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HomeMy WebLinkAbout034-1021-10-050 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430053 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)]. ( "2 V I SS T-rw+s �• Permit Holder's Name: City Village X Township Parcel Tax No: Peterson, Shane I Springfield Townshi 034 - 1021 -10 -050 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: C7O . Op . p QV C C S ( W► 10.29.15.145A20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic LO l ob Benchmark � D � J i Dosing � � / Alt. BM Aeration Bldg. Sewer in 1 7• DD , 91f• Holding St/Ht Inlet Q 1 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet f Septic , 015 I w $ Jr Dt Bottom Dosing t� k Ct Header /Man. 3. .1 g v Aeration Dist. Pipe tb Holding Bot. System 38 PUMP /SIPHON INFORMATION final Grade (2. / Manufacturer Demand St Cover p GPM J" del Number _ �-�. C gT• Fes+ 2 �. �' Lift Friction Loss System Head TDH Ft ,O �2•`�� x.20 .SZ� 22,It 2 �am.�a �e3 Forcemain Length n Dia. �� Dist. to well ^� W C ! SOIL ABSORPTION SYSTEM �3 COPWU/ BEDITRENCH I ( Length No. Of IwaGhes— PIT DIMENSIONS o. Of its Inside Dia. th DIMENSIONS • 5D �� / � SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHI anufacturer: INFORMATION CHAMBE , tom Type Of System: ! ' St /1 L / ) el Number: DISTRIBUTION SYSTEM L FOR Header /Ma old Distribution 61 W x 10" Hole Size x Hole Spacing Vent to Air Intake e(s) 00 Length Dia /' ength , 2 tt Spacing 31 3/ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded T Mulched Bed/Trench Center Bed /Trench Edges Topsoil - I Y es ] No Yes ! 1 No COMMENTS: (Include code discrepencies persons present, etc.) Inspecti # 'L�3lnspecf n 4o: 2: / Location: 1080 310th St Glenwood City, WI 54013 (NE 1/4 NE 1/4 10 T29N R15W) Plot 1 rtrlI� Parcel 10.29.15.145A20 1.) Alt BM Description = 2.) Bldg sewer length = w, - amount of cover - 1 Plan revision Required? Yes No� • I Use other side for additional information. _ ._ __ � e•� Insepctor's Signature Cart. No. SBD- (R Safety and Buildings Division Count � 201 W. Washington Ave., P.O. Box 7162 S CROIX �SCOnSIn.. Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 3va5- Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide TRANS ID # 872958 may be used for secondary purposes Privacy Law, sl5.04 Project Address (if different than mailing address) I. Application Information - Please Print All Informa on - ST /o g0 3�c� Property Owner's Na me 3 20 Parcel N Lot # Block # SHANE PETERSON Jh[ 34-1 -000 1 N/A Property Owner's M ailing Address perry �T. ro a on 2936 73RD AVENUE - City, State Zip Code Phone, Number NE — !4, NF, d,Section 10 WILSON WI 54027 71 (circle one) II. Type of Building (check all that apply) T 29 N; R 15 E oe�o C ®1 or 2 Family Dwelling - Number of 6u-b Name. CSM Number V. rooms 3 4. P ❑.Public /Commercial - Describe Use 9g 0 3 6 ❑State Owned - Describe Use t )C 101) • C) r ❑City ❑Village fXTownship of SPRING EL III. Type of Permit: (Check only one box on line A. Complete line B if applicable) � a►` ; 03c f - 0,2( /O - 0S - 0 6 WA 20� A. ® New 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. of POWTS System: (Check all that ap ply) ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable so ❑ 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 ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sF) Dispersal Area Proposed (sf) System Elevation 450 1 ' 1. 1 450 450 1 99.5 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 1000 1000 1 WIESER CONCRETE X Aerobic Treatment Unit Dosing Chamber 600 600 1 WIESER CONCRETE X VII. Responsibility Statement- I , the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plum is Si gnatur MP /MPRS Number Business Phone Number BENNIE HELGESON K `' - 220292 715/772 -3278 Plumber's Addre ss (Street, City, State, Zrp Code) ~ W1229 770TH AVENUE, SPRING VALLEY, WI 54767 VIII. County/Department Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is uing gent Signature (No Stamps) o 9 ❑ Surcharge Fee) 3ZS Owner Given Reason for Denial "'- lu WUL i� 1'X. Conditions of Approval/Reasons for Disapproval 0,z .,0�.►� �Wtoar - , A-Q uL - LIZ- vA . 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) I 7 A LQ v � m c % p ,d o: s a WL �) • r (4 7:1 C o S ` 4 4 ' o Q d U • z O CL �, Safety and Buildings 4003 N KINNEY COULEE RD A LA CROSSE Wt, 54601 -1831 TDD #: (608) 264 -8777 8 *15consin www.commerce.state.wi.us /sb Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary May 30, 2003 CUST ID No.220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/30/2005 Identification Numbers Transaction ID No. 872958 SITE: Site ID No. 659585 Shane Peterson Please refer to both identification numbers, Rustic Road 3 above, in all correspondence with the agency. Town of Springfield St Croix County NE 1/4, NE 1/4, S10, T29N, RI 5W FOR: Description: Proposed Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 904886 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: Conditions of Approval: • This system is to be constructed and located in accordance with the enclosed approved plans. • 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. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. • 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. • Comm 83.22(7) - 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. 00111 `pt�p72(xlix A i lf-M BENNIE W HELGESON Page 2 5/30/03 Owner Responsibilities: • Comm 83.52(1)(a) - 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). • 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. 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. • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Gerard M. Swim Balance Due $ 0.00 POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm jswim @commerce.state.wi.us WiSMART code: 7633' cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 r INDEX SHEET F ZO PROPERTY OWNER: SHANE PETERSON 1114 2936 73RD AVENUE �O WILSON, WI 54027 ,/- PROJECT NAME: SHANE PETERSON PROJECT LOCATION: NE 1/4, NE 1/4 , S 10, T 29 N, R 15 W MUNICIPALITY: TOWN 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 Page 4: Septic Tank & Pump Chamber Cross Section & Specifications Page 5 WLP1000 /600 -MR ZABLE Tank Specifications Page 6 Pump Specifications Page 7 POWTS Owner's Manual & Management Plan - Pg. I Page 8 POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Sig Address: W1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: May 19, 2002 GEPART ' W DiUISIQN jot- SAFETY AN BUILD NGS SEE CORRESP DENCE C-L v \.0 m W� a C4- r `� O ^ �J CL k -A 0 zj U c 0 © CL ;� Page o a Of a Synthetic Covering Distribution Pipe A STM C 33 v. 0 3 Medium Sand G Topsoil F J� 9 I .I I D E 3 „ b 010 - �! % Slope Plowed CEL 2 "_ 2 /Z Force Main Aggregate From Pump Loyer D 1 S Ft. E I,�o Ft. Cross Section Of A Mound F ,$O Ft. G , S Ft. A yS Ft. H / — Ft. Signed: 6 120 Ft. K IO. Ft. License Number: b Lao. Ft. Date: j _2,5 Ft. l [L.) Ft. W b Ft. 3 L Observation Pipe � K J :_7_ _ a — — — -- — — 1 /- ------- -- --------- ----- r . -2. 0 f � Distributlon Pipe Aggregate I Observation Pipe .Zaso S4. Ares Plan View Of Mound Parlofoled PIP. DaJOII �E'cwo l) / `! End VI-1 Pscloiolcd ( PVC Piet 40`\0'0 o%, ` Holes Located on Bottom are Equally Spaced / P , PIP* Distri bution Pipe Lay p y7• '. S x_/ y 3 1 J, Hole Diameter Inch Signed: " License Number: Lateral " Imo_ Inch (es) Manifold " _ Inches Date: Force Main " Inches 15 �eo. '/to.0 f'ev t- -�eom 1 .--- -_ 7 1 �o�o� Page q Of • SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS WEATHERPROOF v' �V - VENT PIPE 12" MIN. ABOVE GRADE t; JUNCTION BOX APPROVED >_25 FROM DOOR, WINDOW OR WITH CONDUIT MANHOLE COVER FR ESH AIR INTAKE � W/ PADLOCK E WARNING LABEL FINISHED GRADE 4" MIN. 6 ri,n. 2yu q PUL Uf?$ERtWTiont S•D' 18" IN. INLET i � WATER TIGHT SEALS GAS �' TIGHT- �� \/APPROVED A SEAL JOINTS WITH F v -i 1 t_T ER �^ ALM APPROVED PIPE .2A A B , ON 3' ONTO PIPE 03' (a .x i t I SOLID SOIL ONTO SOLID C f SOIL PUMP OFF ELEV . peO FT. —j-- OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE /� X •s �`�' TANK MANUFACTURER: ��, os �'� _ p GAL. DOSE VOLUME INCLUDING GAL. TANK SIZES: SEPTIC / GAL. ��,,C.6,4. 'LOWBACK: DOSE CAPACITIES: A = IC INCHES = 6AL. ALARM MANUFACTURER: S c rv S , ti. MODEL NUMBER: B = 2 INCHES = 32,Sn GAL.. SWITCH TYPE: C = INCHES = ,� - S - , 7 GAL. PUMP MANUFACTURER: D =_ INCHES SWITCH TYPE: = /ya•y GAL. MODEL NUMBER: l S �, .t/1.• rc �,...t• -� _ 1 REQUIRED DISCHARGE RATE 3 •L( F EET GPM PUMP 6 ALARM WIRING AS PER ILHR WAC __Z, - VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE .• FEET + MINIMUM NETWORK SUPPLY PRESSURE . . • FEET + G FEET FORCEMAIN X _ FT /100 FT. FRICTION FACTOR �� FEET �_ TOTAL DYNAMIC HEAD WIDTH DIAMETER _ INTERNAL DIMENSIONS OF PUMP TANK: LEN UID 16• 76 Gal, Per- Tod,-) ShoeC. SA (- SIGNED: LICENSE NUMBER: DATE: 1/88 D o (i o [mow WQ U f.� In m 0 o Q WJ r - � � C� IVa <L J 2B Lo � N D O M Z w v � Zo0 1 ( a N 1 0 CL o � N 0aN, Y� w w acv Z) 0 o►'- v3 a. Q e r7 -V) F 0 m ao �' �o l o a 1i Z U O �k Z - p W �► V o� �s a ��� EL 0- o CN V p m �N �F C70 Z �yl� V)O N t J � a 0 03 r O W O o � R O Z W _p06,tnLA mWW I�tO ` Y '^ .. �O 0 0 F rn � O � N r N I� 3 O g V/ N = a Q �,JI I� w W } ih� ��I'z � JWU �NN I- z O - j 00 _ J F0- I 0 U vi � -� 30 00W OOw Q w r pJF- >ZOOC)Up2 p p Q O Zp C7 Zs Q Z O U 0 QOOQWW W Qd< QWv Z3mU - p Z W � J J Q Q O Z Z J OJ V) F- Z W .z* �t Z a - pr) ----- I X I I I � I I I I I I' II II „5 I „Sty „� W W \ 1 � I • fit' 1 1 1 I w I 1 w ' Il7 j 1 I I �- W I I J LO Q N VI tn j�1 i I z 1 Q- I W o „6£ „9S d r Co U F S TOTAL DYNAMIC HEAD /CAPACITY HEAD CAPACITY CURVE PER MINUTE EFFLUENT AND DEWATERING MODEL 152/153 t, MODEL 152 153 50 Feet Meters Gal. Liters Gal. liters 153 5 1.5 69 261 77 291 12 40 10 3:1 61 231 70 265 152 9 t 15 4.6 53 201 61 231 = Z. • ( , , . ' so! - 20 6.1 44 167 52 197 30 t Ow 8 25 7.6 34 129 42 159 c 30 9.1 23 87 33 125 20 35 10.7 -- -- 22 85 40 12.2 -- -- 11 42 4 Lock Valve: 38.0 Ft. (11.6m) 44.0 Ft. (13.4m) 10 0146M 0 20 40 60 80 100 GALLONS LITERS 6 1/4 0 80 160 240 320 3 27/32 4 5/8 FLOW PER MINUTE CONSULT FACTORY FOR SPECIAL APPLICATIONS 3 27/32 • Timed dosing panels available. 3 27/32 • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase I systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik -Box available for outdoor installations. See FM1420. • Over 130•F. (54•C.) special quotation required. I 1521153 Series 12 1/8 J T 1521153 MODELS Control Selection Model Volts -Ph Mode I Amps SIMIDIOX Du lex 5 i/8 BN15 115 1 Non 8.5 1 2 or 3 BN152 115 1 Auld 8.5 Included 2 w 3 SKN" E162 230 1 Non 4.3 1 2 or3 BE152 230 1 Auto 4.3 Included 2 w 3 N153 115 1 Non 10.5 1 2 or 3 BN1153 115 1 Auto 10.5 Included 2or3 SELECTION GUIDE E153 1 230 1 Non 1 5.3 1 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level That SE153 230 1 Auto 5.3 Included 2 or 3 switch. Refer to FM0477. O CAUTION 2. See FM0712 for correct model of Electrical Alternator E -Pak. All installation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA), or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. BOX 16347 ` Louisville, KY 40256.0347 Manufaclurersol.. SHIP T0: 3649 Cane Run Road ® Louisville, KY 40111.1961 rz wry PaMVg Sirar 1011 httpJ/wwwsoel e, can PUMP !0 1(502) n FAX (502) nQ6928-PUMP 0 Copyright 2001 Zoeller Co. All rights reserved. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of _8 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al 13 NA Permit # Septic Tank Manufacturer WIESER CONCRETED NA Effluent Filter Manufacturer ZABEL 0 NA DESIGN PARAMETERS Number of Bedrooms 13 NA Effluent Filter Model A — x 22()1C3 NA I00 12" Number of Commercial Units NA Pump Tank Capacity al E3 NA Estimated flow (average) 300 qaVday Pump Tank Manufacturer WIESER CONCRETLA NA Design flow (peak), (Estimated x 1.5) 450 gal/day Pump Manufacturer ZOELLER PUMP C(P Application Rate l a lft2 Pump Model 152 O NA Soil App NA Monthly average- Pretreatment Unit Influent/Effluent Quality y 1 ❑ Sand/Qravel Filter ❑ Peat Filter Fats, Oil & Grease (FOG) 530 mg /L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BOD 5220 mg/L ❑ Disinfection O Other: Total Suspended Solids (TSS) 5150 m /L Manufacturer Pretreated Effluent Quality G NA Monthly average** Dispersal Cell(s) Biochemical Oxygen Demand (BOD 530 mg/L ❑ in- ground (gravity) p In- ground (P ressurized) Q Mound Total Suspended Solids (TSS) 530 mg /L ❑ At-grade ❑ Other: Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip-line Maximum Effluent Particle Size Y Inch diameter values typical for domestic (non-00=138 wastewater and septic tank effluent. •+ values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 2 ❑months Q year(s) (Maximum 3 yrs.) When combined sludge and scum equals one -third (Y) of tank volume Pump out contents of tank(s) Inspect dispersal cell(s) At least once every 2 ❑ months CR year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 1 ❑months . C� year(s) ❑months Cjtyear(s) 13 NA Inspect'pump, pump controls &alarm At least once every 1 Flush laterals and pressure test At least once every 3 ❑months C#tyear(s) ❑ NA Other At least once every ❑months ❑ year(s) O NA other. At least once every ❑months ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage ons must Include a visual inspection of the tank(s) to identify any missing or broken Servicing Operator. Tank inspecti 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreattment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintanner. 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 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. OWNER: SHANE PETERSON Page $of a' System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the 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 Maintalner 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 I(fe of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss;'diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to Insure that the system is properly and 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. ❑ Asut P 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. Q 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. I <<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 Name HELGESON EXCAVATION INC Name JOHNSON qANTTATTnm Phone 715/772 -3278 Phone 715/273 -5811 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name JOHNSON SANITATION Agency ST Phone 715 /273 -5811 Phone 715/386 -4680 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agenclgs. This document meets the minimum requirements of ch. Comm 83.22(2)(b)(1)(d) &(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does nd guarantee the performance of the POWTS. WW (ypt) Wisconsin Departrnent of Industry SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations g 4 rvision of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code = COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in sib. Plan must Wqr but Ste• < l not limited to vertical and horizontal reference point (BM), direction a ' /.. of slo p CEL I.D. i dimensioned north arrow, and location and distance to nearest road, SQQ 3 4 — w Z.l —16 APPLICANT INFORMATION- PLEASE PRINT ALL INFORM Tj�,N ���' , R§Vj DBY DATE r \ 0 PROPERTY OWNER: \.v N L 170. 1� 1 :. / t3u`t �TRS ; S11�r1Jt 1�IW CtizZ'�► � �Ufv 1/4; 1 414,S 10 T Z�I ,N,R \ S E(°"1 rvJ PROPERTY 8WA1EA':S MAILIN ADDRESS. T 19, SiJ NAME OR CSM ;3 CITY, STATE ZIP CODE PHONE NUMBER []CITY FIVILLAGE MOWN ' NEAREST ROAD wAj 13)v P>q New Construction Use [SC] Residential / Number of bedrooms 3 [ J AddibQn to existing building j ] Replacement (J Public or commercial describe Code derived daily flow \-k S O gpd Recommended design loading rate bed, gpd/11: 3 trench, gpd/ft Absorption area required 3=1 S bed, 11 3 Z S trench, f1 - Ma:dmum design loading rate Z- bed, gpd$ trench, gpd/ft Recommended infiltration surface elevation(s) °L9,- S ft (as referred to site plan benchmark) Y-1 h, t g' 3f)-o Additional design/ site considerations V t2LT ?Zt U k wlT � LY�eJ; ; -I T 1�0u 1vj y'yc a q' -rZ& C j l Parent material \-C) 'S S O y Qlz 6 L1 f L '11 L L Flood plain elevation, if applicable Q- R - ft S = Suitable for system I CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system 0 S 0 U N�" ®U O S ®,U 0 S 13U I 0 S 1311 1 0S ® U SOIL DESCRIPTION REPORT Nej C 7.txeo Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence GPD /ft &uxry Roots in. Munsell I Qu. Sz. Cont Color I Gr. Sz. Sh. I I B� rendi Z -l3 L0 `i I3 — So 1 - n sb'rt Yrl F,- q. S Z • 3 .2 Ground 3 t3 =21 ► 0Y2 3�b _ gl S 1 e sbk k' cs �� • Z z elev. qL fL 4 3 IO It rz- to j SLl 5/9 S iCA 0--S btZ W, Yc- Depth to 3 limiting Ca'\ lD`1R. 13 -S1LZ- C�1�fi-s factor Remarks: 4 Boring # o -7 10 ` - 12 31 — so Z`f'sb m`Fy � z� s 6 5 10Lf 2 Vl3 3 �� toyrz 316 - s1( le..Sbk m F� �S lv� z _3 z Ground g.fc zQ zq to `?1Z-) �)'SLfV stcl lC-S -- Depth to 3 V 0'J S l rA `-t fL 6 l3 SL LT aVf - limiting - factor Remarks: trt t " CST Name: — Please Print Phone: Arthu= L. We erer 715- 425 -0165 ' egdrer Soil Testing & Design Service -P.O. Box 74 River.Falls,WI.54022 . Signature: Date: CST Number.. can 16 D - —OU 220254 PROPERTY OWNER 91 L — a SON SOIL DESCRIPTION REPORT Page Z or 3 PARCEL LD.# U3 ••— LpZ.� _ tp _ Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft ,,,. ,� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence BouY Roots :t -7 Bed EWA lt�tiV2 y/3 Ground 14 -2 3 I U 7 lZ_ 31 b — s 1 0 ,� �>z )fl'i .� C. S \ , Z 3 elev. �F3`y ylz c-- A3 S�cI 1 c sblz ���c �z ..3 Depth to limiting factor� Remarks: Boring # Ground elev. It. • Depth to — limiting factor Remarks: Boring # a••ti Ground elev. It. Depth to limiting factor Remarks: 3oring # �� R• around alev. It. )eplh to inviting actor Remarks: _ PLOT PLAN Pa 3 o 3 SCALE 1 "= L[�j' ' (y , �i \ �0 riJOT eU�?►�`� �tZ f �� i 8�1 i U r"I OF- 'hZ�'�✓ C 1{ -�1 �t4. S ' / /�� �lY trrr-� - lA. Pve ��� 3t� "pit} �vcPtPC L nT)+ , 00 -1�0 ZZOIS 6-IS-00 ( 715 ) 425- CST Signature Date Signed Telephone No. CST # ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer A� C � * ? — er - y Mailing Address 09 Z W 7 ��' �✓ l LSCfa� ����a Pro p erty Address ��� 3 j d S�• (Verification required from Planning Department for new construction) City /State 6 7ta '-ta) C/t W r Parcel Identification Number as -ao 0 LEGAL DESCRIPTION - OSO� �¢S'�' Zo) Property Location A) '/4, ALL '/4, Sec. 10 , T _2 , ? N -R /S W, Town of Subdivision Lot # / t Certified Survey Map # �3�� , Volume / , Page # 9990 Warranty Deed # �o S�� , Volume / , Page # 1 97 Spec house O yes �J no Lot lines identifiable I yes O no SYSTEM MAINTENANCE 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 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. 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 yea 'ration date. SI 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Ooh 0 �( l 3?) l 03 SIGNATURE 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 1952P 497 687514 STATE BAR OF WISCONSIN FORM 2 - 1998 XATHLEEH H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI This Deed, made between Waldo W. Roll and Donna F. Rott, husband RECEIVED FOR RECORD n wife Grantor. and Shane D. Peterson and Cherri Peterson, husband 9:30 AN and 08-20-2002 and wife, as survivorship marital property with rights of survivorship, Grantee. ►IARRFlNTV DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXERT i 17 the following described real estate in St. Croix County, State of Wisconsin (The REC FEE: 11.00 "Property")' TRANS FEE: COPY FEE: CERT COPY FEE: of One ( I I'Ccrtilicd Survey Map, recorded in Vol 14, Page 39 90, as Document PAGES: 1 463388; LOCATED IN the North One -half (N 1/2) of the Northeast Quarter (NE 1/4), Name Section Ten (10), Township Twenty-nine (29) North, Range Fifteen (15) West, N in Area Name and Return Address TOWN OF SPRINGFIELD, St. Croix County, Wisconsin. TOGETHER WITH a 66' wide access easement across the Northeast Quarter (NEI /4) of the Northeast Quarter (NEI /4) of said Section Ten (10), as designated on said Certified Survey Map, recorded in Vol. 14, Page 3990. Part .d vs.rn2r.10.000 aNE P o f 34_1021.70 -000 Parcel Identification Number (PIN) This is not homestead property. This conveyance Is given In Satisfaction of that certain Land Contract between the above parties dated December 27, 2000 and recorded December 29, 2000 In Vol. 1571, page 06 as Document Number 636010. Exceptions to warranties: Subject to all easements, restrictions and covenants of record, and any lien created by act or omission of Grantee. 1A .w Dated this day of �![� , 2002• `f I 1 .C//�/ *Waldo W. Roll r /L/d �•2n�LQJ � �� • *Donna F. Rott AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) T � County ) authenticated this _day of 2002• 11 Personally came before me this day of 2002 the above named TITLE: MEMBER STATE BAR OF WISCONSIN to me known Of not, to be the person(s) who executed the foregoing instrument and authorized by § 706.06, Wis. Slats.) acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Ronald L. Slier r VAN DYK, O'BOYLE & S1LER, S.C. • ('(" y y Post Office Box 118 Notary Public, State o y Co tissio pcwricM. New Richmond, WI 54017 (If not, state expiration date. 4 . (Signatures may be awhenticaled or acknowledged. Both are not , ncceswry.) Names of persons signing in any capacity should be typed or printed below their signatures WARRANTY DEED STATE. BAR OF WISCONSIN FORM Na 1- I"& INFORMATION PROFESSIONALS COMPANY FONOOU LAC, wl 000. 055.2021 3 �O � 10 a 6 63:3088 V ENH.WALS R14skof of oc 11 CA co►x CERTIFIED SURVEY MAP LOCATED IN THE NE 1.14 OF THE NE 1.14 AND IN THE NW 1.14 OF THE NE 114, ALL IN SECTION 10, T. 29N. , R. 15W., TOWN OF SPRINGFIELD, ST. CRO I X COUNTY, WI SCONS IN O y C � i I m om! � i� UN . PLATTED .. LANDS m .............. 0 ; y ZIZ ,- m m m i tri 0 a Z Q 400. 00' r � �'1.�� NO 1 ° 56' S I " W "n N A 0 O W~ � O N m y N m ° o Z a Q N _ SW- N W-NE n - - --- - - NE -NE _ SE -NE cn "n m i z cn O y a m w rn :Q D .r o� :r m ; `,���natuuw Z `A y O : Q 'iy -y 22. ni r IA C *r N ��� Z p =c oo 2 AP`PR °�_Zm ST. CROIX COUNTY n ony z co m `y ^ 2 W Plannino Toni am,l Cnmmirf , O m2 y q gAo nrT 3 0 2000 �TK8 waimntaa► m c Q 2E r�—Z 3 m If not rocuraea wuiun 3U clays of y approval date approval shall be ; - m null and veld ., 145. T 6' 6 188. 19' � n : � ;� am : ?'t 0V) x r - o a oc� c*) �� rZ tooai ( U y � I •� O � O �I ' I� y :- 0 ;m I rri p i p n — z z v� m oI m �+ a ' 1 Q.TI I w .$T RE�E' T " - - —B _n _ _ - - o� 1328. 4� �- N01056 W - 8. 48' _ 2656.96' mm r"2 UNPLATTED LANDS ................... 2000056A THIS INSTRUMENT DRAFTED BY JIM WEBER SHEET 1 OF 2 Vol. 14 Page 3990 I � _ 1 DESCRIPTION A parcel of land located in the Northeast 1 /4 of the Northeast' /4 and in the Northwest 1 /a of the Northeast 1 /4, all in Section 10, Township 29 North, Range 15 West, Town of Springfield, St. Croix County, Wisconsin, more fully described as follows; Commencing at the East Quarter Corner of said Section 10; Thence North 01 1 56'51" West, a Ng theast 1/4 lin the Northeast east 1 /4, 1328.48 feet to the southeast corner of sa Thence North 89 °47'09 to the POINT OF BEGINNING; 1 /a of the Northeast 1 /a, 450.00 feet Thence continuing North 89 °47'09" West, along the south line of said Northeast 1 /4 of the Northeast 1 /4 and the south line of said Northwest 1 /4 of the Northeast 1 /4, 1150.00 feet; Thence North 01 °56'51" West, 400.00 feet; Thence South 89 °47'09" East, 1150-00 feet; Thence South 01 1 56'51" East, 400.00 feet to the point of beginning. 1 1 Page Together with a 66 wide access easen e nt recorded in Volume � g of the St. Croix county records. Contains 459,673 square feet or 10.55 acres. Subject to any and all easements, right - of -ways or conveyances of record. SURVEYOR'S CERTIFICATE I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the on provisions of the St. Croix County S ubdivision and mapped the above described parcel of Waldo Rott, owner, I have surv p land and that this map is a correct representation of the boundary t O � ti Dated this - 3\'AT• day of M'�c� 2000. JAMES M. WEBER James M. Weber S -1804 8PRM�, Q NELSEN -WEBER LAND SURVEYING, INC. p SUFl"J �vip �� you NOTE: The parcel shown on this map is subject to State, County and aws rules and regulations. (i.e. wetlands, minimum lot size, access to parcel, etc.) Before purchasing or developing any parcel, contact the St. Croix County Zoning Office and the appropriate Town Board for advice. NM 00 omx P0 �pmav i ntollr- d- „ -nC..7 ' 8 i75 mm 2000056A This instrument drafted by Jim Weber m m U o XMxW SHEET 2 OF 2 :^•• •• .' Co ig 0'”" • ° r��� roN w r $ + R13>0 0 c $ = HN= Vol.14 Page 3990