HomeMy WebLinkAbout006-1061-95-000 (2)Wisconsm Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH To PERMIT)
Personal information you provide maybe used for secondary purposes [Pnvacy Law, s.15.04 (1)(m)I
Permit Holders Name City Village Township
Dave Goodrich TOWN OF CYLON
CST BM Elev pp�(� If In sp. B,�Mr�Elev BM Description
vV •� W .1) B 0f 4�TI611
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Sephtikit
—&cj
Z
Ir)EISCC
3LO
Aeration
0
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
Vent to Air Intake
ROAD
Sepn j5y
/
DSI
Aeration
y
Holding
PUMPISIPHON INFORMATION
Manufacturer
Demand
GPM
Model Numb
TDH
Lift
n on Loss
System Head
TDH Ft
Forcemain
Le
Dia.
Dist to WelLei
SOIL ABSORPTION SYSTEM
•
•
,MN®®
.mil/A�%0
•
-.E®m
-.,m
MFMM
•
Evm�
=ffl III
=No=
-■.®
, ♦ •
-win_
---_
---_
RE C
Width I
Leng[hr
No f Trenches
PIT DIMENSIONS
No Of Pils
Inside Dia
Liquid Depth
DIM IONS
%
/_0
`Q
SETBACK
SYSTEM TO
PIL
BLDG
WELL
LAKElSTREAM
LEACHING
Man fac ur
INFORMATION
CHAMBER OR
`
Type Of System -
ff I H�n
% h i
` G [
S
/
'�V✓\
UNIT
Model Numb
l�✓l V .
DISTRIBUTION SYSTEM
Header Manifold It
Distribution
Pipe(
Ix Hole Size
x Hole Spaand
Vent to Air Intake
s
Length Dia
Length Did_ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
zx Mulched
Bedarench Center
BedrTrench Edges
Top
Yes � No
F) Yes No
COMMENTS: (Include code discrepancies, persons present, etc.)
Location: 1947 220TH ST
=7
1.) Alt BM Descnptlon = � --_^
2.) Bldg sewer length = ✓4Y4 wni C.� 5 5 S'F - -(�+'•
amount of cover =j1i M q y Wjj ter
3 %��5ev✓. P� �c, fJ ar+w Ore n'w- So'.,i _e ti uhled C 4 4 43,19 r
,
Plan revision Required? Yes No k"// E� gD 93• 2-0
Use other side for additional informatitf
on. ✓ f0 1
S D-6710 (R 3/97) Dale Insepotors Signature `�� Can No.
'eTCo,rers w.`(( 6e .lab wlnre
a
-
Safety and Buildings.Division
201 W, Washington Ave., P.O. Box 7162
cowty
ST CROIX
Permit Number be filled in by Cc)
Sanitary (to
x
'
Madison, W1 §3707-71j!��
-7�Y9
APR 08 2021
st. L t5'a njt4y Pe rmit Application
State Transaction Number
In accordant '�ciPRT3sD;$7(2�,cM+�n{ndne�d submission of this form to the appropriate gov uni
06
jest Address (if different than mailing address)
is required prior to obtaining a sa uwy permr . : Application forma for state-owned POWTS are submt to
the Department of Safety and Professional Servies. Personal information you provide may be used for seconds
purposes in accordance with the Privacy law, s. 15.04(1 m , Stats.
1947 220TH ST DEER PARK WI
1. Application Information - Please Print All Information
Property Owner's Name
Parcel 4
DAVE GOODRICH
006-1061-95-000
Property Owner's Mailing Address
Properly Location
ziz•at.1b.N3)
2173 CTY RD H
Govt. Lot
NW y, SW 4, Section 28
City, State
Zip Code
Phone Number
DEER PARK WI 54007
715-781-1500
(circle me)
T 31 N; R to E or jt/
11. Type of Bulkliog (check all that apply)
Lot 4
Subdivision Name
1 or 2 Family Dwelling - Number of Bedrooms 4
40 4 cK faly{
Block 4
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use
❑ Village of
CSM Number
z o/V t y
I$Town of CYLON
111. Type of Permit: (Check only one Wit on line A. Complete line B if applicable)
A.
❑ New System
[3 Replacement yttem
❑ Treatment/Holding Tank Replacement Only
❑ Other Modification to Existing System (explain)
B.
❑Permit Renewal
El Permit Revision
❑Change of Plumber
❑Permit Transfer to New
List Previous Permit Number Date
Before Expiration
Uvner
h p q 6
1-191 r /l Z9 43
i
IV.
T of POWTS S stem/Coin nent/Device: Check all that apply)
Non- ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate( f)
Dispersal Area R ircd (sf)
Dispersal Area posed (sf)
System Elevati
600 .7
858
900
92.00
VI. Tank Info
Capacity in
Gallons
Total
Gallons
s of
Units
Manufacturer
Pot dux SZS
y �
8
.�
H
_
H
hh gg
L v
_
a
New Tanks
Existing Tanks
3Zo � r
u
Septic or Holding Tank
1 /WIESER 11
/ WEEKS
1320 12
IWESER / WEEKS
X
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Plu� S W
MP/MPRS Number
Business Phone Number
PAUL R KOEHLER
/
225410
7152462660
Plumber's Address (Street, City, State, Zip Code)
321 WISCONSIN DRIVE NEW RICHMOND WI 54017
VIII. Comity/Department
Use Only
Approved
❑Disapproved
Permit Fee
$C
Date Issued/
y
Issuing Agent ' ature
SYS7FM0
IRQyamer Given Reason for Denial
5z •��
/
I .,tBf�tttfilbiftwSonsfor Disapproval 3 sot%5 Z/tPi'S1-i 3%r�
%e.�pt•f 5`l$itWl E efA
• «.al nail must be serviced l maintained w•j o,f• •>re SJ klm m h$'>�'rl� I Nb4 e✓f o�t, bo+, j
u ) rter t
plan provided by plUmtlef t%o' v�` / `S 5��ya e�fYR1'�-Tors,
CS')etl
ter,enls must be maintained Ir sJ/
j
. ":r)e.:ordinar,: es.
t�/EI �S<i- d� S�S�N'+ Y114i✓I�urtCt I>'s9er
-(-y(��lCt lr
Attecb to complete plena for the system and submlt to the Couory only on paper not len the a 1/2 x u cacao as tlu
y.p J y �a cti)�-
SBD-6398(R.II/11) �—'T 1dL r e✓LA4 Gbt'("
121♦
aim .�p
13
C)AvE
afgrc,i Ip oob- IbL!- `�S ban
s'"Uy�/ s� is r 31 R16r.,�
ST c,oiA cou��b
a 3 �rcML
a
cl0 La
to old sy sFc .`
Rc places Pik �0 1n
o I� s b stet„ ti to
V
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,A yo
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: GOODRICH FARMS
Owner's Name: DAVE GOODRICH
Owner's Address: 2173 CTY RD H
DEER PARK WI
Legal Description: NW 1/4 SW1/4 SEC 28 T 31 N R 16W
Township: CYLON
County: ST CROIX
Subdivision Name:
Lot Number.
Parcel ID Number. 006-1061-95-000
Designer/Plumber.
Date:
Page 1
Index and title
Page 2
Plot Plan
Page 3
System Sizing & Cross -Section
Page 4
Filter Specs
Page 5
Maintenance Information
Page 6
Management Plan
Page 7
St. Croix Cty Septic Tank Maintenance Form
Page 8
_ Warranty Deed
Page 9
CSM or Plat
Attachments: Soil Test & House Plans
PAUL R KOEHLER
04/08/2021
Signature
License Number: 225410
Phone Number (715) 246-2660
Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101).
Page 1
QA, pt
�V
000'
11 ,r,,,,rr
,..APv��:D h
'�.Inq da,j WP
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SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page 1 d 1
Project Name: DAVE GOODRICH
3
No. of Cells
3
ft Cell Width
60
ft Cell Length
3
ft Cell Spacing
6
Per Cell
18
Total No of 10
50
sq ft EISA Per Cell
900
sq ft Total EISA
manufacturar medal L"Im 1 anent FIG R.N..
lnf awr
EZ120 5ft
5.0'
25.0
F21203H-10ft
10.0'
50.0
Gravelless Leaching Unit Manufacturer: INFILTRATOR
Gravelless Leaching Unit Model: EZ1203H-10FT.
Typical Cross Section
Finished Grade 99
ft
�—Observation
Pipe with
approved cap or vent
in
Soil Backfill
Geotextile Fabric
ft Infiltrative Surface
12 In
_
Limiting Factor
�in
Slotted and Anchored Vend
Observation Pipe with Cap
.....................................................
a.............. 0....
Plumber/Designer Signature: PAUL R KOEHLER
Licensem 225410 Date: APRIL 8TH 2O21
-- 0
A
6.5" (16.51cm) SEALED BALL
MATERIAL - HOPE
- 33.02 [83.9crnI - --
- - 20.71152.6 cm I
4" 0 0. 16 cm) BALL HOUSING
TRAVEL MATERIAL -POLYPROPYLENE
5.7 [14.7cm] FILTER CARTRIDGE
MATERIAL - FILLED POLYPROPYLENE
POLYLOK PL- 525 - 625 CUTAWAY
BALL PUSH ROD
FACTORY INSTALLED SECTION A -A
MATERIAL - FILLED POLYPROPYLENE
4" AND 6" FACTORY —
INTALLED PIPE OUTLET
MATERIAL - PVC
OPTIONAL BUSHING --
(FOR 4" THIN WALL PIPE)
PART NO.30142-R
OR OPTIONAL FLOAT SWITCH
(FOR 110 MM. PIPE)
PART NO.30142-EUR
C-:)
4" CAST -A - SEA
N C
a
FILTER OR BAFFLE-
rn
a
r— 4'-2--1
L
CAST -A -SEAL
W320-MR
TANK SPECIFICATIONS
DIMENSIONS:
a
I
W
ti
N
WALL' 3"
o
BOTTOM: 3"
COVER: 4"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER
a
HEIGHT: 58"
c
LENGTH: 4'-2"
WIDTH: 4'-2"
BELOW INLET: 48 1/2"
LIQUID LEVEL: 43"
b
WEIGHT., 3,880 LBS.
'
INLET AND OUTLET-.
'
$
8
4" CAST -A -SEAL BOOT OR EQUAL GASKET
e
c
m
o �
o
INLET AND OUTLET BAFFLE AND FILTER:
�y
�
WISCONSIN. SEE DETAIL 010
W
a
4
a
(OTHER STATES SEE CHART)
c
W 53
LIQUID CAPACITY: 8.00 GAL/IN
<
W"
LOADING DESIGN: 8'-0" UNSATURATED SOIL
=
r..7�U)
TANK CAN BE USED AS:
m a
SEPTIC / HOLDING / PUMP OR SIPHON
.. 00
COVER: MIX DESIGN 08 (NO FIBER)
TANK: MIX DESIGN Ij10 (STRUCTURAL FIBER)
L I
CUSTOMIZED TANKS:
0
y
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
W
nb
3
Z
I
�
RENEWED BY
U
RENEW DATE
3 F
W
FOR APPROVAL
APPROVED BY: SHEET NO.
APPROVAL DATE: /
PRODUCTS NEEDED BY: / 1
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION
Owner DAVE GOODRICH
Permit i
DESIGN PARAMETERS
Number of Bedrooms
4
❑ NA
Number of Public Facility Units
IN NA
Estimated flow (average)
400 gal/day
Design flow (peak), (Estimated x 1.5)
600
al/de
Soil Application Rate
,] al/da /ft'
Standard Influent/Effluent Quality
Monthly average`
Fats, Oil & Grease (FOG)
530 mg/L
Biochemical Oxygen Demand (BODs)
5220 mg/L
❑ NA
Total Suspended Solids (TSS)
5150 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand (BOD,)
530 mg/L
Total Suspended Solids (TSS)
530 mg/L
❑ NA
Fecal Coliforn (geometric mean)
510' cfu/IDOmI
Maximum Effluent Particle Size
Ya in die.
❑ NA
Other:
❑ NA
'Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
WZ414i:
Septic Tank Capacity 1000/320
al ❑ NA
Septic Tank Manufacturer
WEEKS /WIESER ❑ NA
Effluent Filter Manufacturer POLY LOCK
❑ NA
Effluent Filter Model
525
❑ NA
Pump Tank Capacity
al I'd NA
Pump Tank Manufacturer
Q(NA
Pump Manufacturer
IN NA
Pump Model
IN NA
Pretreatment Unit
❑ NA
❑ Sand/Gravel Filter
❑ Peat Fitter
❑ Mechanical Aeration
❑ Wetland
❑ Disinfection
❑ Other:
Dispersal Call(s)
❑ NA
Iln-Ground (gravity)
❑ In -Ground (pressurized)
❑ At -Grade
❑ Mound
❑ Drip -Una
❑ Other:
Other:
❑ NA
Other:
❑ NA
Other.
❑ NA
Service Event
Service Frequency
Inspect condition of tank(s)
At least once every:
3 & monearls)Mls) (Meldmum 3 years)
fX
❑ NA
Pump out contents of tank(s)
When combined sludge and scum equals one-third %) of tank volume
❑ NA
Inspect dispersal call(s)
At least once every:
3 ❑ m(g) l
!)(year(s) (Maximum 3 years)
❑ NA
effluent fitter
At least once every:
nthClean
,I m earar(s) )
❑ NA
Inspect pump, pump controls & alarm
At least once every:
❑ month(s)
❑ year(s)
p[ NA
Flush laterals and pressure test
At least once every:
❑ monthl
❑ year(s)
Q( NA
Other.
At least once eve �':
❑ monthis)
❑ year(s)
JQ NA
Other.
jQ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS inspector, POWTS Maintainer, Septage Servicing Operator. Tank
inspections must include a visual inspection of the tanks) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 Maintalner.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page Z of Z
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(sl for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal call 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(s) in one large dose, overloading the cattle) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the Iffe of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
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 safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property 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 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.
TT� ¢b R- A<$1� 40"S'i XUGn VajrnO� k
❑ 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 AND10R 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
Name COUNTRYSIDE PLG AND HEATING
Phone 715 246 2660
POWTS MAINTAINER
Name PAUL R KOEHLER
Phone 715 246 2660
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name I POWERS SEPTIC SERVICE
Phone 715 417 1429
Name
s C ( G Z!lrcl
Phone
]/S— 3F, — (O a
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(fl and 83.54(1), (2) & (3), Wisconsin Administrative Code.
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)1947 220TH ST DEER PARK WI
located
at: NW ''/4, SW '/4, Section 28 Town31 N, Range16 W,
Town of CYLON 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 +;�,,;r,a flrelserl�•. .Sys,., ,s �iaciL%`3r v�p Opt 7
+j ,r' /*A,v . s /k o Hce4 New e-,�.%
Most recent date of inspection or service APRIL 7TH 2O21
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: loon
Construction: Prefab Concrete x Steel Other
Manufacturer (if known): WEEKS
Age of Tank (if known): 1993
Permit number (if known) 199949
�.� 'Iz� PAUL R KOEHLER
(Licensed Plumber Signature) (Print Name)
MASTER PLUMBER 225410
(Title) (License Number) MP/MPRS
APRIL 7TH 2O21
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
ST. CRO NTY SANITARY SYSTEM Filece
tscorrsue Office Use Only
+� OWNERSHIP/ADDRESS FORM Created212027
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. If you would like to view your issued sanitary permit online, you can
do so by using the Property Files Scanned weblink.
OWNER/BUYER INFORMATION
Owner/Buyer DAVE GOODRICH
Mailing Address 2173 CTY ROAD H
City/State/Zip DEER PARK WI
Phone Number (required)715-781-1500
Email Address (required) dgoodrh@live.com
Parcel Identification Number 006-1061-95-000
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location NW t/4 , SW 1A , Sec. 28 T 31 N R 16 W, Town of CYLON
Subdivision Plat:
Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # iGl j 36 1 (before 2006)Volume . Page #
Number of bedrooms 4 Spec house 0 yes ■ no Lot lines identifiable 0 yes ■ no
OFFICE USE ONLY
New Property Address
(Verification of new address required from Community Development Department for new construction.)
Zj
(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
cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov
SANITARY PERMIT APPLICATION
�ILHR In accord with ILHR 83.05, Wis. Adm. Code
COUNTY
.comp
-Attach complete plans (to the county copy only) for the system, an paper not less than
6'A x 11 inches in size.
❑TCh��VYI
eckg
-See reverse side for Instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT WFORMATION- PLEASE PRINT ALL INFORMATION.
N
PROPERTY OWNER %PROPERTY
!(!/" /ovE-E'v
LOCATION
NG✓Y. S 29 T3� , N, R
PROPERTY OWNER'S MAILING ADDRESS
'
LOT#��
BLOCK#�L
TT
z.l z w G
CITY, STATE ,
Airiv /L'iur ,ao ��
ZIP CODE
saoe7
PHONE NUMBER
* 0
SU DIVISION NAME OR CSM NUMBER
pf t r of
11. TYPE OF BUILDING: heck one) ❑ State Owned CILTM! AGE : C yle,�/ NEAR ROAD
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms —PARCEL TAX NUMBEHib)
111. BUILDING USE: (If building type Is public, check all that apply) i�0 L.(/ �0 c F S 00
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Seiss/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ HotellMotel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE O PERMIT: (Check only one in line A. Check line B It applicable)
A) 1. New, 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 � Seepage Bed 21 ElMound 30 [__1 SpecifyType 41 ❑ Holding Tank
❑
12 Seepage Trench 22 ❑ In -Ground 42 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -In -Fill 2 77£,♦J(,(,�E$ �/i"R%� J Sd
V1. ABSORPTION SYSTEM INFORMATION: J� r(
1. GALLONS PER DAY 12. ABSORP. AREA 13. ABSORP. AREA LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
ft.) (Mindinch)
14.
4 9E,L.EVATION
Lj� REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Ga clay/sq.
0 5?0 3' r 37
! J 503 0 1� / Feet Feet
VII. TANK
INFORMATION
CAPACITY
in all M
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab.
ncrat
Site
Con-
Steel
Fiber- asPlastic
glees
App.
App.
New Istin
Tanks Tanks
shucted
SectJc Tank or "dino Tank
Lift Pump Tank/SI hon Chamber
i
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
Roger 4?(1he1'Ch7 -
Plumber's Signature No Stamps)
MWMPRSW No.:
s3o�
Business Phone Number.
�i5 3&-8�8
Plumber's Address (Sheet, City, Slate, Zip Code): !ske!
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved
Sa7aryPermlt Fee ynlue��er
surcharge F
a
Issuing Agent Signature lNo mPs)
Approved❑Owner
Given Initial
�g4
Adverse rmin
C
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD 6398 (formerly PIb87) (R. 11188) DISTRIBUTION: Original to County, One Copy To Safety & Buildings Division, Owner, Plumber
LOC$Tip epa tmen oTfncu $y, 3i.16.43 RIVATE SEWAGE SYSTEM
Labor and Human sDivisio INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT)
Perm it Holder's Name
❑ City ❑ Village rl Town of
7i
7.00DRICH, DAVID
CYLON
CST BM EIev x
Insp BM EIev:
BM Desc:pton
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holing
"
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG
Ventto
An Intake
ROAD
Septic
1
/
NA
Dosi
NA
Aeration
Holding
PUMP/SIPHON INFORMATION
ManufaCfurer Demand
Model Number GPM
TDH I Lift Friction S stem
Loss
Forcer Dia. Dist To well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County:
Sanitary'
State Pla
Parcel Tax No
aoann�c� 1.. r17<
STATION
BS
HI
FS
ELEV.
Benchmark
ai//
0"
K , �✓??i
5,
Bldg. Sewer
S 5 3
St/ Inlet
g
$5
St(I)f Outlet
/ �r
Dt Inlet
Dt Bottom
Header / Man.
r
g '
Dist Pipe
b,,
/6 ",
yj.3
Bot System
/6. d,W,
F2• Zz. 3
Final Grade
122
9�' `
5.58
BEDITRENCH
Width
Length
No Trenches
PIT--—
Nu Of Pits
Inside Dia
Liquid Depth
DIMENSIONSS
S
DIMENSIONS—
SYSTEM TO
P/L I
BLDG
I WELL
LAKE/STREAM
LEACH
Manufacturer.
SETBACK
INFORMATION
CHAMBER
TypeO ... � <a
/
r
umb
System-�.ro-,-rc
�--/�e.
0
�/
OR UNIT
DISTRIBUTION SYSTEM
Header
Length
Id
Dia
Distribution Npe(s)),
Length's
o
Dia �
� ,��7r
Spacingx�J-//
x Hole Sae
x Hole Spacing
Vent To Airintake
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems On y
Depth Over ,,// ////^^ Depth Over ,/ n xx Depth Of xx5eeded1Sodded ulched
rench Center YQ /7oc aadFTrench Edges y`� Y� Topsoil ❑Yes ❑Yes [INo
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: CYLON 28.31..411
1 � G�/�i' _ .{., (L-�'C' .c x y� .p-� ,ter ., y�;o c �rsr•V .
Plan revision required? ❑ Yes No
Use other side for additional information.
58D-6710(R 05/91)
Celt No
e
TOP OF Aldo 6- K301� dt- Fe�eQ)
BENCHMPgv ARK: r'.v.c -/00.0
ALTERNATE BM: TOP OF CO.ucn 110-Q. Mock- 4307Ck;
&�ev,trlbv-- gf S/
SEPTIC TANK / -PHtEF USHER /
tve6�S e2wael(t eo. 1000 �'aS
Manufacturer: Liquid Capacity: U—_
Nor
Setback from: Well IMSI'AI 10 House 17 Other
7-0 OINr�
Pump: Manufacturer Model# -� Size
Float seperation Gallons/cycle:
Alarm Location �I
SOIL ABSORPTION SYSTEM
Width: ✓� Length S Number of trenches Z
Distance & Direction to nearest prop. line: !d NO pftp.
Setback from: well: N� Fz // House sy Other
1NS1 *61:Q Q, YET- ELEVATIONS �'- a' So�Uv, dd�SGQ r
Building Sewer ST Inlet: '�y S0 ST outlet
PC inlet � PC bottom '-� Pump Off
Header/Manifold ' Bottom of system
0 �' °
`�7 / ' - 9 S TX�vcG�s)
Existing Grade Final grade .c
DATE OF INSTALLATIIO,�N: ' 1173
PLUMBER ON JOB: (-oSeer Z(I(�12rG�v7'
LICENSE NUMBER: M4peS 330?
INSPECTOR:
3/93:jt
lr ' Wis. Defer. of Safety and Professional Se"with
ALUATION REPORT
Division of Safety and Buildings
n aeWis. Adm. Code
County
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I
percent slope, scale or dimensions, north arrow, and locetion and arest road.
Please PdAt all 060n. Review
Personal information You provide may be used for nllary Purposes (Privacy Law, s. 15. (1) (m)).
Property Owner' APR Prope Location
C57 -a da r 6�7 q
pop 1 of 1
ST CROIX
006-1061-95-000
DAVEGOODRICH GovLL NW 1/4 SW1/4 S 28T 31N R 16E(ouWV
Property Owner's Mailing Address ..;��- Lo Block # I Subd. Name or PW
2173 CTY ROAD H t i — 6) Ct Lrr fan e
City State Zip Code Phone Number aity Village LTown Nearest Road
DEER PARK I WI 1 54017 1 ( 711481-1500 HWY 64
❑ New Construction UseO Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
El Replacement ❑ Public or wnxnercial - Describe:
Parent material LOAMY DRIFT OVER LOAMY TH.L Flood Plain elevation A applicable ft.
General conments
and recommendations'.
M
Boring a 0 Boring
0 pit Ground surface elev. 98.5 ft. Depth to limiting factor 108 in.
Soil AppliceiRao
Horizon
Depth
in.
Dominant Color
Munset
Redox Description
Ou. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
nsistence
Boundary
Roots
PD/ft '
8r#1 1011112
1
0-12
10YR 3/2
---
SL
2 MSBK
MFR
CA
1F
.6
2
12-36
7.5YR 4/3
-- — — —"—'—
SL
2 MABK
MFR
CW
----
.6
4 1
3
36-108
7,5 YR4/2
— — —---------
S
0 M SG
ML
_-__
.7
1.6
WIM
&3.6
❑Sonng # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soit�
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1150 mg/L ' E nt #2 = BOD < 30 mg1L and TSS < 30 nWL
CST Name (Please Print) Signature CST Number
PAUL R KOEHLER 225410
Address Date Evaluation Conducted Telephone Number
321 WISCONSIN DRIVE NEW RICHMOND APRIL 7TH 2O21 715-246-2660
JISL dbjju (KI 1/1 q
a
2
z53
T6P eF
P, pE
13.yG
Tor of
pi ht
93.3y
133
i
� csr 13M Ser.
7 b p of '/�" -TP
ElEunriau= /oo.o'
i=
weer
to o2or Box
I i i I
- roP of O
I �
l
S �tSTEM
E/r u�Trous
(130+1.
TIDE uo4-e 5 �'
y27O RS-3ui -T PLOT P/-^tJ
wfo/cor of T.�ok 12-�-53
scb 4o puc
/ uaw i f3t:DBr� Na.ut �NDale causTpucT7'o..t
// vo well wS+Alta To- D��F
-T RENc H- 5pec s —
G " 4:14S//ED -W" if55e,-G•rre-
fr/3R%c. sru,. 293-y otsT 1'150AroN /'•�•*�G z�sE�
s u zri--v -b. "rezvs " /sr
J
fin #{ z - Tor of 5kp+6E FO Won NO,)
Block 6lEvkri6')= 99.5%
v � —
2oo
—ScPnc T,baK—
i000 g_'/S. eRec.^sT—
/tveEn'5 coAjCHx ea-.)
ll _? y " iaye.-Q of iPI TCAO5
LIJ
2i3
'CI
1.,
imLer ro oeor sox
Or
O---)
esr >3M SeT•
ToP of y JP
EIE V^rioU ` /Oo• o
'yam/.ter •frw.,r
Su. foMt-
py�
AS-ISuILT PLOT' PcAPJ
'2-7-13 '• I1-♦?-Y3
utW i (i1:D*M fkWir s,NpEp
to i 'J' i.— uo well WS+AllaD To, DATE.
r` Tor 'i
P'K
r
tySTEH E/E7/AJ%OVf
((iota.
9 2.So'
I — Tpepjct+ Spec 5 --
G 4�4SNED �q" ASf�Ed•►JF +J�+AE�P 7YPm�
f.Y,aR�c . SJ.A • iiiy p%sn��uTie..� P•�er.'v6- vrEv
<Pu-N. Mry e4 "IWVS � /sT v%%f DAop
J
BM 44 2 - Top of rj kp�bF fO WDAhaJ
&lock
2.20d{- sT.
— St PTrc T%taK —
%000 E-a-ls . PRefA 4T-
(4UC-6'S ZoAje.Ht 4r-.
w'00 ^OeP°O Bn1a1 d trY SOIL AND SITE EVALUATION REPORT Pape ofVasco rd Mnmen Rsiaenrw
... .., ... ,.,...,., .. v.._.,........,.
.................COUNTY
sT ceLvx
Anech complete site plan on paper not less than a 12 ■ 11 inches in size. Plan mat vrinde, but
PARCEL 10 a
not limited to vertical and horizontal reference pant (BNT, direction and %af slope, she a
6mensioned, north arrow, and loc n and ci t m nearest road.
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION
REVIEWED BY DATE
PROPERTYONNEFL
'A1V )0 G' 'P'q i c !f
PROPENTVLOCATION
GO/T LOT A/W 114 SW UI,S 2S?T S/ AR /G E (o60
PROPERTY OWNERS MAIUNG ADDRESS
LOT a BLDCKe
BUBO, WARE OR CSM0
z/s7 howl Gv
P?,PT of 2--r� fK.Fts
CITY, STATE ZIP CODE PRONE NUMBER
DUTYOWILucE QfOWN
NEAREST ROAD
A�GU ,Q/CLi Alownp CU/, 5`/0/7 (7/$)1r/(e -Ca57%
GyLON
120 Th.
VJ' Jew C Iructim the [ I TAanher of Dedmins [ J Addtlm loemip buUsq
[ I Replawnent 1 Pia mmrnercirdesatbe
Code derived daily Row Co00 9Pd Recommended deW be1V rare=bed, ao"2 tennch, W W
Absorption area rWed! bed, R2 7� U Rerun, RZ Mamwm desgl ba6nlitale 1� Ded, Wd ' g tench, WW
Reui mraded'netlraRm sutace dwabon(s) :� 'P 5 - 3 R (as urrred b sae prn barldmarlQ
4,1A gOX 'DTSTP03
A06Ronaldesign/shemaderafiars ZiSE TXE.cKl.ss a,,, S/oPE/la.., Tou.e O,Po /1
Parent materiel 5C5 z z CAE rE- - f^ -fAf.-- Flood plan elevaliM R appfaabr 41 R
S. SUtade for System
A❑U
N TNK
U-lltrtitaD
OU
f3O39OFRL
U
Ulek
❑S
elev.
/(.1L fL
Depth to
�^A
>> 8y
Boring M
2
Ground
elm
>B� it.
Depth to
kmtkv
lector
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
modes
Ou. SL Cont. Color
Terre
Sbuclum
Gr. Sz. Sh.
Consistence
Bantry
Roots
GPD
Bed
0--7
/o ,e 3 -7
95
>
St-
7 1y
/Oyk 3/3
—
/5
2-'s1ot
M JR
cs
i�
T-7,�3
,y L�
75- y)eyy
sl
z,f,56Ko
e
CS_
O,n1.S
"P2
c5-
_
z;.8
Q,c,S
cQ1L
_
ii
.00
w
o- //
I /oY,e3/z
s/
z,• -.O
f12
CS
�
6
/-27
/0ye9'/y
--
S,/
3A.,bk
n Fi
CS
If
.S
j.G
5-ht
—fR
cs
C
39-9P
7•SVR /G
'
�,^ ,s
��
a2'
7
-P
r
,ate
11 = R� _'-t 'PoGEzr ZIT,BRickT- 14- 7/S 396- 9/29
Awivsii:l055 Q' actL V19- µuDSo,� C&S Sflo+le OCT 2.8-q3 CSTM1y8Z
Siprrmrs. � � Dar. CST Niar6rr:
Pp0�Y0wl�a (roOD,Pi SOIL DESCRIPTION REPORT Pape Z al 3
Bodnp f
13
Gmund
dev.
99.ft IL
Depth n
4T� S
1
In, 11
y
Gmud
e1w.
yS 3�tL
Da* n
&a%
n9r.
Boring M
5
Gmud
J`'G 'fop IL
000 n
laclol
Soring i
13
Gmund
elan.
K
Depth In
Irdtp
facer
HoriLon
Deplh
Dominant Colour
Mottles
Texyn3
Struc>vie
Corrlstem
Barry
Rood
GPD
In.
Mulreetl
DLL Sz ConL Cobr
Or. SZ. ShAS
lawn
O-g
/0 yR 3 z-
5/
z.f,
n -fz
c 5
2
2 s3
SCALE' /�= 3o
— CLE'�/RTIOuS —
2 2.-
!'o. cPGE ote- cilvOs
97
31
/3H
7d
g/ovg •vo • $;
P r�6 ' 4s'
c � eu�-r�o-v � Sao • o' yo'
135
90
,
5OC,(-,ESTED-SY5Tt^^
ELEVATIONS
+ v�. 7REwCG- 911S0
low rR��cG. 93,SD
x
IBC.
S� • C t`b � X COUNTY
(Itte norif
NO. 633305
STATE SANITARY PERMIT
'f n^ IR7 ZZo 4� s+
L_LLTR� F &�L rREvious No. 1999Y9
OWNER D•tv iJ %oci r'i G h
PLUMBER & I %Gi l er LIC.# ZZ5
TOWN OF WLq1j
SEC ZS ,T 31 N, R E/
AND/OR LOT BLOCK
THIS PERMIT EXPIRES
S
SUBDIVISION
ZCKJa
CHAPTER 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 in force on the date of approval.
(c) The sanitary permit is valid and may be renewed for a
specified period.
(d) Changed regulations will not impair the validity of a
sanitary permit.
(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.
(f) The sanitary permit is transferable.
History: 1977 c. 168; 1979 c. 34,221; 1951 c. 314
Note: if you wish to renew the permit, or transfer ownership of
the permit, please contact the county authority.
ISSUING OFFICER -DATE 1118
UNLESS RENEWED
FO
AIN VIEW
Zot 1
THAT DATE
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (RI1/20)