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HomeMy WebLinkAbout034-1012-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety,and Building Division INSPECTION REPORT Sanitary Permit No: 399503 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: Williams, James I Springfield Townshi 034 - 1012 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: b lb S ; e- r TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , Benchmark / VV Dosing Alt. BM Aer tion Bldg. Sewer a L Holding ; , Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom l Dosing > Header /Man. Aeration Dist. Pipe Holdi Bot. System Final Grade 7 G� PUMP /SIPHON INFORMATION = 3 -:�- S P Manufacturer / Demand St Cover �. GPM , ZJ Model Number L 110d TDH Lift Friction Loss Syste Head TDH j z� �� 33.5 Forcemain Length , I Dia. Dist. to well 3SS 2 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. DIMENSIONS r ?S— Z / S SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHI nufacturer: INFORMATION CHAMB OR Type Of System: V -- IT Model Number. DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake / Pipe( s) "� / it + . Length 2 Length 73 Dia I Z Spacing 3 , / 2 3 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of 1 77eeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes [W No [] Yes FI No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 1( / Z / O Inspection #2:�/ 7 /� Location: 1127 County Road D Glenwood City, WI 54013 (NE 1/4 SW 1/4 6 T29N R /J 15W) �k&ot NA Parcel No:: 06.29 1.) Alt BM Description = 7 +� ly (���/ 0✓ 6�. SP 7;...�1 2.) Bldg sewer length - amount of cover = >S 3.) Contour = zL = �� Plan revision Required? [] Yes No Use other side for additional information. (0 �Insepctor's�_Sidnatu� Cart. No. SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 C ST. CROIX 8 visconsin Madison, WI 53707 - 7162 Site Address / De artment of Commerce �Ol j) 00 ;- ?-- Sanitary Permit Number Sanitary Permit Oct cl 5 0 �3 In accord with Comm 83.21, Wis. Adm. Code, a ta`t. 1- 1mation you p{Gvide� ❑ Check if Revision may be used for secondary purposes P ' c w, $ 1 State Plan I.D. Number SITE # 177521 I. Application Information - Please Print All Info n RE �xlv TRANS. ID # 678900 .� Parcel Number Property Owner's Name 06.29.15.89B JAMES WILL to'' '� - - Property Location Property Owner's Mailing Address 1113 CO RD D C, u .. 2 "" : -�� ' NE % SW • s 6 T 29. N R 15W City, State Zip Code f Lol I�ymber BIo��C}�(umber <. NSA �v /� GLENWOOD CITY WI 54013 5 -7771 Subdivision Name CSM Number N/A H. Type of Building (check all that apply) / ❑City 1 or 2 Family Dwelling - Number of Bedrooms 3 �'I� ''?-� ❑Village ❑ Public /Commercial - Describe Use (ffownship SPRINGFIELD El State Owned Nearest Road CO. RD. D III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) For County use A 1 New 2 ❑ Replacement System 3 EDReplace mentof 6 C1 Addition to S stem T B. ❑ Check if Sanitary Permit Previously Issued it Number Date Issued IV. Type of Permit: (Check all that apply)(numberin heme is for internal use) 44 11 Non -Pressurized In-Ground 21CIMound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other L) V. Dts ersal Treatment Area Information: t ~46rLe de $ •5 Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) Elevation 450 450 450 1.0 N/A 96.33 98.16 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Concrete Constructed Glass Gallons Gallons of Tanks New Existing Tanks Tanks Septic or Holding Tank 1000 1000 1 WIESER CONCRETE X Dosing Chamber 600 600 1 IWIESER CONCRETE X VII. Responsibility Statement- I, the undersigned, assume respo bility for installation of the POWTS shown on the attached plant. Plumber's Name (Print) PI 's Signature womplIS Number Business Phone Number If I BENNIE HELGESON G- a-�r.. 220292 715/772 -3278 Plumber's Address (Street, City, State, Zip Code) W1229 770TH AVENUE, SPRING VALLEY WI 54767 VIII. County /De artment Use Onl tam Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Sps) Surcharge Fee) D / g/ 11 Owner Given Initial Adverse • �ta� � Determination v V f 1&t onditions of Approval/Reasons for Disapproval WrAI a"vf w.sAImv� r!,(2C- Ce.e� gym... a »y I�o.✓TS +w..ic i ciw.Q a w+i�A..vw .�SaLeef F+ay�. i { � 5� b a-�S JR" «.- 44 ,e reS raU �� S,r�•e � �� tr Attach plete plans (to the County only) for the system on paper not less than 81/2 s 11 inches In size s _W fr o &tip kw, z ts»,1 ) —A/( Z :-,: >, SBD}6398 (R. 05101) ,-. ' ilk l a Ylr, S '1���. 6er'. �cv.h��- �I� e� so•� as aas� d G�LY- �" 93.7 E y;, y C r g. S k� C -C - C I uof I I r I I ( ' I I I I 37S" a" PU(- �orc�c �1�' -• / v �cce p - I" S S h 0 V\� Tqur G 4q Pro p°5C Be c4 LI � 5 � 7 To �p�.. c4 Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 TD #: (608) 264 -8777 erc Nvisconsin www w ww.commerce.state.wi.us/sb ons .wisonsin.gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Acting Secretary October 10, 2001 CUST ID No.220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W1229 770TH AVE 1 101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/10/2003 identification Numbers Transaction ID No. 678900 SITE: Site ID No. 177521 JIM WILLIAMS Please refer to both identification numbers, 1 l 13 COUNTY RD D above, in all correspondence with the agency, TOWN OF SPRINGFIELD ST CROIX COUNTY N E 114, S W 114, S6, T29N, R 15 W FOR: DESCRIPTION: THREE BEDROOM MOUND SYSTEM OBJECT TYPE: POWT SYSTEM REGULATED OBJECT ID NO.: 815117 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD- 10572 -P (R.6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" SBD - 10573 -P (R.6/99). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the Mound manual, and section VI of the pressure distribution component manual are complied with. A copy of this letter including instructions and information relating to proper use and maintenance of the system must be given to the owner and each subsequent owner upon completion of the project. • The changes made to this plan on 10/10/01 by this reviewer were acknowledged and approved by the system designer. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. • Limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. BENNIE W HELGESON Page 2 10 /10 /01 • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). In addition, the owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the initial installation of the POWTS in accordance with an approved management plan shall be conducted by a person who holds a registration issued by the department as a registered POWTS maintainer. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/instal tat ion/operat ion. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, FEE REQUIRED $ 175.00 ,— FEE RECEIVED $ 175.00 BALANCE DUE $ 0.00 Charles L Bratz POWTS Plan reviewer Ik Integrated Services WiSMART code: 7633 (608) 789 -7893, Mon. -Fri. 7:45 AM to 4:30 PM cbratz @commerce. state. w i. us cc: JIM WILLIAMS INDEX SHEET PROPERTY OWNER: JAMES WILLIAMS 1113 COUNTY ROAD D RECEIVED GLENWOOD CITY WI 54013 SE 2 4 2001 PROJECT NAME: JAMES WILLIAMS SAFETY & BLDGS D111, PROJECT LOCATION: NE 1/4, SW 1/4, S 6, T29 N, R, 15 W MUNICIPALITY: TOWNSHIP OF SPRINGFIELD COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD- 10573- P(R/99) MOUND COMPONENT MANUAL SBD- 10572 -P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound /.� Page 3: Distribution Pipe Layout 10 Page 4: Septic Tank & Pump Chamber Cross Section & Specifications. O Page 5: Wieser Concrete W 1000/600 -MR Tank Specifications V Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg, 2 Name: Bennie Helgeson Signe Address: W1229 770Th Avenue Spring Valley, WI 54767 Credential number: 220292 Date: August 22, 2001 PI��.,ti�ef'. L�ch� ►�� e�so� aaaas� �LlCu. 93. ,F Et,- ;16 Are Cl- ' I S�qp� I r I ' I I � ' I i ! I I 37 a" PuL (✓once �'1a�r / v Pro fos c �Qe chi. you^ CR Cd' g Of Sr ,-yRNZeS W � - P a ge Synthetic Covering Distribution Pipe Medium Sand Topsoil -_ =_ = -= F 1 ;; D 3 E , Slope 3 1 2 ' — 2 ,2 Force Main Plowed A99re9aie From Pump Layer D /, - 9,3 Ft. E �,o/ Ft. Cross Section Of A Mound F Ft. G 5 Ft. A Ft. H / Ft. Signed: B 7S Ft. License Number: K a .- ?S'Ft. L 7.S" Ft. Date: - Ft. T Ft. W 2S, Ft. 1 . L Observation Pipe J B K A 0 - ------------------------------------ W G _ 1,____.___ Distribution L Of 2 — 2 Pipe A99fegate I i — •a Observation Pipe Plan View Of Mound P.rlor°iad Pip. Dololl C . Ien C _ ' End Vlaw ) POOO(Gled To'� r 1 ,.� PVC Pipe . �E Cpl►„ . J °< �pb� pc �• a Holes Located on Bottom are Equally Spaced � Pip. Distribution Pipe Lay P 73 J R x S -- ,, -� 3 x _ '1 i Hole Diameter Inch _� Signed: License Number: Lateral 1 Inch (es) Manifold " Inches Dare: -- Force Main " �. Inches o E •Pe F --o- + rc X Le'-f< U - S Page_Of �' w�•e:;� � mpg 1�,�.t.� G.r,� s _ ' SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" CI VENT PIPE 12" NEATHERPROOF MIN. ABOVE GRADE L JUNCTION BOX APPROVED 25' FROM DOOR, WINDOW OR —WITH CONDUIT MANHOLE COVER FRESH AIR INTAKE ` W/ PADLOCK '& \ r ---- WARNING LABEL FINISHED GRADE + MIN. Zy �, y " C.Z. peSERVAT"DnJ S.D. 18" IN. PIPE N 18 rn�N INLET I GAS - WATER TIGHT SEALS —� TIGHT /APPROVED FILTER A SEAL JOINTS WITH .ZA T ��w� --�— ALM APPROVED PIPE APPROVED B ' ON 3' ONTOf 4 d PIPE 3' A lG'L — F — SOLID SOIL*';- ONTO SOLID C 1 SOIL PUMP OFF ELEV . 7 Y%� FT . —— OFF D i 3" APPROVED BEDDING UNDER 'TANK CONCRETE PAD SPECIFICA'T'IONS Ls SEPTIC / DOSE TANK MANUFACTURER: Lu leScv TANK SIZES: SEPTIC �O____C�o _GAL. DoSL vo1uME FLOWBACK: GAL DOSE GAL. ALARM MANUFACTURER: S,t�, CAPACITIES: A = � 3 INCHES = C5 „6 � `GAL.' " MODEL NUMBER: I N�l� B = 2 INCHES = SWITCH TYPE: C = S INCHES = 13y GAL. PUMP MANUFACTURER: MODEL NUMBER: $RS D = INCHES = 13y C9" ' GAL . SWITCH TYPE: GPM PUMP E ALARM WIRING AS PER ILHR 16- , 37 ' WAC REQUIRED DISCHARGE RATE � ' VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBU'I'ZON PIPE •� FEET_'�,y + MINIMUM NETWORK SUPPLY PRESSURE . . • • FEET'S I + J ���- FEET FORCEMAIN X o FT /100 FT. FRICTION FACTOR FEET 33. vs 2-0 - DYNAMIC HEAD = S�� s c T ,� 5 , , s �Z DAMETER ' INTERNAL DIMENSIONS OF PUMP TANK /Pa WIDTH LIQUID 16,76 Get /, Per, r "'k SIGNED: LICENSE NUMBER: DATE' 1/88 a i P-nA$ D G . LLJ jk co mV °o a: H F o LO W Z . V / J LY (n m Z�' W o a z m CO C5 Q 0 F 1 oa a o �igLO °OFD EZ N Y� Lj D k' a cv � W v a °��- �mQ ZZ �� pVW 0 0 V o vi oN m ww °� � .�N� O W d o ivto� Na °u' �^ o m w co a. a d .. .. 0) < < Go L9 13 vi . O `�` < w 0. O Q o � ooQ ��Q Wa � Z ro Q° U ° }— z3mc. mmx l m_3 ad c� o z s m z i a • F- z ~ o Zi� e z e — r7 LV `U i' Li i i =i i W LO i N Z uYS O M Ui / I V ..95 Q I •,, V t / `:. E ,� i i . r tl '' n + "G `1 f,:y tr?' X 71 � 't l � ■ • t a i ., .' J•Ja, i, t�'/;' m(.:.:, ]..lvf� rf' fl`f r ; pg�� .qty- 3 aitt, :(i. {` Q ■ ■ ■■ ■NEON ■■■■ N ONE 11 :: ' ■WEE■■■ ■EE■■ ■E ■ MEN S =MWIM ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ SIZE '■■■►\■■■■ ■ ■■■■■■■■■■■■■ .,■■■■.■■■■■.■■..■.......... .........................■ ................... ■....... ■NONE ► ■NN ■ ■ ■�� ■N ■EEfN ■ ■ ■ ■ ■■ p[)V�T� <]VVN���'� A8}lNU�L (1 &8�\rJAGEA0�0T PLAN Page 7 m 8 ^ ` ^ ' s ij k: C I F1 C"tJI ONS � � Omer JAMES WILLIAMS NA ' k C ty 1000 gal C DESIGN � RS Number of Bedrooms 3 El NA Effluent Filter Model A-100 (12-16) 0 NA Number of Commercial Units Q NA Pump Tink Capac ity 600 gal 0 NA Estimated flow (average) WIESER CONCRETE 0 NA Design flow (peak), (Estimated x 1.5) r U 1, i - to-i'lufactuler Soil Application Rate q�lLdda lit H'uiiip NlodL,1 0 NA InfluentlEffluent Quality Monthly average* prea"'talent Unit 0 NA Fats, OH Grease (FOG) -�30 rng/L L3 Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BOD e 0 Mechanical Aeration 0 Wetland Total Suspended Solids (TSS) -�150 mg/L Manufacturer Pretreated Effluent Quality L�l NA Monthly ave.rage'" Biochemical Oxygen Dernand (BOD :��30 my/L LJ ill-jrOUlld 0 In-ground (pressurized) � � � � � � Values typica|fo' domestic wastewater and � ^rpbc tank effluent. ' '^ Values typical for pretreated wastewater. � � MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least onc� evc�ty Elmonths Qyear(s) (Maximum3yrs.) Pump out contents of tank(s) WJ`jej)GQn)L)jjjULl�;jU0� .4,iJ scufn equ,ds one-third (Y.) of tank volume Inspect dispersal cell(s) At luast oi ick� ev U LIi moiiti;s Q year(s) (Maximum 3 yrs.) Clean effluent filter At least once eveiy 0 rnonths LAyear(s) Inspect pump controls & alarm At least once every J, 0 months ff year(s) 0 NA Flush laterals and pressure test At least once every 3 0 months f] year(s) 0 NA Other At least once every 0 months 0 year(s) 0 NA Other At least once every 1 months 0 year(s) 0 NA � � INSTRUCTIONS � MA ~-. � Inspections of tanks and dispersal cells shall banx;4abyaoh.Umiaua|cux�yioUonont ru|lowky licenses or certifications: Master Plumber, Master Plumber Restricted Gowu[ POVVl'6 inspector; POVVTS Maintainer 8epbsge Servicing Ope[ato: Tank inspecdonsmust i�p a visual |nspeubnno[ the bank(s) hoidanbh any /nissiDgorbroken � hardware, |donUfvany cracks or leaks, measure the volunneofconnbhnau sludge and scum and &o check for any back up orpondiOQofefO the ground surface. The dispersal cell(s) sha!1 be visually fnspocted to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface, The pondingof effluent onthe � ground surface may indicate a failing condition and requires the imn notification of the local regulatory authority. When the combined accumulation of sludge and scurn in any tank equfli one-third (Y or wore of the tank volume, the entire contents of thetankoha|{bere/novedbyo8eptoguSnmiuioy()pecninranJd|spooedofinuocondancevvithoh.NR � 113. Wisconsin Administrative Coua. The servicing of effluent filters, mechanical or p/cusudzod P0VV p/aneutj/nent components, and any � other maintenance or monitoring at intervals of 12 months or less shall be pedoi by a certified POWTS Maintainer. � A service report shall be provided to the local regulatory authority within l 0 days of completion of any service event. � START UP AND OPERATION, � For new construction, prior to use of the POVVTS check treatment tank(s) for the presence of painting products orother chemicals that may impede the treatment process and/or damage Uie u1spefsal cell(s). |th/gh concentrations are detected have the contents of the tank(s) removed by a septage sorvicing opemtor prior to use. Page 8 of 8 'System start up shall not occur when soil conaiGoris are f +ozcn Jt tt,a intiitr rtivc: st Trace. During power outages pump tanks may till above norrr,al ievCis. When power is restored the excess wastewater will be discharged to tlie dispersal ceii(s) in one large dose, overloading Ure cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents or tine pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following frorn the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette; butts, condoms; cotton stivabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump purnp) water fruit rr,d veyetable peelings; gasoline; grease, herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMMENT 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 mater ial. 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 systern: • 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 exi�;tiny and proposed str ucture, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil at id site evaluation to establish a suitable replacement area. Replacement systems must comply with tt rules in effect at that time. • A suitable replacement area is not available due to , (Aback 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 reptacew(ent 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. IZI 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 TREAT MEriT TANK UNDER ANY CiRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTEfdOR OF A �f�ANK M AY BE DJFFiCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER ^� r� br (u iviAIN Name HELGESON EXCAV INC ltcrrie 4 , SANITATION r J Oii1 , ,. ; U.� Phone 715/772 -3278 'Phone 715/273 -5811 SEPTAGE SERVICING OPERATOR NUMPER LOCAL REGULATORY AUTHORITY Name JOHNSON SANITAT Agen ST. CROIX COUNTY ZONING Phone 715/273 -5811 Phone 715/386 -4680 This document was drafted by the staffs of the Green Lake, Nturciuette uti l t. n:ra CcuntgLanin and Sanitation agencies. This document meets the minimum requirements of ch. Comm �322(2)(b)(1)(d) (i) and t73. ;i ;, (L) K (J), Cade. Use of this document does not guarantee the performance of the POWTS, GMW (2/01) 4 y.. # * Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Sf C Ro / Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. O 6, a , /J percent slope, scale or dimensions, north arrow, and location and distance to nearest road. © D 2 ^ — 0 a O Please print all informs Re* e by Date Personal Information you provide may be used for u l� ri a w, a. 15.04 (1) (m)). Property Owner property Location / .S K!' / f- M Go . Lot N1F 1/4 ,5191 /4 S �7 T N R �� J W Property Owner's Mailing Address Lot Block # Subd. Name or CSM# d , City State Zip Cod - Phone r ZUUI _ )t ❑ Village f W Town Nearest Road W . 5'0 ) r / /eL Ida zM LL ® New Construction Use: Residential / f bedrooms Code derived design flow rate �� 4 GPD ❑ Replacement ❑ Public or cgmm �16 Parent material / A Flood Plain elevation If applicable 14 ft. General comments and recommendations: Boring # ❑ Boring pit Ground surface elev. 3 3 ft. Depth to limiting factor /S In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2 l D o �.3 S 1 am 6k r= ,if A S 2 M . 8 i ❑ Boring # Boris c7 ® pit Ground surface alley. / 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 0- /o /a S . .2 M 5 6,� R /q S V A j 19 lokley JD�ZM 'Al • Effluent #1 = BOD > 30 220 mg/L and TSS >30 1 150 mgll. ` Effluent #2 = BOD 1 30 mg& and TSS _< 30 mg/L CST Name (Please Print) Signature CST Number G Gc� Sh't 24 -V �;) --) -.1 ez /dress Date Evaluation Conducted Telephone Number Ole w ad a Z 4E lv Sx/o /3 u , Property Owner 914 &S Zf/ 1 , 1 1 AM J Parcel ID # Page of F2-1 Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soll ication Rate Horizon Depth Dominant Color Redox Description R x Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 gn�tSd �R �4 S � M � 8 -/ o ie M 6 F� S l vC - 6 a o 6 5 .s' 6 d .� 6 Fl sPo�s F-1 Boring # ❑ Bong ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication 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 E Boring # ❑ Boring C1 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. •Eff#1 'Eff#2 • Effluent #1 = BOD, > 30 1 220 mg& and TSS >30 < 150 mg/l. ' Effluent #2 = BOD, 130 mg/ and TSS 130 mg/L The Department of Commerce is an equal opportunity service provider a nd employer. If y ou 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. ssD4330 (RA=) t A V - -Pjpo,O&R7 y xts- 5AV -- --------- I I i I I i I_ I r I I I 1 I I I i 1 I - - � i I I - --�- -- I f - f n k j V � ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ qm e s ` A l e Mailing Address ( ( 13 C 4 _ R. a cd D. Property Address New Co., �., v (MS a „ c��� J I ( ;R7 CD • ' (Verification required from Planning Department for new construction) City /State L) (e-I PV c o d C: '� L Parcel Identification Number 0341- D \ 4 � � 03q- /017-- S a / I NGAT. nFgCR1PT1QN O 3 LY - to (Z - 60 ex:0ud csm 't�- 6"5*? 1-116 1 q, S Aewex 1A; 1, /S Property Location 1 /4, S 1 1 1 /4, Sec. 6 b , T_.�:1N -RL_W, Town of Subdivision /r , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (p ° , Volume 141 , Page Spec house El yes Pno SVCTF.M MAINTFNAN('F. 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 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 stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 0/'�ym.' (--. kidtll�" /o SI ATURE OF APPLICANT DATE OM NFR CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro erty described above, b virtue of a warranty deed recorded in Register of Deeds Office. NATURE OF APPLICANT DATE * * * * ** Any information that is mis -represented 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 )r^cve� D� f"c� ;I Cf-t Rd A `I L Z C4f dew d�� ✓��,..1.f R�•J A (/ �� vf,.1435PA,F 453 STATE BAR OF WISCONSIN FORM 2 - 1982 K ATHLEEN 6[]530AL WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI DOCUMENT NO. RECEIVED FOR RECORD Betty L Bloom a single person 06 - - 1499 E:45 AM UARRANTY DEED EXEMPT I CERT COPY FEE: COPY FEE: conveys and warrants to An L- Stalckstm a si ng1e pe=on TRANSFER FEE: 330.00 and James G_ Wi 1 i mst a ni ngl w person RECORDIMG FEE: 10.00 PAGES: 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in S mix County, Return To: State of Wisconsin: Edina Realty Title 400 South 2nd Street Hu dson, #115 l( Sy Hudson, WI 54016 034 - 1012 -60 -000; 034 - 1012 -30 PARCEL IDENTIFICATION NUMBER 034- 1012 -50 All that part of Ej of SWJ lying Westerly of Railroad; South 10 rods of NWJ of SW}; East 11.428 rods of NK of SW'T, EXCEPT South 10 rods thereof and all of SWI of SW's all in Section 6, Township 29 N, Range 15 W. St. Croix County, Wisconsin. This is homestead property. (is) Exception to warranties: Easements, restrictions and rights of way of record, if any. Bated this day of A.D., 19 (SE L) C1JI. � 0( (SEAL) + Betty L Blocxn (SEAL) (SEAL) + AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wis Count authenticated this day of 19� Personally c before me this 1/ day of t —e 199.4_, the above named Qa U�` t B TITLE: MEMBER STATE BAR OF WISCONSIN �dy 4 J � j 11 (If not, Bt Otia� .}j �SG authorized by x70606, Wis. Suits.) pF to me known to be the person who executed the foregoing Stake insLru and acknowled the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Ogland L Hudson, WI 54016 Not ublic, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, ate a ration date: necessary.) ' Names of persons signing in any opacity should be typed or primed below the it signatures. STATE BAR OF WISCONSIN wworiti Leggy Blank Co_ Inc. WARRANTY DEED Form No. 2 —1982 Mma'im. Wye.