q[� 7 ! fL Govt. Lot r A/u/ . A/ae/.l ', Section , State City/ Zip Code Phone Number (e4w9ZfO/ Ll G� / 5�0 / 3 -715. (circle one)_ V r IL Type of Building (cheek all that apply) Lot q Subdivision Name 0 1 or 2 Family Dwelling- Number of Bedrooms 3 Block N ❑ Public/Commercial -Describe Use ❑ City of ❑State Owned -Describe Use CSM ❑D� of Number rVillage A7'Tovm of 6' 4pow000l III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A, ❑ New System Y placement System P Y ❑ Treatment/Holdin Took Replacement Only 8 eP Y ❑ Other Modification to Existing System lain n8 Y (explain) B. newel ❑Pre ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Nummmber and ued r/ Expiration Before Ez nation Owner 3 //�,, ��R _ e of POWTS S stem/Com neridDevice: Cheek all that apply) n-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ElMound a 24 in. of suitable soil ❑ Mound <24 in. of suitable soil Holding Tank ElOther Dispersal Component x lain ❑ ent Devi (e lain) �s V. Dispersalffreatment Area Information Design Flow (gpd) Design Soil Application Ra dsf) Dispersal Area Required (sf) Dispersal Area Pro sf) S yi in Elevation �C VC15 o qS- 17 6 9 $11, 0y2.9 Vl. Tank Info Capacity in Gallons Total Gallons H of Units Manufacturer a„! Qb�y�Dv �r e , o v _ New Tanks Existing Tanks / � � � � r y a o. U ri, �ii y C7 Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersign , assume responsibilily for installation of the POWTS shown on the attached plans. Plumber's Npme (Pin n[ PI ber's Sign tore MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) VIV-50l3or�A, us/ c/ VIII. County/Department Uae Only ❑ Approved ❑ Disapproved Permit Fee S Da1L12ueQ S fj Issui ent S-gnmu l ❑Owner Given Reason for Denial xin d%V9 pprovaUReasonstorDisapp oval 3\ .�.� � 34 4 Y S / 1. Septic tank, effluent filter and dispersal cell must be serviced / maintained w �" B •�� Z i� t as per management plan provided by plumberOL .stx 2. All be �� C��t setbackrequirements must maintained as for the syste zed submit to the County auly on paper not leas than /! % 11 inches in size re IL i Ss'waQ f 4izozo- / -4--`KJL- Af %%Ctl— c�Q wwu v 1 S +4/Y� w/ a ern SBD-6398 (R. 11/11) l�fw 56;.—}i&—�•'f��'k�Mtt/f- S,S___ INbtle� Page 1 of 5 to]a SYSTEMS INC Leaching Chamber Design Spreadsheet Project Name: Michael Cassellius Owner's Name Michael Cassellius Owners Address Legal Description Township County Subdivision Lot# Parcel ID# 1780 295th St Glenwood City, WI 54013 'Nw :n '/. Nw V4 Sect 4, T 30 N, REELWIv Glenwood Saint Croix 016-1007-50-000 Table of Contents pg 1 Coverpage 2 Calculations and Drawings 3 Management and Contingency Plan 4 Plot Map 5 Pump Curve total # of pages: 5 Designer Name: Michael J. Myers License #: 267985 Date: 5/11 /2020 Ph. #: 715-265-4115 Signature: r Design Methods Used 'INGROUND SOIL ABSORPTION COMPONENT MANUAL FOR PRIVATE ONSITE WASTEWATER TREATMENT SYSTEMS' (Vemion 1.0) SBD-10705-P (11.6199) slrs Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc. Spreadsheet provided under license to Infittator Systems, Inc by: 3bAdvisement N12486 220h St, Boyceville, WI 54725 SYSTEMS INC Calculations and Drawings Page 2of g Site Conditions infiltration Elevations Site Type: ovate _ %Slope 11 % # of Bedrooms 3 Depth to limiting factor 80 inches Soil Application Rate: 0.7 gal/W2, Effluent Quality Eft #I Design Flow: 450 gal/day Max BOD 220 mg/I Max TSS 150 mg/I Septic Tank Trench #1 Trench #2 Trench #3 Contour Elev: 115.181 115.181 IN Infiltration Elev: 112.181 112.181 Ft Limiting Factor Elev: 108.51 108.51 N/A Treatment and Dispersal Zone: 3.67 3.67 N/A Cover Material Required: 0 0 N/A In Finished Grade Over Cell: 115.18 115.18 N/A Manufacturer: Wieser Concrete Volume Chosen: 1000/650LP Effluent Filter Selected: Polylock 525 Note: Access opening of sufficient size to be provided to allow removal of fitter. opening to terminate at or above grade. Cross Section of Septic Tank Distribution Cell Choose chamber type: [Infiltrator Quick 4 Standard # of trenches: z _ =J Chamber Length: 4.00 Ft Chamber EISA: 20.1 Ft2 Endcap EISA: 5.1 Ft2 Required Infiltrative Area: 642.9 Ft2 Actual Infiltrative Area: 653.4 Ft2 �✓.Si. Total # of Chambers: 32 Total # of Endcaps: 4 Combined Length of Cells: 132.0 Ft 12" Min Grade Cross Section of Cell 18" Min Cover Material Observation Pipe (if required) Final Grade All joints to -' be water tight D3034or Ground �Effluen[ Sch40 Contour Filter Pipe Leaching System Chamber c, , a length L 6 1. Observation Observatwtt Width ASfM 303q or 5ch 010 4" p 1" Pipe FVC Pipe Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc. Spreadsheet provided under license to InHttator Systems, Inc by: 3bAdvlsement N1248e 220th St, Boyceville, Wl 54725 PAGE 3 OF 5 SEPTIC / PUMP TANK SPECIFICATIONS 4'0 Vent Pipe (No Scale) >10ftfrom Building Electrical must comply with 12' Min. or 2.0 ft above SPS 316 and NEC 300 Established Flood Elevation Weatherproof Extend manhole deer as necessary. (typical) Approved Junction Box Vent Cap ApprovedWarm LoLabe Manhole IMPORTANT: wlm waning Label Nlanlred (typral) Anchor tank(s) as necessary conduit pursuant to SPS 383.43(B)(g) 4' Min. or 2.0 It above Established Flood Elevation I (typical)� Airtight Seal �I/ \ 1 / Finished Grade CAPACITIES @ 17 gaVin a Depth (in) Volume (gal) A 20.9 354.7 B 2.0 34 [C] 5.4 91.3 D 10 170 *Pump Tank Liquid Level = 38.2 in Force Main Diameter = 2 in Force Main Length = 210 It Force Main Void Volume = 42 gal * T A II BT Pump D0 Weep Hole 3' Approved Bedding Matelot Beneath Tank [C] Total Dose Volume (TDV) = 91.3 gal/dose (5X total lateral void volume < TDV s 00.2X design flow) + (force main drainback volume) MIN. PUMP DISCHARGE RATE = 37.1 gpm Guido Disconnect 18' Mln. (typical) 1 I ` Approved Joints with Approved Pipe 3 it onto Solid Ground (typical) PUMP -OFF ELEVATION = 89.01 ft INSIDE BOTTOM ELEVATION = 88.93 ft Vertical Head = 23.25 ft + Min. Supply Head =eft + FM Friction Loss = 2.15 ft + Fitting Loss* = 1.95 ft *(min. supply head x 0.3) = TOTAL DYNAMIC HEAD = 33.85 ft PUMP TANK: SEPTIC TANK(S): Volume = 650 gal Total Volume = 1000 gal Manufacturer. Wieser Conctrete Manufacturer(s) r Concrete MEN Pump Manufacturer. Goulds Install approved effluent filter at the septic tank outlet Pump Model: PE51P1 (Sm attached pump curve) immediately upstream of the pump tank inlet, Controls/Alarm Manufacturer. SJE Rhombus Filter Manufacturer. Polylok Controls/Alarm Model: PSP120V6H150P177 Filter Model: 525 Float switches containing mercury are prohibited. In -Ground System Management Plan pursuant to Comm 83.84 W. A. C. Owner's Responsibility: The component owner is responsible for the operation and maintenance of the component. The county, department or POWTS service contractor may make periodic inspections of the components, checking for surface discharge, treated effluent levels, etc. The owner or owners agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or the department. Septic Tank: Septic tank(s) are to be inspected routinely and maintained by department approved individuals when necessary in accordance with their approvals. The use of chemical/biological "treatments" is not required or recommended. If such additives are used, make sure they are approved by Department of Commerce, Safety and Buildings Div.. Effluent filters are to be removed & cleaned as necessary, with provisions to keep solids from passing the septic during removal. No more than 1/3 of the usable tank volume may be occupied by sludge/scum. 3 year inspection: If tank has greater than 1/3 volume sludge, tank contents must be emptied and disposed of in accordance with NR 113 Wisconsin Administrative Code by an approved individual. If the inspector does not recommend pumping of the septic tank, then the owner must be notified of when pumping should be done as to not exceed 1/3 sludge volume. Septic tank should be routinely inspected to be watertight and of good repair. Absorbtion Cell The absorbtion component must remain free of ponded surface water prior to pump operation. If 4 inches or more water level is detected in the observation pipes, the owner must be notified of possible problems/failure. The designed daily flow capabilities of the component should never be exceeded. Trees and any other deep rooted vegetation should never be planted, or allowed to grow anywhere on the component. Activities OTHER than mowing/maintenance (i.e. excessive walking, pets, vehicles, etc...) could compress the component and reduce it's absorbtion capabilities and/or possibly cause it to freeze in winter conditions. Performance Monitoring: Performance monitoring must be done at least once every three years following the installation or at the time of a problem, complaint, or failure. Contingency Plan: If the septic tank or other components therein (including floats, alarms, etc) become defective, the defective tank or component must be replaced immediately to ensure that the system can operate as designed. If the absorbtion component cannot accept wastewater or ponds wastewater to the surface, the component must be repaired or replaced in it's current location by removing the clogged bacterial mat, aggregate/leaching chamber cell, and distribution piping within the cell and replacing failing components in order to return system to proper working order as required. If repair is not feasible, a new system is to be constructed in a designated replacement area CHECK BOX AS APPLICABLE CHECK BOX AS APPIICARE. SOIL EVALUATION D Scale: .=40' Q SYSTEM PAGE OF50 SITE MAP PLOT PLAN PROJECT NAME: (1D It 9" 10' DESIGN ROW: 450 GPD Michael Cassellius Attach design It" caladasons for oonenercial plans. PROJECT ADDRESS: 1780 295th St,Glenwood City Pipe Material I ASTM Standard (Tables 384.303 & 384.30-5) 100.0 Fr N Sanitary Sewer.. PVC I ASTM D3034 °eVBtlori' Farris Main: PVC / ASTM D2665 esd oriprkn: 1 at Concrete step east side of house Snipe Gradient (%) tnaloM m h p, IMPORTANT: or Tested Am: 11 WellSynW In appinde): O dr.wina as a Show ground elevation conbm at atdhehla hI stvals. _ m IW approprae 11n — h�Lo L- 1 I IZ•2s� — — Iltfe $(fee 3 EDR IN ).lws8 ITT APPLICATIONS Specially designed for the following uses: • Mound Systems • Effluent/Dosing Systems • Low Pressure Pipe Systems • Basement Draining • Heavy Duty Sump/ Dewatering SPECIFICATIONS Pump — General: • Discharge: IY7" NPT • Temperature: 104OF (4000 maximum, continuous when fully submerged. • Solids handling:'6" maximum sphere. • Automatic models include a float switch. • Manual models available. • Pumping range: see performance chart or curve. PE31 Pump: • Maximum capacity: 53 GPM • Maximum head: 25' TDH PE41 Pump: • Maximum capacity: 61 GPM • Maximum head: 29' TDH PE51 Pump: • Maximum capacity: 70 GPM • Maximum head: 37' TDH METERS FEET 1 40 _.. _ •. •. _ 10 O H 35 2 GPM 30 PE41 1 � 15 10 5 GOULDS PUMPS Residential Water Systems MOTOR General: • Single phase • 60 Hertz • 115 and 230 volts • Built-in thermal overload protection with automatic reset. • Class B insulation. • Oil -filled design. • High strength carbon steel shaft. PE31 Motor. • .33 HP, 3000 RPM • 115 volts • Shaded pole design PE41 Motor: • .40 HP, 3400 RPM • 115 and 230 volts • PSC design PE51 Motor: • .50 HP 3400 RPM • 115 and 230 volts • PSC design AGENCY LISTINGS Opus Tested to UL 778 and CSA 22.2 108 Standards By Canadian Standards Association File #LR38549 MMU: PF31, K41, K51 HP..33, CO. 50 00 10.. __ 20 30 40 50 60 70 GPM ll 0 5 10 15 m3A1 CAPACRY Goulds Pumps is ISO 9001 Registered. U`�L �I�U�I G,ST- Zv2a- n \ MAY 18 2OZ0 SOIL EVALUATION REP FT ,� '( �� #126 _ De pa t of Safety and Professional Services ��, / Page 1 of 3 Division o Safety 4d-BulltllOrUEn.; Z-GG v Northland Plumbing, Inc. C0mrw pityrdance with Comm 85, Wis, Adm. Code ye, County Attach complete site plan on paper not kss than 87: z 11 inches in size. Plan must' St. Croon include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0161007-50-000 Please print all information. iewV By Dells Personal information may be used for secondary (Privacy law, s. 15.04 (1) (in)).s `/� you provide purposes Property Owner Property Location Michael Cassellius Govt, Lot NW1/4, NW11/4, S4, T30N, R15W Property Owner's Mailing Address Lot # Blddk # Subd. Name or CSM# 1780 295th St City State Zip Cade Phone Number City ❑ Village ® Town Nearest Road Glenwood City WI 1 54013 i 715-265-7246 Glenwood I 295Th St ❑ New Construction Use: Q Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement ❑ Public or commercial - Describe: Parent material Glacial Till Flood plain eleva6n. if appli ble ff. _ General comments S r n ;I and recommendations: D:2-6,PD/e['7- 2 tD �.af l/ B i t, oDZ ❑ Boring Boring # ❑ Pit Ground surface elev. 115.18 ft. Depth to limiting factor 8�_ in. Sog Appligbon Rate Horizon Depth Dominant Color Redox Description Texture Structure consistence Boundary Roots GPDW 'Efpei 'Eft#2 in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. 1 0 12 10YR3/2 Is Osg a if 7 1.6 2 12- 10YRS/8 s Osg Cs .7 1.6 3 80-84 1OYR8/2 shale shale Om Fde Cs 0.0 0.0 t ('2.15a Boring Z Boring # L Pit Ground surface elev. 113.05 ft. Depth to limitingfactor 81 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistem Boundary Roots GPD/ft' 'Ee#1 'EIW2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-10 IOYR3/2 Is OSg ml Cs if .7 1.6 2 10-20 10YR5/4 Is 059 ml Cs .7 1.6 3 20-56 10YR5/8 s Ogg ml Cs .7 1.6 4 56 64 IOYRS/6 S< 2sbk Miff Cs .2 .3 5 64-81 10YRS/8 s OSg ml Cs .7 1.6 IB T uent #1 = BODs> 30 <220 ffiWL and TSS >30 <_ 150 nrwi ' tmuent 82 = BODs < 30 mg1L and TSS < 30 mgrL C (Please Print) S' alu CST Number Michael Jj Myers 267985 Address orthland Plumbing, Inc. Date Evaluation Conducted Telephone Number 3 130th Ave Glenwood City, WI 54013 1 5/=020 715-265-4115 ?.S sue— �B'�%Be� —G I e/G14� Z '. Properly owner Michael Cassellius Parcel ID# 016-1007-50-000 Page --2of 3 -. Boring 3 Boring # Pit Ground surface elev. 115.18 ft. Depth to limiting factor 80 in, LJ Soil Application Rate L7J Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDMt' -EfW '6#2 1 0-12 30YR3/2 is 059 ml Cs 1f .7 1.6 2 12-18 10YR5/4 Is Osg ml Cs .7 1.6 3 18-880 IOYR5/8 s Osg ml cs .7 1.6 4 80.84 I 10YR8/2 shale shale Om deh cs 0.0 0.0 t.Ib Boring #� Pa Ground carfare elev. 112.23 R Depth to limiting factor $3 in. Soil Application Rate Horizon Depth in. Dominant Color Munseg Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPN 'EastDM'EfM2 1 0-12 10YR3/2 Is 05g ml cs 11F .7 1.6 2 12-16 10YR5/4 Is Osg ml cs .7 1.6 3 16-69 10YR5/8 s Osg ml CS .7 1.6 4 69-83 10YR4/4 cos gravelly mfi cs .7 1.6 Boring Boring # pit Ground surface elev. 110.18 ft. Depth to limiting factor in, Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. 'Consistence Boundary Roots GPDMP 'EMI 'E1fa2 1 0-12 10YR3/2 Is Osg MI cs if .7 1.6 2 12-22 10YR5/4 Is Osg ml CS .7 1.6 3 22-64 IOYR5/8 s Osg ml cs .7 1.6 4 64-76 10YR4/4 Cos gravelly mfi cs .7 1.6 5 76-81 10YR8/2 shale shale Om deh cs 0.0 0.0 Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 g150 mg/L ' Effluent #2 - BODS < 30 mg/L and TSS < 30 mg& The Department of Safety and Professional Servicese is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-31 S 1 or TTY through Relay. SBD-833CrrW (n.111U) Moraintl Mwnbklg, BIG CHECK aO%AS APPM-ASLF. CHECK BOX AS APPLICABLE. 0 SOIL EVALUATION Scale:1"' 40' SYSTEM PAGE 2 OF SITE MAP I 40 A jZq PLOT PLAN PROJECT NAME: (laftww) o t0'esiGRFtow: 450 cPo Michael Cassellius I Attach design flow calculations for commerdal plans. PROJECT ADDRESS: 1780 295th St,Glenwood City Pipe Matedal / ASTM Standard (Tablets 384.30-3 8 384.30.5) 100Sanitary sewer. .0 N / BM 3Y"W: BM Elevation: FT Farce Main: / BM Descrlptlun: 1st Concrete step east side of house Slope Gradlerl t%) Fiduu.nrsn IMPORTANT: of Tested Area: 11 well symtd !n appYcada): p °d� a Show ground elevation conOours at sratable intervals. t. 1 '7 4efti 4:4 - — ar= Ils.rg' 82 : If 3.05' 33: (15.19' 04 rtz.z3' a s - 1Ie. 12' >;+S{ep Eos�s�da eL' i/s�te ip L "tee a �Pf�,aer. �fa t fi�sa°. — ffs.lg'— It SAIL AI L —lt3.9y. m rl- n nrr�,arfn°;1,,7FE SAN-z0zo-- 110 0- v . ._ _ Safety. and Buildings Division County S-F, CYoi MAY 07 2020 2 1 W. Waylington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) �� PS itr Madison, VP70 71 S. C"ox County —Sanitary ermrt Application State Transaction " be In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit ^� Project Address (if different than mailing address) is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s 15 1)(m), Stats I. Application Information - Please Print All Information Property Owner's Name t parcel # nitt�es� �4SSf��/u9 O�F-�i- �o Property Owner's Mailing Address try Location/7FI'0 29Sf'I s� S r' ^ I ovt. Lot '/., ltfL(/ '/., Section y City, State Zip Code hoe Number �% G 4~40 C.e %V 'sl O� 7 15- - �j / 6s- (2,/Zo (circle one) ) ,3 G T_(• �N; R r_�, E o® II. Type of Building (check all that apply) Lot # �1 or 2 Family Dwelling- Number of Bedrooms Subdivision Name Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned -Describe Use ❑ Village of CSM Number / gown of �a �En wOeO III. Type of Permit: (Check only one box on line A. Complete line B if applicable) `*EO stem ew Sys' y ,rr W lacemen[ System t-ent/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B.ermitRenewal ❑ Pertnrt Revision ❑ Chan of Plumber ge ❑Perini[ Transfer to Newre List Previous Permit Number and Date Issued Expiration Owner IV. Type of POWTS S stem/Coin nent/Device: Check all that apply) ❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersaffreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units B o New Tanks ExistingTanks 0 Septic or Holding Tm k lbw ` r Dosing Chamber lIsl� EEI�i VII. Responsibility Statement- I, the undersigae aeso of responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI 's Stgnat MP/MPRS Number Business Phone Number tl� {, 21079�5 �is•us-y��s Plumber's Address (BVeet, City, State, Zip Code) 2 9 i° / e /+k .�t,-� a awe/ lr� / S bi3 VIII. County/Department Use Only Approved ❑ Disapproved Permit ttsFee $140• Daattq Issued �/ I uin Agent Signature ❑ Owner Given Reason for Denial 0,0 �/2i7 20 c IX. Conditions of Approval/Reasons for Disapproval ,.../ SYSTEM OWNER: 3% Jv..i-J �r*M ✓ yy,� 1. Septic tank, effluent filter and La tTh dispersal cell must be serviced / maintained K EKl management by `"'� • as per plan provided plumber. 2. All setback requirements must be maintained , / as per app judule cuplans for the systrm ana abthe ryooy on paper rlesa aoara:t taapbsise �TD-6398 (R. 11/I 1) OWw'tiri(ui.AdS1�t;�,��R7fid` _ � i • Mic.#.e-( C',f4-ll,w5 1 ?y0 24Sft Sf C�lenwaod °C.�iFy, w/ 54.Oro-tx yloovti�( taws, • p (Z(.nweod NwY,Ajty lq SgT3oNRI5w n 0 mu d< v (cs-r vo iser+q! 4 rLL n 0 SIC 14 �eernrn�50 /14L ,waog q' � � abado`J i SJ� Lon cnsl?l/to£liys bl,n7ry �^�N )lPr-odx;-OjJ �s �M ��i^I PGOCANi�LJ PAGE 6 OF 6 Mound Management Plan IMPORTANT: The owner of this mound system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin, Code. Maximum Dispersal Area Operating Limits: Design Flow = 450 gpd; BODE <_ 220 mgL"; TSS 5150 mgL"'; FOG 5 30 mgL"' Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities (i.e., pump re -cycling, float switch settings, etc.) o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) c Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Slats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filters) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. o Distribution laterals shall be flushed once every 3 years or when necessary. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Northland Plumbing Inc Phone: 715-265-4115 Local government unit: St Croix County Phone: 715-386-4680 Local government unit address: 1101 Carmichael Rd, Hudson, WI ZIP. 54016 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contingency Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed mound dispersal component may be re -constructed within the originally approved area after removal of all failed components. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. ST. CROIX COLTIN7Y SEPTIC TANK MALNTENANCE AGREEMENT ANT OWNTERsH[P CERTIFICATION' FORM OwnerBuyer &aA.1 C.t.Sc—"�E Mailing Address / 7 ?D .99S�'� S-/ Property Address ,OO (Verification required from Planning & Zoning Department for new construction.) p City/State L,-Ve+g� �Nr w/ Parcel Identification Number 01(0 — (00 7 -V 'pey LEGAL DESCRIPTION Property Location AIW'/4 , itfd,l '/< , Sec. _5/ _, T 3 0 N Raw, Town of tr linwew% Subdivision Lot 4 Certified Survey MapL# �— Volume Page # Warranty Deed 14 (before 2007)Volume IRS( Page # 3 5-1 Spec house C yesAo Lot lines identifiable)4es C no SYSTEM MALN7ENAT\CE kND 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 V3 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 Safety And Professional Services and the Department of Natural Resources, Sate 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we amlare the owner(s) of the property described above, by %i tue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATL-RE OF APPLICANT(S) 5& /;ke 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) 5/7/2020 3:31:17 PM Percent Grade Classes ® 20 - 25% ---' 12 - 20% Public ROW SCC ArcGIS Web Map 1:2,257 0 0.01 0.03 0.05 mi Lot and Units t park General Common Element Outiot Lot Tax Parcels 0 0.02 0.04 0.08 km WDNR, SCC CDD, SCC CDD, Eagleview and BCC CDD, FEMA, SCC CDD Unit Limited Common Element Shoreland Zoning Wet AppBuilder for ArcGIS SCC CDD I WDNR, SCC CDD I SCC CDD and SCC Hlglmay Dept I FEMA, SCC CDD I Netional GeospetW4rdeligence Agency (NOA); Delta State University; Esd I Eaglevi" add SCC CDD I