HomeMy WebLinkAbout032-1030-50-200 I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
420375 0
GENERJi L INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Bemis, Daniel I Somerset Township 032 - 1030 -50 -200
CST BM Elev: Insp. BM Elev: IBM Description:
/ Do- o o 1'h o-- S vj
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic - / / � � ' \ Benchmark
Dosing / D Alt. BM
Aeration I V Bldg. Sewer
��� � 0�,
Holding Ht Inlet _
fS B�
TANK SETBACK INFORMATION S t outlet s Z p ! . 9
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 4 Dt Bottom
Dosing Header an.
/ e-h
Aeration Dist. Pipe
Holding Bot. System
/� 3,
Final Grade
PUMP /SIPHON INFORMATION . 3 /07. 9
Manufacturer Demand St Cov r .6 a.
Model Number
TDH Lift 'Friction Loss System Head TDH Ft
Fo ain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM - f- -'L
BED /TRENCH Width I Len t Flo. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1 !f ' � 3 �—
SETBACK SYSTEM TO C P/L JBLDG WE L LAKE /STREAM LEACHING nufactur
INFORMATION A CHAMBER OR
Type f System: f / UNIT Model Number:
DI IBUTION SYSTEM V
Header/ anifold Distribution x Hole Size x Hole Spacing Vent to Air Intak
' / ri Pip y 3 7 �' , / -
Length Dia Length Dia Spacing � S
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 3G 10 e -yJ
Depth Over Depth Over xx Depth of r7eeded /Sodded xx Mulched
Bed/Trench Center L s b Bed/Trench Edges Topsoil U Yes ❑ No F-15i Yes U No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I dl 3 / >_ Inspection #2: / !
Location: 661 Lakeside Lane Somerset, WWII 54025 (SW 1/4 NE 114 11 T31 R1 9W) NA Lot 2 )7-1,0 Parcel No: 11.311.1
.19.146A20
1.) Alt BM Description � VK»Q11�`� 2��� � -� (Zt,ul dU
2.) Bldg sewer length = t �� -h/ ` 3 O s� S: o
-amount of cover= puzeto' -D�. t ytSLt (p1,
fit. 4to < Is deAp U
Required? i Y � T�
Plan revision Re —�
4 � "w; es � No
Use other side for additional information. �� YYry - -
SBD -6710 (R.3/97) Date Insepctors Sig ature Cert. No.
I _
- '� - - Safety and Buildings Division County 7
201 W, Washington Ave., P.O. Box 7162 Ti /
*75c'
onsin Madison, WI 53707 - 7162 Site Addrtiss
De artment of Commerce 4/ t' _ � -� y ���
Sani Permit Number
. . �Y i
Sanitary Permit Application
acon you provide (] Check if Revision � 3��
in accord with Comm 83,21, Wis. Adm. Code, penonal inform
_
- nuy be used for seco purposes Privacy Law, slS, i m
Sato Plan I.D. Number
I. Application W'ormatloa - Please Print All Inforntutlon
perry Owtxr's Name Parcel Number
03 - So - 2C70 C. 146 A - 2
Propctty Owner's Mailing Address u roperty Location
Lt1
K 'A S T; N. R
City, Stan Zip Co.1e hone Nr 'e1 ( Number Block Pf6tmber
i
Su ivision Name CS r
11. Type of Building (check all that apply) � ❑City
1 or 2 Family Dwelling - Number of Bedrooms ❑Village
lJ Public /Conuncrcial - Describe Use cr owruhi
U State Owned 3 x -7 3 X �'r' N t Road
3� 3 w a
M. Type of Permit: (Check only one box on line A (numbering scheme for internal toe). Complete tine B if applicable) M
For Count? use
A
1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to
S stem I Tank Ordy Existing S stern
B, O Chock if Saaitary Permit Previously issued
Permit Number Date Issued
rV. Type of Permit: (Check all that apply) (numbering scheme is for internal toe)
44 M Non - Pressurized In-Ground 210 Mound 47 C3 Sand Filter 50 ❑Constructed Wetiand fA
22 O Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pus 510 -Drip Line 3 � �Jn
45 C3 At-Grade 46 C3 Aerobic Treatment Urut 49 ❑ Recirculaung 30 C3 Other
7 ✓yam °�►'
V. DispersalfTreatment Area Information:
Design Flow (bpd) Dispersal Area Dispersal Area Soil Applicauon Percolation Rate System Elevation Final Grade
/ Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) Elevation
VI. Tank Lnlu Capacity eat Total Numtxr Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Fads
ting W
Tanks Tanks /
Septic or Holding Tank
Dosint Clumber
VI1, ResponsiblUtZ Statement- I, the undersigned, as#une respoasiblilty for installation of the POVVTS shown on the attached plans.
is amc (Print). Plumber' Sig MP /MPRS Number Business Phone Number
P umber's Address (Street, Ci , Sate, Zip e)
VIII ount /Dc artment Use Onl
Approved ❑Disapproved Saruary Permit Fee (includes Groundwater Date Issued mg A Signature (N Psi
Sure rge Fee) G
❑ Owner Given Initial Adverse � ^► �� l/� 0/o Q
t Dcterminafion
t� of A royal /Reasons for Disa roval
IX, Cond Uorts Pp
PP S'�d�liY�.dtitf vn CUils�Clc . �� G; ' u �
al;4, MWClt bR, � =
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SBD -6398 . 05/01 I'�C�
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08/08/2002 13:32 7152473038 BELISLE EXCAVATING I PAGE 01
I •
CHECK LIST FOR PERMITS
OWN OR ]RU rIMEE
PERC TEST OF SOIL PROFILE
BLUEPRINT OF MOUSE
�! WARRANTY DEED WITH SEAL; DOCUMENT NUMBER;
VOLUME AND PAGE NUMBER
._� TAX NUMBER OF LAND
CERTMED SURVEY MAP (IF AVAILABLE )
COUNTY FORM, SEPTIC TANK MAINTENANCE AGREEMENT
AND OWNERSHIP CERTIFICATE FORM- FILLED OUT AND
/ SIGNED,
NAME" ADDRESS "PHONE NUMBER "IF NOT ON PERC TEST
PLUMBER
ALL OF THE ABOVE
PLO 67
PLOT PLAN
CROSS SECTION
CHECK FOR PERMITS '
r
EROSION CONTROL PLAN COMMENTS:
For 661 Lakeside Lane Sanitn Permit — owner(s) David Bemis
1. The main source for construction site runoff will be the house foundation excavation and
any soil stockpiled until final grading and stabilization is complete. Septic system
excavation/installation has minimal impact, but apply seed and mulch as soon as final
grading is done to minimize erosion.
�' g
2. Divert runoff away from road right -of -way drainage ditch by creating temporary earthen
berms ALONG CONTOUR between construction activity and Lakeside Lane. Maintain
existing vegetation between house & septic system excavation and any drainage areas.
3. Construction equipment and vehicles must use only one stabilized driveway access that is
designed for heavy equipment; this will avoid muddy, rutted conditions that allow
contaminated runoff into the road ditch. This includes cement trucks, well drillers, and other
vehicles that access the property.
4. Stabilize new cover over septic system with seed and mulch immediately after installation —
do not wait for final stabilization/landscaping of entire site to cover exposed soils on the
system.
5. If builder /excavator grades the site to create temporary berms as recommended to contain
sediment and leaves adequate vegetative cover between work area and neighboring property
and/or road ditch, installation of silt fence MAY not be necessary. Use mulch or other cover
materials to prevent erosion.
Silt fence will be required if sediment cannot be contained on the property with
diversions/berms. Septic system inspector will evaluate ESC plan effectiveness and make
recommendations accordingly.
Please feel free to contact me with questions or ask for assistance with erosion & sediment
con 1 installation.
Pamela Quinn, Soil Erosion Inspector #665054
EROSION CONTROL PLAN CHECKLIST
` e R if Check (./) appropriate boxes below, and complete the site diagram with necessary information.
� QQ
UoF z o Site Characteristics
North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways.
.Er ❑ Location of existing drainageways, streams, rivers, lakes, wetlands or wells.
❑ Location of storm sewer inlets.
L� Location of existing and proposed buildings and paved areas.
4< The disturbed area on the lot.
V" Approximate gradient and direction of slopes before grading operations.
I!� Approximate gradient and direction of slopes after final grading operations.
❑ El Overland runoff (sheet flow) coming onto the site from adjacent areas.
Erosion Control Practices
V ❑ Location of temporary soil storage piles.
Note: Soil storage piles should be placed behind a sediment fence, a 10 foot wide vegetative strip, or should be
covered with a tarp or more than 25 feet from any downslope road or drainageway.
P"" Location of access drive(s).
Note: Access drive should have 2 to 3 inch aggregate stone laid at least 7 feet wide and 6 inches thick.
Drives should extend from the roadway 50 feet or to the house foundation (whichever is less).
P ❑ Location of sediment controls (filter fabric fence, straw bale fence or 10 -foot wide vegetative strips) that will pre-
vent eroded soil from leaving the site. �� ��— SebiMf74 -i re4wi y✓laYt 6r 0 4-VT - _P40,4
'DITCSGV�K A0
X_ Ak�ly�� Gf L LA'F1t3•
El P"' Location of sediment barriers around ohh -site rF( st rm sewer inlets.
• VLocation of diversions.
Note: Ithough not specifically required by code, it is recommended that concentrated flow (drainageways) be
diverted (re- directed) around disturbed areas. Overland runoff (sheet flow) from adjacent areas greater than
10,000 sq. ft. should also be diverted around disturbed areas.
• "ocation of practices that will be applied to control erosion on steep slopes (greater than 12% grade).
Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions,
and re- vegetation by sodding or by seeding with use of erosion control mats.
❑ P of practices that will control erosion in areas of concentrated runoff flow.
Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of
such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod, and rock rip -rap.
When used, a given in- channel barrier should not receive drainage from more than two acres of unpaved
area, or one acre of paved area. In- channel practices should not be installed in perennial streams (streams
with year -round flow.)
❑ a Location of other planned practices not already noted.
Standard Erosion Control Plan
for 1 & 2 Family Dwelling Construction Sites
According to Chapters ILHR 20& 21 of the Wisconsin Uniform Dwelling Code, soil erosion control informa-
tion needs to be included on the plot plan which is submitted and approved prior to the issuance of building
permits for 1 & 2 family dwelling units in those jurisdictions where the soil erosion control provisions of the
Uniform Dwelling Code are enforced. This Standard Erosion Control Plan is provided to assist in meeting
this requirement.
Instructions:
1. Complete this plan by filling in requested information, completing the site diagram and marking ( ✓) appropriate boxes
on the inside of this form.
2. In completing the site diagram, give consideration to potential erosion that may occur before, during, and after grading.
Water runoff patterns can change significantly as a site is reshaped.
3. Submit this plan at the time of building permit application.
Site Diagram Scale: 1 inch = feet
EROSION
CONTROL PLAN
LEGEND
PROPERTY
LINE
EXISTING
' DRAINAGE
TD TEMPORARY
DIVERSION
FINISHED
-' DRAINAGE
LIMITS OF
GRADING
_ SILT
' FENCE
STRAW
BALES
GRAVEL
O VEGETATION
SPECIFICATION
TREE
PRESERVATION
STOCKPILED
SOIL
Please indicate north
by completing the
arrow below.
I
—N—
I
PROJECT LOCATION
BUILDER s OWNER � �� �Eih•S' Jaft&
WORKSHEET COMPLETED BY DAT ��
a
a �c� Indicate management strategy by checking (✓) the appropriate box:
fOCC Q ��
Q om / 0 Management Strategies
0J ❑ Temporary stabilization of disturbed areas.
Note: It is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized
by seeding (between April 1st and September 15th), or by other cover, such as tarping or mulching.
I/ Permanent stabilization of site by re- vegetation or other means as soon as possible (lawn establishment).
Indicate re- vegetation method: Seed La ❑ Other ❑
Expected date of permanent re- vegetation: ' Al- � A
Re- vegetation responsibility of: Builder ❑ Owner /Buyer i-
Is temporary seeding or mulching planned if site is not seeded by Sept. 15 or sodded by Nov. 15? Yes No ❑
•
L� / Use of downspout and /or sump pump outlet extensions.
Note: It is recommended that flow from downspouts and sump pump outlets be routed through plastic drainage
pipe to stable areas such as established sod or pavement.
• Trapping sediment during dewatering operations.
Note: Sediment -laden discharge water from pumping operations should be ponded behind a sediment barrier until
most of the sediment settles out.
COY Proper disposal of building material waste so that pollutants and debris are not carried off -site by wind or water.
D Maintenance of erosion control practices.
• Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to
half the barrier's height.
• Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing straw bales will be
replaced (typical bale life is three months).
• All sediment that moves off -site due to construction activity will be cleaned up before the end of the same workday.
• All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday.
• Access drives will be maintained throughout construction.
• All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized.
For more assistance on plan preparation, refer to Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code,
the DNR Wisconsin Construction Site Best Management Handbook, and UW– Extension publication Erosion Control for
Home Builders.
The Wisconsin Uniform Dwelling Code and the Wisconsin Construction Site Best Management Handbook are available
through State of Wisconsin Document Sales, 608/266 -3558.
Erosion Control for Home Builders (GW0001) can be ordered through Cooperative Extension Publications, 608/262 -3346
or the Department of Commerce, 608/267-4405.
r
EROSION CONTROL REGULATIONS
UNIFORM DWELLING CODE (DEPT. OF COMMERCE)
PROJECTS AFFECTED • Straw bales, filter fabric fences or other barriers to
• All new 1 and 2 family dwellings in Wisconsin started protect on -site sewer inlets
on or after December 1, 1992. • Additional controls if needed for steep slopes or other
• Additions to dwellings built after June 1, 1980, special conditions
MAINTENANCE AND WASTE DISPOSAL
APPLICATION PROCESS • Sediment controls must be maintained until the site is
• Erosion control measures must be included on the plot stabilized by mulching and seeding, sodding or
plan submitted with the building permit application to landscaping
the local building inspector in communities where the . All building waste must be properly disposed to pre -
dwelling code is enforced vent pollutants and debris from being carried off -site
• Plot plan must show:
— Location of the dwelling, other buildings, wells, sur- ENFORCEMENT
face waters and disposal systems on the site with 'Erosion control inspections will be made during other
respect to property lines regular inspections (footing and foundation, rough con-
struction, final, etc.)
— Direction of all slopes on the site
'Violations must be corrected within 72 hours
— Location and type of erosion control measures
• Stop work orders may be issued for noncompliance
CONTROLS REQUIRED FOR MORE INFORMATION, CONTACT
• Silt fences, straw bales, or other approved perimeter • Local building inspector
measures along downslope sides and side slopes • Department of Commerce, Safety and Buildings Divi-
• Access drive sion, P.O. Box 7969, Madison, Wisconsin 53707,
(608) 266 -2128.
STORMWATER PERMIT (DNR)
PROJECTS AFFECTED — Proposed erosion and storm water pollution control
• Any grading or construction project that disturbs 5 practices during and after construction
acres or more and is not covered by a building permit — Documentation that an erosion control and storm
• Smaller sites that are part of a planned development water management plan which meets DNR standards
involving 5 acres or more of land disturbance has been prepared (plan does not need to be submit-
• Effective October 1, 1992 for any new or continuing ted with the application)
project —Other information related to site location and per-
• Exceptions: Indian tribal lands and work done by local mit holder
government staff CONTROLS REQUIRED
APPLICATION PROCESS • Erosion control measures specified in the Wisconsin
• File a "notice of intent" application (Form #3400 -161) Construction Site Best Management Practice Handbook
with the Department of Natural Resources (DNR) 14 • Measures to control storm water after construction
days before construction begins FOR MORE INFORMATION, CONTACT
• Application must include: • Department of Natural Resources, Storm Water Per-
- Timetable for land disturbing activities and installa- mits, P.O. 7921, Madison, WI 53707 -7921, (608)
tion of erosion control measures including project 266 -7078
start and completion dates
LOCAL ORDINANCES
Check with your county, and city, village or town for any local erosion control ordinances including shoreland zoning
requirements. Except for new 1 & 2 family dwellings, local ordinances may be more strict than state regulations. They
may also require erosion control on construction projects not affected by state or federal regulations.
A publication of the University of Wisconsin - Extension in cooperation with the Wisconsin Department of Natural Resources and Department of
Commerce, Ron Struss, Water Quality Educator, UWEX Western Area and Carolyn D. Johnson, Urban Water Quality Educator, UWEX Southeast Area.
UW- Extension provides equal opportunities in employment and programming. This publication is available from county UWEX offices or from Extension
Publications, 630 W. Mifflin St., Madison, WI 53706, (608) 262 -3346. Copyright 1997 by the Board of Regents of the University of Wisconsin System
doing business as Cooperative Extension, University of Wisconsin- Extension. Send inquiries about copyright permission to Director, Cooperative
Extension Publications, 201 Hiram Smith Hall, 1545 Observatory Drive, Madison, WI 53706.
GW0001A Standard Erosion Control Plan for 1 & 2 Family Dwelling Construction Sites DNR: WT- 458-96 R -02- 97- 2M -10-S
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with C 'V• Adm. Code � // f�
County �T• V O 1 k-
Attach complete site plan on paper not less than 8 112 1. Ht�rS sflils�
include, but not limited to: vertical and horizontal refe nce int (B directio» arSd_ parcel I.D. percent slope, scale or dimensions, north arrow, z
on aL d d np o nea'rrrst -raad. 0 a� / A -A )
-r ^I` t
Please print all in ►s btion. Vll ±..4'v' ; J
eviewe by Date
1 c
Personal information you provide may be used for seconrraly� purposes (Priv y w, Q 4 (1),(m)). 9 /U 4 '
Properly Owner v` �r°perty4°cat� °n
T
CC /� ! �OUy . ovt. Ldt 1/4N /4 S f N R E (or
Property Owner's Mailing Address 7ONIN Lo #,� ck # Subd. Name r CSM#
City State , Zip Code Phone Numb _ i
Ity ❑Village own Ne rest Road `
S 2 __5
ew Construction User Residential / Number of bedrooms Code derived design flow rate _ 6 1 SCE __ GPD
❑ Replacement F
I Public or mmercial -Describe:
Parent material _� %cix Flood Plain elevation if applicable A/ 1 Y4 ft.
General comments
and recommendations:
Boring # [] Boring // f�
Pit Ground surface elev! 1f Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 - Eff#2
4 z
r� 2
✓w
g 3 (0 6- o�,�..�
Boring # Boring
pit Ground surface elev�ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I I 'Eff#1 'Eff#2
0- 10 r3' s� 0 J T _ S
s/ Cl rrt _s XA a2 - -3
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 1 30 mg/_ and TSS < 30 mg/L
C � (Please PnM) — — e CST Number
cx_.-_� 16 9 O U
Address Date Evaluation Conducted T hone Number
dO 9 /v O !
l
Property Owner Parcel ID # Page of
F 3_1 Boring # ❑ Boring
)EI pit Ground surface elev. /all /-ft. Depth to limiting factor /� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
3
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color > Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 'Eff#2
F Boring # ❑ Boring
Ground surface elev. ft. Depth to limiting factor in.
1:1 Pit
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
T_
' Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 130 mg/L
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.
SBD -8330 (R.6/00)
t
Soil Test Plot Plan
Project Name Daniel Bemis Shaun r
Address 655 Lakeside Lane
Somerset Wi 54025 C #226900
Lot 2 Subdivision ------- Date 9/16/00
SW 1/4 NE 1/4S 1 1 T 31 N/R 19 W Township Somerset
M Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Survey Pipe
System Elevation 105.1 *HRP Same as Benchmark
Alt. BM Top of Lath @ 103'
Lakeside Lane
Alt
.M. M
O �
B -1
B -3
5% 7 '
Slope 5'
45'
3
B -2 0'
110' 111'
1 '
180 09
'k r aP o f r P -
B.M.
Property Line
POWTS OWNEWS MANUAL & MANAGEMENT PLAN Pa / "f"
FIVE INFO MATION S YSTEM SP ECIFICATION
Owner Se tic Tank Cap acit al o NA
Permit # a.0 3^7 Septic Tank Manufacturer o NA
Effluent Filter Manufacturer o NA !
DESIGN PARAMETERS Effluent Filter Model o NA
Number of bedrooms ,3 ❑ NA Pump Tank Capacity al &NA
Number of Commercial Unit ANA Pump Tank Manufacturer aKNA
Estimated flow (average) p gal/day Pump Manufacturer s NA
Design flow (pea Estimated x 1,5 gal/day Pump Model ANA
Soil A )plication Rate _ , /da /ft Pretreated Unit
Inl1uent /E?I11ucnt C1u,rliry Munthfy \vcruge* to Sand /Ur•avel I"iller t:r Paul Filter
hats, Oils & Grcuse (I`OG) S30 ing /I_ t "i Mechanical Aeration Li Wetl;utd
Biochemical Oxygen Demand (BODs) X220 mg /L ❑ Disinfection ❑ Other:
Total Suspended Solids (TSS) < 150 m L Manufacturer
Pretreated Effluent Quality O NA Monthly Average" Dispersal Cell(s)
❑ In- ground (gravity) ❑ In- ground (pressurized)
Biochemical Oxygen Demand (BODs) <30 mg /t, ❑ At- At -grade OMound
Total Suspended Solids (TSS) :30 nig /L o -line ❑Other.
Fecal Coliform (geometric mean) <10' c[u /i00mL
Maximo n Effluent Particle Size '/d inch diameter + Values typical for domestic (non - commercial)
wastewater and septic tank effluent.
** Values typical for pretreated wastewater.
MAINTENANC SCHEDULE
Service Event Service Frequenc
Inspect condition of tank(s) At least once every o months , ears Maximum 3 rs)
Pump out contents of tanks When combined sludge and scum equals one third 'h of tank volume
Ins ect dispersal cells At least once every o months Ca year Maximum 3 y rs
lean effluent f Ater S At least once every ❑ months ear(s
Ins )ect ntm ), nrm controls & alarm At Icast once every a months ❑ year(s) NA
Flush laterals and pressure test At least once every ❑ months o year(s) ONA
Other: At least once every o months o year(s) 5eNA
Other: At least once every ❑ months ❑ ears vNA
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 tank(s) to identify any missing or broken hardware, identify any
cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the
ground surface. The dispersal cell(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 (%) 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 ch. NR 1 l a,
Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other
maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other
chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have
the contents of the tanks(s) removed by a septage servicing operator prior to use.
I
Owner: ) ao jo / Pase2or 2
System start up shall not occur when soil conditions are frozen at the infiltrative surface,
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal cell(s) 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 soft absorption are.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of
the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants;
fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications;
oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system
is properly and safely abandoned in compliance with ch. 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 properly disposed of by a Septage servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space
filled with soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A 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.
o 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.
C) The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding
tank may be installed as a last resort to replace the failed POWTS.
o 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 the time.
«WARNING»
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES AND /OR
INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY
CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK
MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTAL E
POWTS MAINTAINER
Name �
Phone Name
Phone
SEPTAGE SERVICING OPERATOR PUMPER) LOCAL REGULA O Y AUTHORITY
Name Name J
Phone Phone
08/08/2002 13:32 7152473038 BELISLE EXCAVATING I PAGE 02
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ? Ik VL ' e 1 T I�,2
Mailing Address 1Crz - G.1 i q Bd
Property Address Cp 4
(Verification required from Planning Department for new construction)
City/State 50 ✓"'. 5- Parcel Identification Number
Property Locatio
'Y Z '/. Sec. T W, Town of
Subdivision , Lot #
Certified Survey Map # 637007 , Volume 7 , Page #
Warranty Deed # / ��� 69 , Volume , Page # _ _ �V
Spec house 0 yes -Wno Lot lines identifiableX 0 no
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner slid by a
masterplurnber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on•site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin Certification
stating that your septic system has boon maintained must be completed and returned to the St, Croix County Zoning Office within 30
14 Y$ of the three year expiration date, .
/ft/
03NA OF AFPLI ANT DATE
OWNER CERTIFI ATIQN
I (we) Certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the o wners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE Of APPLICA DATE
' Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. •"'••
99 Include with this Application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
l RONAED F.} y�
63Y469
", r FILED ,2
WIc; . � �w�
,.,,,Q ,..•• �o�,•' L JAN 2 6 2001 t
i ''11+: ..'s ICERTIFIED SURVEY MA M.11
�. C
Located in part of the Southwest Quarter of the Northeast Quarter of Section 11, Township 31
Range 19 West, Town of Somerset, St. Croix County Wisconsin.
NORTH 1 4 CORNER
0 re CAUTION: Prepared for and at the ues of:
0. S£C110N 11 _ 31 -19 p q
C! - FOUND SETBACK RESTRICTION OWNER:
FOUND ALUM /NUM S
b COUNTY MONUMENT PROHIBIT IMPROVEMENTS Daniel J. Bemis
655 Lakeside Lane
+� SEE SHEET 2 OF 3. Somerset, WI 54025
a
m ;ylk UNPLATTED LANDS 1 `, Drafted by. Ty R. Dodge
°c �E"�;2 t �� 60' SEE MEET 2 OF 3 FOR LOT
i ? '� / / R/CHT OF WKES /DE LANE �� A ` � AREAS AND CURW DATA
i S89*51'3 5' E 65221' w N�� L /NE OF THE SW 114
- — T5 OF 7NE M. 1/4
— �..� .. —.. —
204.31 ��/ 216.5Sr k � � O � Z ' 0 •+ -I z
� E 589'34' j3 "W 487.50' -- - -'1 B N o (A -4 0 0 0
V W��fi
0 A as \ - N D Ne
n o
LOT 1 w `'� \ \a � � � Com
ri �, 2 \\ N 0 -
-
' -{ m O � o
/ N89'51'35 "W 440.25 \\ �\ \ \73 y Q
z
m 5 n ° m o
m
�� N C.B.A \\_ �'? _ a
IL
0 to
IZ \ � :....... N89'51'35 "W 308.16' \ C \� �d ? Z o
I D I uI i --� \r - � O
JU, o
L r
, I N89 "W, \\ \y rn D M - 6 m f m
D i Z. alt 66.74 r ` l/ \\ \ \ C,�
Ir i o o �� I AL AL i� g Q O \ \ �N m (f) m
I0 G 4 - - - --/ Z -� \ O a
coC oo ��
Iz c " N �z „ \ \ _3 0
10 o. ....... a Y' a7 o 2- cn
, in r1 gy p - AL+ - \ i p 0 C0
w
CL a
\ . o ° o
0 01 // CZ \.•. \ i a\ \ aoN
LOT 3 \
2 C•B.A Note: An erosion control plan \\ �,L y
for Lots 2 and 3 will need to be �6 \
/ submitted to the St. Croix County
Ll
oning Office prior to any \ o
p struction.
�� �! NOTE- AREAS CE MAY
�w AN AREA POSSESSED BYO S \ \ V►W CON
AT70RNEY B REA/OHNG S110NN AFENCE 00
APPROVED \
v ST. CROIX (.()I ly
rn
• '� \
Piannino 7,...: - -.
` \\ l EAST .WEST 114 LINEt 9'
i �•� �� .�QN G 2 — _ /EVS FEN
\ \\ If n N89'4
3b2 - W 1182.20'
""�-- - -d -/a 489'43 02"W--- 5339.51' - --
N �Prowe► gate a " pproval shall be 1z' �
2666 . 7 'hull and void UNPLATTED LANDS
C) / 200 0 200 EAST 1/ 4 CORNER
M SEC770N 11 -31 -1
p FOUND ALUM /NUM
a \ GRAPHIC SCALE COUNTY MONUMENT
c SCALE IN FEET: 1 inch = 200 feet
i n SOUTH 1/ 4 CORNER
C SEC77ON 11 -31 -19 LEGEND
M it „ 2 FOUND ALUMINUM
y `O COUNTY MONUMENT County Section Corner Monument
of Record
JOB # A00030 • Set 1" x 24" Iron Pipe weighing
Prepared by a minimum of 1.13 pounds per NO ��
A & E linear foot.
LAND SURVEYING & CIVIL ENGINEERING A- Denotes Wetland
Phone No. (715) 246 -4319 C.B.A. Contiguous Buildable Area per Town of Somerset
109 East Third Street, P.O. Box 325 - -- Wisconsin D.O.T. Setback Line (50' From R —O —W)
New Richmond, WI 54017 • • • ...... Denotes County Building Setback Line
Sheet 1 of 3 (100' From Right —of —way)
(75' From Navigable waters)
Vol.14 Page 4024
DOCUMENT NO. T"S SPACE WSERVt o FOR 9ECOM04G DATA
WARRANTY DEED
w ^ ^ S1 ATE BAR OF WISCONSIN FORM 2 - 1982
- -4
REGISTER'S OFFICE
Sr. CROIX Co., WI
Recd for Reco
Marcella Landry a `k a Marce S. Landry _ CO `P 0 51989
conveys and warrants to na n i e l 1_ B e m i _s . a s i flQ l e
RETURN To
Century 21
the following described real estate in St Croix County, Somerset, W i .
State of Wisconsin:
Tax Parcel No: _
Part of the South is of the Northeast 4 of Section 11, Township
31 North, Range 19 West, St Croix County, Wisconsin lying
Westerly of State Trunk Highway "35" except that part conveyed to
Oliver Baillargeon and described in the deed recorded in Volume
11 149" of records on page 172.
TRANS
Vim
This is not homestead property.
(is) (is not)
Exception to warranties: recorded easements and rights of way
Dated this — 1 st day of March — .19 89
(SEAL) _ (SEAL)
<i/r1 JZ (SEAL) (SEAL)
Marc-P1 1 a T.andry a /k /a
y
Marcel AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) STATE OF WISCONSIN
ss.
_
St Croix County.
Personalty come before me this t day of
authenticated this day of , 19 March ,19 AQ the above named
Marcella Landry a k a
It Marcella B. Landry
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not to me knot -n to be the person executed the
authorized by § 706.06, Wis. Slats.) forego ins ment and ac
know
THIS INSTRUMENT WAS DRAFTED BY
Jcihn D - Wa 1 ch . John
Notary Public nty, Wis.
(Signatures may be authenticated or acknowledged. Both MY Commission is Q T�� e x�a�n
are not necessary.) date: Dec. ' 19.8
'Names ot persons signing in any capacity should be typed or printed below their signalers. t oo ,
WARRANTY DEED STATE BAR OF WISCONSIN o f O'f • ASSOC1ATtON
FORM Na 2 - 1982 '�. N qST , Weconan 53M*