HomeMy WebLinkAbout008-1063-20-000 (2)Wisconsin Department of Commerce
Safety and Building Division
GENERAL INFORMATION
Personal information you provide may be used for secondary
Permit Holders Name
Steve & Darla Germanson
CST BM Elev ll,sp BM Elev BM D
TANK INFORMATION
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
(Privacy Law, s 15 04 (1)(m)l
City Village Township
TOWN OF EAU GALLE
TYPE
MANUFACTURER
CAPACITY
Septic
t
Dosing
q{fallon
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMPISIPHON INFORMATION mttev M; a✓)�A
Manufacturer
IDemand
M
Yo
Model Number
TDH
Lift F j
Frict n v
�jDlan
System Head
TCir Ft
_I
Forcemam
Le thl
tl
Dist to Well
SOIL ABSORPTION SYSTEM
BEDf'RENCH Width /� ` Lori
DIMENSIONS
INFORMATION
I V-106
DISTRIBUTION
TA
County St. Croix
Sanitary Permit No.
633827
State Plan ID No
Parcel Tax No.
008-1063-20-000
Sectionrtown/RangeWrip No
22.28.16.321 B
Bot. System
CHAMBER OR
UNIT
HeaderlManifold
� T
Dis(nbulion
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipes) \
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Systems Only
Depth Over
Bed/Trench Center
\
Depth Over
BedFrrench Edges? I�y"
v Depth of
Topsoil
xx Seeded/Sodded
>a Mulched
Y-'
/ L /
U Yes
No
O Yes
No
COMMENTS: (Include code discrepancies. persons present, etc.) Inspection #1
Location: 2475 30TH AVE `,
1.) Alt BM Description - JW� Nu Vow to, f4v
2.) Bldg sewer length = i6y�
- amount of cover
Plan revision Required? ❑ Yes E] No 1 J
Use other side for additional information V?l
SBO-6710 (R.357) Date In pctors Signature
Inspection #2:
15(���
1p
County
sorely and FLalrllnpa 0lwslan4'
201 W. Washington Ave., P.O. Box 71fi2
SY Co.)
Suniwry Permit Number (w be Shed
Madison. WI 53707-716'2
pevOOPTS -33 6'�
Sanitary Permit Application Stula'Tmnaaotion Number
In ncmnlmme whir SPS 3832](2) Will Adm. Coda, wbmlasion ofthic famr to Wo appmprlaw governmental unit
in required prior to obtnlging a mdtoryponan. Nola: Application forms fur slate-mvncd POW IF,
g nddr�s)
me satin i ted to Pmjoct Address (iFdilferent Wm moil'
llle Dgndmrnl or SnSly and Pmfessiond Scmim. ra iinl infonnnlinn ynnpmvlde may be hied for eawndnry
m in ncC011jellf0 will, dwPriv Lmv a i5.od t m Slab. Sa , /) A 2
L AI ilcntiou lnfnnnaflou-Plvase Print All Tn Cormation YVZ,
Pmperty0 's Neme ParcclM
eve GCrma.1S0/!
os8-/OG7-2
-ease
Y.v),vay o,nnre MniNng� a�C YmpedY location �. 3
7 z2.28.1
Ig
City, Stela OwG LoL
VP Code Pltone Numhor N e e Sxtion
•L
wt Syesz S Gsi-?78. 977 mla anC1
T Zi X. RA BorW
A. Type of Bnllding (check all OLnt apply) Lot n
❑1 or2 Pnmily Dwelling-NumberorBedmom+ Z S.bdi,,66. Norm
Block l)
❑ rubllJCanrnrcmw-Dcscnlss Uac
U
cay nf.
❑Stale Owned-D®e Elso r C.�Ser NNNuiall/war (nj/�,� VYllalp of
-
(be( 40TmmofE-av &drrrt
Z-��1 k LiI17Cit •
III. Type of rermft (Catch only one box on Isle A. Complete Ibm B iTappllenb )
A' ❑Naw Syarmn �Rrpinaraeeld Syetem ❑ Tronlmantiynhling Tnah n apinrmm.nt only ❑ Other Minfirianion to Rsls6ng Syal'
(ospinin)
B- ❑Parmil Ronaml ❑ PcnnitRovisiou ❑Clmngr.urTlwrbnr
BeCory Bapimlion
❑Pcmdt TmasfcreoNew List Previous Permit Nnmbcr nod Data In
lied
4
Owner
IV - Type of:POWTS etcm/Com oocngDcvlcc: Check all flintapply)
Nan-Preemrriadln-0mm .0pmIavd=d InOrmtad 0At-0mda ❑ Mound > 24 Jn•ofsuiudik wit 11 Mound < 24 in: ofsuitable �so'iil
rrk ❑oumr Diap®1Comlmnen lain ❑PrehaatmentDevim (ecpl.
l/TrientmentAmInfonnnflon
gpd) Naign Sail.Applisetiml Re daf) spmssl Am R d(sl) DIspLTsnl ALca ,yq
Syslem Hlevollun
a '7 �29 k/o yi
fo Capacity Jn 'Patel it of Q Managlcla
Gallant Gnifoea Units
hkw iknlm nabring Taala
MCkwib�
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_
Tana /e0O 1 1 Via
7CJ `^
�o wlbo
VIL ncapmrsibN 15%mtement-7 am nndermIti , a avroa rarpmmmlti hr lrulatlsana of lno POWTSA"W'. oo 11'. thchd plaria.
Plumber'a Name(Pdnl)
Plumbu'S Signalum
MP(MPRSNumber
Susinow Phonc Nook
x
Zzlel
.s20L46',P
Plumbcr'r Addrrm (Smn� L9LY SW� 2`ip Cndc)
3s,z /yo ' S'T / AP?-f w.7' S—f-ol
Chun /Dc artmmtUsc Onl '
gi,Approvad
❑D)mppmved I PPonedtt Po`o•
❑
Dulc tat
6 Z�
Iasift Agent SIK'm
Darner Given Rcacon forDeninl �t�
•
G
tr]. unmuans ainppravuifiu nsnns lormislrpprovW 7 \ IJIV '(xsj• � •r ]41%eyl aG 5 y.} /CML �V1lt/ j'71
S;;TEMOWNER: J/ i ` f
1.3epnr tank, effluent fifer and l K� t 40 � ,.�,s , GW Y'2T
dlspend cell mu+i be +a kedimMmsinad tr i " /7
m per management plan provided by plumeer.I-
2. An setback ttqulrements must be matntelned �5 �-� ,},k (�.1 M (/�� &- Q ✓JgYIO'� ., - A 5 ^ +L��..
2AlllYYMniti, ..-' c;::Y:4JAn:nt:be 1
J+t'b''t.r- v4AItA4 Ceti4i�/
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ST. CRo SANITARY SYSTEM File#:
Office Use Only
= OWNERSHIP/ADDRESS FORM Creoted 212021
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 !G�(J'ty\
Mailing Address �Ur7 X� 3LiUe�
City/State/Zip 1A)W .th ff(X i (n )% S^UGr2K
Phone Number (required) &S-1- as/ g-
Email Address (required)
Parcel Identification Number 0019- I6Yt3-0Q6 - sari
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location _q0 1/4 , 166 1/4 , Sec. 22, T �,?) N Rj( W, Town of Ear c.�_ 0<�X_( tf.
Subdivision Plat:
Certified Survey Map #
Page #
Warranty Deed # (before 2006)Volume , Page #
Number of bedrooms _� Spec house 0 yes d1no Lot lines identifiable 0 yes 0 no
Lot #
Volu
OFFICE USE ONLY
New Property Address1 I/l5
(VerificaUo new address required from Community Development Department for new construction )
(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 wwwsccwi.aov
CONVENTIONAL COMPONENT DESIGN
Residential application
INDEX AND TITLE PAGE
Project
Name:
Owner's
Name: StCe b{+/honSa n
Owner's
x
Address: ;2 S/)S 3 e a4-�-
i✓o. Jam, ire WZ .Mo zr
Legal Description: /yE Nee S'ZZ -f' Y P t4,0 /i; w
Subdivision:
Town: Ott
County: S { C
Parcel ID# O O i -10 63 _-2 0— 0000 O
Lot #
Designer/Plurnber: 19emi1S �r.�lf� License# ZZl"l
Signature: �— Date: i.-/$•LI
Comments
Designed pursuant to the in -Ground Soil Absorption Component Manual for POwTS Version 2.0
Index+ ldeConv 2/3/2012
I
j
Ps L. f
.wpwCT
,I
R
. ..., qI - -
!4!a g9l v
DOI "i®
ups � wn�
Page _ of _
START UP AND OPERATION
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 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 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 surfaca
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 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 perm anently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper).
• 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 act 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 fines 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 failure of the POWTS a soil and site eva uaion
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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
ff- III SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANTtIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone Phone
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
_Name Names%C/eiK_ _t`7y 2awi:�4
Phone Phone
This document was dratted by the staffs of the Green Lake, Marquette and Waushars County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ik
Soil Absor38on Svsfiem Cross Section
�--- 4' Schedule 40
PVC Vent Pipe
coy.
With Vent Cap
Leaching --1,
Chamber
ft ft
q�.s ft
Final Grade
9Y..L ft
97.E ft
�— System Elevation
Soil Absorption System Plan View
4� ft
I Leaching Trench 1
Vent Or Observation Pipe /1' Chambers
Leachin Chamber Specifications
Manufacturer And Model
EISA Rating 20 sq ft per chamber Soil Application Rate • 7 gpd/sq ft
_30O gpd Design Flow 4 , • % Soil Application Rate + ZO EISA = 21 Chambers
2 rows of /O. // chambers each.
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page -
of -
FILE INFORMATION
Owner
Permit #
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Tank Manufacturer:
❑ NA
;1 Septic ❑ Dose ❑ Holding Volume: /t►si
(qaq
Tank Manufacturer.
❑ NA
❑ Septic ❑ Dose ❑ Holding Volumec
(gal)
Vertical Distance Tank Bottom(s) to Service Pad:
(It)
Horizontal Distance Tank(s) to Service Pad:
0)
Spaciflc carvidrg mechanics must be provided If vertical Is >15 feet or
If horizontal is >150 feet. Specific Instructions to be provided on back.
Effluent Filter Manufacturer:
❑ NA
Effluent Filter Model:
Pump Manufacturer:
Pump Model:
Pretreatment Unit
Manufacturer.
❑ Mechanical Aeration ❑ Peat Filter
❑❑
Disinfection ❑ Weliand
]NA
❑ Sand/Gravei Filter ❑ Other:Soil
Absorption System
0 In -Ground (gravity) ❑ In-Gmund (pressure)
0❑
At -Grade ❑ Mound
❑ Drip-Dne ❑ other.Other:
❑
Service Event
Service Frequency
Pump out cantenfs of tanks)
When combined sludge and scan equals one-third (X) of tank volume
❑ When the high water alarm is activated
Inspect condition of tank(s)
At least once every: Elmonm)(s). (Maximum 3 years)
years
❑ NA
Inspect dispersal cell(s)
At least once every: 3 0Iff month(s)(Maximum 3 years)
❑ NA
Clean effluent fifter
At least once every: p❑rmonth(s)
r4
yeat(s)
❑ NA
Inspect pump, pump controls & alarm
At least once every: _ ❑ monlh(s)
❑ yeans)
❑ NA
Flush laterals and pressure test
At least once every, month(s)
❑ year(s)
❑ NA
Other
At least once every: 0 reerts)s)
❑ NA
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption 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 combrned 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 forany 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 ()5) 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 linked to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
and any servicing at intervals of s12 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
GMW-005 (02105)
Septic -Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer
Tank Model Number
/,000 d
Total Tank Capacity
/00/ fa
Max. Bury Depth
Filter Manufacturer
♦ y�. --,
Filter Model Number
I -i'
Minimum Pump Performance Required
Z GPM Y Ft TDH
Inlet
Outlet Manhole Min. 4" Above Grade With
Locking Device. Inlet Manhole
< 6" Below Grade Sealed Watertight
Finished Grade
Depth of
Cover
Ft
OWet Filter
r`M'w
.`ti^v
Pump Manufacturer
d'e
Pump Model Number
0 ,
Alarm Manufacturer
.o►+�
Alarm Model Number
L
Switch Type
Total Dynamic Head (TDH) - Feet
Elevation Head
/0
Distal Pressure
Network Loss
S
Force Main Loss
Total
d
Securely Mounted
Weather-proof
Junction Box
Vent Min.12"
Above Grade
With Vent Cap
:.Ij
j Off Elevation
•
< t
Manhole Min. 4" Above Grade
With Locking Device
Disconnect
Means
Outlet
A
< 1/4
Weep
B ;< Hole
C
DI>' Bottom
. Elevation
'< Ft
GFMIZAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not
be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock)
installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight frtdngs, and
laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank
excavation and the sleeve is sealed watertight Electrical service complies with NEC 300 and Comm 16.28 WAC.
02/05 LJ Page of
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M
75
22
70
20
60
18
55
16
50
14 45
d
w
S
u 12 40
a
z
>- 35
Q 10
30•
B
25-
B 20
15-
4
10-
2
5•
PUMP PERFORMANCE CURVE
MODEL 140/4140/145/4145
145/ 1401
4145 41�10
0
10 20 30 40 50 60 70 so I so
GALLONS
LITERS 0 80 160 240 3 0
�•--•-•1�1 nninulTC ��nnon
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) Z q75 50f` A-yt
at: Ole '/4, Nl;'/a, Section ZZ Town 0S N, Range
located
W,
Town of �u t"11e , 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 5 Z(
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 1000656
Construction: Prefab Concrete Steel Other
Manufacturer (if known): nt;
Age of Tank (if known): 3 yv3
Permit number (if known) Z 1l
(Licensed Plumber Signature)
(Title)
(Date)
den ru3 ( Ir
(Print Name)
z? l q7/
(License Number) MP/MPRS
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
-EAU GALLE
T,28 N-R. 16
W 21
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IORGENSEN'S
MADSON
=�� E
GAS
LUMBER CO.
Jacobson's Skelly
BOLK & BOTTLE GAS
BUYERS Of LOGS,
TIMBER &
COMPLETE SERVICE STATION,
New Richmond
TIMBER LANDS
TOWING AND ROAD SERVICE
8 Baldwin
SPRING VALLEY, WIS.
698-2438 WOODVILLE,
Phone: 246-4633
TELEPHONE:
NITE - 698-2630 WIS. 54028
1 after hours 246-5134
778-5333
-�- a v -c'XI
,�j -,v+5 �r"
I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy 14w, s.15.04
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
i rl t
Dosing
yj (y`
Aeration
Holding
TANK SETBACK INFORMATION
TANKTO
P/L
WELL
BLDG.
Ventto
An Intake
ROAD
eptic
r
r
A-/ R
NA
Dosing
o? 5
NA
Aeration
NA
Holding
PUMP/ SIPFRONWFORMA ION Z?% •t lium
Manufacturer Demand
Model Number ?jy GPM
TDH Lift Friction System/' TDHg Ft
Loss I Forcemain Length Zo is Fi Dist To Well
SOIL ABSORPTION SYSTEM 2.aS
VATION DATA
Count!§T. CROIX
Sanrta�Ple4T, f�lo.
State Plan ID No:
Parcel ft§&1063-20-000
A9800503
STATION
BS
HI
FS
ELEV.
Ben
q-Z
lvf%Z
Bldg. Sewer
St fit Inlet
so fit Outlet
Dt Inlet
Dt Bottom
&/
�-
Header / Man
7. ZS
Dist. Pipe
�, g
$•4i7
Fr. a
Bot. System
Final Grade
BED R N
Width r
Length
No Oi eniches
PIT
DIMENSIONS
No Of Nis
Inside Dia
Liquid Depth
SETBACK
SYSTEM TO
1016YL
BLDG
I WELL
I LAKE/STREAM
LEA
INFORMATION
C AMBER
Type
r
r
Moe r:
Syste
OR
DISTRIBUTION SYSTEM l i;/�yaf .l�rCh,/�,hGi, �Sfdew/n.�i�//' �l•8
Header/Manifold
D7tn ution Pipe(s)
x!H_ole Size
irHoeS ang
Vent To Air intake
Length � Dia
Length -Bra Spacing - V
Y C{yyrrr
e
—7U
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
xx Depth Of
xx Seeded/Sodded
j
xx Mulched
Bed /Trench Center
Bed /Trench Edges
Topsoil
❑ Yes ❑ No
❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EAU GALLE 22.28.16.321B,NE,NE 2475 30TH AVENUE
Blc� �rt(5�fctwaq(tlia�tl�IeG% t
Ie
-PjLte ( to(: 0V to
Plan revision required? ❑ Yes WNo
Use other side foradditional information. 1(
/° SBD-6710 (R.3/97) Date Inspector's nature Cert No
NOTICE: Please provide the following:
A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
t, J PLAN VIEW
i
INDICATE NORTH ARROW
wwcandrtl3-pautrnentacormtero. SOIL AND SITE EVALUATION Page 1 a--3
Oivbion of Sdely and B ilove q trs f".�dnrmm Nils.
Co83.05, Adm. Code Certified Soil Testing
Attach compkft Me plan on paper not less x.lp' i �� Plan must
Ir"We, but net Iknlbd IN wftd and hortr dwft irNlst�1 '(!fA),edlrecdon and St. Croix
Percent dope, Gale or dirnerrobns, north arrote r durance to neared road. s --- -- ---
APPLICANT INFORMA71ON - prlrKall Inloituft". Pan d I Bo8.1o63-zo Oo (z2.zs.16.3z1s) -
Peracnel kwwmdon you provkla may be ua leiadary pwii-ay tr.x 15.04 (1) MY Date
Owner prop"
lacelirn
G�tus, Brian & Sheila n ( NE 1/4 NE 114 S 22 T 28 N R 16 W
Property OwWs M&M Address f ' 4N Id 8 Block 8 Subd. Nine or CSMB
-- -
�dy _ __.._ . _
--- ' --`
odville
- - �Ip CoQe die � C1(y ❑ v�ag-e- ®Town � --Nearest Road - -
Stafe ft0C20 5/ 6 8-267k / tau tulle _ - 30Th Ave.
❑ New Construction Use, ® Reaiileritial ) Nwnbar9(becirooma � ❑Addit on to ex stlng baiting
® Replacement ❑ Pubic or cnnarterciY dseoribe
Code Derived daily flow 300 gpd Recommended der loading rate •7 bed, gpolfP 8 trw4h. 9PW
Absorption arm required 429 bed, fr 375 french, Ile Me*= design bating rate •7 bed, gpd1W •8 trerrh, 9Pdm"
Recommended Infiltration surface elevation((a 94.0 It (as referred to site plan bonchmar
Additional dasf n I site considerations install - 3' x 36' Sidewindc, Hkapecity "Nrtle-she1P trenches for 2 br (2 - 3' x 54' for 3 br)
Parent material sendyAOamy outwuh Flood plain elevation, B applicable _ NA ft
S=Sug" for system I Converwonal fiotad Waourd Prepare AMade System n FU Hold ng Tank
U=Unsuitable for system Z ❑ U M S❑ U M S' I U ?C S -1 U S U I' S X U
Bering#
k
Ground
slev
93.0 ft
Depth to
94-
Grewd
dev
7.4 ft
Depth to
wftv
factor
HorizonDepth
In.
Dominant Color
Munn
Mottles
Wz.
Texture
Structure Consisten Boundary Roots
Sh.
Bed Trench
1
0-8
I OYR 3/2
al
2 f sbk
dsh
dh
dl
ml
-
cs
cw
cs
cs
- cs '
cs
1 f/m
I m/c
If
- --
---
5
5
.7
.7
.7
.7
.7
.6
.6
_8
.8
.8
.8
i B
2
9-36
l OYR 414
ail
2 m sbk
0 sg
3
36-40
7.5YR 4/4
�k. a
4
40-52
IOYR 516
IS
0 erg
5
52-56
7.5YR 54
a
0 sg
ml
ml
ml
6
56-76
IOYR 516
-
a
-
0 sit
-- 0sg-
7
76-94
1OYR4/6
a
Rom: YrfOI100 2.7 T d� a 70 /O: eaace 1 V7 K 7/e U ®71FaL aOe I, /r /o - - - __ _
1
0.6
IOYR 3/2
at
2 f sbk
Imsbk
dsh
dh �-
dh
dl
ml
cs
gs
cs
cs
(
I f/m
Im-
Im
- -
-
.5
.7
.7
- .7
5
.6
.8
.8
.8
6
2
6-31
/ IOYR4/4
Imooa
3
31.76
I0YR 4M
Ices
I to sbk
--
4
76-90
IOYR 4/4
a
05
0 sg
5
90.95
IOYR 4/6
$
CST Nwws Plew Pdnt) SOWAIre: Telephone No.
Henry F. Grate p� 715-665-2681
- dress P.O. Box 57, Knapp,W1• j4749 --- — 014/1998 22ST Number -- - Ref I
PROPERTYOWNER�•BriangSheds SOIL DESCRIPTION REPORT
u f10.# ooe-lo6z-zoa_otzz.ze.leazlel -
N �y�
6
3
i
Depth to
kntup
kclor
> for
i4nd
s
98.3 It
Depth to
firrd rig
factor
>IW
Ground
do
Depth to
k Nong
hoax
® Page 2 of �3.
Ccrlifica Sail Tewne
Hor =
Depth
in.
Dominant Color
Munsell
Mottles Texture Structure sistencei Boundary I Roots _ - GPDIW,
Qu. Sz. Cont. Color Gr. S7 Sh. Bed Trench
1
0-12
IOYR 3!2
sl
2 f sbk
dsh
Cs
lm
7
---
2
12-28
IOYR 4/4
Imcos
1 m sbk
A
8w
3
28-67
IOYR 4/6
kos
1 m sbk
dsh
dsh
Cs
— --
Im
7
l —
4
67-102
IOYR 4/6
Imcos
I m sbk
.7
-
, t119
1
0-7
lOYR 3/2
4
2 f sbk
I m sbk --
1 on sbk
dsh
— dh
dsh
dl
Cs
gs
Cs
-
I f/m
-Im
lm
--f
'
.4
.7
—.7
,LY
18'
g
2
7-27
IOYR 4/4
— -- — - -
sl _
Is
3
27-41
10YR 4/4
4
41- 00
IOYR 4/6
O s8
rcunrarsa. L---
I
I
rcerrrarxs: ---
Ground-
�
—
I
I —
—
--
—
Depth ID
Mang
fxw
%0
AY<
n(�
Sri, > SW �.w.� -•.�i J...�� �...�..�
ao4- 1 dot-to-uoC2�.is,u:.3t1 q/
2_4�S
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s
[ED)CJ
L ST-�zr- I ��
JUN 14 2021 4
Ws Dept Of Safety nd Pmressional Sery cos X'iL t /iaL lr, t k�r RE ORT page
Divisio^. of Safety an Buildings -
LX �
St Croix CRL6-6'Sroance a, SAS 385 Ws. Adir Code
--
Community Development
County
Attach complete say. plari on paper nc, iess an . " inches m size Plar mus:
'57+1
include but no tinted ioveaical and horzortal referer,.e ecit, (Bm) direc on and
pe, cent since, ,calf or rimers ons, norm arrow and Ic-aror• _Ire di.m.c e to nt,Oest road
parcel I D �0 �_�
06 3 - -ID
Please print all information,
Rome etl by� Date
Fe. nal IY, .CU C,_ cr- ,b, s. J ...- dr - ._- 31 1a,1 n
�
'per.,.x':a071
a - L v0.. 6�� Ph2�-S DA7 Con. la. t
t+4 PE•,,^ 42 T N R /(e B (c w
ee..v Cwrer s Madlrr Ldres_ _c; # j 310.Y �r
Suod Name u CSM#
ayes 3�TN�1%L., --�--
�`.r
A, State Zlp Coo, Rhone Numbs, Cr,
. L - t _ y ❑'Village
g7own Nearest
L `-Fwow 101 11 C_ 1 w.1, i > 7 0 AZI W/ )j2UI_}T7Zl 1___--- to rA C¢q!! r— I .SO
^;ew Ccns•ruc;un Use ®Resid,naal N�mo,r ci bedrn,-:r , _ _ Code de,edidesign flow rate — � '� _ GPD
',Paplacecen; � �,�bPc el cammerc,a'- C,c, l--,
Parant ma(ar e'_ _�.o V �F_-�_� -_--_--- p'-gin ?lain e'r ✓uuor 11 accllcat-le __
General comments
and •ecommenda'ron< ,a �56"i �1��14i �'i�hf. ►yes
Ldogst Ga��//'' Q+ 93,s 6
�i '-- D hc. N'V �
1 Bonn^ g Bonno
71 c- �S c. 1 I1^
Soil Application Rate
Rtlox Descri r ary Roots GPUIft '
Glu p, , c �Sszi•'le yhonsistence ountl _
Sz Con( Colo 1Gr ' "ffk1 fr;t2
Horizon
1�Deft
h
in
De iriani
mmant Colo,
n
o=S
!ulft3--
3
3�r
3i�r5`i2yl
��—I-SL !fP$bIf 9 10 r7
4-Z-=�4
Boren IJ Sonng
❑ Pr GrOc^n suc?ce elev.
-orzo- Cepih IDc%li^an'Crlsr ''eccx Cos-ra
_
Cecil; to ! miring `ac'o1 __
�F�t,.
c
j 6trurtr-
onyiv:e r.?e
Ir
Roots I GPDM '
I �
- 9 v
— —L - — --� Efflue^t tl' =50r �0_ Ir .I and c.,rl - F;nueii�'��._30 mglL and TS <30 mg:_
.: . ame ^-iea,e Pm r�
ano-th S.F. - -
sVoab
8-k6r5
S'ID-F130(RI Ir1I)
�u�
N.
W
0 O
Property Owner
Boring # (�j Boring
n c:, Ground surface elev.
Parcel ID At
ft Depth to lira:tmg Factor in
Page _ of
Anil Anoh� cation Ra—
H,nzon
Depth
it
Dominant Color
Munsell
P.edox Descnphpn
Ou Sz Cant Cclor
Tex ure
Stricture
Gr Sz Sh
onsistence
oundary
Roots
GPD/P
ff#1
ff#2
,r
J
J Bormc
Bo 'ng
p,t Ground surface elev, — Y, Depth to limiting factor in Soil A lica6on Rate
-crzon
Den:',
in
Dom.nan! Color
Munsell
Redox Descr.;; rcr
Ou Sz. Cent col"x
Texture_
Structure
Gr Sz Sri
>nsisdence
oundary
Roots
GPDIit
f1#1 '
ff#2
—1_
I
Ro•ino
Boring # Ground sur ace elev s Depth Ic hm ung factor in
❑ P'� --
Soil Application Rate
Horizon
Depth
in
Dominant Color
Mursell
Redox Descnpnoo Texture I
: u Sz. Cont. Color
Stricture
=z Sh.
onsistence
oundary
Roots
GPDIft '
ff#? "
ff#2
i
` Effluent #' = BOD . > +C < 220 rng!'. and TST = ,a 50 mgrL ' Effluent #2 = ROD , < 30 mg/L and TSS < 30 mgtL
f
Thr Dept. of Safel% and Prufessi:,nal Scr ic." as -'qua! opp„rWnrtt "Cl%1':c hrm tdet and emp10yrr IFyou need assistance to
ase« on iecs nt nn_d m rtn',a! in a, ,li. ec. h:rn iu:, "'mart the Irh.utmcut of 608-266 151 or FTY through Relay.
SH 11 L:I F: /
7
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�• ���X couNry I tl /4te
mt P% f NO. 633827
STATE SANITARY PERMIT
2K75 30+�v�
MfQE � AL PREVIOUS N0.3 Z''/G/G
OWNER
h
PLUMBER �In tit &&,e LIC.# 2 Z 1 /
TOWN OFF
SEC—?..,2,. ,T
AND/OR LOT
t�4.Jj
St N, RE/O
�- BLOCK `—
THIS PERMIT EXPIRES
POS
SUBDIVISION
zac x
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; 1981 c. 314
Note: If you wish to renew the permit, or transfer ownership of
the permit, please contact the county authority.
ISSUING OFFICER - DATE
UNLESS RENEWED
FO THAT DATE
AIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (RI1/20)