HomeMy WebLinkAbout004-1028-10-011Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(mll
r1:I:4IZ17e1:711-- Adrel;l
TYPE
MANUFACT R
CAPACITY
Septic
1� 3
SO
Dosing
v/ 0Ly 1
sW i
Aeration
1
TANK SETBACK INFORMATION') .... t , . _ I i A - � _
TANK TO
P/L
WELL
Bff5G.
ent to Ar In e
D
Septic
7
1
%
1
Dosing
� / J 1
t
I
Aeration
Holding
PUMPISIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Frictio oss System TdJ�; TDH Ft
I. 5
Forcema n Le lh I Dia. it Dist. to weu 1
SOIL ABSORPTION SYSTEM
St. Croix
rnnit No:
641912
ID No:
032200374-C
No
ELEVATION DATA 2 -<'1 ) A ?
004-1028-10-011
ige/Map No:
12.28.15.188E-10
L
i�
•
-_�
r rra
�1 1 i /
--
•
�`I
BED7TRENCH
DIMENSIONS
Width 1
Length
No. Of T&i
PIT DIMENSIONS
No. Of Pits
Inside Dia,
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
PIL
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
T OI tem:
Sys
1'5�
,L�
7'5"�
Model Number
uw r r�rov r rvr� u r a r cm _ -�
Header/Manifold
1 1
Distribution 1 f,
/
x Hale Siz
x Hole sing
Van[ to Air Intake
Pipes) 1
�`(/
tt
Length Dia
Length Dia Spacing
vv.� vv • �r� a pmaauro S.#..a nnh. -- n- a n--�-
Depth Over
Bed/Trend
Depth Over
n Depth nL r _
7i
m Seeded/Sodd
xx Mulched
rater
11
Bed/Trench Edges
Topsoil
as _S] No
Yes Q No
LrUMMtN 15: (Include code discrepencies, persons present, etc.)
Location: 433 320TH STT
1.) Alt BM Description = 1 1 �0�V
2.) Bldg sewer length
- amount of cover = 74 y' / . • L ,
1
Plan revision Required? [] Yes No A ��
Use other side for additional information.
SBD-6710 (R.3/97) Dale
Inspection #1: Inspection #2:
(1ri�il�t1 b!1►�Lhl�ll-(rtN1 i��✓u� �Y�t,✓�c��ria� �b i
p�0+{�.iy ►l a� � �'�YG{ S t �'A�' lOd �v�(�un�pry
1�1 "
n .I.Signa re Can. No.
.6 —1. _ l977
D
County
Safety and Buildings 9iJision
G
MAR 17 2022
01 W. Washington Ave., P.O. Box 7162
Madison, WI 53707-7162
Sanitary Permit Number (to be filled in by Co.)
Ir
Sanita Applica
State Transaction Number
6
Dat/ f —
ZZ0697
In accordance with SPS 383.21(2), Wis. Aim. Code, submission of this form to the app ate gov nW unit
.7 !
Project
is r:quired prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
Address (if different than mailing address)
purposes in accordance with the Pnvac • Law, s. 15.04 I m Stats.
�7 5 L `
r, 3 rt 3;� cJ7
1. Application Information - Please Print All Information
✓C
Property Owner's Name
Iv e IJ (--e [
Parcel k
Property Owner's Mailm Address {�^ 4
Property Location
Govt. Lot ` " " � 1 /4 Section 1 Z
City, State
Zip Code
Phone Number
1
1_
M &&SS 3z `i9
(circle
T N; R i�lQWest
II. Type of Building (check all that apply)
Lots
1 or 2 Family Dwelling — Number of Bedrooms
I
Subdivision
Public / commercial — Describe use
Block a
ity of
State owned — Described use
Na
CSMJtlplbef 10-7 $ (o
1 `i
V"'age of
�+ I
Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
New System
Replacement System
Treatment/Holding Tank Replacement Only
❑ Other Modification to Existing System (explain)
B.
❑XList
Permit Renewal
❑Permit Revision
❑ Change of Plumber
❑ Permit Transfer to New
Previous Permit Number and Date Issued
Before Expiration
Owner
IV. Type of POWTS System/Component/Device: (Check all that apply)
Non -Pressurized In -Ground ❑ Pressurized In -Ground At -Grade Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil
Z q 11
Holding Tank ❑ Other Dispersal Component (explain) _ ❑ Pretreatment Device (explain) i �I _
V.DispersaVlYeatmentArea lnformalion: X% eNl`roVC =
Design Fl w (gpd)
Design Soil Application Ratc(gpdsf)
Dispersal Area Required (s
Dispersal Area Pr (sf)
System Elevation
rAm
/17
00
VI. 19A Info
Capacity in
Total
a of
Manufacturer
Gallons
Gallons
Units
;n
C7
New Tanks
Existing Tanks
Septic Tank
X—
Z,SO
;
t.�a
Lift Tank
X
Ir
''
VII. Responsibility Statement- I, the undo ned, assuntr ivapanelilifty lovinstaliation of the POW-M shown on the attached plates,
Plumber's Name (Print) her'
MP/MPRS Number
Business Phone Number
Lewis Bork
�253976
715-231-7375
Plumber's Address (Street, City, State, Zip Code
E7818 County Road E Menomont , 54751
VIII. County/Department Use Only
Approved
❑ Disapproved Permit Fee
Da Issued
Issuing Agent alure
❑ Owner Given Reason for s&76-.o0
3Z 7,
IX. Cg pprovaUReasons for viol �) V r I FM4 S\/C 1 jAAAryt � y
`1' (o'
1. Septic tank, effluent filter and (
dispersal call MUM //'1�^ yl,u�7(j
as per management plan provided by plwnba[ I
s. An setback requirements must be malntaiMd II �e. J� _ 1 ,b 5 1 h St � of f ��a 1 /�
t'W `f"'
tl per appllcabN code/ofdlrleSttl. 1 { /
p
>4 R
SBD-6398 (R. 11/11)
kf—
CHECK BOX AS APFUCWE. CHECK BO AS APPLICABLE. C/ 34:4 3
SOIL EVALUATION Scale: '"=4T YSTEM PAGE 2 OF6
SITE MAP . . I 40 LOT PLAN
orIzz
PROJECT NAME: �0� or DESIGN FLOW:_ OPD
.vi tm aw Lee. Attach d"n flow calculadons for COMMWCW pens.
PROJECT ADDRESS: 413 Pipe Matedal I ASTM Standard (Tables 384.303 & 3M.30.5)
` l W Sentry Sewer. 4 D-2665
8M BymDoi: BM El
N 2 D-T 5 -
Face M
set 0 tln: IMPO
WeM �RTANT:
T Oredlenl (%) 'a '� IB eppllcaele} dMAno an by
or riled AneG '_--- "O an ow op Around
Show And ekvatlon contours at edtabk Inkrvals
O
0
fob w�ti
S
d
32�A lob.
d
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fobs'
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4•s �'
No 0595 5fdr
March 9, 2022
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 2024-3-9
Plan Review: PWTS- 032200374-C
Lewis Bjork
E7818 County Rd E
Menomonie, WI
SITE:
Brandon Lee
433 32011 St
Town of Cady
St Croix County
NW Y. SW X S12, T28N, R1SW
FOR:
Description: 4 Bedroom — 600 GPD —14" to
limiting factor- Effluent Filter - Maintenance
required.
DIVISION OF INDUSTRY SERVICES
10541 N RANCH RID
HAYWARD VA 546+344W
Contm Thm"h ROW
NIp.IMIp.m 9**WOQrilll ndL#WV-NMOM
WMM MOOnrn QOv
Tay [r•n • Oowrvw
Dow" C MI - iKvNrY
Conditionally
APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
SERVICES
DIVISION OF INDUSTRY SERVICES
i
SEE CORRESPONDENCE
Mound Component Manual — Ver. 2.0, SBD-
10691-P (N.01/01, R 10/12)
Pressure Distribution Component Manual — Ver.
2.0, SBD-10706-P (N.01/01, R. 10/12)
The submittal described above has been reviewed for conformance with applicable Wisconsin
Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This
system is to be constructed and located in accordance with the enclosed approved plans and with any
component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin
Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per
s.145.06, stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Reminders
• The site shall be properly prepared prior to plowing. Any grasses longer than 6" shall be cut short
and removed. To avoid matting, any leaves or loose organic matter shall be raked up and removed.
Cut trees and shrubs flush to the ground and leave stumps. Avoid operating equipment on the
Mound site. If necessary, use only tracked equipment, during dry conditions, with minimal passes,
to avoid compaction.
• Components and soil removed from an existing drain field shall be properly disposed of so that
there Is no risk to public or environmental health.
• A sanitary permit must be obtained from the county where this project is located in accordance with
the requirements of Sec. 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 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.
• 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.
Owner Responsibilities
• The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also
receive a copy of the appropriate operation and maintenance manual(s) and be responsible for
ensuring that POWTS is operated and maintained in accordance with this chapter and the approved
management plan under s. SIPS 383.54(1).
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 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 Industry Services reserves the right to require changes or
additions should conditions arise making them necessary for code compliance. As per state scats
101.12(2), nothing in this review shall relieve the designq 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 and the POWTS management plan to the
owner and any others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely,
f09WIWR&Wbwl
Joshua Rowley
POWTS Plan Reviewer, Division of Industry Services
(715)813-9111
Joshua.rowley@wisconsin.gov
PAGE 1 OF 6
Mound Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10691-P (N.01/01, R. 10/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12)
Pg 1 of 6 Index & Cover Page
Pg 2 of 6 Plot Plan
Pg 3 of 6 Mound Cross -Section & Plan View
Pg 4 of 6 Distribution Network Specifications
Pg 5 of 6 Pump Tank Specifications
Pg 6 of 6 Management Plan
Attachments:
Pump Curve
POWTS Application for Review
Soil Evaluation Report & Site M
Project Name / Description
rA� bra LLB - Nak; Moo
Owner Name(s): 'j�1 A(\<L J I Cc,, Phone: 480 - 08 -32Y9
Owner Address: `133 32L-2'M -0'+ U.:115or, zip: S Ka L7
Project Address:
Govt. Lot: 1/4 of SAry 1/4, Section, TN-R I L.) E❑or W®
Township: _ C Ag_A f County: C v o
Project Parcel ID 0: _]1 , LYi - I 0 `U I C
Designer Information
Designer Name: Lewis Biork Phone: 715 -231 -7375
Designer Address: E7818 County E Menomonie WI zip: 54751
E-mail: IewishorkANahoo.com Conditionally
License Number: 253976 APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
Remarks: SERVICES
DIVISION OF INDUSTRY SERVICES
ID 0
SEE CORRESPONDENCE
Signature \ Date:
inal signature required on each submitted copy
CHECK Box AS APPUCA X CKECK BO AS APPLICABLE. � 3c 3
SOIL EVALUATION Scale: 1"' 40' YSTEM PAGE 2 OF6
SITE MAP I LOT PLAN
PROJECT NAME: 10, DESIGN FLOW �_ 0p0
Brm jw L-m Attach design flow colcuMgorn for oommorcW plan.
PROJECT ADDRESS Lf 13 Pipe Material J ASTM Standard (Tables 384.30.3 6 3154.31D-5)
A`a I N san"Sewer 4 1 0-2685
eM a!'mbd: �aM/�Elev�lon. • �' ' • i:� Force Mein. 2 i D-2§$5
am Owee's~
M,sra a+
e ronn a IMPORTANT:
a sated Ar.r ILf`�' Well rovBd
i er(r rr O r.., ny .n o+ Show prnd elevatlon oontaxB at soluble intervals.
on u. aoyopree ram.
L,ewy5 o
� w�u
0
0
o
a ,oy.
0
No 05P6 aft &U- s
W=
0.5' TO 2.5' WASHED AGGREGATE
(min. 6.0' beneath distribution pipe - min.2.0•
over distribution pipe and covered with
appmved synthetic fabric)
• ? ASTM C-33 SAND FILL
min. 0.5 It
T
D
Ptowed Surface
SINGLE -CELL
MOUND DISPERSAL AREA
D= Z It
MIA MIN. 6.(r OF TOPSOIL COVER E = v ft
min, t .0 ft System Elevation = Q i cx:)ft
Lateral Invert Elevation = co .4. ft
Surface contour gn n
Elevation = 1C] ft
-- o g t
ft
E
10 % Slope
(Show force main, manifold, and flush valve locations on plan view.)
CROSS SECTION VIEW
(No Scale)
M
24 7Z
PLAN VIEW
(No Scale)
0 Schdl 40 7
PVC Lateral ,'� _ ft It
(typical) IMPI
I Obseniabon I
L— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — J
ft r B � ft
_ K = -A
i � ft Irypkar)
Iy3
Bend as necessary to follow contour
DOWNSLOPE TOE _
L= ft
Prohloit disturbance and vehicular traffic
within 15 feet of downslope toe.
Reset Page
D
0
M
LO
O
n
M
DISTRIBUTION NETWORK SPECIFICATIONS
(No Scale)
FLUSH VALVE DETAIL
(No Scale)
Orifice in — — Valve Box Lateral
Center of Threaded Cap (insulation optional) S = It
for Head Testing
(optional)
\ Shield orifices for
gravelless applications
Ball Valve J �
(optional) /
� Lateral Length (P) = '77 fi
5' '
't3 Scholl
PVC Mangold
�'0 Schdl40
PVC Face Man
(slope to pump tank
r for drain -back)
First Orifice
(typical)
,Jiaterals to be level
' Schdl 40 PVC Lateral 0 = ' in
(typical)
Number of Orifices per Lateral =�
Orifices equally spaced:
(check a) Oft b) below] \
a) along bottom of lateral ~� Orifices equally spaced
Fkish Valve along bottom o(tateral
D► n olong top of Ware) Assembly
with every th hob (typical - see detall) �
facing down Last Orifice
(typical) (typical)
Spacing (X) _ �'^
LATERAL INVERT ELEVATION = 1 I j) ,� fl (t'pical) .,
(typical)
Orifice Diameter = � ( in
OBSERVATION PIPE DETAIL
(No Scab)
Screw -Type or -�
sip Cap (loose) +
Finished Grade
(mulched 3 seeded)
4-0 PVC Pipe .:.
Topsol Cover
Top of pipe to terminate
(mitt. f foot)
at or above finished grade f
(4) 114�190 Slots
apart
Anchor Device
Infiltration
Surface
Orifice Discharge Rate = t gpm
Number of laterals =
Lateral Discharge Rate = 1Q. gpm
TOTAL DISCHARGE RATE = 33 GPM
(typical) First Or"Ice
(typical)
box.
ND MANIFOLD
(CONNECTION
Check
UN,�
applicable
Mmgold
(riser Pipe optional)
First
/Orrififi�ce
(iyptr
al)
/>
Y)
�-� X —� 1 x 2
X%2� X --I
(ty"l) (typical)
CENTER MANIFOLD
n
Mangold
rn
(riser pipe optional)CONNECTION
PAGE 5 OF 6
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
1'0 Vanl Pqe
»o a non,
Bolding Electnol resat comply math
120 Min. or 2.0 a above SPS 316 and NEC 300
Established Flood Elevation Weatherproof Extend morhole riser as rim oessan'.
(twcsl) Junction Box
'�'�'� Approved LorJvq Manhole
IMPORTANT: Vert Cap n warning babel Attaohad
Anchor tank(s) as necessary ��
lNaa4
pursuant to SPS 383.43(8xg) ." Mtn. or 2,0 1above
t ' T /_ EalaDsshaa� )EtavMgn
Finished Grace
CAPACITIES @ 3) 71 gaVin
demona
Wa:.
. : .:
EMMA
*Pump Tank Liquid Level = 36 in
Fo_q "in Diameter = r min
// 0
orce Main Length =ft
3' Approved
Force Main Void Volume = .gal Z�
no
[C] Total Dose Volume TDV = 9!0 gal/dose
(5X total lateral void volume S TDV S 0.2X design flow)
+ (force main drainback volume)
MIN. PUMP DISCHARGE RATE = gpm
All small 95�
ffA1arm9-n,.
d '1.4 I/
6' Min
I
Approved Joint wNh
Approved Ape J A oMo
Solid Ground
Irrwal)
A ON = V ( ft
MIR
j INSIDE BOTTOM
111100" ,� ELEVATION = =1 ft
Material Smooth Tank
1 Vertical Head = 1 (,eft
+ Min. Supply Head = 7 X5-�ft
+ FM Friction Loss = 5 ft
+ Fitting Loss' = ft
*(min. supply head a 0.3) +�+�
= TOTAL DYNAMIC HEAD = `ft
PUMP TANK:
SEPTIC TANK(S):
Volume = gal
Total Volume = gal
s
Manufacturer. ll�l L�r'Z
Manufacturer(s):
Pump Manufacturer: 2 k.1141L
Pump Model: I li L (SeeattachodpunrDcurie)
Install approved effluent filter at the septic tank outlet
immediately upstream of the Qymo tank inlet.
Controls/Alarm Manufacturer: � EtL 0V"146
Filter Manufacturer.^ i'J12c ry�-a
Controls/Alarm Model:
Filter Model: I T Ddemon
& Z• I Lf 6'
Float switches containing mercury are prohibited
PAGE 6OF6
Mound Management Plan
IMPORTANT:
The owner of this mound system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be
considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore,
all inspection and maintenance activities shall be performed by a registered POWTS Malntolner in accordance with SPS
383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow gpd; BOD6 5 220 mgL-'; TSS 5150 mgL"; FOG 5 30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e.. leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e,, distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities (i.e., pump re-cyciing, float switch settings, etc.)
o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tanktat shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(*) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113. Wisc. Admin. Code.
o Effluent flltertsl shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
o Distribution laterals shall be flushed once every 3 years or when necessary.
System maintenance reports shall be submitted to the proper local government unit in accordance vW
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: /is -- 3 66 - 8L-�
Name of individual or company.lewis Bork FamilySeDft rV Phone: 715-231-7375
Local government unit: (✓,Jr Phone:
Local government unit address: , /A �j / / � ZIP: Jac
Any defective part of this system A lSer rep6 reed, r br mol0ed pursuant 16 SPS 383.51 (1), Wisc. Admin
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continaencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed mound dispersal component may be
re -constructed within the originally approved area after removal of all failed components.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383 33, Wisc. Admin, Code.
+11 Sena I'Illucni Pumps LtKllcr Pump Cumpau.k
hltpa:. www.tecllcryump..cum cn-na'pruducts'sump-eIII ucnt-pumIn cl..
to
tr
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2LL
50
14 - 45 153
12 - 40
35
Q 152
10
a30
$ d 25 151
8
J
r
6
20
15
4
10
2
9
PUMP PERFORMANCE CURVE
MODEL 151 /152/153
0_j
10 20 30 40 50 60 70 80 90 100
GALLONS
LITERS
0 40 80 120 160 200 240 280 320 360
FLOW PER MINUTE
i o(5
2'21 ^II I R. I0:05 AM
164'
1
II
II 4' CAST -A -SEAL ill
FILTER OR
BAFFLE
WVLP1200/800-MR
TANK SPECIFICATIONS
DIMENSIONS'
WALL: 3'
BOTTOM: 3'
COVER: 8'
MANHOLE: 24' I.D. PRECAST CONCRETE RISER
HEIGHT: 53' O.D.
LENGTH: 164' O.D.
WIDTH: 96' 0.0.
BELOW INLET: 410 0_D.
4' CAST -A -SEAL VQD LEVY; 36'
VAIGHT: GOTTOM 12.000 LBS.
COVER 8,170 LBS.
INLET AND OUTLET:
4' CAST -A -SEAL BOOT OR EQUAL
GASKET, CAST -A -SEAL BOOT OR EQUAL
INLET AND OUTLET BAFFLE AND FILTER:
WISCONSIN, SEE DETAIL If0
(OTHER STATES SEE CHART)
LIQUID CAPACITY: 22.4264 �/IN SEPTIC)
LOADING DESIGN: 8' 0' UNSATURATED SOIL
TANK CAN BE USED AS:
SEPTIC/SEPTIc, SEPTIC/PUMP
OR SEPTIC/SIPHON
N g 4" LENT COVER: MIX DESIGN /8 (NO FIBER)
TANK: MIX DESIGN /9 (SMALL FIBER)
iO CUSTOMIZED TANKS:
FOR CUSTOM TANKS CONTACT WIESER CONCRETE
INLET _ - -- DUTLET
T
M i r7
I
3_ J.
PUNT PAD DRAWINGS SUBMITTED
n FOR APPROVAL
SIDE VIEW
APP40VED BY:
APPWVAL DATE:
PRODUCTS NEEDED BY:
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REOUIREMENTS
S F
ST. CROJ,d' LINTY SANITARY SYSTEM File
Of ceUse Only
��I OWNERSHIP/ADDRESS FORM 0001*1212027
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of your new or replacement sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email.
OWNER/BUYER INFORMATION
owner/Buyer Brandon Lee
Mailing Address 433 320th St
City/State/Zip Wilson, WI 54027
Phone Number (required)480-688-3249
Email Address (required)lee.family4@outlook.com
Parcel Identification Number 004-1028-10-01111 1
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location NM t/4 SW 1/4 , Sec. 12 . T 28 N R 15 W, Town of Cady
Subdivision Plat: . Lot #
Certified Survey Map # I VLAD-1 00
!!10 'Volume Page # �.
Warranty Deed # , �LA i C.7R(before 2006)Volume Page #
Number of bedrooms 4 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no
(J OFFICE USE ONLY
New Property Address ` 33 3 �" 5, --
(Verification of new address required from Community Development Department for new construction.)
3 , z z, zz
(Staff Initials) (Date)
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified
survey map if reference is made in the warranty deed.
Community Development Department — Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
cdd(o)sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.00v
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Wisconsin Department of - } '
Division of Safety and Bui ings
MAR
Attach complete site pia on paper not less than 8 1/2 x 11
include, but not limited verticalandhoriedr4al"rb/erence
percent slope, scale or d eflsjpr> h �grtl1 i►tim HH1Y
'
L E NMORT
nm 85, Wis. Adm. Code
county 5
ies in size. Plan must
t (BM), direction and Peloel I.D.
1d distance to nearest road. [■YJ
Please print aN information.
Personal Information you provide may be used for secondary purposes (Privacy Lew, s. 15.04 (1) (m)).
Csr-a4q'3L —ass
Page 1 of 3
by Era
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Property Owner's Mailing res Los # Block # d. Naor CSW
t{•33 32o�t 5{• SubCme S - a
City State Zip Code Phone Number Icy Village ■ Town Nearest Road
80 9 GAd 'S10-w 54.
E] New Construction UseE] Residential / Number of bedrooms ^ Code derived design Ilow rate 6920 GPD
❑ Replacement Pu lic or commercial - Describe-.
Parent material L6Nb &%.4— +r It Flood Plain elevation it applicable Zone,ft.
General comments
and recommendations: .+M�b �� t13(,t�� Mov-* � 5� t@m 604 qQ t
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FB-1 Boring # 0 Boring i' p� _y
El Pit Ground surface elev. 96 ft. Depth to limiting factor I l in.
Soil Application Rate
Horizon
Depth
In.
Dominant Color
Munsell
Rat Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
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❑ pit Ground surface elev. 510 ft. Depth to limiting factor -AB--fn. QM s.,, i�nnn, Rmo
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Effluent #1 = BOD > 30 < 220 nIgIL and TS5 > mglL tmuenl We = tskwv � ou mg.0 ono I C.0 _ . nyyL
CST Name (Please Print) CST Number
Lewis Bneturork Lewis Bjork 253976
Address I Date Evaluation Conducted Telephone Number
E7818 County E Menomonie WI 54751 IZ j i ,p j 715-231-7375
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Property Owner Parcel ID # `«"'q 016
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Boring # El Boring
❑ Pit Ground surface elev. IA�-ft. Depth to limiting in.
2 3
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Redox Description
spy -rims
❑ Boring # Boring
• Pit Ground surface elev. ft. Depth to limiting factor in.
Rail 4nNirnlim Rwtw
Qu. Sz. Cont Color
EBorkV # g BoringPit Ground surface elev. ft. Depth to limiting factor in.
Sol Application Fiala
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Effluent #1 = BODS > 30 < 220 rr9t and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 30 mglL and TSS < 30 mWL
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.
SB11-1133OTnt (R 07M)
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CHECK BOX AS APPLCABLE. CHECK BOX AS APPLICABLE. Gc,,r 34i 3
❑ SOIL EVALUATION D Scale: I"40' ❑ SYSTEM PAGE 2 OF
SITE MAP i PLOT PLAN
PROJECT NAME: 102 DESIGN FLOW: 6— GPD
BAfm V wL Attach design flow calculations for commercial plans.
PROJECT ADDRESS: H 13 32DIM Pipe Material / ASTM Standard (Tables 384.30-3 8 384.30-5)
�l A N Sanitary sewer 4 / D-2665
BM $yrrtbd: $ BM Elevation: • w ' W
.. � Force Main: 2 D-2665
BM Description
Slope Gradient 'h I,�snort by IMPORTANT:
of Tented Area: L_ Well Symbol (If applicable): 0 dr.winq •n amm Show grou rid elevation contours at suitable intervals.
on the appropme 6r
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•&64, COUNTv NO. 641912
STATE SANITARY PERMIT
q?3 3zo� 54-
E66*ON L PRWJPVS'N'b%.,-���
PLUMBER t3 LIC.#
TOWN OF Ca.,l./
SEC %Z ,T N, ROE
AND/OR LOT I BLOCK
/'� a A AS _
PERMIT EXPIRES
SUBDIVISION
OFFICER -
CHAPTER 145.135 (2) WISCONSIN STATUTES
(a) The purpose of the sanitary permit is to allow Installation
of the private sewage system described in the permit.
(b) The approval of the sanitary permit Is based on
regulations In force on the date of approval.
(c) The sanitary permit Is valid and maybe renewed for a
specified period.
(a) Changed regulations will not impair the validity of a
sanitary permit.
(e) Renewal of the sanitary permit will be based on
regulations in force at the time renewal is sought, and that
changed regulations may impede renewal.
(1) The sanitary permit is transferable.
History: 1977 c. 168; 1979 c. 34,221; 1991 c. 314
Note: If you wish to renew the permit, or transfer ownership of
the permit, please contact the county authority.
DATE
RENEWED B
VIEW
ZZ
T DATE
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (RI 1/20)