HomeMy WebLinkAbout032-1049-30-010 (2)•'°° PRIVATE SEWAGE SYSTEM
uoetl St. Croix
Sadly and e.eei.a omen• INSPECTION REPORT
nn'•rvinal
624916
GENERAL INFORMATION (ATTACH TO PERMIT)
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Jay&Colleen Chambers
TAN OF SOMERSET
032-104930-010
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TANK INFORMATION ELEVATION
TYPE
MANOFACmRER..1MS
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TANK SETBACK INFORMATION
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PUMPISIPHON INFORMATION
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COMMENTS IInnwemeemwepenumpemna,e rcl Ilnepernan p,1�
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SYSTEM PLOT PLAN
Chambers Bedroom SepGC System
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CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name
Chambers A Bedroom Replacement Septic System
Divines Name
lay B Colleen Chambers
owner's Address
331 Rice Like Red
Somerset, Wl 54025
Legal Descrlptlom
SES/a, NW1/6, Elf, T31N, R19W
Tmnshlp
Somerset
Count
St Croix
Subdivision Name:
NA
Lot Number
1 Block Number
Parcel l D. Number 033-104930-010
Plan Transaction No.
Page 1
Index and age
Page
Plot Plan
Page
Exlsting Septic Tank Spedficatlons
Page
Existing Tank Certification
Pages
Proposed Tank Specifications
Page 6
Effluent Filter Information
Page)
Valve Information
Page
System Axing g Cross Section
Page
EZ Flow Information
Page 30
Management and contingency plan
Page 11
Septic Tank Maintenance Agreement
Page 12
Warranty Dad
Page 13
CSM or Plat
Attachment
Soil Evaluation Report
Designer John Schmitt
Jcnese Number MPRS 223760
Date 7/20/2020
Phone Number: 715-960-0186
Sagnature 1- ! /
tit C
In- round Soil Absorption Component Manual Version 2.0 S41D-10105-P IN. Ol/(l)
pap
SYSTEPLOT PLAN
Chamb
C�amDere4 Bedroom Septic System
room
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FWUu 16, 2010
WEEKS CONCRETE PRODUCTS
RAYWEEKS
102215TH STREET
NEW RICHMOND WI W17
Re, DescriptionSEWAGE TANKS, CONCRETE
Manufacturer WEEKS CONCRETE PRODUCTS
Product Name SEPTIC, HOLDING, OR PUMP
Model Numbe'fal 10M
M9 IN L L, 21 76 GAUIN., BC IN MAX DEPTH OF BURY 511 G P D WHEN USED AS
SEPTIC TANK BASED ON A 3 YR SERVICE INTERVAL FOR RESIDENTIAL
WASTEWATER, TANK DIMENSIONS. & IN L X IN W X 691N H I
Product File No Ol W0a0
The sped Wns ary0r FAans for Mrs pWmdrq Product have Mwt revg And OMntball to ha in compY with
chyken Comm 62 through Be. Wisconsin Administrative Code, W ChMM 145 and 160. Wisconsin SMWMe
The Department hamby issues n approval based on the Wisconsin Statutes and the Wisconsin AdmirnsVarvt Cecil This
approval IS valid bM91he end 01 JUNE 2015
The approval Is contingent upon compliance with the fallowing sllpulatlOnlsl'
This lank must M designed to withstand the Pressures t0 which it wit be suNlM
The manufacturer must keep at the manufacturing plan) a eel of plans and spedlicahons bearing the Weartment'a
stamp of approval The plane and specifications must N open to Inspection by an authorized representative of the
department
When this product receives wastewater from dwellings and Is used as a sepri lank, It will produce an effluent quality
with a maximum monthly average value for BOD50f greater than 30 me and ten Than or equal to 220 ml T35, or
greeter than 30 mil or lass than or equal to 150 mgh TBS. and F 0 G of Ina than 30 mi
Approval Is nsuad for this product As being aqulvalenl to a IIWr outlet water closer when the Ilatum drain is installed
in the ver ad season. The Wagn made the intent of s Comm 11132 (5) (c) and 84 20 (5) (n1, Wks 4 . Code, which
requires water closers to discharge through a minimum diameter 3' drain pipe or fining and 00 bowl To cool to ANSI
3landendA112.192M The intent M the Wde ¢ met since Iniz product provides the same lurtfgnal performance 6s water
classics that most ANSI Standard At 12192M.
BEOWNO: Bedding material shall Es. uss l to provbe a seldom Wool surface. A min. of Finch been Of
Mrrd Or granular pod On top 01 a form and uniform pace N recommended The tank Should not bear On rocks. Sites
whh high ground Water tables should have financially designed beading. Sells sheuM be canonical smash this for
This approval supersedes the approval Issued an 4/2112WS under product file number 200501N The Approval letter shall
be incorporated with your previously Approved plans anchor specifications approved under product file number 0050106.
Am of May 1S. ON, a copy of a Successful water tightness test report for this product must tea AVAILABLE FOR
INSPECTION AT THE MANUFACTURER'S PLANT prior to this product being used AS A POWTB holding or Metrienf
tank In Wisconsin.
The department Is In no way endorsing the product or any adventiekpg, and is not reasonable for any situation which may
health from its use
Sincerely,
drain MacCubbm, CST
En ginning Consultant —Plumbing Product Rwrewer
Commerce, Salary S Buildings Drs. PO Box 265E 201 W Washington Ave. Madison WI 5370gl
Phone- BD6286-0055, Fax E03-2834456. E-mad Jean MacCubdrYgWronemgM
SEO1056r{IN toff f kM 10001003D C
Pap 3
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 331 Rim take RJ., Sw aximl. W1 U025 located
at: SE 'G ew �/4, Section 17 , Town 31 N Range 1e W
Town of somercei , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes_ No_
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capamty 10eo
Construction. Prefab Concrete x Steel _ Other
Manufacturer (if known): weeks
Age of Tank (if known) O IMI
Permit number (if known) 3702M
64 (Xp John Schmitt a.
(Li need Plumber Signature) (Print Name
Was 223750
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and a. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
1 CASi-A-2µ
r UA
1 CASs-A-3AL
I /'L-
TILLER CR BAiRE
I92._MEW
®""
W320-MR
TANK SPECIR ATIONS
MMENNp
NNL 3'
WREN S
COLER 1'
MMHN N' 10, MECAST CpIC M El A
HDp E SB' 0.U,
IEMfTN: Bo- on
MIoiN W. 0.0.
mow RAcr: w 1�- O.o,
L LEVEL U'
MMIi: 3BB0 185.
WET A WHET.
1' UV-A-W& 9Wi pt EWAL
CA¢U. CAST-A-Y MR M EWK
WI£T. MT BY u fI
SCWSIN. m Cr ro
(0A MA WE O n
UWD WARR 80 GAL
LOA Cf9Ej1: B' W VMSATR M S
TN Cm BE OBEO M.
4 M/ 1101bN'/ R m 9
COMA- MI E 9 R 1p f9R)
iAKK wxAOESW no SIRVCIURK i1MA)
WSTMM TA &
FOR WSR TA C TACT W4 p]W,]RIE
FOR APPROVAL
P�AL MR
MAiTz WM n:
PDLY�9lC;
Q3 /eat.
PL525 Effluent Filter
I'L--i3 kAer
The PL-525 Filter is rated for 10,000 GPD (gallons per day) chalung it one of the largest filters in its class It Ms
5B Weer fast of 1/16- filnadon gets Like Ole Polylok PLlk the Polylok I'L-525 Fee an automatic shut-off ball
'mulled with every filter Wfim the filter is removed for cleme,& the ball will float up and temporally shut off
the system se the effluent with I leave Pe tank
n Fund!
Inb' Filrcafion Slots
•
• Rated for 10,003 GPp (Rallmu per day) a"'"es'
• 10,000 GPD IOpXeniO
Arreptearleer 6"SC"D40 Pipe Antrim, I -evC
Aciepe 4" and 6•' 5C11D 40 ptPe P comb IhMk
• Built in gas aenermr
• Automatic shut-off ball when filter is removed
• Alarm accessibility mlel br
• Attepb PVC extension handle 100%rGPO
P1-515 mmullalion.
Id♦W for randential and communal waste flow, up to
10,000 gallons per day (GM)
1, locate the outlet of the apvc Link.
i. Remwethe laMcover and pumptaM Jrecessary
3 Glue Ox film housing to the K or 6' outlet pipe 11
the film is not center H under the seats opening use a
Polylok E,tend & Lok or piece of pipe to ,met filter
4 Insect tee P1,525 filter him its housing
5 Replace and seaare the septic lain cover
I'L-iE5 Maintenance
The P1,515 Effluent Filters will operate efficiently for
several yea under normal conditions before maturing
cleaning It recommended Wt the filter be cleaned
every, ?UTM the tank as pumped, 0, at least every three
years, If be installed filter contains an optional alarm,
the owner will be rubbed by an alarm when the filter
t Nsswtcmg Servicing should be done by a cued
aryM lank pumper or imuller
1 Locate the outlet of the septic lank
3 Remove lank cover and pump terik if inerrancy
3 Do not use plumbing when film or removed
4 PWI 1`L525 cartncip out ed 1M dousing
5 Hose off filltt over the septic lank Makesure all
solids fail back into septic her
6 Wen Os, filler counties back tom the housing making
were tle film is properly shared and completely deal
]. Replace ared secure scene tank cover.
KXO W riper
am Alt/16- 1
FdamenAm
® sseaaa xKl as
i
F'ok* LW a M romance �Y astab
w swriJ mwiwW aWm wmeryanas
Poli Inc. 3Farheld Blvd Wellmgf9rd, CT 06493 Ul Free gF 965.95M Fax 303]84A514 www.poMok tom
Page 6
glean—F-
t�aenwX C.doY FRYN puweeW
v I
E110ry
TFe Bull Runyst Valve" Is designed to spite flows of amMIC
ngerflelaa or systems In aion it i to Me ost pu lic h al longsWallifeana eg dIvice availn Is Ina moatpummr dissera apemeanp device avahas m. wy no car ct witl
appliwasteationswater Tea th nva ebsow k-p n and ex rnalwastewater are to me . The hande ana om neoperating [Feto a notherc TM1e ccompl ov r team oarminut flela i0 anoMrning he a aloewiShedhou In less Ma^W
nine by simply turning [M1e valve without digging or
contact with wastewater The Bull Run Valve k available In a' sGl 40 pvc
and Is suitable wherever up[Ic dis mi systems
- Inm rvmemal. Industrial, and
resused
idential appruaone
OPERATING THE VALVE
FeY
Few
The direction control handle should be related
No I
No 2
periodically to direct effluent to me or Me other
of two septic fields. After removing Me screw up
at Me top of Me riser Nde, Me valve handle can
0
VtlR
Be named Arm Me valve key fumlMed.
Poo am1
on No 2
BULL RUN VALVE
dunng
Complete Valve Kit
Sal
Employees
Contains
Tcog
I. Bull Run Valve body
Tti7
"M�
SWILL Ri VALVE a KEY Oft,
MMMMA
Wu WX vxH RIaB�w/r/Sl(gEa
m
MU RUN VALVE KEY 28-
2. 28- Valve Key
D. Rlur Cap Adapter
a. WaRrtIght Access Cap
BRVC USER-d'
ADJUSTABLE TO 28' HIGH
IN -GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down -sizing credit)
n cmF
TYPICAL TRENCH
PLAN VIEW
eaem T. P)ir.�sa..
Weeks/Meser Concrete
sr.. Tr.wwi.�.�.)
1IM Ia 320 a
ETun FYW
PolNdc
o.N Evrims 525
OBSERVATION PIPE OETNI
Maen
(NO Scalea-O) Peftmw Lateral y ob..aom npe 10 fl
ltYgmO Imlre Iw�li
__________
B=�R —� IT
W
Prl O
INSTALL PER TRENCH. EZ1203H Bundle T
No I) A
8 Mftlunde G NEISANut=450 M YMNb/IMi
vrr w�renrir.xrA.ra.en�ss�
a Sfl WMea®35N EIBNUNt=�fl'
=PIOPMBCEISAMO =450 II' Rmiuimd lMimmon ARJ= 857 fl OIStnLulxin l eMcj.
x 2 trendies = Proposer! Total EISA = 900 W branched manifdd
RESET
Installation Instructions for
EZJhm Systems in Wisconsin
...............................................
Amoonsln oepanmem of Commemq eatery a,o emmmgs
[gotten, has rawewed the mach tlmrvs and/or plans for this
product and determined it to W In compliance wM chambers
Comm By though At, NAscons, Pdmm Cade, and Chapters
145 and 160 Wearer Statutes. All wbes must mat the $dg
irS^fndsto fyLocatoroilleopondelenchisannotedon
I regulators
The approved Amount are 1'p3H (3-IT bundles rnM pipe n
center burden 5or 10' 1en911u) vq 1 239HP (3-12? boundoes
wpm pee in maker bundle in 5' or IO'tergms.
A single pipe bundle romans a thus mer pedonned pipe sur-
mounted by EPS aggregate and is held togmer mN ply
mr rm ing, A single aggregate bundle contains aggregate
only and Is held together you polyeAykne retling
MebrletraM Bqulprrrant Needed
• EZWow Bundles
• EZAow GeNeatlk Forest
• EZAwv around Foe Gwlflars
• Fes IN Header and Inlet
Sa deroetEWcavamr
1n"Iffir ors Instructions
The ressuchons for mstolinkin of Utum, products are given
bi This post must be installed in accordance wth state
miea defiwucro ned in matters Comm 82 through 34, sm Ad-
m9reMeCade, and chapters 145 and 160 West bell
Goes, as vol as me Ii heath department's currant desgn
manual
1. Ater the bral Goal department has determined sting,
cmPguretoq and leymt for me E2flow systems, make
or mark wth pant the settle, of trenchem and lines Be
careful to eel comet tank, invert pipe, under line or dis-
amen tors and tench bottom Wervatom before insmt-
lmen of pipe bundles
2 Remove PdmM EZflou shipi bags poor to phorg
Handles in me hersch es) Remove any Gabon bags in the
open betook ryakm s boosted.
3 The pr duct fruit have geomNik Word that meets so
gmrements of s Comm 84 W (6) (g), Ws Arm Code,
mseded! diazi on his of the prWut and extending
Work, among Me Wave of the product to a point it Most is
aches from to bottom of product.
4 Men naboll" in a tra O the terom should be dug to
a Width of 35 ncM1m This not only saves bet Worse, -
ton, but also Worst teller bad -twang aspects after
ba?filnng is completes
4*EZfloww
.,Ironer R
................. 6 ................ 6 ......
5. The Almrytlon area (Sip necessary for a given site shill
War mad board on m si nnum day Wool few (GPC) and
the Perm saEXity M the site g tartan cd4re s met, the
EIS4 sizing con he used In Wisconsin msuning in a 40%
smeller drowneld
S Place Ullow bundles) in the EZflmv mnfigural ap-
proved by system design permit spoof for he kwhou-
lar site The hp or conk most bundles contanug pipe
are laved and to and ogh an internal post counter Any
additional aggregate any bundles that may be regaled,
should be butted against the other ag9regaleanly bun-
dles antl do not barred Work type of connection
Y The top of ter MO cylinder minims a filler more pre-
anufacturedln�nereM ga ngregete the
form Is named to Warrant Will mWnon, The Installer
shall make sure the the GEO a poraliko d upward and is
in contact with me feint contionod in the adjacent ry11n-
der befog bar}eovg
E. Mar EZaow Oreklleld systems should be imbued In a
most harsh in all urethane Oxon across We aM9 the
trenrnbaftom)and shoummuowthe conkurame ground
surface eardston (morrm depth), with col continuous
adfouvy 10.1aot cyiMnal bundles pacef end to end,
Wild carnal bundle dishibuWn paw ImercmnHed,
wnham any dams, retention aeither waNn amps
9 The tench top shall be Posted sucM1 that wafer vall not
pord BrkAll shma be, seeded a sodded immedmely
after Gumaedan to reduce erosmn
10 EZflow EPS bundles are Worlds and can fit In nrnM
herchas W maybe necessary to avod pees, boulders, a
other sometimes
11 EPS aggregate re lighter than water, therefom, it might
be mxpanted that regard buoyancy fortes would tend to
youssm FIPow assanNirs to Wont but of ground whan
pmMing ozvrs. Field erpe rend War sM1avn, M1wmuer,
fhat this is not a emblem when die ems M1m a mintmum
W C W Will mover or recommended by manufactures
........................ 6........... 4......
Page 9
PAGE 4OF4
In -ground Gravity Management Plan
IMPORTANT:
The owner of this Inbound gravity eynbm atoll he responsible for is pe peWel operation and mainterunw pursuant to
requirements of SPS 382-381. Wisc. Admn Code Pursuant to SPS U3,52 (2), Ww. Admin Cade, due system sell
Ce conzdered a human health hazard it not mentioned in accordance who does apto management Nan.
Furthermcon all inspection and maintenance activities snail be performed by a registered POINTS Mtlnto in
acwNance with SPS 38352 (3), Wisc All Code
Maximum Dispersal Mae Operal Limits:
Design Flow a 600 god; 90055 220 irl TSS 51fi0 rryl FOG 5 30 no
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
age of system
nuisance factors to e were beer compwnis, etc I
meClanlCN malfunmm (l e, pumpy veo watchm. noata. etc I
material fehgae(1 e, Cei durable, common etc)
o solids volume inwasrMic treatment tands)and any pegboard appuneworcei (I a. disnWnom l drop town)
o nplect«imVc use(L6,"coWngd"gnc"ateepmhmiMaalvmef,arc.)
extent of pondmg in distridi cell m'orto dosing
o III geguledtles-Ifapplicable (Le., pump ter-cyumg, noel swllcn swings etc.)
o NeMwlcomponenls-Ilappllrable(Ie.."king,mnnedons.swllces,wnV s.tlmen,al"S,efc.)
o defraWmlaleral or lelVg cnlm Countingmwwure hit"60el peawre- compart W dmlgn pWA m)
o Surt pscharge A effluent or sewage back-up Into Structure served
Maintenance Checxllat MAINTAIN EVERY 3 YEARS (or when necessary)
a Seot c and dose tenklel shall be pumped by a Counted saptage servicing operator Ilcensed under 0. 28148 Wis
Slats when Ste wilume of "lids In Me Ynk(s) exceeds onai (113) the IIpuld volume 0 Me to a
83 required by local o dmance. C epafal of contents small be purwanl to NR 113 Wow. Mmin. Code.
m Effluent Mail shall be'repMed awry 3yeam aM&Wl be planned wM1" necessary to ranwa wry
a�muletWwlidsacwrdiNtomanNaCtuWsaped tams AwrvlargpnMwllalwaysegr"ter Menl2
months
System maintenance repents shall be submitted to the proper loin geothermal unit In accordance end
SPS M.55 YR". Adman. Code. Report any c Went Callum or multifunction W:
Name olnaavidual or company Schmitt& Sons Excavagng, Inc. Phone 715-760-0486
Local government unit St. Croix County Community Develapement phone, 715-386-4680
Lpr lgwemmentumtwm , 1101 Carmichael Road, Hudson zip 54016
Any efecova pan or this wdo Bell the persuaded,r"i . a rw"rB5 Audi to SPS So(1), Wisc. Adman
Code.RopeirwmOawmenlatklWmmalNncMingc Wenbshaiiwmgyw SP5303, Wac.Mmin CWe.
No Product for chen i or physical reslpraton of Me POSITS maybe used unless approved by the department In
accordance wIM SPS 384, WISC Adman Code
Conenpencv Plan
In Me avant Mel any rated! VwMent comparenl of Mae POWte cennM be reduced, It snail be reNaced punuam W
a plan submitted to the appmpele egenry for rime"and epproad A failed nground pspersal Component may be
abandoned and replaced by a coda -complying dmpenel Component In a pre-detmmined area M suitable sells
System Abandonment
If unit of Mls POATS is dumenuM, it shall be abandoned in accordance wed SPS 311 Wed. Admin. Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerlBuyer Jay & Colleen Chambers
Mailing Address 331 Rice Lake Road, Somerset, WI 54025
Property Address 331 Rice Lake Road
lVarifonion rcquiM room Plennrng&2onrng Cepanment torn rumronl
ot,,,,,wSomerset, WI Formal Identification Number 032-r1049-30-010
LEGAL DESCRIPTION
Property Location SE it, NW u. see 17,T 31 NR 19 W,Townof Somerset
SubJlvislon Plat: Lot# 1
Cernfted Survey Ma x 9G4}S4 ,Volume 2S" Pi 588.E
M4r++u
3pmc ZD= 4
y Deedp 91?1'4S (before 2007)VolumePegep
some house Dyesrdw Led lmu marionette 00yosorm
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use end maintenance of your sepnuystem could and in its connotes ran=to handle wares Pmpee
namesmaintenance ofpump'ngom the septic tank every three years or sooner, if needed, by a licensed stoma. Won you ut mo
the system an an the n of the septic mnk as regain the waste disposal system Ownermamurenceandsfuns
tergruidlon s ere e}'crfM in pSPS 181 RII) end io fbapler 1E-St Cmu Coumy Sanitary Omrnxe
The pmpoMowumegmamymen uSt Cmrx mcd pPlenmmg R lomng simpleecraanrfintwnhe i nerietl bytM
and by a mavq plumber. journeymen plumbq, rero-iged plumber or a IimuM pumper venymg that I I I the ororne
iowzh tl1 tlfgol's1m, ismptoperppetating condition mdlar(3)efltr inePectlaneM pumping Uf necemryktlie zPoo un4n
.. m.n to mnonlaege
It". the undersigned have mad the above rcgmrtmmrs and agree to maintain the covets sewage common system with the
undemssnforth Mmin,esssbythe Depanmemof SaRry And Pmfeesronal3eavrcerandthe DeWmemofNaWt Raoutaa.
Suteof1hnwmin Cenifnimn swing that you, mum; sysem has ben mnnnaed man be completed and assumed 0 the A Lloix
( mm) planning to Zamng Depnmem within 30 days of the name year expiation date
I ewmfy thin&I summenn on this farm am we to the ben of mylom kmwledge I/we sedan the awnegtl of the
format, denounced above by finite ofa wamnty data sanded in Register arIXe4 Win
Numbe a16Mr m
lR< /1I Jay_ ry��1��Lo
IGNA'IT1RI.Oh APPLIC'ANT(S) ATE"
"'Any tell ... a use n innmptnemed may rain in in, ammry petmu being revoked by the Planmrrk R Zoning Neutraem •"
Indutle wnh NIS minimum s mini wnrrvnp &,it room Ihv Regrrtur oI Ideas Vmu and a com of the cenif el rurvry man if
,common a made in ...may dma
(REV. Plat
I ,
C@patin6NQ1
y Sit"�°:
a SdIL E
aVA�n@T
! p F i5elwgsf en`
And
m r e 'mn.amine
Moen RW Amfprmaumn
CnamMre. Jay 6 Cmlaen
Portnoy dmkn Mnnnq Aemese
331 Roe Lake Road
cp -. - Bosh Bacot —PMnn Nomper
Or contemn Jet Panel Nunbi 0 MMmo
ww�..l Pmr<d wmm.rdn ono
Peremmwnei ount(RuW_wo loamy land)
xnral¢mmenb RepaAngnl Real sways ld amnrmlma sso
lid e2065
Peak I or ,
SL Crov _
Fellow D
au-twa3G.61G
Lot SE1N NJJ1/1 517 T31N R19W
ep6, SOW. Name w CSw
1 CSM2&MW
Cm vw9• *nn freemen Road
wft
S��a° got scM1 mom^PNrIII el yemo u.'onedeemel n
I /.za. r .c, MM.R f i.ar _
. Borings soon • < d_
Of Grou 99 R
Horned pear
Commend Cuv
RWm Carolled
Tennre
Structure
COOHIll Solely
Root
GPGm•
In
M11114111
Gu Sa Coll Cow
Gr Ee BX
dark, Emait
1
0.24
IOyr3/1
done
9
Intel
mir 9w
If
06 10
2
24A5
Igt3/9
rear
Is
050
ml �r
2m
0J 16
3
45120
10p5/6
rear
s
Os9
mI —..
......
02 1.6
F-2]wneak
Sonng
PA
9228
run
wgnl xmn'CedenYrm
ryhtlo 120,
SaI
IApMN
pepX
wn Cow
Red" insurance
Tamil
Suunoxs
Bourbary
rear
_ _ GPGT'na
W Sa CM Call
Gr 4 SX
1
022 _
Litm
9
_ 2ms[k
Orgw
if
0.6 10f
2
2210
1(tr
mrG
h
N
All chv
2m
02 16
3
40120
10yr5/6
none
5
(ag
ml --
--
02 16
•eCO Ip<220mpt eMi53>]0 <rl0 neat ' Earned 62•BGG,� m my. eN i nWmeat
CST Name lEYare Pmll S~ CST Feet
M iIMe6tlJ. 2224M
Adder+sn.ee sW Tetanalme- — , p.l. E.".w ea.e.n.a - .IePXrr�Nwne�
INl I2W 61 eM Rnnmaa wl N011 711"020 71S26y1924
prceem Ownn Iona ;_]aI COlken pPlmnot 032104i30-010. _ ._ pe" 2 of a
nFor. I al
-
, o MSbWnRY
'ale[^
6mrn
am Coy
orgwm�w
enure
4nxlwe
LonuMno
bvCerynRI
Se Carl CWr
Gr Se Sn
_ _NON
1
0-19
Oil
none
9
2m
m 1,
gw
1f
0.6 1.0
2
19 33
10p319
none
Is
any
ml
on
spin
0 ] 16
3
33120
10yr5/6
none
s
Osg
ml
--
---
07 l6
F41
ameremitp
Re
Gonave 1110*1
96 B]
fl gpm'0
emunS reI
lDI
m
SaY�lppre Re1R
MONm
NPIP
Control Cab,
er g s[rpnon
aSa
enure
SLVWS
LomnYrce
fiwMery
G7
In
III
Ou Carl Color
Gr Si SX
_
1
0to
10173/3
none
at
2mgr
mM
as
2N
06 1.0
2
1032
1017411
rode
sl
2n
morn
9w
lvf
06 10
3
I2 lG0
I0)(116/4
none
s
Cm
ml
....
_.._
07 16
a
Sorge
Mail
PX GmwO"I euv
9] 1]
fl Ceplfl la lmXlnp lerKK
}W e-
In
SOP opplolpn Role
Hanson
seen
Coll Carl
migion
anon
spol
m Cmlem EpaMery
Gl
no
M uneell
0. so Cons C
Gr Si an
I
0.16
1(yr3]2
none
sl
2mgr
morn
AS
2N
06 10s
2
1632
10yr1/1
mfe
9
2nupP
m r
Ow
1N
Ob 10
3
32i00
10p61R
s
Osg
m
07 16
EflMnE1. >N<YA^W W169 Lot. IN ^GM1 'EMuenIO.Bb.. JJ^K eM ISS <9lmyt
Xc IkiliOf Comm.m f. an Vo.l l op pmonIII r mNcr and ILL In ounml a .... mm'e 1,form
rl ml in an alnoou.W...I Poll aa..nnu In' 0.Mnm.m 1 niP.nry :11I or 11)Nrb]NP -
annam W pram II
Jaya cabers cnamee,a
JJ/ aim Lake red
sdna,sat. W sxozs
Pio 032-1049aon/o
SEtI< NWt/6 $P TJiN F19W
Torun W Swreeaet
Centludetl by Tlia�maa J/$�mM11
CST M429
]/152020
Tx
G
x
I2u'
BMt o�, Top o/Eusi4ng Sane Tank Cower
BM 2 9C Ot' SeWhc tank mllel Poe
st croix County, WI
Legend
contlnnea law
!
~
�i..
..
i �
H
d mn
is
�0
.� .
,,..
.�
,l.
,.�`
i
r hoor
Dmmosm m mmmame
smmy MauMnae D.uelo,
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION
fATTACH TO PERMIT)
peraw lmwmaem No, pow MY or br
xxn pmae. I'mxY law. a 15.IN rival
Olsoq KalAmrip
Somerscl TawnsM1lp
me
rP2
PUN -
TANK INFORMATION
ELEVATION DATA
CTE
MANUFACTURER
CAPACITY
STATION
Semis
r,30,1114)WA'
Benchmark
Dow"
Alt BN
AeraLan
Bldg Sewer
Holding
St/HIT mles
TANK SETBACK INFORMATION
iVln outlet
TANKTO
Pit
WELL
BLDGIta
An'Tpzp
ROAD
Of Inlet
roSO,
$Dr
;L( S,
I
NA
OF Bottom
Dosing
NA
Header/Man
Aeration
NA
Got Pipe
Holding
Bar SyAem
PUMP/ SIPHON INFORMATION
Final Graide4re
M
Manu rNr
pain
St Core
Model N
G
TDN I ❑
D R
F am
Length
Dig
o
OILARPTION SYSTEM q pjn
,�
y(
a
iT SOILCOVFR
arms St, Croix
w!l or
032-10
0236
9N0�000
RD
arg
Ni
orr.0
wwo
MMEN
SYSTEM TO `m
V/L BLDG
WELL
TAKE/STIR
IFACNINO
i war
SCT9ACK
CMAMRR
INFORMATION
v
Sr
yam,
DR UMT
swim
ez'
DISTRIBUTION SYSTEM
L
w•
>^SO'
K Pressure SysLma Only as Mound Or A\hGradef Systems Only
wamw.r
Dpme of
se.d.ersaa.a
mD
..w.r
FINr DNo
DY.1 Na
COMMENTSImdoder code pesxtp errspe ITo�i2(/s�Lo3312icc "So Rd.).W5 1 to col w. m 1
"
I ) AltBM Description [y V ur.h�} �CTVJ
2) Bldg r length -Z
-mmunt ofcover = is 'r
+s.:Q ra.wv�.
Plan revision Featured? ❑Yes Ib 01 - 71 YLG
dreamer o
side for additional information
SBDH11D lR.sary DA, impmorrvSmr... Cenm
SaM1ry am WastesDiwbn
fOO/U/II SANRA ATION NBIwnmamam Amosat
PC Wo,
• Attach complete plarm(to the county capY.6nirj far otlm caI
tlUnaln.11 �acnesinux 'jj �� .
RIr C
0 w a.r.m,yramaaa
• see..rer<xee3a.rmwmwgfor(Mn okkkk
3}z.s
a(
T SL
PemxMl hlann.am�PmHMm.,Mw.aM_ yds.
IP,mryuw.. n,lmn SDYh Wnioryun
3 zPp'�6P'L6
a.LM
T
� A� der
ro N.5 / i .NrR F(Orl.MI.419
--/vnomrvum
shall
a
sub n�wn ho umbr(0Icheck
one) ❑51we Oxnatl
C%rdaic
FMI.419
lor2Famx Dwellin Na of bedrooms��INGUSE:
Rr WilemgaMmwblcmm.Rtbx,pgPl PanYTa x bermas2-p49-
3c- I
ment l Como /.2mbly
Hall 6❑Metlical Faolity/xurvrp Home 10❑ WWaor Rneational Facility
PoaM[M ]0MarclwMne Sales/Pepin 110 Restaurant/gar/pnirpm
ISchod 8❑Mobde Home Perk 120l
l Motel 9 ❑ qba l facts 13001her vury
IV. TYPEOFPERMIT: ICM1eckonlyorrebo(onlineA Cherckbaaonlioeg,dapqueblq
A) I LINew 2 0Repla(ement 3 pReplammenl of a 0Rxonnttsion of 5.❑Repair of an
_ ____ 5ptem________ System............. Tank Only__________ ___ EvstnySystem_..... ... Enslmy Sysem
8) ❑ A Sanitary Permit was previously issued Permit Number Dau hs
V. TYPE OF SYSTEM: (Check omyara)
Nan P,euurizatl Oirx,bunan Areas unzed OrsMbu[wn Ecommmiriml OMw
11 ❑Seepage Bee 210Mound 30 ❑Speafy Type al ❑Hold, ng Tank
12®Seepage Trench 221]In Grouts premium @0 Pat Rrvy
2
13❑Sectors Pit �3 K.T7 430 Vault
1405ynem-In.FIl A
VI. ABSORPTION SYSTEM INFORMATION:
t Gallons Per Day 3 RbsorV Ar(a 3 Absop Area a. Lwdmg Rate 5 Perc Rate 6 $"ad 2 Final Grade
ryurree (sg h1 ProposN lsp hl(Glowagp hl (MindricM1) FUraow
e• FM
ANK
VII.I FORMATION
Cal
H�galpE°tr6�
GalloWn
Tanis
M•nalactoeisxame
°hbw-
sued
y„�a
Mk4ank
❑
LkftP❑
Vlll.r RESPONSIBIL" STATEMENT
I, the undersigned, assume responpbHHy for nstallauan of the proud sevage System Shoals on the attached None
rill, annO bertAgmlvn N Par
n.xumM
)/s s ccs
umbers Addeu Rrra Zp'( al
IN. LUUNlYiDtFAKIMENT USE ONLY
❑Disapproved Perron ram ^^'^
: ^m22S,
sound
xa ImeMaSumpy
W(Approved
❑�reei oelerm�nalbon
aoa
00
X. CONDITIONS OF APPROVALIREASONS FOUR D/I{APPROVALt r. W iv" aye a.et r e
•ehyuhl,m/4.
/�( i.�:..
u��+ma c. ns 4w5e_�le
sE s1.�c1 sFaed yl
d® nN Mrw oYaursxrarr rr