Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
014-1023-40-000
Wisconsin 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)(m)] TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO F,L 0,'ELL BLDG. Vent to Au Intake ROAD Septic Dosing Aeration Holding PUMPISIPHON INFORMATION SUIL AI35UKF FION SYSTEM ELEVATION DATA M r St. CI"OIX Sanitary Permit No: 6419672 014-1023-40-000 gelMap No. 10.31.15.157 STATION I BS I HI I FS I ELEV. 1 BM ). Sewer It Inlet Cover BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: Model Number: UNIT 167101 RIDN 1IVIV 0TA I CM Header/Manifold Distribution x Foie Size x Hale Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing JVIL LrV YCR Y Pranquira Svstnms nnlu yr Mnnnrl 0, A}_r.rorle Cu�+.me rinly Depth Over Depth Over roc Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Ej Yes 0 No 0 Yes 0 No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: Inspection #2: Location: 2242 CTY RD P 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes E] No Use other side for additional information. Date Insepctor's Signature Can No. 1 zo t- n D " fo Safety and Build s Division County S{ Cr ���\\\IJI $ " \ p 1 2022 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707-7162 sanitary Permit Number (to be filled in by Co.) MAR x-I��� �O`�� 162 x it Applicati State Transaction Number In accordance wm h Wis. Adm. Code, submission of this form to the appropriate governments] unit�- Project is required prior to obtaining a sanitary permit. Note: Application forms for sta ed 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 Privacy Law, s. 13.04 I m Stats. 22 Z G 1. Application Information- Please Print All Information Property Owner's Name Par el # 01 - IOZ2- '-�+� O '� �r� —coo ' F/ +j UJ V (� . I, IV G Property Owner' Mailing Address Property Location 14rol &3 Govt. Lot /. 1/4 SectionC City, State AA , ' ,�. Zip Code 154005' Phone Number ''7p a(' • Lmiz LA+le Uz i�� / 81 ICU 19 (circle T t' ' N; R is_ West II. Type of Building (check all that apply) Lot # ivision + 7gAr 1 or 2 Family Dwelling - Number ofA roommss � — Public / commercial - Describe use Block # City of y- State owned - Described use Na — CSM Number Village ofr—CC'b 1 Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ew System Replacement System Treatment(Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List 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-Gro d At -Grade Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil Holding Tank ❑ Other Dispersal Component (explain / / Pre t Device (explain) V. DispersaV restmentArea Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elev ' n 1 yS0 .6 '15t� -ITO loo ' VI. Tank Info Capacity in Total # of I Manufacturer rA Gallons Gallons Units New Tanks Existing Tanks 7 L 0. � ! Septic Tank X IMO I SAC14 5kikZ X Lift Tank ox Goo I x V II. Res risibility Statement- 1, the undersig , assun respor4$bl for stallation of the POWTS shown on the attached plans. s Plumber's Name (Prim) Pl ignature MP/MPRS Number Business Phone Number Lewis Bork 253976 715-231-7375 Plumber's Address (Street, City, State, Zip Cot) E7818 County Road E Menomo ' I 54751 VIII. County/Department Use Only Approved ❑ Di Permit Fee $ Dote Issued v"? Iss in Agent Signature ❑ O Re r Denial (f/ 1 J� Zp �EM OWN: -PProv teasorrsiorHisapproval ?j �, 'l t''" S 1. Septic tank, effluent filter and ��S ttai�r. f-PJ-%tL� , dispersal cell must be serviced I maintained nn _ 5c? t� ►a ate e J as per management plan provided by plumber.tXJ t^^ a - . 2. All setback requirements must be maintained fwx �^ tD MJAIPV ! , /k / 6 a.- n SBD (R. 11/ I)\-,( s�-4o Ifwx� d�s�essQ- -+CK BOX AS APPLICABLE. HECK BOX AS APPLICABLE. OIL EVALUATION Scale; 440' SYSTEM PAGE 2 CIF4 G o SITE MAP LOT PLAN PROJECT �NAME: 10, DESIGN FLOW: _ 1 5D GPD qssirmwA Attach design flow calculations for commercial plans. PROJECT ADDRESS: f. i.4Z Pipe Material / ASTM Ste rd (Tables 384.30 3_8 3,p.305) ' N Sanitary Sealer-: "1 / Z66 BM Symbol: {� BM Elevation: FT FT Force Maln�_ / - SM Desdrlptlan: � kE Q� C0 -•5 Slope Gradient indicate north � ��"^IMPORTANT: of Tested Aron, ��i�'S Well Symbol (If applicable) ✓/� drawing an wow S" ground alevadon contours at suitable intervals. on tM approprlte Nro. _ _ �w� �3jwM ►� crop IA�J No vyll Yctt -500' to Co. Rd. P—� 100 C,"Co P QA,�L n3 cCU cS March 14, 2022 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2024-03-14 Plan Review: PWTS-032200404-C LEWIS C BJORK E7818 County Rd E Menomonie WI 54751 SITE: Steven Ulrich 2242 County P Town of crest St. Croix, County P.O. S10, T31N, R15W Total Amount: $250.00 DIVISION OF INDUSTRY SERVICES 2850 MIDWEST DR STE 104 ONALASKA WI 54650 Contact Through Relay httpl/dsps.wi.gov/programs/Default.aspx www.wisconsin.gov Conditionally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE Tony Evers - Governor Dawn Crim - Secretary FOR: Description: Three Bedroom At -grade System 1 Sloping site At -Grade Component Manual - Ver. 2.0, SBD-10854 (N.03/07, R. 1112), 450 GPD, 36" depth to limiting factor, Maintenance required, Effluent filter, New construction 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 • 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. • Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches. Proper soil moisture content can be determined by rolling a soil sample between the hands. If it rolls into a 1/4- inch wire, the site is too wet to prepare. If it crumbles, site preparation can proceed. If the site is too wet to prepare, do not proceed until it dries. 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. 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 managernent plan under s. SPS 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. 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. 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 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Gerard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892 — voice \ (608)785-9330 — fax 0enV.swim(cDwi.gov At -Grade Plan PAGE 1 OF 6 Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10854-P (N.03/07, R. 01/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12) Pg 1 of 6 Index & Cover Sheet Pg 2 of 6 Plot Plan Pg 3 of 6 Dispersal Area Cross -Section & Plan View Pg 4 of 6'r Distribution Network Specifications Pg 5 of 6 Pump Tank Specifications Pg 6 of 6 Management Plan Attachments: Enclosures: Pump Curve POWTS Application for Review Tank (s) Soil Evaluation Report & Site Map Effluent filter Owner Name(s): Owner Address: Project Address: Project Name / Description 6 T =nI U I ✓L I L�/1 -- Nl,ttii A�-�l'flU� UGS �4�I H z C1e Phone:_�L-_ Zip: Govt. Lot: 1 /4 of _ 1 /4, Section1>10, T_J1 N-R ( S E ❑ or WD< Township: rLSf County: 5+•GtL-0%y Project Parcel ID #: O-14t) —C=0 Designer Information Designer Name: Lewis Bjork Phone: 715 -231 -7375 Designer Address: E7818 County E Menomonie WI Zip: 54751 E-mail: lewisbjork@yahoo.com License Number: 253976 Conditionally APPROVED Remarks: DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE Signature: Date:1-Z8 -Z Z final signature required on each submitted copy. CHECK BOX AS APPLICABLE. SOIL EVALUATION Scele: 1"=40' SITE MAP D aD eo Bc PROJECT NAME: �! 6yfnf (� laK�c h T° PROJECT ADDRESS 12,42. CZf A& • +-5 BM Symbo` � SMElevellmn '� FTBMDescnWon: �.i�% S►uF ON �• Slope Gradient (76) Ind"Is �onh ]y of Tented Aroe. ,�' Well symbol (T eppl�,calNe) 0 dra%,np an aApa �On Iha appropnte sia. MAlf rX. .-' 70776 �tw � �3j� 0 cPV IA-J. 4 No Wi, ( Ycff HECK BOX AS APPLICABLE. �- SYSTEM PAGE 2 CIF4 LOT PLAN DESIGN FLOW. Li5D GPD Attach design flow calculations for Commercial plans. Pipe Matenal / ASTM �Stagd�rd (Tables 384.� 3_8 W 30-5) Sanitary Sewer . ///T Force Main: /_sS[�=3L=sa IMPORTANT. ground elevation contours at suitable intervals. S'mjpci fw bAa -500' to Co. Rd. P 2 (co �i11� ,44- QtVL 13 FCIAE,S PAGE 3OF6 CROSS SECTION VIEW (No Scale) 0.5' TO 2.5• WASHED AGGREGATE MIN. 6.0" OF TOPSOIL COVER (covered with approved synthetic fabric) *1 •escra.o We parr min. 12' IBMN i-----5.0fl Surface Contour W t Elevation = ft PLAN VIEW (No Scale) 5.0 ft - --_� I SLOPING SITE //, 7.5 B!0 PLOWED SURFACE AT -GRADE DISPERSAL AREA (Show force main and flush valve locations on plan view.) —7AZ5.0 ft (typical) PLOWED PERIMIETER -- - - - - - --- - ------ -- ---- -- -- --------------- - - - -- - I/ VA ' T ZZ VA 2.0 ft AGGREGATE BED A_ to ft ! ft—'O — — — — — — — — toP��— — — J lV r r r r r- r - r r �� - - - - - - - - -- - — — — — — — — — Prohibit disturbance and vehicular traffic within 15 ft of downslope toe. 'b 0 T l Bend as necessary to follow contours. Reset Page DISTRIBUTION NETWORK SPECIFICATIONS FLUSH VALVE DETAIL (No Scale) Orifice in — — � Valve Box Center of Threaded Cap (insulation optional) for Head Testing (optional) \ \ 1 ) \ 1 Ball Valve \ \ (optional) / \ Orifices equally spaced: check a) OR b) below)10, a) along bottom of lateral b) = along top of lateral Flush Valve J with every th hole Assembly (No Scale) Laterals to be level Schdl 40 PVC Lateral 0 = Z in (typical) Shield orifices for graveliess applications (typlcaI - see detall) Last Orifice facing down (typical) LATERAL INVERT ELEVATION = `�� ft (typical) OBSERVATION PIPE DETAIL (No Scale) Screw -Type or .�,. Slip Cap (loose) v Finished Grade (mulched & seeded) 4-0 PVC Pipe :,' �;.. Topsoil Cover Top of pipe to terminate (min. 1 foot) at or above finished grade (4) 114'-f/X 6" Slots @ 30 apart , Anchoring Device •. '; • . Infiltration Surface Orifice Spacing (X) = 2'� (tYPtceO Orifice Diameter = 3�1`�+//�� in First Orifice (typical) in 2' "0 Schd140 PVC Force Main (riser pipe / (slope to pump tank optional) for dra"ack) Lateral Length (P) = 37 ft Number of Orifices per Lateral = 19 Orifice Discharge Rate = * &6 gpm Number of Laterals = Z Lateral Discharge Rate = 1 2.54 'gpm TOTAL DISCHARGE RATE = 25.08 GPM (typical) Fast Orifice (typal) END MANIFOLD Ica I) ❑ CONNECTION Check applicable box. Manifold (riser pipe optional) D First Orifice (typal) n m 1-- x --# —Xvz wz x ---1 .p (typical) (typical) O CENTER MANIFOLD -n Manifold �, j (riser pipe optional) CONNECTION (3) PAGE 5OF6 SEPTIC / PUMP TANK SPECIFICATIONS (No Scale) 4"0 Vent Pipe >10 8 from Building 12" Min. or 2.0 it above Established Flood Elevation (typical) IMPORTANT: Anchor tank(s) as necessary pursuant to SPS 383.43(8)(g) Finished Grade CAPACITIES @ 1KJ�� galAn Depth (in) Volume (gal) A 4 (Z. 13 a 2.0 3214ILL [C] r, o 16 Z1. rr Approved venl C,ap *Pump Tank Liquid Level = ?J� in Force Main Diameter = L in Force Main Length = 30 ft e. E'!ectrical must comply with SPS 316 and NEC 300 �TI Weatherproof .. 4. * T A I I 0 3' Approved Force Main Void Volume! = `t.&% gal [C] Total Dose Volume (TDV) = gal/dose �- (5X total lateral void volume <_ TDV < 0.2X design flow) + (force mair drainback volume) MIN. PUMP DISCHARGE RATE = 25.08 gpm Extend manhole riser as necessary. Approved Locking Manhole witn Wam,ng Label Attached (typical) 4" Min. or 2.0 ft above Established Flood Elevation - (typical) �AlrtightSeel Quick0isconoecil `� /�y�) 18" Min. 1 C0 ° J ° 7. • typical) ^ A Approved Joints win i Weep Hole Approved Pipe 3 ft onto Solid Ground ° Repical) ,Alarm _—on PUMP -OFF Pump m.�on • ELEVATION = �� ft INSIDE BOTTOM c:oncrate Block ELEVATION = �� ft Material Beneath Tank, —T �; ft 10, Vertical Head = + Min. Supply Head =Z.45�ft + FM Friction Loss = ft + Fitting Loss* = .^I`J ft *(min. supply head x 0.3) �' Z� = TOTAL DYNAMIC HEAD = ft PUMP TANK: SEPTIC TANK(S): Volume = gal Total Volume = t(,�,ZJ gal �At s� IN aflW- Manufacturer:, Manufacturer(s): Pump Manufacturer: �■ Install approved effluent filter at the septic tank outlet Pump Model: attached pump curve.) immediately upstream of the pump tank inlet. Controls/Alarm Manufacturer: SV &MW.5 Filter Manufacturer: C)'WNCO Controls/Alarm Model: A (Iii Filter Model: Fr-QBZZ - <<'/60, Float switches containing mercury are prohibited. Page 6 of 6 At -Grade Management Plan IMPORTANT: The owner of this at -grade 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 Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area ODeratina Limits: Design Flow = "LSD gpd; BODS 5 220 mgL"; TSS <_ 150 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, contusion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution i 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 -cycling, 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 Maintecance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) c Septic and dose tank(s) 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 (1t3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filterisl 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 with SPS 383.55 Wis. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Lewis Bjork Family Septic Service Phone: 715-2311-7375 Local government unit: 1101 Calm l!- ►�^-k 94. Phone:15-38b- 1820 Local government unit address: 51. az%l ZIP: %016 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wis. 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, Wis. Admin. Code. Contingency 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 at -grade dispersal component may be re- constructed within the originally approved area after removal of all failed components. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wis. Admin. Code. 50 times 1:01uem Pumps! Zoeller Pwnp Cumpam hnps:.,www.zocllenpump:,.cunven-nwpruducis'sump-effluent-pumps el'.. to cc UJ NLu ~ WW �u- 50 14 � 45 --k 12 - 40 Q 35 ' = 10 152 30 Q 8 151 25 o g 20 15 4 10 2 5 0 -' GALLONS LITERS PUMP PERFORMANCE CURVE MODEL 151/152/153 10 20 31 40 80 1 50 60 70 160 200 2< FLOW PER MINUTE KYxi] 90 100 of 5 2`21'2019, 10:05 AM a WARNING DEATH MAY OCCUR IF TANK IS ENTERED WITHOUT PROPER EQUIPMENT NOTE. SEE INNER WALL PHOTO ON THE "EXCLUSIVELY AT SKAWS' PAGE. u W0 a7.00 27.00 2'�WW a+.ao _L a4.00 s.00 ,Zoo -4 i—Z00 G� 4 INCH PRESS SEAL CASKET FILTER SECTION VIEW OF TANK AND COVER 39.00 OUTLET END VIEW OF TANK OUTLET 4 INCH PRESS SEAL GASKET Model Number: 10001 600 SKAW PRE -CAST Phone: (715) 967-2277 Approved for: SEPTIC/SEPTIC,SEPTICIPUMP,SEPTICISIPHONORHOLDIN(3 Toll Free: 1-800-924-8625 Weight n m. a m. Uq, Depth Gel. / In. Nom. Cap. 26255 sco Street, New Auburn 54757 Fax: (715) 967-2707 MOM ft 42. 39' 16,47 642.330. www.skewprec"I com Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ► _ of 3 Division of Safety and Buildings in accordance with Comm 85, Wis, Adm. Code County �� ! �� t 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 (13Mj direction and Parcel 6 I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ..e lO w 40 ^QOa Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Lew, s. 15.04 (1) (m)). Prop" t ` ^ Property Location 2 � V E N v�,. { LN GovL Lot 1l4 I M S I D T p( N R I a EE((a) W Property Owner's Mailing Address Lot # Blocic # Subd. Name or CSM# 54 "W4 G,3 7,242 C.TLt P city State Zip Code Phone Number ally Village ■ Town Nearest Road 00 r ka 191 oas (-I, • 80 Fbetist I c. QNew Construction Use[D Residential / Number of bedrooms_ _ Code derived design Clow rate 1 GPD ❑ Replacement 11 Public or commercial - Describe: Parent material 1602 00 ti 1111 Flood Plain elevation If appliu"e ft. General comments /, and recommendations: v A-Ir- rP4(,, Dra A)v% liOr"4 'r6% B-1 Boring# ❑ Boring — Q Pit Ground surface elev. 100 ft. Depth to limiting factor yi in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont Color Texture Structure Gr. Sr Sh Consistence Boundary Roots GPD/ff 'EM#1 'Eff#2 7. Ili � 1 1 �' C • 6 Z- * SL a MA. I &% Lp • `f 4 7-41Q SK'LSIa FtFI,D% I 7"s.4.Ld. I — -- I Boring a L*4-" Pit Ground surface elev. _ R. Depth to limiting factor 3181 in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/ff 'Eff#1 'Eff#2 3 2 ti.k hww cs 2-r • i6 . • .5 i Z+5bk JU Gs zF • 8 aC.-j ZM,ldk wow C Li • cmuent 01 = evu , ,w :� [[u m91L ana I ba >:w < 15P mgJL I It Etnuent #2 = BOP < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number Lewis Bork L3MI��wisBjork 253976 Address Date Evaluation Conducted Telephone Number E7818 County E Menomonie Wt 54751 �.' �to LIZ, 715-231-7375 Property Owner V 1 (( V 1 B 3 Bong Fp g - MM 19 Pit Ground surface elev. IW Parcel ID 9 b 14 — 1 Oz 3^Lip —moPage _. ft. DOM to limiting fader ?A In 2 0( 3 Redox Description •Color MMIMM ..,u � ■�.��r r�r� ., MMr ■I r �N #H Boring u pit Ground surface elev. ft_ Depth to limiting factor In. Redox Description n ___--__IMMIMMMMIMMI ❑Boring * Boring — ■ pit Ground surface elev. fl. Depth to limiting tailor In. Redox Description —_ -__I -- —M--I — -_ 'Effluent #1 = BOD, > 30 < 220 rnWL end TSS >30 < 150 mg& ' Effluent 92 = BUD, < 30 mglL and TSS < 30 mg1L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-KVM f eU (R O7 (x)) CHECK BOX AS APPJCABLE. /OIL EVALUATION sDatB: ," = 49 SITE MAP ° 40 60 Bo PROJECT NAME: • to' PROJECT ADDRESS. ZZN Z._� _ BM Symbol. 1$1, BM Elevation: '� FT BM DuKr1p11on. 946Z 51*146 0e4 Slope Oredlenl (%) '�6 well Symbol (s applicable) p of Tested Nee. _—� 6AA5 r,it. 9?� WWb o� 114D !1�00 uv 6rd . A ►,so wi<< Yctt CHECK BOX AS APPLICABLE. �' ✓� N ❑ SYSTEM PLOT PLAN DESIGN FLOW: L� GPD Attach design flow Calculations for commercial plans. Pipe Material I ASTM S N Sanitary Sewer 5 Force Mein Inaxeta none M $ grou nd ale orrMrq an on ** apawas line. 30 taodard (Tables 384._& X4.30-5) IMPORTANT: vatlon contours at sultable intervals. 2'slo Gov i Prw1.�r� 11 Safety and Buildings Division S'4'. Crow ;J SIP p 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)S Sanitary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project 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 Privacy Law, s. 13.04 1 m Stats. A �u G 1. Application Information — Please Print All Information Z 1 Property Owncr's Namc Parcel H U w o - tot -CX)O Property Owner' Mailing dd Property Location WtV L Zi Code Phone Number Govt. Lot City, State r _ r P t Ana hftVl�. n rO l� 5p oeIS- 9019 /. l/4 ircleovo II. Type of Building (check all that apply) Lot x T �' i ITT; R tS(()test I or 2 Family Dwelling — Number of Bedrooms_ Subdivision Public / commercial — Describe use Block a Na ❑ City of State owned — Described use _ L CSM Number Village of C 7 Town of [II. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System I Replacement System I TreatmentMolding'rank Replacement Only ❑ Other Modification to Existing System (explain) Permit Renewal El Permit Revision El Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued rue fore Expiration Owner IV. type of rvw 15 bystemlt-omponeattuevtce: It-necre an tnat apply) Non -Pressurized In -Ground ❑ Pressurized In -Ground At -Grade Mound a 24 in. of suitable soil Mound < 24 in. of suitable soil Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. DispersalMeatment Area Information: Dc sign Flow (gpdI Design Soil Application Rate(gpdsfi Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ySo . 6 -"! Wo '1 SD too VI. Tank Info Gallons I Units Septic Tank 1 11000 I 1 JA?c Lift Tank IGM I I do JA VII. Resaonsibillty statement- 1, the undersia saluAt rcapon bt for istollation of the POW15 shown on the attached plane Plumber's Name (Print) PI ignaturc i MP/MPRS Number Business Phone Number Lewis Bork 253976 715-231-7375 Plumber's Address (Street, ('try, State, Zip C ) E7818 County Road E Menomd)iorWI 54751 VIII. County/Department Use Only ❑ Approved ❑ Disapproved Permit Foe Date Issued Issuing Agent Signature S ❑ Owner Given Reason for Denial IX. Conditions of ApprovaURessons for Disapproval SBD-6398 (R. I I/11) ST CROI•y. UNTY SANITARY SYSTEM File #: --'�` nly + @ " OWNERSHIP/ADDRESS FORM 2120office Use 1 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. OWNERIBUYER INFORMATION Owner/Buyer Steven Ulrich Mailing Address 52 Hwy 63 City/State,/Zip Clear Lake, WI 54055 Phone Number Email Address 715-781-8019 Parcel Identification Number 014-1023-40-000 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location _ 1/4 , _,1/4 , Sec. 10 , T 31 N R 15 W, Town of Forest Subdivision Plat: Lot#— Certified Survey Map # Volume . Page # Warranty Deed # \ 0 r 4 r�0 (before 2006)Volume Page # Number of bedrooms 3 Spec house 0 yes ■ no Lot lines identifiable O yes 0 no OFFICE USE ONLY New Property Address IV = 1L4�r`�`9 (Verification mess required fro mmunity Development Department for new construction.) (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 o 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 cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 715-245-4250 Fax www.sccwl.gov MAR $1 IM St. Ct0%revel°y N s � mo o0 -, FRONT ELEVATION Lk m MR yd, � 12EI(R ELEV4TION 3344ss •p xr ET Ec Fy _ 'm n� r nm m� G Z Z R. Ir - $ieVC UIEICh ��^• "�^^V wn ' PACE: — u.•.- / 9WEF3EVAl10N9 v.umm UNA 1IY91� PIA P A ID! U; (AP Steve Ulrich EEYI ROM P"E: 3 5 ... �O .. .. :r ...-.. _.. .. .... 'O Z F n l _ % I a � ye l 5 `��•• mrn�mDDv ro: m. Dw:m.e :� . 4/5 Steve Ulrich •° �•a••:rn...TSi� FOUNMl10N.'d-ems^ q��q quMN W: 1/1}/H31 •MMiD ND1NY 4 Z mg � L Ie y F' lu1 • po.c.. F� N N eg (+ x I4]jj °N mm b- y� : Y n kEl � a i ufflu pp r j, µdi • 11— �5ry Y.:i _`^,yr�.,v eiepv br me auiio:np in vaev Steve Ulrich 5/5 -'.:^p• Daum w: RWF fl+a/m» uxno mwr !;I Wisconsin Departm nt of ie SOIL PORT Page 1 of 3 Division of Safety an Buildinith Comm 85, Wis. Adm. Code CountyAttach complete sitelpla pap1 inches in size. Plan mustinclude, but not limit point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 01 q " 10 Please print all information. R wed b�- Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location �0EN uI..f«1N Govt. Lot 1/4 N61/4 S (tJ T 3 N R (s E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM_#f ^ /// 52 4iW,r 43 O-V,S1)1ccc.el c'irycR,r E State [lp Cade Phone Number I �ity Village LJTown vjea^st Road I � 1 S4 0051(c S ) JAI - 8o lf [roe th-r I C N 2A P u New Construction UseE) Residential / Number of bedrooms _ Code derived design flow rate ` s-o GPD 0 Replacement F Public or commercial - Describe: Parent material 1005P 0J A- Tl u — M S4r--F S Flood Plain elevation if applicable ft. General comments e LX `'vvet j^w C and recommendations: =mob{ ^ � ` A+- Grp4t ors A-" tOr"r F3 C O/v � w 34 ria. j. o ., a s r-? es.w e-y +o S B-1 Boring � � Boring M Pit Ground surface elev, 100 ft. Depth to limiting factor_ i . Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 r s... ._.%— 021 Ag% .r —. -- _ ��l�i<•7li•JrL'�•'� • • �s�r�;:riuuM•��a-�•�r�ia-��•�I OR n � ©©MMMi PBoring # s erlms Q Q Pit Ground surface elev. Is ft. Depth to limiting factor 3a in. Snil Annliratinn Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/ff 'Eff#1 I 'Eff#2 b 3 i Z+66k hVWW Cs 2F. .6 Z -J •S 2.fsbk vr►�.. Gs ZF . � •8 `i�•51y ZM-&6k w►,w 5 3 5 "1�y 6 ZVA 31-t ` Effluent #1 = BOD > 30 < 220 ni and TSS >30 < 1 ni Effluent #2 = BOD < 30 ni and TSS < 30 mg/L CST Name (Please Print) e CST Number Lewis Bork wis Bjork 253976 Address Date Evaluation Conducted Telephone Number E7818 County E Menomonie WI 54751 I ..` B-toZZ 715-231-7375 M' r•;z s 01 Property Owner U 6Vrnt rick B-3 Boring # g E MM pit Ground surfaceelev. IW Parcel ID # v i • ~ j O-2.3 _ LfO _Page of 3 —ft. Depth to limiting factor in. Snil Annliratirxt Rata Redox Description Qu. Sz. Cont Color MEMO iME���i��11*�. Boring # Boring H Pit Ground surface elev. ff. Depth to limiting factor in. Soil 4nnliratim Rata Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Stricture Gr. Sz. Sh. Consistence Boundary Roots GPD/ff 'Eff#1 'Eff#2 ❑Boring B°ring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu, Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDKf 'Eff#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. M-9330Tnt (R.OU00( . • • • •�. • � Y •... ♦ •• ! •�� i :�.� ��• r• ..-• • Y'� .n "• � .• 'Y• �t .• •' '� �` �' '`. f«• • ( • S�. • ,. ,� • • " r' • 7 t .•. ; Y• ♦ � �� • • • � 1 � � • + r CHECK BOX AS APPLICABLE. ❑ SOIL EVALUATION Scale: 1 40' SITE MAP I ao so ao PROJECT NAME: 0c;1 FVFiJ (� �/-K�����G�1 10 ' PROJECT ADDRESS: 1• N BM Symbol: }}���A�BM ElevatiioonL�_ loco /� � FT BM Descripllon. _ BAfi �kF ON �,0r•• Slope Gradient (°h) '�� drawing north M of Tested Area. Well SymbW (if applicable): Q � drawing ro anov On the approprile lira. WAS}��M.A. 4Z5397/� u estop IAn1. I c�o w4! f Yttt CHECK BOX AS APPLICABLE, % -✓t F-ISYSTEM PAGE 2 OF PLOT 1yPLAN! DESIGN FLOW, i GPD Attach design flow calculations for commercial plans. Pipe Material / ASTM Stagd�rd (Tables 384.30 3 & .30-5) Sanilary Sewer: `'� / 604 Force Main: 2. / .Z �Y" IMPORTANT: ground elevation contours at suitable intervals. 2.5"o �oZ FIo�E i I d6< ,... )) 1 r 1 I ` i i 1 Al ♦. J (3 *AwM) R�IX couNrY NO. 641962 STAT SAANITA.�2Y PERMIT -49 r A NS�� PREVIOUS NO, OWNER PLUMBERL tSp iL TOWN OF - Ffire;- SEGO ,T�LN, R %1, AND/OR LOT B _ ft s. (a _ Li EXPIRES Lic.# dX537+?6 145.135 (2) V4VSCONSIN 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 may be renewed for a specified period. (d) 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. (i) The sanitary permit is transferable. History: 1977 c.168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of SUBDIVISIONthe permit please con ctthecountyau ority. ISSUING OFFICER - DATE Z RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)