HomeMy WebLinkAbout020-1112-50-200 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, is 15 04 (1)(m)]
Permit Holders Name. City Village Township
Mark Johnson I TOWN OF HUDSON
CST BM I Insp. BM Bay IBM Description,
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Wt �
1 Z o
_
Kf
Aeration
Holding
TANK SETBACK INFORMATION CbWrS DU h�UJ
TANK TO
P/L
WELL
BLDG.
Ventto Airintake
ROAD
Septic
=x�
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Nu ber
TDH
Lift Z
Fn tion Loss
Sy 64em He
TDH Ft
Forcemain
Length
ia.
is to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 1 L ngt17 •�� No Of Trenches
DIMENSIONS (N� -3 w
SETBACK SYSTEM TO PIL I BLDG WELL
INFORMATION Type Of System. r
�, a l >zs' z9" -2so
DISTRIBUTION SYSTEM
TION DATA
County. St. Croix
Sanitary Permit No.
631264
State Plan ID No
Parcel Tax No:
020-1112-50-200
Section/Town/Range/Map No
12.29.20.458A-20
BS I HI I FS I ELEV.
I • `_
fa1.5
1Do
Alt BM
Bldg. Sewer
St/Ht Inlet
SVHt Outlet
1
Dt Inlet
DBo
J0.�
p
i O
O� [
I"7. 7
Header/Man.
l .
141.3
k
z
Q 3.3
Bot System
t Z
. Z
4 3.3
0�
Cover
-611-1-2-1 1,/1,3
TZ-7. z f1{,
(.)1Gtmr 1Yl S f-3 7 •�1 RN.I
CHAMBER OR
UNIT
n Yr-t
Qv�Gt
Headeru mfQlPo� 1j
P1 r �4N
Length Dia
iPtnb' hon
Pi
ID
Lengtgt h Dia Spacing
x Hole Size
x H acm
Vet to Ai( Intake 1
N c11.. 4Si
SOIL COVER
x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
BedlTrench Center
5
`
Depth Over
Bed/Trench Edges
1'Z 't
xz Depth of
Topsoil
xx SeededlSodded
-
xx Mulched
- Yes .- No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I Inspection #2
Location: 1056 HWY 35 —pvl vA� UVI) I ( ko,-A E,J _1
1.) Alt BM Descdption - Bo 44M l y kI-, .� V A. 1�N ) Y�5 1'G7 l I(.0 •I..O VSC Q �l5 T� {h� �%yl t 1'1 �
2.) Bldg sewer length = J
-amount of cover=fix\S 1 ,fir,
Plan revision Required? ❑Yes No
Use other side for additional information. I (/%/��_--- f "•II
SBD-6710 (R.397) sepclors Date InSignature Cent No
0
GA -AI - 2.oZ I— oL/ -7
S'
1
i� r
Safety and Buildings Division
County
{- r
201 W. Washington Ave., P.O. Box 7162
Madison, WI 53707-7162
Sanitary Permit Number (to be £lied m by Co)
anitary Permit Application
an Number
In ce wrth.SPS 38i ? 1(2), Wis A Codc, suhnussuon of tins form to the appropriate g ental unit
is quired prnh to�C `ias No¢ forms for POWTS
Prolea Address (if diffcrrnt thou mailing address)
,g.(t.sagl(�y ,Application state-owned are submitted m
the uo SRVteS. Personal inforrnatton you providt may be used for secondary
m accordance wfth the Pnv "Law, s. Sow.
J
L A lication Information —Please Print All Information
Property Owner's Name
Pw=l 4
Properly 0%=e /ss Mailing Address
Property Location
�' z0
Gout Lot.
v/
Nt,J��=
Cm State ZipCode Phone Number
_
<.�2_
H. ype of Building (check all that ? q
"tide �07-N
T_LN; R E C(w )
apply) of
2 Family D Ihng-Number of Becrooms I
Subchnsiou Nam: �/
Block #
El Pubho/Commermal- Deimbe Use
-
❑ City of
State Oxncd- Desmbe Ui CSM Number 39R'B'7
❑ V,iilage of
ZC>/U
�Towaof
III. Type of Permit: (Chxk only one boz on line A. Complete line B if applicable)
A
Re lacement S P yst.>a
❑ Trea®rnUr7oldmg Tavk Replacanrnt Only
❑ Other Modification m Existing System (explain)
B- ❑ Ptutunt Reffmal
Perms Re mion
❑ Cbmge of Plumber
Perron Iransfer to New
List Pr us Perms Numb d Date W�3
Before E uatuort
i
/J
FV. Type of POWTS SVStem/COrnonenuDevice: Check all that I, G
Non-PresRau1Wd In-Cnoun ❑ Pressurized In -Ground ❑ AX-Crade ❑ Mound > 24 m of suitable soil ❑ Mound 124 m ofsunanle soul
❑ Ho amg _: Other Dispersal Component (e ) _ Prmcarrnmt Dense (esflam)
V.Dis rsalfI rea ent Area Informadoo: i'LG L
Desu Flaw gpQV Design Soil Apphcan Dlpenal Area RN (i I Dis
Q persal Area Pro (sf) Svstgn Elev
/Z
VL Tank Info Capacity in Total # of Meoufacn,
Gallons Gallons Units 1 r] -:
New Inks Easong Tmis 1 CXt6T .% A—L LI�� '\ v
o == v a s
�Jk� c zr+Lcl l/ v A
TT i:J wP in r;7 G
Sepuc a Holdtag Tack
,
Dosing CLambv
VII. Responsibility Statement- I, the undersigned, responsibility for installation of the POVM shown m the attached plaas.
Plumber's Name (Prim) Pl Signature W/111PRS Number Business Phone N ber
� l
Plumber's ess( Ctry. tote. Zip )
%Street,
Countv/De artment Use Onl -
tsV1p�IIIL
Approved ❑ Disapproved
\
Permit Fee Date su
Issuing Ag igtature
❑ Owner Grvm Reason for Denial
SZS,nc�
VL Coadkions of Approval/Reasons for Disapproval 7J t fµ . 10 s
SYSTEM OWNER V T /�•t5141 V) WlZ'e e%� I S71'I ^C
ry
Septic tank. effluent filter and a�. a {�^ibd oF- r-e, �- J `J
dispersal cell must be serviced / maintained A ( OF
management plan prevld ed by plumber. � �r�/•y Lfms 6��� S�u-`'�/7-(':/!•�d p�'e�
as per
i.)SCC 1�9 raN40ri�!!�rfT(rp:ih?.aa;pf re
} Pr SBD�d g8 11
re�rd: oQ� Q
%AWO K.l W A
`j> �+�s�a �4r tit f/S� Pr.vj GEC S�/S✓•er� s't'tA{t yl r/erutvtlC
!Yl{p t
otA 2oo3 Sett 4e,4) /' /
Y
ST. CR lucasY4iz SANITARY SYSTEM File useonty
OWNERSHIPIADDRESS FORM CreaW ZRO21
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of your new or replacement sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email.
Owner/Buyer /)/4 i k l I/-{ T
Mailing Address
City/State/Zip 5
- { Phone Number (required) t j
Email Address (required) /i)c
Parcel Identification Number tri0�[,�^ Sy
(found on the property tax bill)
Property LocationR/�'/4 ,�1/4 , Sec.I? T Z-j'N R e--3W, Town of
Subdivision Plat: �,—
Certified Survey Map
warranty Deed # _
Number of bedrooms
rZ.
Volume /57-� Page
2006)Volume Page
Spec house O yes O no Lot lines identifiable�e4ifttts-
New Property Address I ('- KLX i7 /V
e—efiitatwLjn new address required from Community Developmentw Department for neconstruction)
3 / (
(Staff Initials) (Date)
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified
survey map if reference is made in the warranty deed.
Community Development Department - Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 fax
cddPsccwi Gov 1101 Carmichael Road, Hudson, wl 54016 wwwsccwLgo
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi54017
715-246-4516
Date: 3/3/21
Owner:Mark Johnson
Location: NW1/4 SE1/4 S 12 T29N,R 20W 1056 Hwy 35N Hudson
Manuals Used: In -ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cros ction
4-6. Maintance ontigency Plan
7. Filter Cros ion
Signature
License n ber #226900
System PLOT PLAN
PROJECT Mark Johnson ADDRESS 1056 Hwv 35N Hudson Wi 54016
NW 1/4 SE 1/4S 12 /T 29 N/R 20 W TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 95.0/94.9/94.8 4' below grade 3/3/21 BEDROOM 4
DATE
CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1216 # of chambers 60
, BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION too' Filter Lifetime Filter
❑ BOREHOLE O WELL -H.R.P. Same as benchmark
Vents B-2 Vents Scale = 1 /4" = 10'
Scale = 1 /4" = 10'
1 % Slope To Highway 35
60'
B-3
See attached comments
0'
B-1 3-3' X 82' cells with >3' spacing
5' 0 10' Vent
10' 15 >6,. Quick4 Standard
20' 1fY of Cover Leaching Chamber
Valve with 20.0 ft2 of Area
ST 5.6ft^2/pair of end caps
4' Long 12
B.M.* 16' 34" Grade at System Elevation
40' 20' 85'
Well
Existing 4
Bedroom House
M
4
Property Line 5
�f 3
All piping shall be ASTM SDR 30/34, within / ST
10' of tank, piping shall be ASTM F891 v�
Cross Section of Quick 4 Standard Leaching Chamber
Typical cross section for 2 of 3 cells
Quick 4 Standard
Leaching Chamber with
20.0 ft2 of Area per
Chamber ttA2 pair of end plates
(' 6
Typical Installation
Vent All Grade
4 �30/34 Septic Tank
4' Lone 1 5'
Spacing_ 5'
System elevations:
A 95.0'
Grade at System Elevation
1N
To be >1' above grade
Finish grade elevation
99.0'
,Vent
I"
at System Elevation
3-3' X 82' Cells
Observation tubeNent
Same on other end To be located on end of Cells
20 chambers per cell
O�
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page_, of_
-ILE INFORMATION
Owner
Permit #
DESIGN PARAMETERS
Number of Bedrooms
p NA
i Number of Public Facility Units
''ANA
i Estimated flow (average)
L r
gaUda
Design flow (peak), (Estimated x 1.5)
alida
Soil Application Rate
aUda /ffz
Standard Influent/Effhtent Quality
Monthly average`
Fats, Oil & Grease (FOG)
530 mg/L
Biochemical Oxygen Demand (BOD5)
5220 mg/L ❑ NA
Total Suspended Solids (fSS)
<150 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand (BODs)
<_30 mg/L
Total Suspended Solids (TSS)
<30 mg/L X—LIA
Fetal Cogfonn (geometric mean)
510° cfu/100ml
'Maximum Effluent Particle Size in dia. ❑ NA
'',Other:
'Values typical for domestic wastewater ana septic tank effluent
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity
1 D�5 __
al ❑ NA
Septic Tank Manufacturer
� Q (nj
❑ NA
Effluent Filter Manufacturer (!
O NA
Effluent Filter Model
_
❑ NA
Pump Tank Capacity
I NA
Pump Tank Manufacturer
NA
Pump Manufacturer
NA
Pump Model
NA
Pretreatment Unit
13 NA
❑ Sand/Gravel Filter
0 Peat Filter
CI Mechanical Aeration
❑ Wetland
❑ Disinfection
❑ Other
Djcpersal Cells)
❑ NA
44o,Ground (gravity)
❑ In -Ground (pressurized)
❑ At -Grade
❑ Mound
❑ Drip -Line
❑ Other:
Other.
O NA
Other:
0 NA
Other.
❑ NA
Service Event
Service Frequency
Ilnspect condition of tanks)
At least once every:
`-7 ❑ nth(s)
�j ¢year(a) (Maximum 3 years)
❑ NA
Pump out contents of tank(s)
When combined sludge and scum equals one-third (Ya) of tank volume
❑ NA
'Inspect dispersal cek(s)
At least once every'
❑ month(s)
JZ-"ar(s) (Maximum 3 years)
❑ NA"
_ _
Clean effluent filter
At least once every:
�� ear(s)S)
❑ NA
rspect pump, pump controls & alarm
At least once every:
[I month(s)
❑ year(s)
NA
I -lush laterals and pressure test
At least once every:
❑ month(s)
❑ year(s)
NA
Other.
At least once every:
11 month(s)
year(&)
NA
ixner.
U NP.
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individupt 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 hanhva,e, 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 calls) shag 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 pomiing of effluent on the ground surface may indicate a fatting 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 (Ya) or more of the tank volume, the entire contents of
'he tank shag be removed by a Septage Servicing Opeatar and disposer of in accordance with chapter NR 113. Wisconsin
Administrative Code.
INI other services, including but not limited to the servicing of effluent fitters, metx,anital or pressurized components, pretreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POW76 Maintainer.
A service report shag be provided to the local regulatory authoot ,within 10 days of completion of any service event.
pap —of—,
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of paining products a other chemicals #W
may Impede the treatment process and/or damage the dispersal celi(s). If high concenhatlorm are detected have the contents of the
tanks) removed by a septage servicing operator prior to use.
System start up shall not occur when soil condliions are frozen at the infiltrative surface.
During power outages pump tanks may fill above nomm highwater levels. Y4iiert power is restored the excess wastewater will be
discharged to the dispersal cells) in one large dose, overloading the call(s) and may result in the backup or surface discharge of eRlueriL
To avoid this situation have the oontertts of the pump tank removed by a Septege Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in menualy operating the pump controls to restore normal levels
within the pump tank.
Do not drive or park vehicles over tim ks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
t5 feet down slope of any moved or at -grade soil absorption area.
Reduction or elmdnallon of the following from the wastewater stream may improve the performance and prolong the life of the POWf$:
antibiotics, baby wipes clgarete butts; condoms; cotton aaabs; degreasers; dental floss; diapers; disnhfectents; fat: foundation drain
(su rnp pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat snaps; medications; oil, painting products;
Pesticides; sanitary napkins; tampons; and wafer softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to Insure du t the system is properly
and safety abandoned in oomplmce with chapter Comm 83.33, Wisconsin Administrative Code:
• Alf piping totanks and pits shall be disconnected and the abandoned pipe openings seem.
• The contents of all tanks and pits shall be removed and property disposed of by a Septege Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their ravers removed and the void space filed with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS falls and canna be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
O A suitable replacement area has been evaluated and may be utilized for the location of a replacement sod absorption systepn.
The replacement area should be protected from disturbance and compaction and should not be indrtnged upon by requhled
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the n eled
for a new soli and ode evaluation to establish a suitable replacement area. Replacement systems must comply with the rdel in
effect at that time.
❑ A suitable replacement area is not avallable due to setback and/or soil limitations. Barring advances in POWTS technology a
fang tank maybe installed as a last resort to replace the failed POWTS.
-15�The site has rot been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sal and site evaluation
be performed to locate a suitable replacement area. If no replacement area is avalable a holding W* may be Installed) as
-a lest resort to replace the failed POWTS.
Cl Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomet at the wbalive
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, PIMP OR OTHER TREATMENT TW UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O� A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
POWTS INSTALLER
n
Name
Phone
POWTS MAINTAINER
Phone
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name
/ .eQ ,
Phone
--d
"/ f 1 �'/177
Name t�cl
Phahe
This dorms• t was dralfed in compliance with chapter SPS 3a3.22(2)(bx1)(d)&(1) and 333.54(f), (2) & (3), Ansoorhaeh Administrative Code.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the '��Q /% �(�`j��1M� residence located at:
N-__ ._'� j� 's, Section 'I2.. , T0� N, R?J W, Town of.
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
i.xist time serviced: to
Pi-d flow back occur fromrption system?
Yes No (If no, skip next line).
Approximate volume or length of time:
.:.,parity:-.C— 1
Construction: Prefab Concrete 7\ Steel
Manufacturer: (If known):�P�Qti
Age of Tank If known) : X-1 �t'�/-R
(Si re) (Name) Please print
gallons -- minute;;
Other
7,44lvz) -
(License Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
r>lumber (applying for sanitary permit) Certification:
Di accepting the above statement regag
condition, I certify that the tank to ,
conform to the requi.r ents of ILiR
inspection opening o r outlet bfe
Name ✓ Y sign _
�}ing existing septic tank
3 best of my knowledge w:il.l
Wis. Adm. Code (except for
Z6Y
MP/MPRS7 � ��
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERA4. INFORMATION (ATTACH TO PERMIT)
Personal memnation you provide maybe used for secondary purposes [Privacy Law, s.15 04 (1)(m)].
Permit Holder's Name City Village X Township
Johnson, Mark I Hudson Township
CST BM Elev f Insp BM Eler BM Descdptioo
llo •q3 I10.43 ��,.: � ;., -:-wee
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
PUMP/SIPHON INFORMATION
Manufacturer
De nd
GP
Model Number
TDH
Li
Friction Los
S tem He
TDH Ft
F main
Length
Dia.
Dist to Well
SYSTEM
3 1_engim
91.M
3 I
ELEVATION DATA
"'°""' St. Croix
;an'dary Penult No:
430150 0
hate Plan ID No'.
'arcel Tax No
G Zo-1112- sv- zco
'ection/Town/Range/Map No
19999n 4S /
STATION
BS
HI
FS
ELEV.
Benchma L
r, �•��
� t2 •�
t l O. i 3
Alt. BM
Bldg. Sewer
I
,2
St/Ht Inlet
St/Ht Outlet
D4•, b �/
Dt Inlet
Dt Bottom
b,L r
t
�•13
Header/Man.
It-LV
If,Lr
f!•�
/
too •:13
Dist. Pipe
11-
tC V
ILA®
io I
Bot. System
2 .
-46
r (r
Final Grade
` -I.L
ll
St Cover
U
SI D q
o- 341
CHAMBER OR 1Swti C11
UNIT Model Number: t 2 ar
DISTRIBUTION SYSTEM L-1 io cyst ((c- �.e.,t ll fx"
Fleader/Manifold tl
Length�� Dia
Distribution
Pipes)
L a Spacng
x Hole Size x Hole Spacing
Vent to Air Intake
, :?s I
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
Topsail
j ] Yes [r No
J Yes t:J No
CO %F T (Inclu coded re{�encies, persons present, etc.) nspect on #1�w71 /� y Inspection #2:
1.) Alt BM Description
35LN �udts�oMn,'IcWC( 54p16 (NW 1/4 SE 1/4 12 T29N R20W) 0 Low 1�� _ I No:. �1229.2D� ri
! •�-'ww..,IRvl•" C.M. LLl\/ D� I � _ .�fw�dji7p—�'�
2.) Bldg sewer length = t col a Ckol .�. t5 t . p �� N
-2aammounnttt ofncover = `�-v .t. A`n,,�Ip—a \J ,p�wn-rf-�S(� q,�rQ, V1121c y. .�•-
Plan revision Required? 8�l 7 s' N•• " _ _ - WAY _�b(N�7�Zv`t a'a •t1nSm.C.Z7�N' r _— r
Use other a for additional information..._�_K_�V0.�
SBD-6710 (R 3/97) ale 1� Insepctofs SignatureCan. No
Safety and Buildings Division
Cousry
` �-�(
NY14consin
201 W. Washington Ave., P.O. Box 7162
Sanitary Permit Number (a be filled in )
Madison, WI 53707 - 7162
.
De art of Commerce
(608) 266-3151
O
Sanitary Permit Application
stare I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
Project Address (if different than mailing address)
may be used for secondary purposes Privac Law
t'3
I. Application Information - Please Print All Informs on
S a
Property Owner's Na me i}!_ S- l ;
I
Parcel M I.otX Block p
_
Property Owner's M ailing Address - _. ,i ,
Property Location
0 S
fyV�jL u, 4F 14,SM60111 /yZ
City, State
Zip Code Phone
Number
(circle )
� N, ROE a
H. Type of BuHding check all that apply) � rcr S Nwt
19 l or 2 Family Dwelling - Number of Bedrooms y Ol
Subdivision Name CSM Number
S
❑ Pudic/Commercial - Describe Use
k 1/ 4 . /S
❑City_❑Village ®'Township of fp �i
-7
❑ State Owned -Describe Use S�O S _
III. Type of Permit: (Check only one box on line A. Complete tine B if applicable)
A'
10 New System
❑ Replacement System
❑ Treauoent/Holding Tank Replacement ONy
❑ 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 S : (Check all that apply)
P9 Non -Pressurized In -Ground ❑ Mourd > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed wetland ❑ Prmwiud In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter ❑ Lculking Coamber ❑ Drip Line ❑ Gravel -less Pi ❑ ex m)
V. Dispersaliffreatment Area Information: — i
Design Flow (gpd) Design Soil Application Rate(gpds
Dispersal Area Requir7(soD�isp�ersal
Ara Proposed (0
System Elevation
VI. Tank Info
Capacity in
Total
Number
anu
Prefab
Site
Steel
Fiber
Plastic
Gallons
Gallons
of Units
Concrete
Constructed
Glass
New
Existing
I
Tanks
TaNn
Septic or Holding Tart
Aerobic Tresi nem Unir
Dosing Clamber
VIL Responsibility Statement- 1, that undersigaed, assume responsibitlty for installation of the POWTS shown od'the attached plans.
Plumber's Na me (Print)
P)umber's ' gnacure
MPIMPRS Number
Business Phone Number
Iry
=.21y
—
Plumborrs Addre as (Street, City. State, Zip Cod
6
VIII. Count ent use O,-X
Approved
❑ Disapproved
Sanitary Permit Fec (includes Groundwater
Date issued
Agent S' No Stamps)
❑ Owner Given Reason for Denial
Surcharge Fee)
I
11
IX. Conditions of Approvallitesisons for Disapproval
''��
�ft,r: wi-dL 'r-�i�aCw' IMs,14�' � �Vl(J[CSC (/iflQ.t
Attach ooaspbats plats (to tha County tab) fw the system on paper aot lea than 5112 x 11 inches in site
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Sloe View
75' —
EQecow LwvM
— q*P'. SeMVa Q,OI
Chamber
•- to 67.
'PLOT h CAM SECTION PtN
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Wisconsin 2
� EVALUATION REPORT Page of
Division of fetyand Buildings,
m a nce with Comm
" 85 Wis Adm Code
�. County C- n
Attach co on paper no -of e s than B 112 x 11 inches in size Plan must -
include, but not limited to, vertical and honzmtal reference point (BM), direction and Parcel 1.0 ., .,
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 7,f-O
Please print all information. viewed y Date
Pera*mil adormawn you vro may be uaad for secondary Wn=a, (Pmacy law. 15 06 (1) (m))
Property Owner Property Location
Govt Lot ZZa 1/4S 1/4 S T N R ��� E (Irw
Property Owners 'ling Address Lot # Block # Stbd Name or CSM#
it s G7 :7,j �W A/ / 1-)—'for
❑ New Construction Us Residential / Number of bedrooms Code denved design flow rate 6Go _ GPD
Redacerrwt ❑ Public or merdaI-Desrnbe:
Parent material 44,f Flood Plain elevation if applicable /ly, ,fir Z oN F— ft.
General comments and recorrvnendabons: Z11 5e,2, r�
System Type ,� Syst Elevation i y
M Boring # El Boiling
A'Pit Ground surface elev ft Depth to limiting factor in,
Sal Application Rate
Fbrizon
Depth
In.
Dominant Color
Munsell
Redox Description
ou. Sz. Cont. Color
Texture
Strum"
Gr. Sz Sh.
Consistence
Boundary
Rools
GPDM
-Eff#1
'Eff#2
D
�
D
c
iYIWZ—
F7
Boring
Boring
# ED- Pit Ground surface elevl �' ft. Depth to limiting facto & in. Sol] Application Rate
Florizon
1
Depth
in.
Dominant Colo
Munsell
Redox Description
ou. Sz. Coral Color
Texture
Structure
Gr. Sz. Sh
Consistence
Boundary
Roots
GPDM
'Eff#1
'Eff#2
+5 ,
q 75
6
Effluent #1 = BOD. > 30 < 220 ng/L and TSS >30 < 1M Effluent #2 = BOD, < 30 mg& and T55 < 30 Mg1L
CST Name (Please Print) ure CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1432 120th St, New Richmond, WI 54017 — _ J 715-246-4516
Property Owner
Parcel ID
Page _of
Boring # onng (' //nn \\,�
El Pit Ground surface elev � ft. Depth to limiting factor in
Soa hcetion Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPOM
•Eff#1 I
•Eff#2
1-1Boring
# ❑ Boring
❑ Pit Ground surface elev. ft Depth to limning factor in
Soll Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDM
•Eff#1
•Eff#2
❑ Boring # ❑ Boring
El Pit Ground surface elev. ft. Depth to limiting factor n.
Sal Aodication Rate
®®�•
• : •
Effluent #1 = SOD, > 30 < 220 rrKYL and TSS >30 < 150 mg7L • Effluent #2 = BODr < 30 mot and TSS < 30 mglL
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.
5eo-33w to duos
Property Owner
Parcel ID #
f�
Page _ of
®®r
Y
®®®®®MQUiM
❑
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDIff
'Eff#1
'Efr#2
F-1
pit Ground surface elev. ft. Depth to knAng factor — in.
Effluent #1 - BODY > 301220 mglL and TSS >30 < 150 mg& ' Effluent #2 = BODY < 30 nI and TSS < 30 mWL
e
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
Soil Test Plot
Protect Name Mark Johnson
Address 1056 Hwy 35 N
Hudson Wi 54016
Lot 2 Subdivision
N W 1/4 SE 1/4S 12 T 29 N/R20 W
Boring Q Well PL Property Line
BM or VRP Assume Elevation 100 ft.
CSTM #226900
5/3/20
Township Hudson
County ST. CROIX
Bottom of siding
System Elevation TBD *HRpSame as benchmark
III
Nay 35
d comments
I dug borings on May 3rd, 2020. 1 dug 3 separate borings next to the original drain field and
I found no redox features in the soils. I did find that the original soil test should have been
sized for a .5 loading rate(fine sands). I did not find very many small bands but after about
100" 1 find that the soils were more saturated. The existing system is draining slowly but I
believe it is due to a water softener being used. The house has 3 person living there. I did
dig behind the house by Borings 1,2, and 5. 1 found the same bands a mottles indicated on
the original soil test. The lower elevation borings are not suitable for a conventional system.
I suggest installing a new system at a .5 loading rate approximately 4' deep due the fact of
the elevation of the sewer line leaving the septic tank and a having a valve installed. Also,
caution would be needed for at the end of the tested area there is a small ditch that has
seasonal run-off going threw it. This area would need to be avoided.
s� • �rt�i X COUNTY
NO. 631264
STATE SANITARY PERMIT
IOS�o /Ji 35 ill
REVIOUS NO.
OWNER ffl Q (*K S- "
j 6h r 5M
CIiAPTER 145.135 (2) WISCONSIN STATUTES
. (a) The purpose of the sanitary permit is to allow installation
of the private sewage system described in the permit.
(b) The approval of the sanitary permit is based on regulations
force on date ormitapproval.
PLUMBER u» Ai4
%%�� .{� /�
LII�• �/ '/' QUA
rV� (�V
The sans
(c The sanitary permit is valid and maybe renewed for a
TOWN OF
specified period.
specified
(d) Changed regulations will not impair the validity of a
sanitary permit
ST;1 Cam, T�� N'
�1
R 20
(e) Renewal of the sanitary permit will be based on regulations
in force at the time renewal is sought and that changed
regulations may impede renewal
(Q The sanitary permit is transferable.
AND/OR LOT 2
BLOCK awpw�
History: 1977 C. 168; 1979 c. 34,221; 1981 c. 314
�
csm/5 0
SUBDIVISION
Note:transfer ownership of
he ecount permit,or authority.
If rmit, leas to c renew contact
the permit, please contact the county authoriTy.
AUTHORIZED ISSUING OFFICER -
DATE 3 Z/
THIS PERMIT EXPIRES 317
1 ZOZS UNLESS RENEWED BEFORE THAT DATE
POST IN PLAIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (R. 10/11)