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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division y
sa itaryPerm' N 0
No:
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
New ard, Scott I St. Joseph Township 030 - 2123 -50 -000
CST BM Elev: ! Insp. BM Elev: I BM Description: I 1, _ # Section/Town /Range /Map No:
(gyp, vp, p P44- =c-ST I 33.30.19.1003
TANK INFORMATION U ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1 X50 Benchmark I
2S ,0
Dosing Alt. BM �►� iti�
Aeration Bldg. Sewer 1
d.
1 3D .O
Holding St/Ht Inlet r
0. D
TANK SETBACK INFORMATION SUHt Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , SD I 1 s, ISM D6Q ttom
Dosing k �� , Z+ If Header /Man. _
Aeration Dist. Pip
10. So
Holding Bot. System IV- 1 3
1 1.34
PUMP /SIPHON INFORMATION Final Grade
Manufacturer S Dema St Cover
GPM
Model Number
TDH Lift Friction Loss System Hea TDH Ft
Forcemain Length 1 Dia. ,, Dist. to Well
2 If I
SOIL ORPTION SYSTEM 4 ,4,
OM RENC Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIME NS tq.� /eq, C2
/
INFORMATION SYSTEM TO 1 P/L B LDG WELL LAKE /STREAM Manufr�rl
Type Of System: CHAMBER OR
v, 3Z ' ' t � ' �� 1 UNIT Model Numb ' � t , t �� G � zll
DISTRIBUTIO YSTEM U 1 r0
Header /Manifo Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) 3D
Lengt Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of r7eded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil — El Yes No �;; i Yes I _I No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: A. 4* _ 0 T / - � � w ,f i Inspection #2: r
Location: 588 128th Ave Hudson, WI 54016 (NE 1/4 NE 1/4 33 T30N R19W) Perch Lake Estates Lot 5 Parcel No: 33.30.19.1003
1
1.) Alt BM Description = �JiDt t? -&41 ( � Wt-Q1)
2.) Bldg sewer length = __ 8 1 U
amount of cover = 110 .�. S� � Ct0 r � ,
� - - - -- -- - - -- — -i T -- -
Plan revision Required? L =_ Yes X No rn "�"r dbr t I ��ll
Use other side for additional information.
Date
SBD -6710 (R.3l97) Insepctor's Signature Cert. No.
pq
� N
` Safety and Buildings Division County / C
m 201 W. Washington Ave., P.O. Box 7082
i scOns n Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled 111by Co.)
(608)261 -6546
Dep artment of Commerce 'J3
Sanitary Permit Application p�y State Plan I.D. 77A her
In accord with Comm 83.21, Wis. Adm. Code, personal information you pro E ^E
may be used for secondary purposes Privacy Law, s15.04(Ixm) Project Address (i (differe than maul g address)
I. Application Information - Please Print All Informati� �� a
Property Owner's Name V Parcel # Lot # Block #
, S&Tr 0 3o a 3 -SO area
Property Owner's Mailing Address Property Location
v., �� /., Section
City, State ,-y� Zip Phone Number
S 6�".eg S � 7 Q 2- r(/S' - � //�� circle
T JIJ N; R�E of W /
II. or 2 Fami of Building (check all that pply) / Bh,c� �7�L�1✓rt'u ��
ly Dwelling - Numbs of Bedrooms Subdivision Name ^/ CSM Number
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use S I,C/ �y �Q� ❑City ❑Village *ov_.h;. f
T• ���
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - T
A. ❑ New System
❑Rep t System ❑ Treatment/Holding Tank Replacement Only ❑ ther Modification to Existing System
B• ❑Permit Renewal errt»t Revision ❑Change of ❑Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
❑ Non - Pressurized In - G round C1 Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade 11 Single Pass Sand Filter ❑
Constructed Welland 11 Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit 11 Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter king Chamber ❑ D 'p Line Gravel -I Pipe ❑ Other x ain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (so System Elevation
6201) 1 ��� �5�. 8`70 l/ er�1 3
VI. Tank Info Capacity in Total Number Manufacturer 1 Prefab Site Steel Fiber Plastic
Gallons Gallons of Units �� Concrete Constructed Glass
New I Existing
Tanks Tanks
Septic or Holding Ta
Aerobic Treatment Unit
Dosing Chamber /
1 70 VII. Responsibility Statement- 1, the undersigned, assume re§Wnsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Zher's Sign atur MP/MPRS Number Business Phone Number
um s Address (Street, City, State, Zip e)
VIIIXountyMepartment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Gro4mdwater Dat iss A n7Sign tu re ps)
Surcharge Fee) '� � D Qj ,
❑ Owner Given Reason for Denial S V / 6
IX. Conditions of Approval/Reasons for Disapproval
ery,
4
Attach complete plans (to the County only) for the system on paper sot less than 81/2 x 11 Inches In size
SBD -6398 (R. 08/02)
;r 4 0' 1 A.' :15 F tX 715 396 1886 ST CR1 Co ZO" I \G fsLl dui
12
County Sanitary Permit Application $T, CROIX COUNTY WISCONSIN
In aecord with 15.04 St. Croix County Sanitary Ord,nanoe ZONING OFFICE
Personal information you p may oe used for 5ewn;I Y purposes ST. CROIX COUNT' GOVERNMENT CENTER
!Privacy taw. S. 15.04(1)(m)) Hudscn,aWII54016 -771
10
(715)386-4680 Fax (715)366-4685
Attach complete plains for the sy stem on paper not less than &1/2 x 11 inches in size.
County Sanitary Perrnit # Check it revision to previous applk.ctiun
I. Application Information • Please Print all Information Location:
Property Owner Name 1':M
,,.. _ NE 1/4 NE ua, sec
SCOTT NEWGARD T 30 N , R 1 W
Property Owners Mailing Address, j; 00 s Lot Number 81orJ( Number
424 MEADOW LANE 5
City, State Zip Code hone hS+ r' Subdivision Name or CSM Number
SOMERSET, WI 54025 651 -142 -5402 �. —_ j PERCH LAKE ESTATE
11 Type o Building, (oheok ono) pity ❑ village Town of
1 or 2 Family Dwelling - No. of Bedrooms: Z_ ST JOSEPH
G Put)IWCommercial (describe use):
C State-owned Nearest Road
III. Type of Permit: (Check only one box on line A. Check box on line 8 if applicable) 60TH STREET
Parcel Tax Number(a)
A) 1.O Repair ❑ Reconnection 3.❑Non•plumbing 4. ❑Rejuvenation 030 2123 - - 000
i Sanitation
Permit Number Date Issued
s)
® State S2nIt-ry Permit was previously issued 430040 6/3/03
N. Type of POWT System: (Check all that apply)
Q Mound Sand Filler Q Construo ed Weaand
_ Non- piesaudzed in-ground
:k Pressurized In- grounc ❑ Holding Tank ❑ Single Pass ❑ Drip Line
r- ❑ R irctdatln ❑ er
' Tr eatment Unit eC 8
-- At- race ❑ Aarob�c ea
V. Dis ersel/Treatment Area Information:
1. Design Flow (god) 2, Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Perodadgn Rata 6. system Elevation 7. Fin o
Required Proposed (Gals. /day /sq.ft) (Min./inuh) 93. Lower Elevation
600 .7 857.14 857.14 N A
(9 4.73 Upper
an h orntitt on p f n o ons i o of 7anufa0tW,'W Prefab Site Con- 1661 Fib PlasUC
New Existing Gallons Tanks Concrete structed 55
Tanks Tanks
SEPTIC 1250 ❑ p ❑ C
DOSE 750 750 1 1 WIESER LQKUTIL ❑ ❑
VII. Responsibility 8ttttement
I, the undersigned, aaaum0 responsibility for rep31riteconnencton /rejuvenaUon)installatlon of non-plumbing for the POWTS shown on the attached plim. A
license is not required for terralift rep air or the installation of non-plumblng sanitation sy stem.
Plumber's Name (prini) Plumber's, Signature (no slam MP/MPRS No. Business Phone Number
BENNIE HELGESON —
Plumber's Address (Street, City, Slate, Zip Code)
W1229 770TH AVENUE, SPRING VALLEY WI 54767
vin. county use only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
O Approved Owner Given Initial Adverse
Datcrtnination
IX. Conditlona of ApprovatfReesons for Disapproval:
P
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Qtyn ev ' �C rT ITV 2�J G circ� Page__ Of `7
SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
y" PUC..VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF
> 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT W�NPADLOCKV�R
FINISHED GRADE WARNING LABEL
� 4" MIN.
G ri +n.
Zy"
4 "PUL 0e6ERVATiotJ z. D.
18" IN. fIPE ;� 18 en tN•
INLET
WATER TIGHT SEALS GAS- ,
TIGHT i �� /APPROVED
FI A SEAL JOINTS WITH
2A$V1- I , ALM APPROVED PIPE
APPROVED i0 „ �� B O N 3' ONTO
PIPE 3' , SOLID SOIL
ONTO SOLID _ C I '
SOIL PUMP OFF ELEV . 9D.5 FT • OFF
D
3” APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE i� ,)
TANK MANUFACTURER: WICS e r
TANK SIZES SEPTIC a GAL. DOSE VINCLUDING
DOSE y GI�My FLOWBACK: �� GAL.
GAL.
W = � INCHES = qO 3 GAL.
ALARM MANUFACTURER: " •ems vo � s� w,,. . ACITIES: A .
MODEL NUMBER: � 6 = 2 INCHES = 4 AL'
SWITCH TYPE: _FftJ g
PUMP MANUFACTURER:
C= /0 INCHES= lLZ, GAL.
MODEL NUMBER: D = �� INCHES = GAL.
SWITCH TYPE: ,�I
DISCHARGE RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 WAC
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . • . •
+ FEET FORCEMAIN FT /100 FT. FRCTION FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH /i 'I ; WIDT DIAMETER
LIQUID
P-6
SIGNED: LICENSE NUMBER: DATE:
1/88
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MODEL: 3871
Submersible SIZE: 3/4" SOLIDS
RPM. 1550
Effluent PUMP HP: 0.4
METERS FEET
25
O i
w 6 20
5
z 15
H
2 �.
1 —
0 pp i 0 20 30 40 50 GPM
0
2 4 6 g 10 12 m' /h_
CAPACITY
�GOULD► w5iawc
.j � • y ..� � .: �Kz�ri'r
Effective October. 1988
SPECIFICATIONS ARE SUBJECT TO CHANCE WITHOUT NOTICE PRINTED W U. : 8A.`
A i oRA roulds PUMOS. I ic. ,-
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page °f-z—
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner SCOTT NEWGARD Septic Tank Capacity 1250 gal . O NA
Permit # Septic Tank Manufacturer O NA
DESIGN PARAMETERS
Effluent Filter Manufacturer ABEL 0 NA
�
Number of Bedrooms 4 ❑ NA Effluent Filter Model A -100 12 "X 16'' NA
Number of Commercial Units 13 NA Pump Tank Capacity 750 al a NA
Estimated now (average) aUda P Tank Manufacturer WIESER CONCRETE12 NA
Design flow (peak), (Estimated x 1.5) 600 aVda . Pump Manufacturer OULDS PUMPS INCA NA
Soil Application Rate 0.5 aVda /ft Pump Model 3871 EPO411F E NA
monthly ` Pretreatment Unit CKNA
Influent/Effluent Quality y avers 9 e ❑ Sand/Gravel Filter ❑ Peat Filter
Fats, Oil & Grease (FOG) 530 mg /L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ Disinfection O Other.
Total Suspended Solids (T'SS) 5150 m /L Manufacturer
Pretreated Effluent Quality f� NA Monthly average" Dispersal Cell(s)
Biochemical Oxygen Demand (SOD 530 mg /L EKIn- ground (gravity) ❑ In- ground (pressurized)
❑ At -grade ❑ Mound
Total Suspended Solids (TSS) s30 mg /L 13 Other
Fecal Coliform (geometric mean) s10' cfu /100m1 ❑ Dri -line
Maximum Effluent Particle Size Y, Inch diameter septic tank effluent.
(non- commerGaq wastewater and
•• Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑months year(s) (Maximum 3 yrs.)
Inspect condition of tank(s) At least once every 2
Pump out contents of tank(s) When combined sludge and scum equals one -third %) of tank volume
❑ months tl year(s) ( Maxlmum 3 yrs.)
Inspect dispersal cell(s) At least once every 2
Clean effluent filter At least once every 1 ❑months . C�year(s)
Inspect pump, pump controls &alarm At least once every 1 ❑months C�year(s) C NA
Flush laterals and pressure test At least once every ❑months ❑ year(s) 0 NA
NA
Other At least once every ❑ months O year(s) O
Other At least once every ❑ months ❑ year(s) O NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or
certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage
Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to Identify any missing or broken
hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up
or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels
in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the
ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y,) or more of the tank volume, the
entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR
113, Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components; and any
other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintanner.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
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(s) removed by a septage servicing operator prior to use.
OWNER: SCOTT NEWGARD
Page - 7 of
'S' sfem start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess
wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the
backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a
Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer, to
assist in manually operating the pump controls to restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact,
the area within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life
of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers;
disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat
scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONKMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to Insure that the
system is properly and safely abandoned in compliance with 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 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 HELGESON EXCAVATION Name IJOHNSON SANITATION
Phone 715/772 -3278 Phone 715/273 -5811
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name JOHNSON Agency I ST. CROIX CO UNTY ZONING
Phone 715/273 -5811 Phone 715/386 -4680
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d) &(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not
guarantee the performance of the POWTS. GMW (2/01)
Safety and Buildings Division County
� 201 W. Washington Ave., P.O. Box 7162 ST CROIX
®SCOOSIO. Madison, WI 53707 - 7162 Sanitary Permit Number (to be fi in b
Department of Commerce (608) 266 -3151 '�3 0 0
Sanitary Permit Application State Plan Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide /J-�
may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Ad res (if dif e t than mailing address)
I. Application Inf mation - Please Print All Info atio 4
'RECEIVED
Property Owner's Na me Parcel k / 3 Lot X Block At
SCOTT NEWGAR Z MAY 2 3 2003 0 = i; 5
Property Owner's M ailing Ad ss ST. CROIX COIJN iY Property Location •�a(-
424 MEADOW LANE ZONING OFFICE E '/4, NE 'ti,Section 33
City, State Zip Code Phone'Number
SOMERSET, WI 54025 651- 542 -5402 78 _ (circle one)
II. Type of Building (check all that ply) T 30 N; R 19 E or G)
®1 or 2 Family Dwelling - Number of B oms 4 � Subdivision Name CSM Number
❑ Public/Commercial - Describe Use � PERCH LAKE ESTATE
"" ❑ State Owned - Describe Use 2 % �� W , v Pf2 m e ❑City ❑Village VTownsh ip of ST JOSEP
III. Type of Permit: (Check only one box oX line A. Complete line B if licable)
A. New System ❑ Replacement Syste ❑ Treatinent/Holdin; Replacement Only ❑ Other Modification to Existing System
B. El Permit Renewal ❑Permit Revision
❑ Change of ❑ Permit Transfer to N List Previous Permit Number and D Issued
Before Expiration lumber Owner
IV. Type of POWTS System: (Check all that apPI
Non - Pressurized In- Ground ❑ Mound > 24 in. of ' I oil El Mound '< 24 in. of suitable soi ❑ At-Grade El Single Pass Sand Filter
❑ Constructed Wetland 11 Pressurized In- Ground_ EI H g Tank ❑ Peat Filter 11 Aerobic Treatment Unit El Recirculating Sand Filter
El Recirculating Synthetic Media Filter Leaching Ch ber Drip Line ❑ Gravel -less Pie ❑ Other (explain)
V. Dispersal/Treatment Area Informs 3 J. I •S - 6e_ «
Design Flow (gpd) Design Soil Application Ra 1 Dispe al a Required (sf) Dispersal Area Pro sed (so System Elevation ✓ 73
600 '.7 7.14 857.14 3 5 VP� r
VI. Tank Info Capacity in T 1 Number Man ufacturer Prefab Site Steel Fiber Plastic
Gallons Ions of Units // Concrete Constructed Glass
New Existing
Tanks Tanks 6
Septic or Holding Tank 1
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility State t- I, the undersigned, assume responsibility for insta ation of the POWTS shown on the attached plans.
Plumber's Na me (Print) Plu
ber's Si gnature s P /MPRS Number Business Phone Number
BENNIE HELGESO 220292 715/7Z2-32
Plumber's Addre ss (Street, City, State, Zip Code)
W1229 770TH AVENUE, SPRING VALLEY, WI 54767
VIII. unt /De artment Use Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing ent Signature Stamps)
Surcharge Fee) � ^1 l s" 0' D /
❑ Owner Given Reason for Denial
IX. Conditions o Approval/Reasons
ApprovaUReasons for Disa�AAA
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/03) i
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Wisconsin department of Commerce SOIL EVALUATION REPORT Page --/—of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north earest road. G 3 6 .Jp G — GOCP
E Re wed y Date
Please print 11 in �j
Personal information you provide may be used fi ir secondary purposes (Privacy Law, s. 15.04 (1) (m)). J �
Property Owner P1 Dperty Location
JCO e ��y G A. Lot 1/4 g 1/4 S 3 T 3 C) N R t? E of W
Property wne
Or's Mailing Address - ZO N G F CE k
L t # Block # Subd. Ne7 or CSM#
/$l0 C;i es turr:v L�r. 1`erc�i -�
City State zip Code Phone Number ❑ City ❑ Village [Town Nearest Road
AJsG. - 7/Y ) 3 '77- '767 5 C, k1 11 l� 7% 1 4U
ew Construction Use: IB'9esidential / Number of bedrooms Code derived design flow rate GPO
❑ Replacement ❑ Public or commercial - Describe:
Parent material �,� r� DU.0 � TJL L _ Flood Plain elevation if applicable _IV �
General comments 61-5 £� Ln cc aa� C'h�.y. �+ e--s
and recommendations: OU C7 � 7/ F _ 3
,5 5 r<" f.+. abed . � f/. 7
en dur
Boring
a Boring # a'Pit Ground surface elev. ft. Depth to limiting factor >9 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2
_ V
Boring # Boring
❑ Pit Ground surface elev. y g t ft. Depth to limiting factor 7 In. Appl ication I Rate
Horizon Depth Dominant Color Redox Description Texture Structtre Consistence Boundary Roots GPD/fP -.>
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
r O r7 (oyR a L) , S
f oyR
o — k 15 0 s .
' A 1� �4
Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 1 30 mg1L
CST (Please Print) l Si ture CST Number
vtc �( �so�,
Address ate E aluaton Conducted Telephone Number - 2
y y_ 3o � 7-) - 3a78
�tiv� r�rr �/���� Ct1T
s� 76
Property Owner S C 0
# 2(,kLx rl Parcel ID# 6 30 - 1O�! - 40 — Page 'D of 3
Boring
D Boring # B
n/ �v d
1jJ F'it Ground surface elev. �f1 J � ft. Depth to limiting factor - O in. Soil Application Rate
Horizon Depth th Dominant Color Redox Descri ption Texture Structure Consistence Boundary Roots GPD/N
p 1 •Eff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz, Sh. Eff#
-2 io k 9 �- ,M (X) 1
`
3
u�r ✓
❑
❑ Boring # Boring
tJ Plt Ground surface elev. 99. S ft. Depth to limiting factor 7 � � i n. Soil Apoication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •E MIN
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
c5 - 2 -- � -( b r -r S
3 - o
a Boring # Boring Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil ADDlicadon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •E GPD EfF#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
a
> < 150 m • Effluent #2 = BOD 5 30 mglL and TSS 5 30 mgA-
Effluent #1 = BOD > 30 < 220 mg/L and TSS 30 _ !3�-
5
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.
M -8330 (R.6/00)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
t � 1
C Q (I
Owner/Buyer
y'
Mailing Address
Property Address
"requiT ruling Department for new construction)
City /State _ Parcel Identification Number
0 3 a- a �� 3- 5r) — COD
LEGAL DE SCRIPTIO N
t r: t /+ Sec. _ 2� , T_ N -Tt _W, 'Town of S a
� Property Location ice_ /,, �.
Subdivision Lot #
Certified Survey Map # - , Volume Page #
Warranty Deed # 'Volume Page #
Spec house L1 yes a no Lot lines identifiable 9 yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. proper asaintemince
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put iato the System
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St, Croix 'Lotting Department a certification form, signed by the owner and by a
master plumber, journeymanpiu.rnber, restsictedplumber or a licensed pumper verifyitag that (1) the OII-Slte wastewat c � l yet=
is in proper operatiuS eonditio:t and/or ( 2) after inspection and pumping (if necessary), the septic tank is leas than udp'
Uwe, the undersigned have read the above requirements and agree to mabttain the private sewage dapoml Sysfn Frith tha Standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of WiscA'I C'0r ifi &i oa
stat' that your septic syste has been maintained must be completed and returned to the St. Croix trounty ZoB
da ys f the three year exp' tiott date.
Y
6
DATE
A P ICANT
OWNER CER ;CATION we a m (are) the o WW (s of
we 'fy that all statements on this forth are true to the best of my (our) knowledge. Y { )
the esc ed above, by virtu f a warranty decd recorded in Register of Deeds Office. p�
t� 2 O
DATE
S IGNA DF AppLIC
w *. ** w Any information that is mis•represcnted may result in the sanitary permit being revoked by the Zoning DopSrtmetli.
#Mass+
w Include with this application: o tift
of the ccred survey rnap f r efere nce De s o f f ic e
in
a c the warranty deed
t7d wdsc:ie calk 2Z 'Few LVIBLLI 'DN Xtid dais: WDdd
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 3 of 4
FILE
INFORMATION SYSTEM SPECIFICATIONS
Owner SCOTT NEWGARD Septic Tank Capacity 1250 gal O NA
Permit # Septic Tank Manufacturer 9 TESE R CONCRETE O NA
DESIGN PARAMETERS Effluent Filter Manufacturer ZABEL O NA
Number of Bedrooms 4 ❑ NA Effluent Filter Model A -100 12 "X 16" NA
Number of Commercial Units 13 NA Pump Tank Capacity a l O NA
Estimated flow (average) 400 gal/day Pump Tank Manufacturer 12 NA
Design flow (peak), (Estimated x 1.5) 600 gal/day . Pump Manufacturer Q NA
Soil Application Rate 0.5 al/da /ft Pump Model Qt NA
Influent/Effluent Quality Monthly average` Pretreatment Unit CKNA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand/Qravel Filter O Peat Filter
❑Mechanical Aeration O Wetland
Biochemical Oxygen Demand (BOD 5220 mg/L
❑Disinfection O Other:
Total Suspended Solids (TSS) 5150 m /L
Manufacturer
Pretreated Effluent Quality 13 NA Monthly average" Dispersal Cell(s)
Biochemical Oxygen Demand (BOD 530 mg/L iKIn- ground (gravity) O In -ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ At -grade O Mound
Fecal Coliform (geometric mean) 510 cfu/100ml ❑ Drip-line 0 Other
Maximum Effluent Particle Size Y Inch diameter Values typical for domestic (non- commerclal) 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 2 ❑ months [R year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one -third (g) of tank volume
Inspect dispersal cell(s) At least once every 2 ❑ months [I year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every 1 ❑ months . gyear(s)
Inspect pump controls & alarm At least once every ❑ months ❑ year(s) IR NA
Flush laterals and pressure test At least once every ❑ months O year(s) IR NA
Other. At least once every ❑ months O year(s) O NA
Other. At least once every ❑ months O year(s) O NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or
certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage
Servicing Operator. Tank inspections must include a visual Inspection of the tank(s) to identify any missing or broken
hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up
or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels
in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the
ground surface may indicate a failing condition and requires the Immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y,) or more of the tank volume, the
entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR
113, Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreattment components; and any
other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintanner.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
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(s) removed by a septage servicing operator prior to use.
OWNER: SCOTT NEWGARD
Page 5 of 4
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess
wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the
backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a
Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to
assist in manually operating the pump controls to restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact,
the area within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life
of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers;
disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat
scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
A13ANDONOMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to Insure that the
system is properly and safely abandoned in compliance with 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 shalf 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:
11 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 blomat 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
POW IN STALLER POWTS MAINTAINER
Name HELGESON EXCAVATION Name JOHNSON SANITATION
Phone 715/772 -3278 Phone 715/273 -5811
S SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name JOHNSON SANITAT10N Agency I ST. CROIX COUNTY ZONING
Phone 715/273 -5811 Phone 715/386 -4680
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not
guarantee the performance of the POWTS.
GMW (2/01)
i
2 165 P 2 58 '7 1
STATE BAR OF WISCONSIN FORM 2 - I" XATHLEEK H. WALSH
WARRANTY DEED REGISTLV OF DEEDS
Document Number ST. CROIX CO., VI
This Deed, made between nelwin R. Mqsarn RECEIVED FOR RECORD
03/1012003 3909AM
E1E*T 0
Grantor, Imi"' Sc ott Newgard and Ellmobeth Snow -Newgard, husband REC PER: 1L.
and wife, - — TRAYS FEE-. 189.90
COPY FEE
CERT COPY FEEL
PAGES: I
Orontes.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 5, Perch lake Estates, St. Croix County, Wisconsin, Name And Ketum Address
Ftewm to W
PweerTffle I
= US Hwy 8
-CfdX FINS, M 54024
030-1099,40-006
Parcel ldcritificaVon N umber (11N)
This Is not homesteadolopeny.
CK) (is not)
Exceptions to warranties: Easements, restrictions and righu-of-way of record, if any.
Dated this day of M arch 2003
Delwin R. MagsaT
AUTHENTTCATION ACKNOWLEDGMENT
Signaturc(s) Delwin R. Malpam STATE OF WISCONSIN
County
authentIcat d t ay of March 2003
of reran bcfbro me this day of
the Above named
'rITLb; MEMBER STATE BAR OF WISCONSIN
(if not, --.- W me known to be the persons) Who cxccutcd the Forcgoing
authorize t - 1706.di�. - Wis. Sja-t3,)'- instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED B
Attorne Kristin& 0 1 a -1d
r's"'
rb g Notary Public, State of Wiscon-�i
6 My Commission is pormunent. (If not, state expitatioll dzktc,
(S1W:8 MrC1 May be authenticated or acknowledged. BA arc not necessary-j
-------------
Names of persons signing in any capacity must be typed or printed below their signature. 14orm0am Pmfossonsle Compan Forla du Lmg, W1
WARRANTY LIKED STATP 13AR OF WISCONSIN SPO-WS-2024
FORM No. 2 - 1999
I'd
G 14d9;Z: TO 7-30C ZT 'held LtSLL!ZST�: 'DN XU-� rails: W06J
;f
,p an
',
Mw
ty' a tr
3 Baths 3 Beldroorns
Total U ving Area:...... 24M sq. R
Main Level ...................1,668 sq. ft. r l
Upper Level .....................495 sq. ft. t
Bonus Room ................... 327 sq. ft.
Exterior Wails: ... ............................2x4
Width........................................... _ ... 52'7 ' E
Depth.................. ..........................50'11 j
FOUndation optkms: r _
Basenvent, Cnmispmm , =� - _
,. . TIC
BLJLPEPMN T PRICE CODE. ...... .. ..... E } _ -- '°` °"" °"•``
T
Trav and vaulted ceilings increase
the feeling of spaciousness. With a frill bath nearbN. the study can become
a Guest room. I , ave the secondary bedrooms on the upper level easy
access to a spacious bonus room. — Donald A. Gardner
DECK
BRKFST.
GREAT RM. n
J�
Lal� MASTER -4 .9 -0
n
BED RM. 16 -8 x - 10
15 -8 z 13 -4
— --------------
���
d K;.
UTIL 11-4 12 8 —
_ maeear bash x .7-10 z 6 -8
p up cl
..i I bath
N BED RM ' DINING s ,4 ow
C� 1999 Dawn A. Y
F ER
n -o x 12-0 n -4 12-6 All rights reserved 5
BED RM. `I =
11 x u b .h -0 d
GARAGE PORCH
22-4 x 21 -4 —
41 It-
BED RM.
l— 'rea 131-10 below
BONUS RM. -
52 -7 ... _.___._._.. 15 -4 x 21 -4