HomeMy WebLinkAbout032-2163-16-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 624815
Personal information you provide may be used for secondary purposes [Privacy Law, s 15.04 (1)(ni
Permit Holder's Name City Village Township Parcel Tax No:
Chad Schmit I TOWN OF SOMERSET 1 032-2163-16-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Tmn/Range/Map No:
aIn hD to %UV-(.r 14.31.19.1408
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
r
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
5
I
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Nimber
TDH
Li
ctio Loss
ystem ead
TD Ft
Forcema
Length
Dia.
Dist. ell
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
Yw
SUHt Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
q6, 7-
Dist. Pipe
Tti
9.3
Q7, 1
Bot System
'T Ll
11
Final Grade
3
n ^.
7�!
St Cover
VA 1V4
y�.33(
V 7.1
V
SOIL ABSORPTION SYSTEM rMMW--� E Z F l ._,s -7+-7 )
BEDITRENCH
Width-3
Length
N e
PIT DIMENSIONS
No. Or Pits
Inside Dia.
Li uid Depth
DIMENSIONS
L. 11
SETBACK
SYSTEM TO
IP/L&064BLDG
WELL
LAKE/STREAM
LEACHING
Manufactu
INFORMATION
CHAMBER OR
TypeOfSystem:
ht
TV
'71bO'
UNIT
Model Num r:
V4-X5
Header/Manifold L� r�
Distribution
Pipets)
xHole Sae
xHde Spacing
/ I
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Ontv
Depth Over
Bedrrrench Center
��
/� 1
I
Depth Over
Bed/rrench Edges
' {
R- t
xx Depth of
Topsoil
nc Seeded/Sodded
xx Mulched
D Yes
®NO
o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 210362ND ST I' `/ en l_ On I rs e,k V 1
1.) Alt BM Description V T ^/ i- y�
2.) Bldg sewer length
- amount of cover =
Plan revision Required? Yes No �„ L1 %rt ---- .%vw� 1 ; 5 / C
Use other side for additional informati L V I1- r ILVvJ /✓ b J
SBD-6710 (R.3197) Date Insepctor's Signature Cert. No.
�h�-ZoZo- 1Z(Q
Safety and Buildings Division
Ccrmry `
,
Sanitary Permit Number (m be sued m by Co.)
y`
MAY 2 0 2020
1201 MWashington Ave., P.O. Box 7162
K
Madison, WI 53707-7162
�2
St. Croix County
t
Cu
ermrt Application °
�`T°°.— ��
In accordance with SPS 393212), Win. Adm. Code, wbmistsiou of dtis fo® to the apptopriatc e- unit
Pwi m Addtea (if diffuem than meling addnm)
is regave3 prior to obtammg a saairay pe®it Note: Application forms to state-oavned FOWTS are submined m
die Depmenot of Safety and Professional Service. Personal information you provide may be used for secondary
m accordance with the PrhIq law, S. 15.04(l)(ML Sttls.
L Application laformetion- Please Print All Information
Property Owner's Name
Pmcdo o32-Z �t,190
Property Owner's Mailing Address
Prapoty location
2-1 v t
GovL Lot
y Ii2y,SSe_4,6ectioonnr�W►�)
side
Zip PhonaNmobc
-
1
dl`
T N; R '000
��j�Q
( 1 T"')
IL ype of Budding
g (check all that apply) ca
V
SubdivisiwName
yDwelling-NumbvofBodrooms ��
,
#
Block
(%
❑ Public Conn crcial- Describe Um
❑ City of
❑soot Owned -Describe Use CSMNumba
❑ of
ILL Type of Permit: (Check my one box on line A. Complete line B if applicable)
A
System
t syaxa
❑ Tteam ent'Holding Tack RepiaeemM Only
❑ Other Modification to Existing Sy*m (exphhm)
E.
❑Permit Resawd
❑Permit Revuion
of Pl
❑ Change umber
Permit New
Litt Previous Permit t,�b�aenJd/lit
MOM Expiration
Ow
123oo 1
30
of POWTS S steen/Com nemnaevice: Check all that apply)
ln-Cxouod ❑ Pressurized 1ad3round ❑ AtCrrede ❑ Mowd> 24 ur of mdable soil ❑ Moc d <24 w4armimb1e sol
Holding Tank ❑ Otba Dispose! Compmmt(=plain) ❑ Devire (exP )
V.Dis rsaVlreatment Area Information. aJ
Des' Flow (gpd) Deign sol Appliutiw Rate(Wdsi)
I Disposal Aoca Required (sf) pass Area (
Systers Elev n
S ?s.
6 so
s•
VL Tank Info
Capacity in
Gallons
Total
Gallons
g of
Untts
Man Lba
New Tab Exiting
Tanta
oPii
3
3
'ti
w
Ci
G
Septic m Hokin Tads
VEL Responsibility Sty ent- 1, the and a respousibility for inattention of thePOWTS shows on the attached plans
Ph;; i 's Name (him)
s Signame WA( sNamba
Business Phwe N
lrAt,��
(//t �%i7
-
Plmaber's Address (Street, City, State, ) s .
VIIL Co i runent Use Oni
Ye Approved ❑ DisappC�
Pam�itFee
Dot Issued
Issuing Agent—S.
3/ZmzO
❑ an for Denial
JW
DL Coaditioas of Approval/Reasons for Disapproval tin`. xsA.t_
YSTEM OWNER:
Septic tank, effluent Alter and
dispersal cell must be ! d
by 11u `
provicedded y plumber..
as per mane ement Inn provided plumber atIIaa'
:ll'
per or system apamtlx tyoW paper uoa es is
asa licable code or lnance
SBD-6398 (R 11/11)
`J
PROJECT Chad Schmlt
SW 1/4 SW 1/4S 14
System PLOT PLAN
ADDRESS 2103 62nd St. Somerset Wi 54025
/T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX
SYSTEM ELEVATION 95.5/95.0 3.5' below grade
5/19/20
3
DATE
BEDROOM
CONVENTIONAL
XXX AT -GRADE
CONVENTIONAL LIFT
HOLDING TANK
MOUND
SEPTIC TANK SIZE 1000 gallons
LIFT TANK SIZE
DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7
'
ABSORPTION AREA 650
# of chambers 13 total
BENCHMARK
V.R.P. Top Of 2' jRe
ASSUME ELEVATION
100' filter hi�
❑ BOREHOLE
O WELL •H.R.P. same as benchmark
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 5/19/20
Owner:Chad Schmit
Location: SW1/4 SW1/4 S 14 T31 N,R 19W 2103 62nd St. Somerset
Manuals Used: In -ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. EZ- Flows Cross Section
4-6. Maintance and Contigency Plan
Signatu
License
PROJECT Chad Schmit System PLOT PLANADDRESS 2103 62nd St. Somerset Wi 54025
SW 114 SW 114S 14 /T 31 N/R 19 W TOWN Somerset COUNTY ST.CROIX
SYSTEM ELEVATION 95.5/95.0 3.5' below grade DATE 5/19/20 BEDROOM 3
_
CONVENTIONAL XXX AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 13 total
,\i BENCHMARK V.R.P. Tol Of 2" DIDe �
�T ASSUME ELEVATION 100' /Fi]fCP
❑ L J BOREHOLE WELL *H.R.P. same as benchmark l\_at A- fob)
Cross Section of a Two Cell EZ Flow In -Ground Dispersal Component
Design Flow 4 .,rT + Loading Rate % = Required dispersal area Sq Ft
Required dispersal area �J_ + 50 (EISA) = II _ (number of units)
Geotextile fabric to meet Comm 84.30(6)(g) Wis. Adm. Code 2
Minimum of 12" of cover over top of cell
Two observation/vent pipes to be provided per cell
Not to scale
Cell #1
System Elevation: C S �Ft
Final Grade: ! [ l 0 Ft
Cell #2
System Elevation: ! �; Ft
Final Grade: �j >r
Ft
ST. CROIX COIJNI"Y
SEPTIC TANK MAINTFNAA'CE rtGREhMENT
ANI)
- \ OWWNER'(SIIIP CERTLbICATION FORM
Mailing Address
Properly Address._.-_
(Veijficatiou required from Planting &. Zoning Oepartmeta for tiew ctmslractiou.)
City/State--Sc vdC l___ Parcel Identification "
LEGAL DESCRIPTION Property Louatio/n.�V4 , Sex:. ff—, 13T N R4 W, ToWn
Subdivisitm l�Ccc rr�. o -----._ ._._ __....-- _------ --- -.--- -_.._ _ —_ Lot #
Certified Survey Map # _---___
Warranty Deed # S_ �. / . Volurue Z!{; S.5- age#.-0
71
Spec house yes 0
I-ol How; identifiable (�910
SYSTEM MAINTENANCE AND OWNER CERT11"ICATION
Improper use and maintenance of your septic system could result is its pramanrre faihne to boodle wastes. proper
maintenance consists of pumping out the septic tank every throe years or sooner, if needed by a licensed putnper. What you put into
the systian cut affret the flan tion of the septic tank as a treatment stage in the waste disposal rmtent. Owner maintenance
responsibilities are specified in §C:omai. 83.52(1) and at C haptet 12 - St. Croix County Sanitary Ordinance.
The property owner agree to submit to St. C.r'oia Counly planning &Yon ing Department a certification front, signed by the
owner and by a toaster plumber, journeyman plumber, restricted plumber or a Hcer.sed pumper verifying that (1) The ou-site
wastewater disposal system is in proper operating condition and/or (2) alhn inspeadon and pumpmg (if necessary), the septic tank is
less than 113 full of sludge.
L/%w, the undcrsigtrod (rave road tau above reyuirenicuts and agme to mir tain die privam sewage disposal system with the
standards sort forth, herein, as set by the Department of Conmer'cc and the DgAirorient of Natural Resomves, State of Wisconsin.
Certitication stating that your septic system has been mainttuned crust be completat and returned to the St. Croix County Planning &
Zoning Department within 30 trays of the three year expiration date.
llwe certify that all statements on this form are. true to the best of my/our knowledge. I/we un✓are dic owners) of the
property described above, by virtue of a warranty deed recorded in Register of Dods Office.
Number of bedrooms 3
S1GNL A'117REi OF APPLICANT(S)
DATE
***Any information that is misiepresented rimy result in the sarrirar'y permit being n woked by the PWunhng & Zoning Department •♦.
Include with this application a mcurded warranty doed ftoni the Register of Deeds Uffice and a copy of thu certified survey map if
reference is made in the warranty deed,
(REV. 08105) r
c(-0,4,-tr n"t.-, cv-i
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pop _of_
im
'ILE INFORMATION
Owner
Permit #
DESIGN PARAMETERS
Number of Bedrooms
❑ NA
Number of Public Facility Units
i
`If1,NA
Estimated flow (average)
gaVday
Design flow (peak), (Esti nated = 1.5)
auda
Soil Application Rate
aUda tf?
Standard Influent/Effluent Quality
Monthly average'
Fats, Oil & Grease (FOG)
s30 mg/L
Biochemical Oxygen Demand (BODE)
s220 mg/L ❑ NA
Total Suspended Solids (TSS)
<150 mg/L
'Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand (BODs)
40 mg/L
Total Suspended Solids (TSS)
QO mg/L
Fecal Coliform (geometric mean)
510, cfu/100mi
tMaxlmum Effluent Particle Size
)6 in dia. ❑ NA
IOfher.
NA
'Values typical for domestie wastewater and septic tank effluent
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity
al 0 NA
Septic Tank Manufacturer
❑ NA
Effluent Filter Manufacturer
❑ NA
Effluent Filter Model
J47
❑ NA
Pump Tank Capacity
al NA
Pump Tank Manufacturer
NA
Pump Manufacturer
NA
Pump Model
NA
Pretreatment Unit
❑ Sand/Gravel Filter
• Mechanical Aeration
❑ Disinfection
O Peat Filter
❑ Wetland
O Other.
NA
Dispersal Cell(s)
In -Ground (gravity)
❑ At -Grade
❑ Drip -line
❑ In -Ground
❑ Mound
❑ Other:
❑ NA
(pressurized)
Other.
O NA
Other:
O NA
Other.
❑ NA
- — - Service Event
Service Frequency
Ynapect condition of tank(s)
At least once every:
O mO ea s(a) (Moodrinurn3 yNfe)
0 NA
!Pump out contents of tank(s)
When combined sludge and scum equals one-third of tank volume
❑ NA
Ilrispect dispersal cell(s)
At least once every:
_ o s(s) (Maximum 3 years)
❑ NA
Clean effluent filter
At least once every:
( serfs)
❑ NA
nspect pump, pump controls & alarm
At least once every:
month(s)
❑ year(s)
r NA
l9ush laterals and pressure test
At least once every:
❑ m year(s)
❑ year(s)
Other.
At least once every:
❑ month(s)
❑ year(s)
tNA
or:
MAINTENANCE INSTRUCTIONS
!Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Matter
(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 falling condition and requires the immediate notification of the local
regulatory authority.
Nhen the combined accumulation of sludge and scum in any tank equals one-thi d ()§) 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 wilhir. 10 days of completion of any service event.
Page _ Df _,
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) 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(e) 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 higthwater 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 surfeoe discharge of effluentt.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
affluent 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 yehides over tanks and dispersal cats. 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 e0minabon of the following from the wastewater stream may improve the performance and prolong the life of the POWT$:
antibiotics baby wipes: cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dis'Irttedarhts; fat: foundation drain
(sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting productls;
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 prope fiy
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 sail,
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 sod absorption systeirn.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by requi*d
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the rm*d
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rut" 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
1 holding tank may be kstalled as a last resort to replace the failed POWTS.
—he site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sot and site evaluation
must be perfortred to locate a suitable replacernent area. if no replacement area's 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 tthed time.
«WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANWOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT, RESCUE O� A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE
POWTS INSTALLER POINTS MAINTAINER
Name '/ ` Name
Phone 2 ; I J— 6 —Ll,1. � Ph °ne 3 ' L J b
SEPTAGE SERVICING OPERATOR PU ER LOCAL REGULATORY AUTHORITY
Name L 1 A� rr2
Phone
This document was drafted in compliance wdh chapter SPS 383.22(2xb)(1)(d)8.(fl and 3113.54(1), (2) & (3). Wisconsin AdmM'straave Code.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the S L;A resi ce located at:
Section / , T3 N, R W, Town of
5o anQ r�Q�; Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly. .
Last time serviced: ZQ LO
Did flow back occur frok absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time:
Capacity: `Oc-- 7
Construction: Prefab Concrete ( C_ Steel
Manufacturer: (If known):UxA--
Age o ank ( I f known) : Is Y-ec( f>r
gallons minutes
Other
( nature) (Name) Please print
(Title) (License Number)
s -7-0
-
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement
condition, I certify that the tank
conform to the requirements of IU
inspection opening er outlet bai
Name Sign
arding existing septic tank
:he best of my knowledge will
, Wis. Adm. Code (except for
MP/MPRS� ' ICJ
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1128
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page - I of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 6% x 11 inches in sae. Plan must County
St. Cron
nduda, but not limed to: vertical and horaorlal referernce print (BM), direction and - --- -
percerd slope, stale or dineveiae, north arrow, and location and d'etance to nearest mad. Parcel I.D.
Please print aH information. wed Date -
Persmel r* mabr you VwW maybe (Privacy Law, s. 1504 (1) (m)). G(�(iyfiys, • (d .:2 6
Property Owner n ._I V ED Prpperty Location
Grand Properties, LP WLot SW 19 SW 114 S 14 T 31 N R 19 W
Property Owners Mailing Address JUN 1 9 2002 # Btorlr # suba. Noma «Cslaa
712 Rivard Streeet, Suite 300 16 Gavin's Acres
City State zi Codg1?t(gq�ei, ; City Village ✓ Town Nearest Road
Somerset I WI ZC ZiHF000 I Somerset I 60Th St.
✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code dedved design flow rate 450 GPD
Replacement Public or commercial • Desc ribe:
Parent material Outwash Plain Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sgft rating. Possible system elevation for Area I
ism Slope is 5%.
❑ Boring
'I Boring # be Pit Grouch Surface elev. 100.32 ft. Depth to limiting factor >91 in. Sol Appllcetion Rate
Dominant Color
Munsel
Redox Description
Du. Sz. Cont Color
Texture
Sbudure
Gr. Sz. Sh.
Corestarnce
Baadary
Rook
'E
10yr3/3
none
Is
lcsbk
mvir
Cs
2i
•7
12
211
7.5W"
rmrle
Is
Osg
mI
9w
—
.7
12
10yr5i8
none
Dag
mill
—
7
1.2
a'—
�s
cr
❑ Boring # Boring
✓ Pit Ground Surface elev. 100.32 It Depth to limiting factor >90 in. Sri Application Rate
Horizon
Depth
in.
Do n rarri Color Redox Deew"on
Mmeel Du. Sz. Cori Dolor
Te dwe
Surx twu
Cx. Sz. Sh.
Consistence
elnxdary,
Rook
1
0-10
10yr4/3
none
Is
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Effluent #1 - BODS> 30 < 220 mgfL, and TSS >30 < 150 mgA. ' Eflhleri 02 - BOD <_30 mill and TSS <30 mgfL
CST Name (Please Print) Signature: CST Number
Thomas I Schmitt `"� 227429
Address Tom Schmitt f Date Evaluation Conducted Telephone Number
588 Valley View Trel Somerset, WI 54025 6115102 715-549-8651
properfy owner Grand Properties, LP Parcel ID
Page 2 of 3
✓ Pit Ground Surface elev. 98.72 fL Depth to limiting factor >96 in. S Apocabm Rate
F Boning Boring _-
Ha¢on
Depth
In.
Dominant Color
Murreed
Redox Description
Ou. Sr. Cant Color
Torture
Structure
G. 82. Sit
Consistence
Boundary
Rods
GPDffe
'E01 'EB#2
1
0.13
10yr313
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Horizon Depth
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I
I
❑ Boring # Boning
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Horizon
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Redox Descrption
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Texhae
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*Effluent #1 = 90D5> 30 < 220 mgll. and TSS >30 < 150 rrgll ' Effluent #2 = BOD5 < 30 mgA- and TSS < 30 mglL
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
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Page 343
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r Wisconsin Department of Commerce
PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal informabon you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)I.
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACIJY
Septic�y
p bO
Dosing
W�
/AL)
/0 i� 'r7 y A
Aeration
Holding
TANK SETBACK INFORMATION
WELL
BLDG.
VenttoAir make
ROAD
top
ETANK
PUMP/SIPHON INFORMATION
Manufacturer
Demand
Model N bar
TDH
Lift
Friction Loss
System Head
TDH t
Forcemain
Length
Dist. ro well
SOIL ABSORPTION SYSTEM
County. St. Croix
430123 0
k
14.31.19.
STATION
BS
HI I
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
L
qd• y7
(( C
SUHt Inlet
Sc
1 3
SUM Outlet
fS
Dt Inlet
Of Bottom
/
Header/Man.
. 6S
9-7 76�
Dist Pipe
7 �%
Bot System
�y
Final Grade
SO
St Cover
•L
BED/TRENCH
Width
Length
o. Of T
PIT DIMENSIONS
No. OI Pits
Inside Dia.
Liquid Depth
DIMENSIONS
3ri
L•-�
SETBACK
SYSTEM TO
P/L
JBLDG
IWELL
LAKE/STREAM
EACHIN
Ma�glurec
INFORMATION
CHAMBER
"
T Of System:
7
3'�
'
> lt�
./
Motlel Number
DISTRIBUTION SYSTEM . A r
s/r r F
HeaderMlan fold
h
LengN Die
Pipes) 6�i h T..14 - C /
Length)
Length Dia n9 J
x Hole Size
x Hole Spacing
-
SOIL COVER
v P .esa.. Cvat.mc n.I. . Ur ...d nr At.C,rada Svsteirls Only
pLkd CtW4"" r 7/a1*r1
Depth Over
i
Depth Over
Depth of
xx SeededfSodded
xx Mulched
BdfT erench Cenler /�
J
Bed/Trench Edges
Topsoil
] Yes �;j No
i
Vas-�: No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:/0163 Inspection #2:
Location: 2103 62nd St Somerset, WI 54025 (SW 1/4 SW 1114 14 T31N R119�W) Gavin''ss Acres Lot 16' ! `+ 1 Parcel No: 14.31.19.
1.) Alt BM Description =
2.) Bldg sewer length = 1r�yr-
. amount of Cover O 17
Plan revision Required? ', Yes ...///
Use other side for additional information. No � iO3
SBO-e710 (R.3/97) Date Insepctols SiQnalll2 Cad. No.
F -
Safety and Buildings Division
County
an
201 W. Washington Ave., P.O. Box 7162
isconsin
Madison, W153707-7162
(608)266.3151
Sanitary Pppppn_n�it Number(to Geed in by Co.)
1-130 1a3
Department of Commerce
Sanitary Permit Application
State Plan/LN mbber
In secord with Comm 83.21, Wis. Adm. Code, personal information you provide
A
may be used for secondary purpos I
Project Addj& (if different than mailing address)
a/03 (oc)xd S�k--
I. Application Information- Please Print
All Ini
rmation
3 0.
Property Owner's Name
JLJ14 1 "1 LUUJBlock
p
&.400 PRoPE1e7iEs 1.
.
(�
Property Owner's Mailing Address �,,
c'.,,N3 UI=f
PropertyLocation
/1 104,eo ST. U/I
u/
� Y., 5ry %., Section Al
any, State
Zip Code
Phone Number
d1) m Ce$67 W1'
S�10d r
TES -d y �-syao
T 3/ N; Rieird
s )
Ill. Typeof Building (check all that apply)
Subdivision Name CSM Numbs
�lor2 Family Dwelling -Number of Bedrooms 3 �_
❑ m Public/Comecial-Describe Use
a A�
CAVIAIS ROMS
❑Ci ❑Village BTownehip of SOiei ekS
❑ State Owned -Describe Use W A) %-
III. Type of Permit: (Check only one box on line A. Complete fine B if applicable)
gI 2-
A.
�NewSystem
❑Replacement System
❑ Treatment/Folding Tank Replacement Only
❑ Other Modification to Existing Syaw,t
B.
❑Permit Renewal
❑ Permit Revision
❑ Change of
❑ Permit Transfer m New
List Previous Permit Number and Date Issued
Before Expiration
Plumber
Owner
IV. Type
of POWTS S stem: Check all that apply)
1KNon-Pressurized In -Ground ❑ Mound> 24 in. of suitable soil ❑ Mound a 24 in. ofsumble sod ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wedand ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Fther ❑ Aerobic Treatment Unit ❑ Recirculating Sand Fiber ❑
Recirculating Synthetic Media Fiber X—hinitChamber IlDrioLine 11GjamakinsPipe ❑ (ex lain)
V. Dis ersatrFre stment Area Information:
Design Flow (gpd) Design Soil Applicatio f)
Dispersal Area Rcqui (sf)
Dispersal Proposed Syat= Elevation I'll
//1' -d
6 A/3
6,53 ' 97, D
0
VI. Tank Info
Capacity in
Total
Number
Manta r
Prefab
Site
Steel
Fiber
plastic
Gallons
Gallons
of Units
� •-YX
Concrete
Constructed
Glass
New
Existing
I.
Turks
Terms
�7[
Septic or Hawing Tank
OQQ
/OQC
/a a
a•••
X
Aembic Tremnent Una
DosingCMmber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached pram.
Plumber's Name (Print) Plumb 's Signature
MP/MPRS Number
Business Phone Number
Jew N SeNm117 F
67,137E o
7i5_-3-(19-66 rl
Plumber's Address (Street, City, State, ode)
616 /rl!OTH nvl ,Soar 4ER SBi l f%I aSYO� s
VIII County/Dessartment Use Only
E5rA'pp..d ❑ Disapproved
SanitaryPeraitFcciincludesGroundwater
Surcharge Fee)
Date Issued
i Age Sigo turc S s)
❑ Owner Given Benson for Denial
oa
' Conditions.nf ApprovWReasong for Dleepproval • / s /M� p� �/q_, N �,/ ,r,t,__ � � �� s
,fi Y•IfL-u�rlrn'ti"n^r.w, "`"I'� -nLW f�C
_"
ir wit 44
z ®u vKa,&4 na44lu
h cote to pb s (to the �Coun�ty onl or tintsysidil,on Naar not I taan 81/2 11 inrho In
SDI
SBIS-6/39 (S R. 0f/03) _� �rdrh, syr4l," t .
es
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