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HomeMy WebLinkAbout038-1171-10-000 Wisponsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515074 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Swigglum, Shawn I Star Prairie, Town of 038- 1171 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: C't).9L S; I 13.31.18.831 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER APACITY STATION BS HI FS ELEV. Septic Benchmark S 166 O +1 � G . 04S Jo �i 7 2 Dosing Alt. BM 9 9. S Aeration Bldg. Sewer t 57 5 �... -. � Holding St/Ht Inlet TANK SETBACK INFORMATION SUHtoutlet 1 7,43 5 TANK TO P /L r WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 1 I I 119 13 13 Dt Bottom 'T T Dosing Header /Man. -j g •� 9y 33 Aeration Dist. Pipe 9. , y y•33 Holding ot. System g /(3.2-5 y3. 1:5 PUMP /SIPHON INFORMATION Final Grade 5.6 4717 Manufacturer De ^and St Cow, C .d ,./ • q j qq ,t Model Numb?v'- 21. D m f TDH Lift Friction Loss System TDH Ft Forcemain Length Dia. ' Dist. to well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No, Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1 z / - 5 t 7 e". r� SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR i tw -�CrL Type Of System: t n /� UNIT Model Number: GaA.�ewk�av�wX 13 - C DISTRIBUTION SYSTEM /u /�.F -1I �►-�/ = 3.3 Tof,.� Header /Manifold " Distribution x Hole Size x Hole Spacing Veto Air I ake, 2 / Pipe(s) �, ^ Length 13 Dia L Dia � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Topsoil .�� �es E] No " Yes Ef' No COMMENTS: (Include code discrepencies, persons present, etc.) - Inspection #1: / / Inspection #2: Location: 1328 Country Court New Richmond, WI 54017 (SE 1/4 SW 1/4 3 T31N R18W) Country Meadows 1st Add Lo Parcel No: 13.31.18.831 1.) Alt BM Description = g', I Lt, c6i4- " ✓�C �� Jet d Ginn 2.) Bldg sewer length = �jr 5� r 1 / 1 u� �Q 5 �� ��e ✓`� ( SG�U - amount of cover = L- , e � ► --^ t Plan revision Required? 0 Yes No �� r Use other side for additional information. - Date Insepcto s Sign re Cert. No. SBD -6710 (R.3/97) i t commerce.wl.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 i s c o n s i n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 51 5 a Sanitary Permit Application State Transactior}Number In accordance with s. Comm. 83.21(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 Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information ou provide may be used for secondary / �� PUTP in accordance with the Privacy Law, s. 15.04 1 m tats. I. Application Information - Pleas t All Information Property Owner's Name / Y Parcel # JUN 12 2009 Property Owner's Mailing Address Property Location �� I ST CROIX COUNTY 1 PLANNING & ZONING OFFICE Govt. Lot Za Zip Code Phone Number " S� y,_ ya, Section _ (circle one II. Type of Building (check all that apply) A, Lot # 1 or 2 Family Dwelling - Number of Bedrooms �3 ? Subdivision Name 0 A " ,0 S ❑Public/Commercial - Describe Use J ❑ City of ❑ State Owned - Describe Use // CSM Number El Village of N .4- /! f-/ 4- / .A Town of 7 I e) III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System y � p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner gg IV. Type of POWTS System/Component/Device: Check all that appl � on- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable so ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) _T jfAwiartil V. Dispersal/Treatment Area Information: Z tG Design Flow (gpd) Design Soil Application R (gpdsf) Dispersal Area Required (s Dispersal Area Proposed (s System Elevaho 3 � 3 I. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks E y o Y R Septic or Holding Tank / / Dosing Chamber G VII. Respon 'bility Statement- I, the undersigned, assume responsibili or installation of the POWTS shown on the attached plans. Pa (P 'nt) Plum ber's Si a MP/MPRS Number Business Phone Number ess (Street, City, S te, Zip Code V111. County/Department Use Onl pproved ❑ Disa Permit Fee Drat� ssued ssuing Signature �/ �, wn n Reason for Denial $ 1 I IX. Condit& %J)f * reasons for Disapproval aleQ sy ,s,, 4 •p 6, 1. Septic tank, effluent fiker and J dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All setback reqUilirtmenft must be maintained as per applicable caft / *&W WW Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 M fT `1 If �5 I / 9 1 f f � y "R.r j 44 ,3 ki { ., Wisconsin Department of Commerce` ° OIL EVALUATION REPORT Page__Lof- Division of Safety and Buildings . in accordance with Comm 85, Ws. Adm. Code County Attach complete she plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. - P/ease print all information. Re wed by Da Personal information you provide maybe used for secondary purposes (Privacy Law, s. 16.04(1) (m)). Property Owner RECE Property Location } Govt. Lot - 1/4 1/4 T ' N R E (or Property Owner's Mailing Address Lot # Bloc Subd. Name or CSM# � as City to Zip Cade FIRliniii City gle T Nearest oad PLANNING 8 Z G OFFICE ❑ New Construction User) Residential / Number of bedrooms Code derived design flow rate GPD J W Replacement � /J [I Public or commercial - Describe: Parent material fYIJ`�r)�S Flood Plain elevation if applicable ft. General comments / and recommendations: 1 Boring # X Boring X pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 lee .) �1 m _ 5 Boring # Boring ®, pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Z r Al .[ I • � a 4 q Ad Jul �I * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 15 mgA- * Effluent #2 = BOD < 30 mg/L and TSS a 30 mg/L CST 17M CST Number - Td dress Date Evaluation Conducted Telephone Number r I - Property Owner2kfal I Parcel ID # ?R - 1171 - /D �, Page Z2— of a Boring # ❑Boring ® pit Ground surface elev. ft. Depth to limiting factor � /T in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2 r A q q A ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # ❑ Boring. Ground surface elev. ft. Depth to limiting factor in. 1:1 pit Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 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 ou need assistance to access services or 4 PP tY P Y need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) Property Owner Parcel ID # ?R - 1171- 1 0 y Man Page of ❑ Boring # ❑ Boring ® pit Ground surface elev. - Depth to limiting factor � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Qont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 A 4 F Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F Boring [] Boring. ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD. > 30 < 22Q mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format; please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) /A✓- his f i r 04J, s �4 -- S W 114 AND SECT O SE -114 - S W 1 ION 13, T31 N, R 1 SW, OF STAR PRAIRIE, ST. CRO.IX co WIS. -RUSE 'T LOTS 6 & 7 TO ONE (1) COMMON ACCESS POINT NE BETWEEN LOTS 6 & 7, AND RESTRICT LOTS 4, 5, 8, 6 • 17. AND 18 TO ONE (1) ACCESS POINT AS DESIGNATED UTILITY EASEMENTS ER, POSSESSOR, USER, NOR LICENSEE. (NORTHERN STATES POWER COMPANY] CT VEHICULAR INGRESS OR EGRESS WI TH /- l HER C PERSON RT, AS SHOWN ON THE PLAT. OTHER THAN BY WAY OF THE (ST. CROIX TELEPHONE COMPANY) LOT LINE N =- LANDS BY OTHER - -- — _ _ NORTH LINE SW -SW & SE -SW 2 227.26' 230.001--- - 200.00' — — _ — 200.74 5 .88 0 51 '11 "E. 1524.04' _ 3% _ W N �O '_ 2 �o 15 � 12 13 om o N W o° 48 0 55 = , 095 , 948 SQ . FT . SO • j z 1 - o - _ 14 N .2s Ac. o • N o <+ 1.10 c AC. AC 2. 63 1 M 96 SG-FT. z f co A.P. / sFreQC ^ 45 AC . A.P. \ 50 _174.78'"_— _ o 20 \� \ ► X51 ' 11 'W 267.00' ?o /� ,� (20, 30 _ \ \ A.P N I o "51'110E 267.00' (8) 22 ez ?�� \ / N 158.00 — _� (9) < S) �� 6 // \eo. ( NI AP, � ✓�\ X101 0���0� �g // �Si � \ V4 Y \ S'S p .9 • 6' ro � 0 B . \ � \ ° BLO- ETBg L /NE 0 0. , i E a N Q � \ 12 � Rzoa SETBACK N ,Y 1 •�\ w !00 W 57, 426 SO-FT. o ,> .o .32 AC. a `+ 0 90, 393 SQ . FT . 2 90. SO- i o ►ni o 2.08 AC. ,2.08` �. ,a in u Lo i / A. G. 15.6 �iI 21 (13� —288. 00' NG DRAINAGE I N88 34 ' 10 "W `���� EASEM ENM EA pNy ( ~ ION N f? T '��� e p 6 6� - rh0 � are no Ub 6Ct,0�? � �, 1 J t thi E ENT � REST W E� 5 G .S • 2 3.11$, 236.20 and 236.21 (1) and (2), _tea PC the Wis. Admin. Cody aQ Soil Absorption Svstem Cross Section ft -� ft 4° Schedule 40 Final Grade PVC Vent Pipe With Vent Cap �t� ft Leaching Chamber System Elevation �3 ft 4-1 ft ft Soil Absorption System Plan View ft -3 ft ft Leaching Trench 1 M" Chambers I III III III I I I III I 1 4' Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model EISA Rating sq ft per chamber Soil Application Rate �� gpd/sq ft gpd Design Flow + Soil Application Rater EISA = L Chambers 3 rows of chambers each. Page of ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existi g septic and/or dose tank presently serving the following residence: Bence: A y� (Street address) located at: _ 1 /4, ) 1 /4, Section 4 1 own Range /,,? W, Town of �,� �� , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25 an it (they) to g � q ( Y) appear(s) to be functioning properly. Most recent date of inspection or service p Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab 6oncrete Steel Other Manufacturer (if known): �4 S Age of Tank (if known): Permit nu b (if known) w ( ber ignature) (Print Name) (Title) (License Number) MP /MPRS A ; (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 4'i'LL -:5�Z'2 Property Address � (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location 1 /4 ,,- ,} 1 / 4 , Sec. ,13 , T I N R �[&__ W, Town of Subdivision �1��,��: 9i7.�vJ�S _ , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes (9 Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 Owner maintenance responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, 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 Deparunent 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 Planning & Zoning Department «-ithin 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIG OF APPLICANTS) DATE "* *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department * ** = -Nude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if - :e -ence is made in the warranty deed. : E'V. PS X15) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page -/— of FiLE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity ga l ❑ NA Permit # Septic Tank Manufacturer ) ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units 1�'NA Pump Tank Capacity gal ANA Estimated t mated flow (average) gal/day Pump Tank Manufacturer ANA Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer RrNA Soil Application Rate / 7 gal /da /ft2 Pump Model ANA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD <220 mg /L ❑. NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) f7 NA Biochemical Oxygen Demand (BODO <30 mg /L In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L Z NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size y in dia. ❑ NA Other: ❑ NA Other. ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve ❑ month(s) every: IS ear(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (%) of tank volume ❑ NA inspect dispersal cell(s) At least once every: El earw (s) ,i�year(s) (Maximum 3 years) ❑ NA Ciean effluent filter At least once every: ❑ month(s) ❑ NA 0 year(s) !,aspect um p p, pump controls &alarm At least once every: ❑ month(s) ❑ year(s) -® NA Flush jaterals and pressure test At least once every: ❑ month(s) J9 NA ❑ year(s) u � At least once every: ❑ month(s) year(s) year(s) ❑ NA Other ❑ NA VIAINTENANCE 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 Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined .accumulation of sludge and scum in any tank equals one -third (y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. - ' I START UP AND OPERATION Page, of 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. 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 Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; 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 chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: J 9 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. Cl Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTAL E POWTS MAINTAINER Name Name Phone _ _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was dra` et `- = ance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page of 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. 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 cells) in one large dose, overloading the cells) 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 Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; 9 P pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings 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: J% A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sod and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTAL E POWTS MAINTAINER Name Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafte� '- -;c--„ :ante with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Q. D I PACE Jt B 5,44484 WA>i RA `;r DEE Document Number HEMR'S OFF ST.'CROIX my.., Wi Pltc�diacf�aoid Return Address. MAY L- U-- at 10:00 A. M iieaWK nead3 1 Parcel I.D. Number: 038- 1171 -10 Gary Brunclik conveys and warrants to Shawn A. Swiggum and Kim M. Swiggum, husband and wife, as survivorship marital property, the following described real :.state in St. Croix County, State of Wisconsin Lot 14, Country Meadows First Addition in the Town of Star Prairie, St. Croix County, Wisconsin. This is not homestead property. Exception to warranties: Casements, restrictions and rights-of-way of record, if any. Dated this clay of May, 1996. $ T /d 8 ER EAL) _(SEAL) ary rttnclt AUTHENTICATION Signature(s) Gary Brunclik authenticated this day of May, 1996. Kristina Q& . TITLi;: MEMBER STATE BAR OF WISCONSIN THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristima Oglancl Hudson, WI 54016 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT /` •, c PEc'ED Owner �+ ldj/d� Address u _'a Nit City /State '� cRO x tv, sr ZONING OFFICE t Legal Description: Lot Block Subdivision/CSM # �il�a //� / 1 G•� Sec. / , T-V N -R W, Town of PIN # 63 8 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/K/ Setback from: House Zo Well :� p/L Pump manufacturer Model `— Alarm location <- -- (HOLDING TANKS ONLY) Setbacks: Service roal, Vent to fresh air intake Water e Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Width Len gth Number of Trenches Setback from: House Well A P/L eso" Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark cx Elevation Q l 4? / A Building Sewer / Z ST/HT Inlet 6 ' ST Outlet-- / + r PC Inlet PC Bottom Header/Manifold �+6 , �� Top of ST/PC Manhole Cover 4 i Distribution Lines /, ( ) Bottom of System( Final Grade Date of installation / / V P rmit number✓�i' State plan number I Plumber's sign License number 4Z 7 0c"Ab Dad 1" Inspector Complete plot plan �+ . NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIE OL 3 � ,y 4� INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safetyand Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary MW: Personal information you provice may be used for secondary purposes [Privacy L I t, s.15.04 (1)(m)). 9P.iTjY}�Ql� F ' [�,�X �[(j[ape Igwn of: State Plan ID No.: CST BM Elev.: riA Insp. BM Elev.: BM Description: E�iK 1'tCKl Parcel �90 '1171 - 000 1°p . /D o von S or TANK INFORMATION ELEVATION DATA A9800298 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (,) i n7v Benchm r 3. 10'. / / f Dosing ,�� �AA 5• n q q Aeration Bldg. Sewer 5 - 7X '77, Holding SDi�l Inlet G -;d 94, 97 TANK SETBACK INFORMATION w a W+C Outlet 16 &C/ TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet Septi 1l p� �l� 'Z rl NA Dt Bottom Dosing Header / Man. 6.95 Aeration NA Dist. Pipe 7- 9G . 0 1 C,.aS 94 Holding Bot. System T 8•sz qv 14 . 6 PUMP/ SIPHON INFORMATION Final Grade T� 3 �y 679 -2-7 Manufacturer Demand �,I(y� ��( Model Number GPM TDH Lift Friction S st TDH Ft Forcemain ength Dist. To well SOIL TION SYSTEM BEDVJIENC Width ZZ LengthJZ 23— No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN N J Y DIMENSION SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type 0 p / [•• CHAMBER Moe Number: Sy e �K OR UNIT D �{ DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 1 D Dia. Length Spacing g� Z � C re 0 J SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed / Trench Center Bed / Trench Edges Topsoil El Yes ❑ No E) Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) rte vJ4 �f Spl Col LOCATION: STAR PRAIRIE 13.31.18,SE,SW 1328 COUNTRY COURT �Ak 3M— i a / P J� F �� o n<b fT�n �.1 ►v lkovf 3�' U, Nod i i 5ff /1cd a.� /� S�C��►� - ► as ri no, 9 q '0 acv, Plan revision required. 1 ] Yes No Use other side for additional information. l SBD -6710 (8.3/97) Date Inspecto Signature Cert. No. OiI TARY PERMIT APPLICATION 0 1eE. W and Bu ashngtongAve sion SAN sconsin In accord with ILHR 63 .05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ci than 8 112 x 11 inches in size. V - C f' 0 ) , ) • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision V,.vi.Usaqppation [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location �k�W P-,., u yh.,, 1/a ) 13 T 31 N, R I AE(or Property Owner' Mating Addre Lot Number j� Block Number City, State Zip Code Phone Number Su v ision Name or CSM Number II. TYPE OF WILDING: (check one) ❑ State Owned qty Near st Road ❑ Village /� n Public 1 or 2 Family Dwelling - No. of bedrooms Town OF a (, C,p(rt l✓ III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/Condo _ 11 �_ 3 '�� • f �. 3 ho 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3. E] Replacement of 4_ E] Reconnection of 5 E] Repair of an rstem System ____ _________TankOnly______________ Existing system --- --------- - ---- -- B) B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental - Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12.-4&Seepage Trench 22 ❑ In- Ground Pressure j - 3' X S& .Z5­i 42 ❑ Pit Privy 13 ❑ Seepage Pit 1 - 3, 43 ❑ Vault Privy 14 ❑ System -In -Fill Sic{�wir►cI a ✓° l n�► (1✓0� Ckc. nom. VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade I / Re fga ft.) Proposed q. ft.) (Gals/day /sq. ft.) (Min /inc h) 95 � Feet EI at;on Feet Ca cit (-.)0 VII. TANK in g allons Total # of Prefab. Site IFiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name concrete Con- Steess Plastic App S eptic Tank Tanks New Existin structed Tanks (�(� ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 11 I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name; (Print) Plumb r' Signaturi: (No S s) MP /MPRSW No.: Business Phone Number: r✓��, � Plumber's %dress (S a City tate, ip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitar Permit Fee (includes Groundwater D at I ssu d Issuing t Si a (No Stamps) Approved � Surcharge Fee) pp Owner Given Initial Adverse Determination ' 0 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8398 (R.11M). DISTRIBUTION: Original to County. One copy To: Safety 6 Buildings Division, Owner, Plumber I PLOT PLAN PROJECT Shawn Swiaaum ADDRESS 835 E. 6th St. Ant #7 New Richmond Wi 54017 SE 1/4 SW 1 /4S 13 /T 3 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 3532 DATE BEDROOM BEDROOM 3 CONVENTIONAL )00C IN- OUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE <10 ABSORPTION AREA 604 # of chambers 19 BENCHMARK V.R.P. Top of Iron Stake NE Corner ASSUME ELEVATION 100 ❑ BOREHOLE (D WELL *H.R.P. Same as Benchmark Vent SYSTEM ELEVATION 95.1 >12" Sidewinder High of Cover Capacity Leaching Chamber with 31.8 ft ^2 per chamber 'Long 16" 34" Grade at System Elevation 95' * M. 201 Property Line Ac 54' N) 0 w B -4 2°Io Slope b 1 trench 34" X 56.2 0 6' Spacing between trenches and 1 trench 34" X 62.5 20' 25' B -3 -2 30 , B -5 30 � r , Pro 3 T Bedroom fD House 5' Vents 10' B -1 C Country Court r)tPARTNIENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. MADISON WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: � /sw '/a 13 /T31 N/!/, (or) W � t,�.� / 5/ IA-- � C NTY: MAILING ADDRESS: <183 — 5;4&y /Je . CA,,-St �r. -2.10 G� i T V -0 2 5C USE DATES OBSERVATIONS MADE rres�1t NO. BEDRMS.: COMMERCIAL DESCRIPTION: rp � PROFILE DESCRIPTIONS: PERCOLATION TESTS: XResidence Q X New El Replace Z/ /y' Zz or RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN -FILOLDING TANK: RECOMMENDED SYSTEM :(o tional) ZS DU ZS DU ixS DU DS ©U L H DS I( oe- If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: / Floodplain, indicate Floodplain elevation: � - PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- tq(p �. / y 7 ,q 3 99.E o -C�p =Q // 1/1 ;64ly zy- 3e- "'e.e��.'� 3 B-3 leo - � ` s u� s `/ ,- T ' 6s -fie'' 0 98 '7 Z" , �e. 6�.s, / z -Spa B- 54 B- S gr �g ZY > 9s PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 P E R PER INCH P_ 1 4 /R / v / %icp / & P_ Z V7 P,3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the urface ele tion at all borings and the direction and percent of land slope. 0 C . 6 rlti -+.u. 6C-� 4/0 SYSTEM ELEVATION 9 �' .� Ul IM' E s , i m .. �, x " .> lllsss I f _ y1 P � P I r 1 � ✓ � � - [ '0. T f , a i y , 3 I 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified—Iii the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: IF CERTIFICATION NUMBER: JPHON NUMBER (optional): CST SIGNATURE: C DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) — OVER — r - As ST CROIX CO UNTY SEPTIC TANK MAINTENANCE AG REEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address s � Property Address -1T ea t- (Verification required from 142nnitig Department for new construction) City/State ICL ` r i f_i e- l�= Parcel Identification Number LEGAL DESCRIPTION Properly Location _<j,y t/.,_ ' /., Sec. T_3j N- Rjj._W, Town of r ! Subdivision , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # ��� , Volume Page # Spec house O yes)o no Lot lines identifiab14 yes O no SYSTEM MAINTENANCE Improper use and maiatenanceof 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 SL Croix Zoning Department a certification form, signed by the owner and by a masterplumber, joumeymanplumber, restrictedplumberora 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 jr., fill of sisdge. IN Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources. State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St: Croix County Zoning Office within 30 days of the three year expiration date. 2 �GVIMA 6F )LppLjeWr 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. � l l t3NATURE OF APMCANT 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 cone of the certified survey map if reference is made in the warranty deed 9? • WARRANTY DEED 544484 Document Number S CiM M" saata■+ MAY 3 1 1996 10:00 A. Return Address �- Katj....� OS A,k M c,�.. parcel I.D. Number. 039 1171 - 10 s sid Kim M. Swiggum, husband and wife, is to Shawn A. Swi88u� in St. Croix County. State of Gary, Brunclik conveys and warren following described real AS survivorsbip marital Property Wisconsin: Wisconsin. Lot 14, Country Meadows First Addition in the Town of Star Prairie. St. Croix County, S 1 This is not homestead property strictions and rights-Of-way of record, if any. Exception to warranties: Easements, re t day of May, 1996. TBA WER Dated this s FEE (SEAL) _ (SEAL) a AUTHENTICATION Signature(s) Gary Brunclik authenticated this day of May, 1996. ICristina �� � RSTA � TE BA TITLE: MEMBER OF WISCONSIN TEIIS INSTRUMENT WAS D�ETED. BY. Attorney Knstina 0g 1 Hudson., WI 54016 __........... . � r .+ ri L U to N I � •O° �t m t N OI ._ b ` J o i . i 0) ~• l� i a in U to n 4 0 U ��i¢ �� H in O �S 1 • ;i c .. 2 co 1 C 1 K y Ottl liCl �L1 vi N N 2 I ct 0E t tl (^' i N c.l to \ \ 1: in :h 2 W b 1 lav •.._ _.... .Sd 9DL M., i_t:.9 Z o e C M -LZ.9: ham - 1- N .v j IN - 8£ . v: ¢ / a at O `•' N to N tn - _ w < /1 C 0 p '% . � p �/ �I «'r a.\ � 2: °.. °i � � � L I N ' <i - 3 �,I ` �- I (n I a �1 ti n ' / / a tV `�� O O i U Z =I f-; G9' in !� QD .0 OI , 3.LZ.91. 00N t' �. .E6 • f 2 00'00 .S[N i LE'CZT � M LZ.9T .005 o tL U O s\ cu K �1 0 1 2 OI N b n f b b o a O •° '� O � N� N M 3 in CU 2 Q I o t I W I O 2 n t tc cu = a G ` y JI n 0►'LEt n w 1 1 01 < OI N $.Lt.9i 00N : n ; �$ 3.f[.6C,t N —T— _ o m o W in V) R LLJl J ^' .49 W F w `� b O U. .� 3 cy C9 Q 1 j ! ' in `i� I /L .`�,y.. r� of (V . ! Q O y Z I to s b I� a ! � �• w co / / I m uj K 2 m / /> 0' . ��'. / p� ~+ `t+ 0O ~ 0 r2 N O p ► r 1 O O !� / e / �i 6 0 /�' ��ti: �' M.LE. Ei OON J( /;�� iS'd9 t / + / \� � _ •+ter O � , 'O ,O � �O � 3 _• — _ ._ / o v °� ^Q L9ba ' d Ol co i K r k7, 61 m .6a 66C M.LS.EI.00N N � O n � I m I W 0 1\ t 1 �' 1