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030-2016-20-100 (2)
�r�:2 a n ; ivision County 1400 E Washington Ave Sr. Z"ta/X COUNTY P.O.Omfl"2 Sanitary Permit Number(to be filled in by Co.) UrJJ1�((;E/ LOPMEI�IT Madison,WI 53707-7162 -11113 ' Sanitary Permit Application State Transaction Number In accordance with SPS 38321(2),Wis.Adm.Codes submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Services_Personal information you provide may be used for secondary Purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ' I. Application Information-Please PrintAll Information 88�' G//LGow /vER �A.rE Property Owner's Name / Parcel# T6 EL .Sly/rN O.?G - -,?o-/00 e/ Property Owner's Mailing Address Property a i-A4L Location /f Govt.Lot.!!JE 7 City,State Zip Code Phone Number S/,rJ �/, SE '/4, Section .36 circle one GlDSo�! �/.Z ,rj golG 7/S 8!-Ob/7 T ,30 N; R / # H.Type of Building(check all that apply) Lot# Subdivision Name 9 t or 2 Family Dwelling-Number of Bedrooms cz:� 3 6k 4b I 6 C,?' lock f1 D Public/Commercial—Describe Use ,J •of / f State Owned—Describe use CSM Number S ya 7 ys ✓ ®Town of Sr . S6Pw MA � Q � oG /! Qc. 3/3 III.Type of Permit: (Check only one box on line A. Complete fine B if applicable) Q A- 0 New System D Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) List Previous Permit Number and Date Issued B. D Permit Ren 0 Permit Revision Change of Plumber �Permit Transfer to New Y4 3/-/7 /d ;j8_o700 y Before Expiratio Owner IV.Type of POWTS System/Component/Device'. heck all that a 1 ErNon-Pressurized In-Ground D Pressurized In-Ground ❑At-Grade D Mound 2:24 in.of suitable soil D Mound<24 in.of suitable soil `� D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain} a V.Dis ersallTrea ent Area Information: Design Flow(gpd) Design Soil Application Rate(gpds Dispersal Atea Required(sf) Dispersal Area Proposed System Elevati� Ill y!s-p .7 6 Y3 /y9 a 9S. o VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units 9 °E `—' 0 o V r, y a`� oqn •in New Tanks Existing Tanis 4` 0 in Septic°r 1{°ldi`>g�`xd` 6✓/6 SE.Q Co.✓G i¢ErE Dosing Clamber VII.Res onsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's re MP/lt>�RS Number Business Phone Number ew 1ELK£' �� a.3l3 Y4 7/J' 6 7.7-S,7LL Plumber's Address(Street,City,State,Zip Code) Al Ga P8 .Sr. wx a.5' �u�t,e.do cJS sy73< VIII un !De rtment Use Onl Approved Disappro Permit Fee Date tied issuing A t Signature caner Given Reason for Denial $ Ifs. 5 Z7 fJ` IX.Coniti , s far isapprov al t 1 kt 1. eptie t nk,a tPlnn 3 ("a dispersal cell must all be serlG V(MAMAekt , t as per management plan pFOVided by ply ' t > D QQ cl- d�- t 5 2. A -S,0 utremer#L lra*.#t as psF applki bci t> /Oldi111110M, Iti t(, U`/� AA,t Attach to complete plays for the system and submit to the county only o per not less than 8 1/2 x Ix inches in size SBD-6398(R 081]4) N31 0 o vl - n z t v v c o: b o ti a C V � v ",4"4 rt V t ,. v rA `y b y `o � y n o `` flc0 .y 3� 0 Private Onsite Wastewater Treatment System I(ucd and Title Page PsojecNaoae: .1 o�c Sroiri✓ • 3- iSR J.✓t�.v,ro l�o,�TS ms's Nam w. Ovffi x s Addmg: ' /7u0 deg►, tJ.r Sya/� -'70,�� ?8/' 00/7 Legal DesaiptioII: -SL.J, SE,�34, 32.-V /Q it Mumczpalit : Town, fie, • 2ftg of Sr. Josue/N county- _ Sr- e,Ra/X Subdivision Name: Lsr1 .5 '/a7ys- adz. //, /W.J/3 Y LotNumber- L,_ BlockNumber. Parcel LD.Number. Page I /'5 yzx r Page 2 ss- <AEc rla-. ¢ G)Ijw Page 3 .SE�}-iG v�e�✓J� .SPEU�0 r"¢A}"ia-,,S Page aolwjw (s %9 wewgg Page-5 Page 5 04,,,1- nrx J.d r-�'�►r�.,1c� /.,�Ao. Page 7 Page 8 F 7T.-GfI,Vj'-vrs - sar4 4dR L IWIf e-'64—'004 Page 9 Name of Desigaw. TaN.✓ /�Ezx£ f icenseNbmber: IW- olf �3/3yL Sigaatare: Date: Designed to the Poltovdng POW-1 S Componom Manual and S,0-5 91-85-. lh-Cliound Sod Absorr =gomuonent Maps d far PO"W TS(V 2.0)SBD-I0705-P(N 03101) VI 0 nt i `'lls �i a V 2 +u o o !k H 41 �o T Ilk 4 v ti u v v a¢l e ,y R W W iz C1 r v 4 Q v � h IK A 41 h 0 I, ` v N Z ti Z o a ri °0 Ilk V v Property Owner �7afl S Ly Parcel ID# Page a of -� 3 Boring# ng Boring ® Pit Ground surface elev. /40.0 R Depth to limning factor >130 in. Son Application Rate Horizon Depth DominantColor Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu.Sz. Cont Color Gr.Sz.Sh. *Eff#1 *Etf#2 / - 3 e 8 — l .+ or o s �/' /0 3 /- o /.art 3 S R t s L ac/ v A Pit Ground surface elev. /d?.D fL Depth to limning factor > 3d in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Shvchre Consistence Boundary Roots GPDff in. Murrell Qu.Sz. Cont Color Gr.Sz.Sh. *Eff#1 *Eff#2 / a-/S Ag YL 31g? -- / .7 1/S- a YL T/ 3 3 8-6-.� /o ra — sc l �{ avjo /o Yet 6-11t — ,s fl F-I Boring# Borirg Pit surface elev. tt pth fA limning factor in. Sal Amlication Rate Horizon Depth Dominant Color Redox Description Texture Struchrre Consistence Boundary Roots GPW lo. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. '81#1 *092 *Effluent#'f=BOD,>30:5 220 mgA.and TSS>30:5 150 ffQ& *Effluent 42=BODS a 30 rrg&and TSS_<30 nv& ` S804330(Rm 1131 "'•,-;4' 1; { l.'. i Wisconsin oepatinent of Safety and Professional serum Division otindustry Services SOIL EVALUATION REPORT Page / of 3 in accordance with SPS 383,Wis. Adm. Code Coin Attach complete site plan on paper not less than 812 x 11 Inches in size.Plan must include,but not limited to:vertical and horizontal reference point(BM),direction and Paroal I.D. percent slope,scale or dimensions,north arrow,and location and distance to nearest toad. o •a?o/ - a- oo 5J/B8- o J Please print all Information. R Da nal Perso information you provide may be used for secondary purposes(Privacy Law,s.15.04(t)(m)). Property Owner Property Location f ❑ �oEt S �rN GovLLot .S6✓114 `C114 S J,/ 3o N R/9 f( Property Owners Mailing Address Lot# Blocic# Subd.Name or/C" f-Aa[ �4aeW ,wl1/�E /o SIR7YX aa . 3av City State A)Code Phone Number Elskr Bm" UTown Road 41j-Z-1 SY614 1 ( ) 38/-o6 7 Sr Jas 877Vlzio.JWlemL14. New Construction Useig Residential/Number of bedrooms 3 Code derived design flow rate V,ro GPD ❑Replacement ❑ Public or commercial-Describe: Parent material Flood Plain elevation if applicable and ndre<Arntne°0 one: �D�FP /.✓�aeu,,o PoJ,�rsJ L f,BELaa/ �a,�e� . 7 pPd�fr'�oAOJwr6 /LSr�� GRASS F/B-lo s✓/F!✓ ,QJtr,SJ✓ I'JlE6� ydfo S[a/E © Bonng# OWN J ® Pit Ground surface elev. 1446 R Depth to limiting factor >/?S in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *0102 / /'6'-x 3 / 2 a a S — a Xx V111 - S c/ /c Jv Z 5 - (o 114-Y2 7 s Ya. - k J� Cu! - 5/ S yB-!as or s s 'ty/ — / I Fd-1 Boring# ❑ Boring J D� Q Pit Ground surface elev. /O/.O R Depth t4 limting factor >/d0 in. Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu.Sz. Cord Color Gr.Sz.Sh. *Efwl *Eff#2 w a1-37 o - / .2 slA aid 3 7-66 /aYA -r/4 -3a r rR s s c-1 P; e.w — a 3 60-1,�o /oYL S/Y k G - J JJEn G Aw/ R i✓A NEO �i N w+o !' *Effluent#1=BOD >30:5 220 mg1L and TSS>3D:S 150 mglL =BOD : 30 mglL anti TSS_<30 mg& CST Name(Please Print) Michael J.Hassett Signature CST Number 1-503 issirway St- e Address Eau Claire,WI 547A1 Date Eva Telephone Number 10 715-5774383 CST,MFRS-224974,D-1152 SBD4330(R07/13) Property Owner Panel ID# Page 07 of 3 -3j Boring# Ong Z pit Ground surface elev. /do,o fL Depth to limiting factor >130 in. WGPDff Horizon Depth Dominant Colo Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 2 .73- /A$,,&, YIJ 2 n Sdk A I - Z Ao 3 /- o /aY-c s/6 Za xxt 3. aBoring# Boring pit Ground surface elev. /D.?O ft. Depth to limiting factor >/-?O in. Soil nation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. -Eff#1 -Eff#2 f d-/S a YL 3 — / a Ya s/ /o Ya S — Se l Y L ,t ❑ Boring# Boring U Pit Ground surface elev. ft Ipth to limiting factor in. Sol!AmAcation Rate Horizon Depth Dominant CAAor Redox Description Texture Structure Consistence Boundary Roots GPDItf' in. Munsell Qu.Sz. Cont.Color Gr.Sz Sh. -Etf#1 -01#2 I *Effluent#1=BODS>30<220 mg1L and TSS>30<150 mglL 'Effluent#2=BOD5<30 mg&and TSS<30 mgA- sin-x GM97rt3) N .• • ; r ^ rn t3l o r°c C n H a r z 00 n No y ` 94 `^ 4 b rk 0 F� w I q n iAy N a a i tv 0 f Li MVED Industry Services Div' .r County q ` 1400 E WashinSthhl A+e '. -, ; J, _ ` ���pp'+ (� r11►'J P.O.Box 7�6l ��` Sanitary Permit Number(to be filled in by Co.) I ` li(ti U Madison,WI 53701 7' [� q I "mlam; [� I ix cauNrr ;QMMUNI IT State Transaction Numbpr amtary Permit Application NNVA In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Services.Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15. 1 m,Stats. e Qi ✓1�ow X1�ER ORruE I. Application Information-PleasePrintAllInformation Property Owner's Name Parcel# -J o 6c ,Sly/r* l% arc - -o?o-/oo�•- ' Property Owner's Mailing �Address Property Location � H 1913— 'U) 7a/ 1;444 A614RGM 'awa-, Govt.Lot City,State Zip Code Phone Number s(J y,, ,SE �'h, Section circle one GI�So�J /✓.Z JryO//. 7/,S 8!-�O/7 T .30 N; R /� &OdV H.Type of Building(check all that apply) Lot# 3 Subdivision Name Pf 1 or 2 Family Dwelling-Number of Bedrooms J ✓ V. o\ Block# r. ❑Public/Commercial-Describe Use amity,of \ CSM Number Qof ❑State Owned-Describe Use ,Sy/a 7 yS VOn Town of .Sr - O.Shc" Uol. // �c III.Type of Permit- (Check only one box on line A. Complete line B if applicable) n e New System ❑Replacement System g P ❑Treatment/Holdin Tank Replacement Other Modification to Existing System(exp am yst Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit T fe ew .,3/-'7, /6 -o?8-a0o y Before Expiration Owner IV.Type of POWTS Svstem/Com onent[Device: Check all at a ! i�NOn-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gra 4 in.of suitable soil ❑Mound<24 in.of suitable soil 2 AJ t Y- ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) l-?�-�Tb V.Dis rsaUTreatment Area Information: Design Flow(gpd) Design Soil AppliRate(gpdsf) Dispersal Area R i (sf) Dispersal Area Propose (sf) System Elevation yso .77 �y3 Ly9. a 98.s� VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units New Tanks Existing Tanks / 10 p n 2 m W C� b-F-W a A+= �. a Septic or? mrk �ODO "' 000 ! L✓/ESER �O.J C i2ET6 Dosing Chamber VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber' at MP/[atPRS Number Business Phone Number D/Yi� �ELK6 � Plumber's Address(Street,City,State,Zip Code 6a 98 Sr wY aS �u,�A.t�o GJl :5'-Y 71d VWX Coon epartment Use Only Permit Fee Date Issued Issuing Age i Vre Appr oved Dis ` r I er Given Reason for Denial L 6 y /IX.Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: l/p pe t/ll-,/ 6c ex 1.Septic tank,effluent filter and 1 s j,�6ee 14`^el dispersal cell must be serviced./maintained GJ//n as per management plan provided by plumber. J7jf 2.All setback requirements must be maintained ✓e�'� Z as per a lic Attach to complete plans for the system and submit to the County only on paper. Trot Less than 8 U2 x 11 inchesJj s a L&,n d SBD-6398(R-08/14) ' Private Onsite Wastewater Treatment System h dex and Tlde Page ( � -.�/CE4 J/�1J rl' - ' Idle //t�li L64dO �OIt�TS OwneesAddrm: 7a! A444 duccN 4J T LegalDesadpdow tJ Mumicipality: Tm age, QKyof Sr. Toss PN count+: Sr. L�ta,x SibdbidOn NBl M C S,N 7kr 44,.4/ 3/3 J/ LotLNm bw. /o BlockNumber: Parcel I.D_Number: Page 1 4- p—lr1 c 5 xr r Page t Aa. ey LAO.Cf- S'U Yjeo..j ¢ Page 3 -,ee riG dJ �eQC .S�PEGiFi���'io d S Page 4 oA iJrS 44Ad ',e 's sV law., e%6?+&. e-�j r 'A'ad Page 5 Page 6 Page 7 Page$ ,� r�Gils�t�ut's - Sores �'r��L rsR r/Qie� /P�l�on7� Page 9 Name of Desipw. e q v AE ggKE Licem NuMber Al Sigaure; s Dale: Y-/ Design to the Following POW-rS Compmwat Mmml and -SP-5 81-85; 3n-G�SoR.A.b �g=v=Mempa for PE VM (Va.2-01 8BD-i0' 05-P(N 01101) VI \\ V o a do � ,Y, W C e � Z a ` V ri 4 7.4 � O �Qz t 1 � Q 0 M f--•-F--h —F---i �,bo M y � �loop a It r o r fj kv a 40 3 •3� � y / � v o � � r o 0 v h ^lr�,✓�9N�d a o O- a z ch rn m r 61" 86" D z c D 42" z r � m r^ IQ � ° rn -a O m UP 41" O / \ � 4" CAS m En 0 3" 36" 4" D o i in m >m UP 38" m �a J A 4" CAS \m / N 4 .'D m -0 c fJ � m o '� o -P 3 a C mD� z ° 39" 0<0 y rn -mj KFD m D r OCr D D rn m 0 m<rr1 x� C) a z C) m A -t 0 ZO Z z 0 0 � z P 3� cnD Z �� nC� A p�D G1?D r�if�m9rr*r rz*ly0 ODD Z m x- sv''z vFcn -r D �o ccn =v OS05 c6 �z ZI r-OZ � my mC) 0m D N D-4DTZ. n ZC -�mi�C 2-1°� .. ... r- x"" (n M�z Oo mEn rr� n0 wisp A rnmzrn�-n°m a=tn zZ oo p0 �� a' DDS _jrr--f 41 >;" b� M t� A D u z o ZD ii* m o n� MW i m vrc. 00c)- z0 � o w m n 7C (n � OD D O�N O m m ao -[nl N N z A C O " m m r� I r to O m (n w v m z W n O O O Z m G7 m.i m m CD ;0;0'O a n °n oo ° Oz cm c to by - zn0 D°o ° caa,m D m < 0 a)o m .. H D m -0 z 0C D t>t r r G+a D OD Z n � t*1 z Z�° a0 0 � ° - Dv 0 Z D D v0?r v0� ?O-1 ° O O r z P r r -r m 0 � Z r O U) N v C7 � ° z °�s ° °z 0 -i 0 v Z r c ,rn Fn H z 0 A A Z m N ;a m z ;u `\v r - � m DRAWN BY: SME SCALE: 1 4"-1'-0" RE-POUR: 11 V m+ SEP PCM MANUAL MIENER ounCIETE DATE JANUARY 2010 DATE . POST-POUR: Z W3716 US HWY 10 MAIDEN ROCK, WI 54750 ° REVISED JAN. 2010 800-325-8456 FILE wMmoo-ur L CROIX Corvr) Tj 'K E ji N I I- N I (R%f -o' % 13 Lo t I D Al rrupvn� Ad"%�S Citv S-'at� —201 G— IOC) 30 LEGAL DESCRIPTION j P'or'%"m �% to Certified Survey Map ;' 313 N%a rran ti, Deed SX'S'-I'E-'►l M.AINITENTANCEAND OWNER CI RIAW AUON 0!17U11'7MI� Irm der. th,--S vs!C7 n t:;ic 11n': 1?...c vp C Z tT inz F-Ften-. aj- T Vc Me h:. :0A• L:i., Numt) rooms el Sit. Al I R F OF A P N T IAT L , An i:it i rr--at i o,P, r- re 1 -n- c I I n r I c 7 t !ndu&tivllh tills tLc wz--:-, man It ref,nncei,rnaj.--in START UP AND OPERATION Page_of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process'and/or demag'wthe soil absorption system. If high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended,as the excess wastewater will be:discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to•the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contras until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade sal absorption area Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes;•dgarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants,fats,foundation drain(sump pump)discharge,fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils,painting products,pesticides,sanitary napkins,solvents,tampons,and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taker out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. .SPS383.33,Wisconsin Administrative Code- All piping to tanks,pits and other sal absorption systems shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be rernioved and property disposed of by a Septage Servicing Operator(pumper). o After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil. gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the locati on of a replacement sal 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,tot 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon faildre 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. Q 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK e SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY - ' RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER• Name J ELKE -,?3/J Name .76N,j AE[CE Phone . ./ IS- 4C 7.7-S,2« SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name Name Sr-, 44oix t DFf/CE Phone Phone POWTS OWNER'S (MANUAL & MANAGEMENT PLAN page_Y of�_ FILE INFORMATION SYSTEM-SPECIFICATIONS Owner TO E� .S/*//T"H Tank Manufacturer. !�//ES 6,t L0,0CArrF ❑NA Permit tR Septic ❑Dose ❑Holding Volume. /,070 (gal) DESIGN PARAMETERS Tank Manufacturer. C9 NA Number of Bedrooms- ❑ NA ❑ Septic t?Dose ❑Holding Volume: (981) Number of Public Facility Units: ®NA Vertical Distance Tank Bottoms)to Service Pad: 7 (ft) Estimated(average)Flow: d b p (gaYday) Horizontal Distance Tank(s)to Service Pad: /ao (ft) Specific servicing mechanics must be provided if vertical is>15 feet or Design(peak)Flow=(estimated x 1.5): y rp (gal/day) if horizontal is>150 feet. specific instructions to be provided on back. In Situ Soil Application Rate: .7 (gaUday/ft�) Effluent Filter Manufacturer. Xe,6 r 0 NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: Fats,Oil&Grease (FOG) _430 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODS) 5220 mglL ❑NA - [I NA Total Suspended Solids(rSS) •4_150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/t - Manufacturer. Pf NA (BODO >220 mg1L ❑NA ❑Mechanical Aeration ❑Peat Filter (rss) >150 mglL ❑Disinfection ❑Weiland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other. (BOD5) 4430 mgfL Soil Absorption System (TSS) -e30. ❑ NA Fecal Coliform(geometric mean 510`, 0 At-Grade (gravity) ❑ Ground(pressure) [I NA ❑ k-Grade de ❑M ound Maximum Effluent Particle Size Ys in dia. ❑NA ❑Drip-line ❑other Other: ❑ NA Other. ❑ NA MAINTENANCE SCHEDULE Service Frequency Service Event- Pump out contents of tank(s) tXWhen combined sludge and scum equals one-third(%)of tank volume p When the high water alarm is activated Inspect condition of tank(s) -At least once every: -3 ®OKs s) (Maximum 3 years) ❑ NA inspect dispersal cell(s) At least once every: 3 yeaKs)) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: I'3 means)) ❑ NA Inspect pump,pump controls D months) ®NA alarm At least once°every: Q year(s) Flush laterals and pressure test 'At least once every:- 0 month Flush , NA Other: At least once every: ❑month(s) ❑ NA ❑year(s) Other: ❑NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorpidon systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third(ys)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator(pumper)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 4_12 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event � START UP AND OPERATION Page 5 of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process-and/or damage-the soil absorption system. if high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended,as the excess wastewater will beidischarged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of efficient-and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to#he pump or contact a Plumber or,POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes,-cigarette butts, condoms, cotton swabs, degreasers, dental {loss, diapers, disinfectants, fats,foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils,painting products,pesticides,sanitary napkins,solvents,tampons,*and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. SAf383.33,Wisconsin AdMinistrative Code: fl All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator(pumper). e After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soli, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure,lot lines and welts. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacemerd area. *Replacement systems must comply with the rules in effect at the time of their permit issuance. A I Q suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be i rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ 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 maybe instatled.as a last resort to replace the failed POWTS. Q Mound and at-grade soil absorption systerns•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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY QRESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name EL,�E !®-d3/3 Nye -✓6hW 4946- �/�EtXE Lu�v,6l.�c Phone /S 7,?-SJ6L Phone 7is L7.?-S526 L SEPTAGE SERVICING OPERATOR(PUMPER) -I/Aj r^lb.t.1 LOCAL REGULATORY AUTHORITY Name a me sT' 2/!Phone [�N hone 71.5' 3-94- y6 8a an ME m m m C/) r{ '`i} 'o is _ o ► = rD .,; P'P N� -i O o.a m - m @ Sy m ell,m n _-ro G 3 Qn cr s m � if m w c N m N @ an @ 2 m ''► w' O p.x O 0O3 c �, ° � o s d = m 3 'n. a e I m 3 3 @ O jOn n p C m ? R S J N (D 0' 7 91 rD @ 3'7 : N of C 7 O f0 W P m QN _..i Q� ��0. � O •n i'1 � € E O 1, .w�i 0 W O D. 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CONTAHEO THEREIN WIT OUr THE WRITTENNPERNIMON OF NPMoP,WI SA016 MCCORMACK CLASSIC CONSTRUCTION IS PROHIBITED AND MAY 3E)76?t211- SUBIER YW To A CLAIM FOR DAMAGES.COMRiGM O a b F ®® agar a�A r myr� m roaar ° n as Wil 'hill �p`yr"�C�7nS �E ASS°qEE55(1 Q SSA 6] PRO 10 Z i�C i¢ AZ j! n 3A nM Am ZOZ p iy O C °m nr� z b E i F. m s= 5� 0 z iESP N O DRAWINGS PROVIDED 8Y: PRO]ER DESCRIRIDN: NO. DESCRIPTION BY DATE THESE DRAWINGS ARE THE PROPRIETARY WORK PRODUCE AND m1I o McCormack Classic Smith HOUSE PROPERrY OF MCCORMACI(CIASSIL CONSTIIICTION,DEVEIAPED .A •r"t• a Construction wt FOR THE EKCIUS.USE DP MCCORMACN CLASSIC la+ CONSTRUUWN.USE OF THESE DRAWINGS AND CONCEPTS 573 138th Ara CONTAOED TNfREIN WM40UTTME WRI17pN PERMISSION OF N Nadaen,WI Sa016 McCORMACK CUSSIC CONSTRUCTTON 15 PROHnWMD AND MAY ITS)760.2111- SUB]ER YOU TD A CUNT FOR DAMAGES.COPMGIff O r------------------ ------ I I r• 14• ° 40 I 3'-y�---6•'Y---y.Y-0'�13'-6• Y.8" 10'-0• o - - ; I I ": 6 N I C4 I I 9i I q I I I I I I I I I I I I I --------- - Y I I I �rn I I I I I I I I I I I I I I I I I I I I I I I � I I I I I � I 11• I I p Q I I LLI I I 40' 4 I , A O ® ® O C q 00 � ® ® oo ® ® ® ® G O T cm cm In En cm cm cm cm 1aaTrr s i Al N O OMW1NOg PROVIDED BY: PAOIECf DE5CRI7IlON: N0. DISCRmRON BY DAZE THESE DRAWINGS ARE TFIE VAOPRIEI'AA1'ygAl(►AODURAND OHIRM V' �1m1 0 McCormack Classic Smith House PROVERfY OF MCCgtIMIX CU551C CON5TAUCi1FR DEVELOFED Lq y a Construction WI FoRTHEIX[VJSNEUSEOFMcCORMAC(C1A45{0 572 128M Ava CONSTRUCTION.USE OF THESE DRAWINGS AND CONCEPTS to H d..,WI$4016 CONTANED THEREIN WRHOUTTHE WRITTEN PERMISSION OF IF 341]60-2211. SUBIERYOU NAICWNFOR DAMAGES.PCOPYRIGNTO �Y PROPERTY OWNER Dave Anderson SOIL DESCRIPTION REPORT Page--2 ;f 3 PARCEL I.D.# -pending Lot #10 Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft Boring# Horizon in. Munsell Ou.Sz.Cont.Color Gr. Sz. Sh. I Bed ITmr& v '>` 1 0-12 10 r2 7 none 1 2msbk mfr cs 2f 1 .5 .6 2 12-28 10yr4/4 none sicl 2msbk mfr gw if .4 .5 Ground 3 28-34 7.5 r4 4 none sl -2mci r mvfr qw na .5 .6 elev. 101.35t. 4 134-82 7.5 r4/6 none s osa ml na na .7;,-.8 Depth to limiting factor z i +82" Remarks: Boring# 1 0-10 10 r2 2 none 1 2msbk mfr cs if .5 .6 .2 .3 r: 4 € 2 10-27 10 r4 4 none sicl if r mfr if 3 27-33 7.5 r4/4 none sl 2mgr mvfr gw na .5 .6 Ground elev. 4 33-80 7.5 r4/6 none s os mvfr na na .7 .8 102.1 ft. �- Depth to / limiting oi8 factor +80" Remarks: Boring # _ 1 0-12 10yr2/2 none 1 2msb1k mfr cs 2f .5 .6 U 2 12-23 10yr4/4 none sicl 2msbk mfr gw if .4 ' .5 3 23-30 7.5 r4 4 none sl 2m r mvfr 9w na 1 .5 .6 Ground elev. 4 30-80 7.5 r4 6 none s os ml na na .7 .8 101.25 ft. Depth to limiting f10r" Remarks: Boring# Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Wscolsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Vabor:end Human Relations g - Division of safety 8 Buildings in accord with ILHR 83.05, 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%of slope,scale or PAR dimensioned, north arrow,and location and distance to nearest road. ndi APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R ED BY DAT PROPERTY OWNER: PROPERTY LOCATION ,'2d Dave Anderson GOVT.LOT SW 1/4 SE 1 6T T ` 19 PROPERTY OWNERS MAILING ADDRESS LOT# I BLOCK# SUBD.NAM 0 0*4I G 0�� � 706 19th. St. S. 10 na CSM pe CITY,STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE [NfOWN A Hudson. , WI. 54016 (715) 386-8207 St. Joseph ' rrDr. 1c] New Construction Use ] Residential/Number of bedrooms [ ) Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed,gpd/ft2 .8 trench,gpd/ft2 Absorption area required 643 bed,ft2 563 trench,ft2 Maximum design loading rate .7 bed,gpd/ft2 .8 trench,gpd/ft2 Recommended infiltration surface elevation(s) 98.35 ft (as referred to site plan benchmark) Additional design/site considerations na Parent material outwash Flood plain elevation,if applicable na ft S=Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable forsystem S ❑U CAS ❑U CAS ❑U ®S ❑U 91S ❑U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Bed Tmench 1 0-9 10 r2 2 none I 2mqbk mfr cs 2 9-27 10 r4/4 none sicl if .2 .3 Ground 3 27-33 7.5 r4 4 none S1 2m r mvfr gw na .5 .6 elev. 102.08 ft. 4 33-84 7.5 r4 6 none s 0SQ mvfr na na .7 .8 Depth to limiting factor +84 r-T I Remarks: Boring# ..ti,.. 1 0-10 10 r2 2 none 1 2csbk mfr cs if .5 .6 2 2 10-21 10 r4/4 none sicl 2msbk mfr if .4 .5 Ground 3 21-82 7.5 r4/6 none s 0Sq ml na na .7 .8 elev. 102.2 ft. Depth to limiting factor +82" Remarks: CST Name:—Please Print Phone: Gary L. STeel 715-246-6200 Address: 1554 2 t . , Ave. NeW Ricbrnond, WI. 54017 m 02298 Signature: Date: CST Number: 7-5-96 PROPERTY OWNER Dave Anderson SOIL DESCRIPTION REPORT Page-2 Qf 3 PARCEL I.D.# pending Lot #10 Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ftie Boring # Horizon in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Bed Trench 1 0-12 10 r2 7 none 1 2msbk mfr cs 2f .5 .6 3 2 12-28 10 r4/4 none sicl 2msbk mfr gw if .4 .5 Ground 3 28-34 7.5 r4 4 none si 2m r mvfr 9w na .5 .6 elev. 101.35t. 4 134-82 7.5 r4/6 none s osg ml na na Depth to limiting S factor z z +82" Remarks: Boring# 1 10-10 10 r2 2 none 1 2msbk mfr cs if .5 .6 2 10-27 10 r4 4 none sici if crr mfr qw if .2 € .3 3 27-33 7.5 r4/4 none si 2mgr mvfr gw na .5 : .6 Ground elev. 4 33-80 7.5 r4/6 none s osq mvfr na na .7 .8 02.1 ft. Depth to limiting factor +80" Remarks: Boring # 1 0-12 10yr2/2 none 1 2msbk mfr cs 2f .5 E .6 "' S`` 2 12-23 10yr4/4 none sicl 2msbk mfr gw if .4 .5 U Ground 3 23-30 7.5y r4 4 none sl 2m r mvfr Crw na .5 .6 elev. 4 130-80 7.5 r4 6 none s oSQ ml na na .7 ' .8 .01.25 ft. Depth to limiting facto0r 1l Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PROPERTY OWNER Dave Anderson SOIL DESCRIPTION REPORT Page-?of 3 PARCEL I.D.# pendinu Lot #10 Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Botrrdary Roots GPD/ft in. Munsell Qu.Sz.Cont Color Gr. Sz. Sh. Bed Trench 3 1 0-12 10 r2 7 none 1 2msbk mfr cs 2f .5 .6 2 12-28 10 r4/4 none sici 2msbk mfr gw if .4 .5 Ground 3 28-34 7.5 r4 4 none si 2m r mvfr 9w na .5 .6 elev. 101.35t. 4 34-82 7.5 r4/6 none s os ml na na .7; .8 Depth to limiting S factor Z Z +82" Remarks: Boring# 1 0-10 10 r2 2 none 1 2msbk mfr cs if .5 .6 2 10-27 10 r4 4 none sici if r mfr qw if .2 ':. .3 Ground 3 27-33 7.5 r4/4 none sl 2mgr mvfr gw na .5 .6 elev. 4 33-80 7.5 r4/6 none s os mvfr na. na .7 .8 02.1 f. Depth to limiting factor +80" Remarks: Boring# 1 0-12 10yr2/2 none 1 2msbk mfr cs 2f .5 .6 2 12-23 10yr4/4 none sici 2msbk mfr gw if .4 .5 Lj 5 Ground 3 23-30 7.5 r4 4 none si 2m r mvfr qw na .5 .6 elev. 4 30-80 7.5 r4 6 none s osa mi na na .7 .8 01.25 ft. Depth to limiting f+A l Remarks: Boring# Ground eiev. ft. Depth to limiting factor Remarks: SBD-8330(R.05192) STEEL'S SOIL SERVICE Gary L. Steel Dave Anderson 1554 200th Ave. CSTM2298 SW4SE4 S36-T30N-R19W - New Richmond, WI 54017 MPRSW 3254 town of St. Joseph (715) 246-6200 lot #10-CSM N 1"=40' BM.= top of NW to C el. 100' At r ' iA Gary L. Steel 7-5-96 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463167 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Houle, Timothy St. Joseph Township 030 - 2016 -20 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: 36.30.19.4181310 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI S � LEV. Septic Benchm Dosing Alt. M i Aeration Bldg. Sewer j Holding St/Ht let TANK SETBACK INFORMATION St/Ht yet TANK TO P/L WELL BLDG. Vent to it Intake R AD Dt Inlet Septic Dt Botto Dosing eader/Man. Aeration Dist. Pipe Holding Bot. Sys nal Grade PUMP /SIPHON INFORMATION Manufacturer Deman St Cover GPM Model Number !? TDH Lift Friction Loss System Head H Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits kI de Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of System: UNIT Model Number. DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil a Yes No [j Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 887 Willow River Drive Houlton, WI 54082 (SW 1/4 SE 1/4 36 T30N R1 9W) NA Lot 10 Parcel No: 36.30.19.418B10 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? F R No — I Use other side for additional information. SBD -6710 (R.3/97) Date Insepctors Signature Cert. No. Safety and Buildings Division County OF 201 W. Washington Ave., P.O. Box 7162 j Nvisconsin Madison, WI 53707 — 7162 Sanitary Permit Number (to Ke filled in by Co.) Department of Commerce (608) 266 - 3151 4�31(P 2 I Sanitary Permit Applicati Ilu State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informs yo may be used for secondary purposes Privacy Law, O Project Address (if different than mailing address) I. Application Information —Please Print All Information * ' o T \ J O hl X` J A,J' Property Owner's Name O C T 2 7 2 Q Q 4 Parcel # L.ot #/ Black* . � Property Owner'fMailrng Address 6 1. CROIX COUNT Property Location / ZONING OFFICE City, State ^ ' Zip Code Phone Number Abu ° — `�' ° Sectio eAl T R rre at c I. T pe of Buildi g (check all that apply) �I or 2 Family Dwelling - Number of Bedrooms SalwsimrlQBme CSM Number / _� ❑ Public /Commercial - Describe Use < y ❑ State Owned - Describe Use E3City of M III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit 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) Z Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculatin Sand Filter ❑ It Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel - less Pipe ❑ Other (explain) S • V. Dis rsal/Treatm t Area Information: 13s Design Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required (sf) Dispersal Area Proposed (sf) Syst Elevation t VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units w 1.2 R _ /pip 1 � Concrete Constructed Glass New Existing r•� Tanks Tanks Septic or Holding Tank / Aerobic Treatment Unit 7 Dosing Chamber VII. Respo sibility Statement- I, the undersigned, aquine responsibility for installation of the POWTS shown on the attached plans. Plumb 's ame t) Plumbe Si MP/MPRS Number Business Phone Number Plumber's dress (Street, City, tate, Zip C ) L VIII. Coun epartnient Use Onl Approved El Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issui Agent Sign" o Stamps) Surcharge Fee) � ❑ Own Given Reason fo Denial I -2 2r, Ztb IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER. . 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not has than SM x I I inches in size SBD -6398 (R. 01/03) I I I I I I ! I ti I I l I 1n I r I I I I l I -7 I I I ' i I r . I ; ' I r I w i I 1 I I L I I i s , I I I — I I : ; I , I i I I I I IR 0 a >� Al vi , , e � V r O o ^ 2 n Wiscothsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 !Tabor ynd Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code kN Y 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 % of slope, scale or .. dimensio ned, north arrow, and location and distance to nearest road. di APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION BY DAT PROPERTY OWNER: PROPERTY LOCATION Dave Anderson GOVT. LOT SW 1/4 SE 1 �_ 6T ,T '' 19 PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAM 0 <a(ko"ItVC�G�� � 706 19th. St. S. 10 na CSM _e CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE [!gTOWN A Hudson., WI. 54016 (715) 386 -8207 St. Joseph e r Dr. ] New Construction Used ] Residential /Number of bedrooms R (] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily Flow 450 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd/ft Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd/111 Recommended infiltration surface elevation(s) 98.35 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL 1 HOLDING TANK U = Unsuitable fors stem I Z�S ❑ U LAS ❑ U CAS ❑ U I R1 S Cl U FK7 S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoUr - dary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 0 -9 10 r2 2 n cs ............°... 2 9 -27 10 r4/4 none sicl lfsbk mfr CM if .2 .3 Ground 3 27 -33 7.5 r4 4 none sl 2m r mvfr cfw na .5 .6 elev. 10 2.08 ft. 4 33 -84 7.5 r4 6 none s osQ mvf n a na .7 .8 Depth to limiting factor +84' Remarks: Boring # 1 0 -10 10 r2 2 none 1 2csbk mfr cs if .5 .6 2 10 -21 10 r4/4 none sicl 2msbk mfr qw if .4 .5 3 21 -82 7.5 r4/6 none s osa ml na na .7 .8 Ground elev. 1 02.2 ft. Depth to limiting factor -7 +82" Remarks: CST Name:— Please Print Gary L. STeel Phone: 715- 246 -6200 Address: 1554 2 t . , Ave. Ney Richmond, WI. 54017 m02298 Signature: Date: CST Number: 7 -5 -96 -0 PROPERTY OWNER Dave Anderson SOIL DESCRIPTION REPORT Page 2 gf 3 PARCEL I.D. # - pendinq Lot #10 Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in Munsell Cu. Sz. Cont Color Gr. Sz. Sh. Bed Trench « 1 0 -12 10 r2 7 none 1 2msbk mfr cs 2f .5 .6 2 12 - 10yr4 /4 none sicl 2msbk mfr gw if .4 .5 Ground 3 28 -34 7.5 r4 4 none sl 2mcir mvfr qw na .5 .6 elev. 1 4 134-82 7.5 r4/6 none s osg ml na na .7 .8 Depth to limiting S factor 2 - +82" Remarks: Boring # 1 0 -10 10 r2 2 none 1 2msbk mfr cs if .5 .6 :�:: 2 10 -27 10 r4 4 none sicl lfcfr mfr qw if .2 .3 3 27 -33 7.5 r4/4 none sl 2mgr mvfr gw na .5 .6 Ground elev. 4 33 -80 7.5 r4/6 none s os mvfr na. na .7 1.8 102 ft. �. Depth to limiting factor +80" Remarks: Boring # 1 1 0-12 10yr2 /2 none 1 2msblc mfr cs 2f .5 .6 5 ' 2 12 -23 10yr4 /4 none sicl 2msbk mfr gw if .4 .5 U Ground 3 23 -30 7.5 r4 4 none sl 2mcir mvfr 9w na .5 .6 elev. 4 30 -80 7.5 r4 6 none s oscl ml na na .7 `:.8 101 ft, Depth to limiting f +V 0" Remarks: Boring # ............... .. Ground elev. ft Depth to limiting factor i Remarks: SBD- 8330(8.05/92) I STEEL'S SOIL SERVICE Gary L. Steel Dave Anderson 1554 200th Ave. CSTM2298 SW4SE a S36- T30N - R 19W New Richmond, WI 54017 MPRSW 3254 town of St. Joseph (715) 246 -6200 lot #10 -CSM N 1 " =40' BM.= top of NW to @ el. 100' 1 �3 r (' f c b -1 0 Gary L. Steel 7 -5 -96 l POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page �, or ,__'2 FILE INFORMATION SYSTEM SPECIFICATIONS r Septic Tank Capacity al O Nil 0 wne P .- permit # �� Septic Tank Manufactur�lr ❑ _ DESIGN PARAMETERS Effluent Filter Manufacturer 0 N A Number of Bedrooms 'S' C1 NA Effluent Filter Model ❑ NA Number of Public Facility Units VJ NA Pump Tank Capacity aal ANA Estimated flow (average) gal/day Pump Tank Manufacturer N <. x 1, 5 Pump Manufacturer NA Design flow (peak), (Estimated ) of /da - Soil Application Rate s Pump Model 11I NA al /da /ft Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ANi` Fats, Oil & Grease (FOG) 530 mg /L 13 Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L .J NA 0 Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L C) Disinfection 0 Other: Monthly averse Dispersal Call(s) O NA i Pretreated Effluent Quality Y g Biochemical Oxygen Demand (BOD 530 mg /L .i In- Ground (gravity) C) In - Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA 0 At-Grade 0 Mound a Q Other; Fecal Caliform (geometric mean) 510 ctu /10011i1 ❑ D T Maximum Effluent Particle Size Y in dia. 0 NA Other: 0 Ni{ Other: 0 NA Other: C3 NA * I or domestic wastewater and septic tank effiuent. Values typica Other: ❑ NA I t rca f MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: O month(s) (Maximum 3 years) 0 NA (� earls) Pump out contents of tank(s) When combined sludge and scum equals one -third (4) of tank volume 0 NA At least once every: ❑ month(s), (Maximum 3 years) O Ni, Inspect dispersal cell(s) Iff year(s1 ❑ . p Ni., � Clean effluent filter At least once every: month(s) years) 0 month(s) ofi�Ni Inspect pump, pump controls & alarm At least once every: ❑ ear(s) ❑ month(s) ff NA . Flush laterals and pressure test At least once every: O year(s) Other: O monthls) ❑ NA At least once every: ❑ earls) Other: 0 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. Tanis 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_ ' i T he dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes es 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 thu immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third %) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at Intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 1 days of completion of any service event. C3MW IAIt) Page 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. 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(&) In one large dose, overloading the ceills) 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 arQZ1 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 ;;meayscraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the systern is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings �ealed, • 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.-- 0 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 _ Name S o, Phone _ — Phone SEPTAGE SERVICING OPER (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone �v Phane ,t ! "his document was d In compliance with chapter Comm 83.22(2)(b)(1)(d) &(Q and 83.54(1), (2) & (3), Wisconsin Administrative Code. i ST CROIX Ct) "UN TY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Tt vtA— o kq A (}u' Mailing Address EL 2 l L L EA T 4-4>/L1 0 I T / �g7 Property Address L o �� � � (l U� l2w (Verification r from Planning Department for new construction S-I- J"o sI,, k t 'dw laQ C City /State W LScd ra Parcel Identificat.on Number LE GAL DESCRIPTION ��gg 101 Property Location S ln.) /,, S E 14, Sec. , T 30 1 , • -R W, Town of 34 Subdivision ._-__, Lot #. Certified Survey Map # 5q 7 2 - c.{S-- , Volurie , Page # 3 Warranty Deed # _ JAS q 12- , Volur i 1 Z3 q , page # . `D 9 Spec house &"Y 0 no Lot lines identifiable hd yes ❑ no SYSTEM MAINTENANCE Improper u se and maintenanceof our septic system Y p y em could result to its rcmature failure allure to handle wastes Proper maintenan consists of pumping out the septic tank et/ P P cry three years or sooner, if n ;edcd by a licensed pumper. What you put into the system can affect the function of the septic tank P as a treatment sta in the was ;e disposal system. The property owner agrees to submit to St. Croix Zoning Dep: irlment a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pun iper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping I if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to mai itain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Departm ont of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed an i returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. rGlvA - 'q c� b / I -2 -/ 6 � S TURF 0 ��PPLICANT //--- ---_ -� DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the bes of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in R:gister of Deeds Office, SIGNATUR F APPLI ANT l (Z�y 6 DATE Any information that is mis- represented may result in the sanitarl permit being revoked by the Zonin De De partment. g P ffffff "* Include with this application: a stamped warranty deed from the ReI ister of Deeds office a copy of the certified survey map if r. is made in the warranty deed