HomeMy WebLinkAbout032-2177-04-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
479298 � 0
GENERAL 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:
Rivard, Aaron Somerset, Town of 032 - 2177 -04 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/0 fl� C, 11.31.19.1508
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 3 Z Benchmark
Alt. BM
3.l /02-
Aeration Bldg. Sewer
Holding St/Ht Inlet
7.0 9 St/Ht Outlet ZZ.
TANK SETBACK INFORMATION 7.Z T 6 . O
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
i
Septic -756 / Al' / 6 / Dt Bottom
Dosing U Header /Man. ��
Aeration Dist. Pipe AP . gZ
Holding Bot. System C 1. 5 96. 7Z (3U1
j,.,
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer GPM Dema St Coverr k il 3. ' 162 CQ
tt'' .L. (f6 ��t,,
Model Number
DH Lift Friction Loss J !!stem TDH
main Len th Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS - 2— � lG:v..
SETBACK SYSTEM TO / P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: t 7 �3/ �Z, / UNIT Model Number.
lie
DISTRIBUTION SYSTEM Z 3+ Z3 = Flo
Header /Manifold it Distribution x Hole Size I x Hole S pa g Vent to it In
5 S ) j Pip \ J fJ A
Length Dia � Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Se eded/ dded xx MUIc ed
Bed/Trench Center Bed/Trench Edges \ Topsoil Yes j ] No Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 628 222nd Avenue Somerset, WI 54025 (NW 1/4 SW 1/4 11 T31 R19W) Hid en Hills Lot 4 Parcel No: 11.31.19.1508
1.) Alt BM Description
2.) Bldg sewer length = 5
- amount of cover
77�
7
/b -- - - -__ - -- Plan revision Re quired? I ] Yes o j w '65 � Use other side for additional information Date Cart. No.
,BD -6710 (R.3/97)
Safety and Buildings Division County��
l vi 201 W. Washington Ave., P.O. Box 7162
S�Ol�sin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 7 t h Z '�
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide 7 :-
may be used for secondary purposes Privacy Law, sI5.04(l)(m) Project Address (if different than mailing address)
I. Application Information - Please Print All Informa ' J Jp
' � ,� (off _
Prope Owner's Name / Parcel # Lot Block #
Q
r _
Property Owner's ailing Address G - Property Location
ST. CR0IX COUNT
%., Section —L
City, State Zip Cod Ph
L (circle
II. Type of Building (check all that apply) T N; RE o�
1 or 2 Family Dwelling - Number of Bedrooms Subdivi ion Name OSAQ �lnrnber
❑ Public/Commercial - Describe Use afy2- la,._
❑ State Owned - Describe Use Cam(, 2-3 -t City ❑ Vill a Cfownship of t► 'emu
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 32- ~ 2- 1 - 7
A, ,INew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that a 1
Non- Pressurized In- Ground ❑ Mound> 24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter gLeaching Chamber ❑ Drip Line ❑ el -I Pipe xplain}
V. Dis ersal/I'reat ent Area Information:
Design Fld) Design Soil Application Rate(gpdsf) Dispersal oposed (sf) System Elevation
3 77 ` ,/
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing \ Z A i A /
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Respogsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumbe s ame t)\ PlA�sSig , MP/ MPRS Number Business Phone Number
Pl ber's Address (Street, City, kate, Zip 64 )
VI oun /De artment Use Onl
roved ❑ Sanitary Permit Fee (includes Groundwater Dat Iss ed Issuing t Signature (I`l tamp
pp isapprov Surcharge Fee) 4
❑ erG• eason3arBer}ial
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1. Septic tW*, effluent filter and
dispersal cell must all be services / maintained
as per management plan provided by plumber.
Z AN setback requirements must be maintained
as per aDplicable code , ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/03)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of 3
Division of Safety and Buildings _
County t�eIh�Commd85, Wis. Adm. Code C
Attach complete site plan on pape not less than 81/2 x 111 inches �pp n size. Plan must ✓ �' C �`
include, but not limited to: vertical nd horizontal reference point ( M), direction and Parcel I.D.
percent slope, scale or dimension , northtIR(kv, ins to and istance to nearest road.
Please prin9fl�� Re iewed by Date
Personal information you provide ma be usedZ@ pMses (Pri acy Law, s. 15.04 (1) (m)).
Prop9trty Own/err n Property Location
j C k T !Q ; , Y e Govt. Lot A w 1/4 Sa' 1/4 S T N R �r ■ (or) 0W
Property Owner's Mailing Address Lot # Block # Subd. Na or CSM#
Z ZZC� h lave �/.'��. - 11ills
Ci State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
(h�rs�y �uZ S2s (7is) 27 �1 S ' 7 v
New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material GnC Z- f ffc� D Le l- 4�".j Flood Plain elevation if applicable ft.
General comments ✓Sys« �L. yS"I� �'��',"'� y' �.ek
and recommendations:
F) I Boring # E] Boring
® pit Ground surface elev. r Y ft. Depth to limiting factor /d in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
3,12 �/� S %✓'�5�✓ /`� u us /r7
2 �� 7sra i Neu s/� 2AS�le C-6
,Y/7 L S - �i� A w � � ' 7 4,
s- /to
F-z-] Boring # ❑ Boring ,T*�
Pit Ground surface elev. C/ ft. Depth to limiting factor 71 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary R P / z
P p ry
Dots G D ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
r /oy4 3� l SG /sd•� m 7
A
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L
CST Na n�gg (Please Print) gna CST Number
Address Date Evaluation Conducted Telephone Number
SBD -8330 (R07 /00)
Property Owner / L `'� �`v Parcel ID # Page Of
M Boring # ❑ Boring p
® pit Ground surface elev. o ft to limiting facto //L in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
l 6-- 6 /l' /
Z 1,23 AX - ^2 Z-
1 gs.ED
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 /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
F-1 Boring # ❑ Pit Boring
❑ Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E1ff#1 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 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.07 /00)
I
pf
Property Owner �G` '`v Parcel ID # Page
Boring # ❑ Boring G
pit Ground surface elev. p ft. Depth to limiting factor P-/AII in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
z 6 �'s!/� �� ��f� 1 G C w /M .I /,
93 .8 0
252 V Z-
Lo
F] Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Solt Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ t
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
a Boring # Boring ❑
El 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 /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 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.
SED -9330 (R.07/00)
OWNER Page 3 of 3
Name i `L �� Brian Parnell
Address �t G
CST 231314
Date
A Benchmark ) FL) C ) / V (Y — IlaIzz
A Benchma 2 A �'� �D � o e 71ee
❑ Soil Boring J
i Suitable Area
1" = 40' Scale
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer A44J Aq
Mailing Address ?' Z — L
Property Address CO2 S
(Verification required from Planning Department for new construction)
City /State 15ptuyt6cS L Parcel Identification Number - ZS
LE DESCRIPTION 032- 2(77 o4 r dn2)
Property Location &LV " A, Sal 1 4, Sec. / 1 , T . 31 ... -R / W, Town of �0
Subdivision c•• /5 Lot # _�•
Certified Survey Map # , Volume , Page #
Warranty Deed # ZS 6 ' 370 , Volume 7_16 1 Z , Page # g �'
Spec house 0 yes A no Lot lines identifiable ;K yes 1:1 no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper main tena ❑cc
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 and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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.
I /we, 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
P P
stating that your septic system has been maintained must be completed and returned to the St, Croix County Zoning Office within 30
days of th ee year a tion date.
1Cr ATURE OF'APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the prop described ab e, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGN TURF OF APPLICANT DATE
* * * * ** Any information that is m is-rep resented may result in the sanitary permit being revoked by the Zoning Department.' * * * *
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
7963710
U. Z $ 12 P 3 $ KATHLEEN H. WALSH
State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX Co., WI
Document Number Document Name RECEIVED FOR RECORD
06/01/2005 10:06AH
WARRANTY DEED
EIfW 1
THIS DEED, made between Richard Plourde
( "Grantor," whether one or more), REC FEE: 1 L. 00
and Aaron W. Rivard TRANS FEE: 150.00 COPY FEE:
( "Grantee," whether one or more). CC FEE:
PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant Recording Area
interests, in St. Croix County, State of Wisconsin ( "Property") (if more space
is needed, please attach addendum): name and Return Address /
Lot 4, Hidden Hills. St. Croix County, Wisconsin.
d Bo X I P8
Qsc" (0, �J l S`Fo ao �f
032 - 1031- 95-025
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated �� tzo
(SEAL) G'� / (SEAL)
* *Richard Plourde
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Richard Plourde
STATE OF )
authenticated on ) ss.
COUNTY )
*Kristina diland Personally came before me on
TITLE: MEMBER STA E BAR OF WISCONSIN the above -named
(If not, to me known to be the person(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
*
Attorney Kristina Ogland Notary Public, State of
Hudson, WI 54016 My Commission (is permanent) (expires: )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003
* Type name below signatures. INFO -PRO— Legal Forms 800- 655.2021 www.infoprotorms.com
POWTS OWNER'S MANUAL & MANAGEMENT PLAN ,. Page of
FILE INFORMATION SYSTEM SPECIFICATIONS tt
Owner Septic Tank Capacity al ❑ N!'�+
Permit # Septic Tank Manufacturer C3 N'
DESIGN PARAMETERS
Effluent Filter Manufacturer ❑ NA j
Number of Bedrooms DNA Effluent Filter Model - ❑ N11
Number of Public Facility Units ,Z NA Pump Tank Capacity al � NA
i
Estimated flow (average) gal/d.a y Pump Tank Manufacturer
Design flow (peak), (Estimated x 1.51 al /d2 Pump Manufacturer .�.9' NA
Soil Application Rate gal/day/ft' Pump Model
Pretreatment
« UnitN
I
S
tandard Influent /Effluent Quality Monthly average*
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration D Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
❑ l
Pretreated Effluent Quality Monthly average Dispersal Cell(s) Ni, N!�
Biochemical Oxygen Demand (BOD 530 mg /L Pain- Ground (gravity) D In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L NA ❑ At -Grade 0 Mound
Fecal Coliform (geometric mean) 510' cfu /1001111 Q Drip-Lino D Other;
T Maximum Effluent Particle Size Y in dia. ❑ NA Other, C1 N
Other: ❑ NA Other: C3 NA
❑ NA I
*Values typical for domestic wastewater and septic tank effluent.
Other.
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑ Jnonth(s1 " (Maximum 3 years) ❑ NA
Inspect condition of tank(sl At Least once every:
Pump out contents of tank(s) When combined sludge and scum equals one -thlyd . %) of tank volume ❑ NA
❑ monthls) NA
Inspect dispersal cell(s) At least once every: (Maximum 3 years) D
Cl month(s) . ❑ N
Clean effluent filter At least once every: year(s)
❑ month(s) K Ni-
Inspect pump, pump controls & alarm At least once every: p y ear(s)
Q monthls} , NA
Flush laterals and pressure test At least once every: O year(s)
Other: 13 month(s) ,ANA
At least once every p earls)
Other: O 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; Septag® 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 (Y 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 Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
RMW (4/01,
1
f
<rs, 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 o , other chemicals
that may impede the treatment process and /or damage the dispersal cell(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(*) In one large dose, overloading the collie) and may result- ln beokup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator pr)or.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 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;; Meet- 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 systern is
properly and safely 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 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 musi
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.
❑ 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.
❑ 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 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 INSTALLER POWTS MAINTAINER ..; ,.� vr�o �saf'a~,?J • - :,rn� „ . ;;:
.
Name Name
Phone / _ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AU10ORITY
Name Nama
Phone Phone <
''his aocument was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code,
START UP AND OPERATION "-- ;`l ;'r t Page of ,
For now construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(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(#) In one large dose, overloading the collie) and may result- In•tho`beokup or sudo" discharge of
effluent. To avoid this .situation have the "contents of the pump tank removed by # Septage Servicing Operator prfot:to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually'boorating 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 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; "; ; meaVscraps;'. 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 safely 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 a 1pd, 1.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage .Servioing 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: ;;,.r "t.::
jy 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.- ~--
❑ 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.
0 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 AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUM$TANCES.' DEATH MAY RESULT, RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
i
Phone
Phone
Phis document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.6411), (2) & (3), Wisconsin Administrative Code.
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Belisle Excavating, Inc.
489 192 ° Avenue - Somerset, WI 54025
Phone (715) 247 -3254 - Fax (715) 247 -3038
CUSTOMER CONTACT INFORMATION FORM
NAME: kOA) A - 49 ' 1 19 PHONE: 7 ` Z4 _ Z- 74 ` v
SPOUSE: PHONE: �' ` ' 3103
CURRENT ADDRESS: �Z��` dIL
alk -E/151!�F5
MAILING ADDRESS IF DIFFERENT FROM ABOVE:
EMPLOYER NAME, ADDRESS & PHONE NUMBER:
SPOUSE'S EMPLOYER, ADDRESS & PHONE NUMBER:
Wiscofr.ln Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings _
li te�1 oml 85, Wis. Adm. Code County
Attach complete site plan on papei not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical ind horizontal reference point (E M), direction and Parcel I.D.
percent slope, scale or dimension , norti> RRv, Irif loJQW and i listarice to nearest road.
Please r rip �� G�F'C (;UU1V I Y
IL ����p�� Reviewed by Date
Personal information you provide ma used�,,1f0PPqeDses (Pri cy Law, s. 15.04 (1) (m)).
Prop rty Owner / Property Location
/ C /� TO ( (e / �Ye Govt. Lot �/�/ 1/4 Sa 1/4 S T �� N R �r ! (oro
Property Owner's Mailing Address Lot # I Block # Subd. Na or CSM#
,, 7e , c ///lls
1 1 � ' State Zip Code Phone Number ❑City ❑ V llage ® Town Nearest Road
New Construction Use: ® Residential / Number of bedroomsy Code derived design flow rate `'y GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material 6/?6 2 P }tC-e p w-t 4."j S el, *, .1� flood Plain elevation if applicable
General comments $yS�tns► �L, y �'� 7'r,':'+►u y 4��4
and recommendations:
a Boring # ❑ Boring -
® Pit Ground surface elev. /, O ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
1 �7 /Ord 3 � /4 S 11 k- /-2 v us /ter .4�
2 7 - i7 7, S'� I
3 /7 -ZS
7 sort / Y/ - r L� O rs �� � �� 7v
/did'
2 Boring # [] Boring �� 0 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 /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Z y-lz 7si��6 G 2A av� c�-
1Z 7SY�j if- �S or? r Z-
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Na (Please Print) gnature CST Number
/; 6 e 23/-?/95;e
Address Date Evaluation Conducted Telephone Number
SBD -8330 (R07 /00)
Property Owner & �`v r " Parcel ID # Page of
Boring # ❑ Boring M p
a ®Pit
Ground surface elev. 16V o ft. Depth to limiting factor v in.
Soil i
Appl cation Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in o //4 M un Qu. Sz. Cont. Color / I Gr . Sz Sh. 'Ef1 'Eff#2
Z 6 Z5 O fr / Z- �— i� e 7 /,
Boring # Borin g
F] ❑
� ❑pit
Ground surface elev. ft. Depth to limiting factor in.
SoA Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Boring # ❑ Boring
El 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/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 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- 2648777.
SBD -8330 cR07,00>
OWNER : Page 3 of 3
Name logjP Brian Parnell
Address 2 Zo a - e- CST 231314
�5 e�Sct bil- Date
A Benchmark 1 ! Vf --� // pyC p "pe 4 L / 00, 0
® Benchmark 2 N& %l / Pi e 7/ee /� /
❑ Soil Boring
;_ 1 Suitable Area
1" = 40' Scale
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Parcel #: 032 - 2177 -04 -000 07/08/2005 10:33 AM
PAGE 1 OF 1
Alt. Parcel #: 11.31.19.1508 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
07/01/2004 00 0
Tax Address: Owner(s): * = Current Owner
*
RICHARD L PLOURDE PLOURDE, RICHARD L
` 624 220TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description * 628 222ND AVE
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.780 Plat: 10/13- HIDDEN HILLS 032/04 4/15
SEC 11 T31N R19W PT NW SW HIDDEN HILLS Block/Condo Bldg: LOT 04
04 LOT 04 (3.78AC)
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
11- 31N -19W NW SW
Notes: Parcel History:
Date Doc # Vol /Page Type
07/01/2004 767565 10/13 PLAT
12/31/2003 750406 2483/200 EZ -U
09/03/2003 738643 2398/532 EZ -1
1209/341 TD
more...
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 02/25/2005
Description Class Acres Land Improve Total State Reason
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00