Loading...
HomeMy WebLinkAbout040-1306-34-000 Wisconsin Department ofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 506297 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: McCollum, Michael I Troy, Town of 040 - 1306 -34 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /aCp a m % CS} 08.28.19.1861 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r Benchmark 8esing . t Z, Alt. BM Aeration Bldg. Sewer +j • .5 �E Holding St/Ht Inlet i71 1614, G (o St/Ht Outlet — 7 6 v 3. 45 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet G . Septic il + �� 7 ' Dt Bottom / Z3 Dosing - Header /Man. Vs ^3 . 5 1 Aeration Dist. Pipe Ws j; $S ia3 3 f ' � Holding f Bot. System Scq� 'FCC � Final Grade PUMP /SIPHON INFORMATION 5. /bS .7 Manufacturer Demand St Cover GPM J- .n�r✓k — (0 3. 3 167. - cz Model Number .- . �.� Wes--- " ► ", g 5L ioz. 33 TDH Lift ction Loss System tso DH Ft I .y1 /a 1 Forcemain Length Dia. Dist. to Well q. 5 1a /• 3 SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Tre nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid epth DIMENSIONS 3 �� -3 --- SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: 8 , , r, r% INFORMATION CHAMBER OR (7 a Type Of System: UNIT Model Nu ber: DISTRIBUTION SYSTEM E / Z i- I z 4-/ Z :Z- P Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) \_. /� Length �Z Dia Length Dia Spacing ,3f 4 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only e Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center �( Bed /Trench Edges Topsoil Yes L No Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 413 Jordyn Lane Hudson, WI 54016 (SW 1/4 NE 1/4 8 T28N R19W) Sunset View Lot 34 Parcel No: 08.28.19.1861 1.) Alt BM Description = I G L.! tiS 4 ' - " 2.) Bldg sewer length = 2, - 7 - amount of cover = 1 Plan revision Required? ❑Yes G� o I ` ";_- -� Use other side for additional information. .�I SBD -6710 (R.3/97) Date Insepctor's ignature Cart. No. I f commercemi Safety and Buildings Division County 4 201 W. Washington Ave., P.O. Box 7162 St. Croix i seo n s i n Madison, WI 53707- 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 5 2 9 Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the opriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms fo -owned Project Address (if different than mailing address) POWTS are submitted to the Department of Commerce. Personal information you provide ay b s r secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats, 413 Jordyn Lane I. Application Information - Please Pri All Information Property Owner's Name �����` (Cn # Michael & Diane McCollum 040- 1306 -34 -000 Property Owner's Mailing Address AUG r U 11 M7 operty Location 593 High Ridge Drive, Unit A U o ` Govt. Lot City, State Zip Code Hudson, WI 54016 715 -381- (circl ) II. Type of Building (check all that apply) �k � L T 28 N; R j XX XX— 4 or 2 Family Dwelling - Number of Bedrooms U 34 Subdivision Name Sunset View ❑ Public /Commercial - Describe Use 1 ❑ City of CSM Number ❑ Village of ❑State Owned - Describe Use / G� L, 1 5� / S f) 5 Mown of Troy III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A ' New System ❑ R System y p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) c B • ❑Permit Renewal El Permit Revision El Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner ,'l e7- IV. Type of POWTS S stem / Con on ent /Device: (Check all that appl C ,� Non - Press In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation Wieser 0.67 1� 857.1 900 EISA ✓ 102.3/101.9/101.5 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units � E o New Tanks Existing Tanks w c 6 u __5 ✓ e n U in Septic or Holding Tank x 1250 1250 1 Wieser Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for imoa llation of thVIO shown on the attached plans. Plumber's Name I rint) Plumber's Signature MP /MPRS Number Business Phone Number x rn - ..L�j uv.� Imo_ '` ?�a-99 '` ��.-- de3 -( 6 4 �s' Plumber's Address (Street, City, State, Zip Code) r, k N-� rzJ VIII. County /De artment Use 6nl Approved Disappro Per Fee D�aate slued Issuing Merit Signature er Given Reason r Denial $ / 5 ' �b D lzb /O 7 IX. Condii%�� *Reasons for Disapproval 3 c 1. Septic tank, effluent filter and dispersal cell must all he services / mainlined P1_ as per management plan provided by plumber. 2. AN setback requirements must be maintained as Par M*lc*le code / o **Io s. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 �GC-a1� O ho- 1 �co o 0 (D ......... To bra PLOT PLAN Scale Ile- All I 1�ti.�1((J�� U � ` I � •^ V QK 1 k� Ol oZ,� �1 T "JO y. w / S�4Q.� `SU.�eI`S Sys( � cY•�.a..� � OV• � � 0.1 -/y��W O�s..� 0 S5 b„ C. \0.21 C-0 1`.ww. O n(n ... .................. low PLOT PLAY scale c t- � tt • � fr1'� lw.� 0. \ t �'r ON w z� CA 0-0 kc V 2 U Z W �•3°jo U 1 kX y�tw ob,cg oZ,� 1111 0 1 IL \ IS Li oi ( Sshb 1 z 3 �t 0-0, 0) . �owwQ 10 p , o ' oaV 1" l ZC, " OiFiZ LDT O1J ,M 1 Z: .'� ; �.. lQ � . 7' Qti' 2 �';1'tt:C._ i �lu�rRV� P1'RL' 1�% L:,Pr'T"}} ., • • loz.3/ gyp LA l l 1 o�.q --a �I••u. z 0 .-0 73, 4� i ❑ lJ�il �t'� •4i 0!i ��y. Q .a�iWvR �Av J et q.- SGk��c� Wisconsin Depar of Co uildin ff 2 200 SOIL EVALUATION REPORT Division of Safe and Page \ of • in accordanc a with Comm 85, Wis. Adm. Code ST. CROIX COUNTY County Attach complete site Ian orimmCtDomman 8 1/ x 11 inches in size. Plan must S 1 Cep ) include, but not limiA to. vremc-ai ;Ind nonzontal reference point (BM), direction and Percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. evie ed by ''Date Personal information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). Property Owner Ltd ZZ 2oor Property Location Subd. Name or CSM# Pro S T �8 1 a Owner' - N R W E or P rtY s Mallmg Address � � ) Lot # Block ,. P o. Sox 3 3 3 — �s � City State Zip Code Phone Number � El City ❑ Village ® Town Nearest Road B ��M l.Rk� ).") s c18'L 0 1 S � �l$S New Construction Use: ® Residential / Number of bedrooms - Cade derived design flow rate l j S - ❑ Replacement Uy GPD ❑ Public or commercial - Describe: Parent material G LAC) )4 Flood Plain elevation if applicable General comments ft. and recommendations: 'Z�zCp h-1 l� � 1 U L bf a. -' n 1 � k-1 01 = C�StC.S 1 L /�` � �� ` Boring # ❑ Boring ® COO_ F� 2tm pit Ground surface elev. ) 6 S ft. Depth to limiting factor 3 in. Horizon Depth Dominant Color Redox Description Texture Soil Application Rate Structure Consistence Boun in. Munsell Qu. Sz. Cont. Color dary Roots GPD /ftz Gr Sz Sh . . . 'Eff#1 'Eff#2 O - )3 2 �3 _AS lo�c 3/ — s i l Zt shk yS -q3 )0�2 V/G _ S b v S9 M .� t . Z •- i golf fr i Boring # ❑ Boring ® Pit Ground surface elev. ) 6 Z ft, Depth to limiting factor } 4 T in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 •Eff#2 O -)u LU-2iZ 3LZ -S Z 1D 31 S`l �z 3! l -Z .� .l Effluent - #1 - BOD > 30 < 220 m and TSS > s _ 9� 30 < _ 150 mg/L • Effluent #2 = BOD < 30 ma and TSS < 30 mg/1 CST Name (Please Print) Sig ture - Arthur L We'Rerer �- 03 Z1S - 3 CST Num Addres 4d s 2 2 0 2 5 4 e g e r e r S o i l Testing & Design Service Date Evaluation Conducted Telephone. Number 421 11. Hain St. River Falls, UI 54022 Z —p 3 715 -425 -0165 I Property Owner E. ` y��(� NS�1`1 Parcel ID # G Page of Boring # ❑Boring CG.� ® n pit Ground surface elev. U ft. Depth to limiting factor A -1 S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 �o 2 3 1 Z — s` z�gb5 -c r,•�`� cr z 1.� • S • � , � � zy - �s�rz�►y — S� US`s v►�l ew _ --� �.Z .� I� F-1 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 /ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 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 /ft- 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 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. SBDL3330 (R.6/00) I PLOT PLAN Page 3 of -' Scale I'= 50' e-�(S I - m w o , 2 G o 1 LO Q-oe- -Te- ► 1 2 tp 6.7' off, 4 TOLL- 31 . a(� Lv/ c� Z - 03 715 425 - 0165 220254 v — Z �S — 3Lf CST Signature Date Telephone No. CST No. Job No. Wisconsin Department of Commerce SOIL EVA LUATION REPORT " Division of Safety and Buildings Page of • in ac oordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inch t (BM), direciicn and es in size. Plan must Count j include, but not limited to: vertical and horizontal reference poin 5 l C�j percent slope, scale or dimensions, north arrow, and Iccat on and distance to nearest road. Parcel I.D. Please print all information. Reviewed by . Date Personal information you provide may be used for secondary Pu -,cses (Privacy Law, s, 15.04 (1) (m)). Property Owner i Property Location S 1/- '�-1 - S . T � � N R � � E ', Property Owner's Mailing Address i (cr)'v'; P Lot # Block # Subd. Name or CSM# o_ fox 3 3 3Y — Is��s Crty State Zip Code Phone Number City Village Town Nearest Road t3f�M �Rtr_� 1 S�1 CIO (�1 )�S _�35 J New Construction Use: ® Residential / Number of bedrooms -'�: Code derived design flow rate k i S - �j UO ❑ Replacement Public or commercial - Describe: G Parent material G t_\P110 1 1 V - 1 General comments Flood Plain elevation if applicable f`1 {; and recommendations: �Z. � �-t M `rJ� � � !^� L +J� �Z � UJ /IYJ � LIZ -+—� ? �,�� 2�L,'- C }= f•��, ,:= ^- v �Ll a Boring # ❑Boring rVi r Pit Ground surface elev. } b ft. Depth to limiting factor = in. Horizon Depth Dominant Color eex l Rd Description Scil Acolication R2-,a- xture I Structure Consistence Bounday R I rccts *" �GPD /ftz in. Munsell Qu. Sz. Co t I Gr. Sz. Sh. E #-, f O— 13 l I Ef=2 ' �) I C..� s El Boring # ❑Boring ® Pit Ground surface elev. t 6 Z ft. Depth to limiting factor } t: � in. FHoriz 6cn Depth Dominant Color Redox Descri , Soil Application Rata P I Texture Structure 'Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff, z) —I w4tz 3I - z- t 3 s L1 tz So 1- 3 S k Z i Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 m CST Name (Please Print) - s _ gIL and TSS < 30 mg/L Arthur L �iJegerer Sig ture CSTNumba 220254 Address 4i e g e r e r S o i l Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Iiain St. River calls, tdI 54022 1Z- ZZ-0- 7I5 -425 -0165 Property Owner `y �-31 ( 7 P✓l Parcel ID # �'�LJ'� 1 k/ (S Page of Boring Boring # ❑ C� ® pit Ground surface elev. ( U u U ft. Depth to limiting factor 7 S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 - zj� , -,bk. M`C� C tLj z� .s 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 /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2 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 /ft 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 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. SUD4330 (R.6/00) . ' i c7gr�ea♦ , .�.�TfiY.IMAA - .. _ �*aiN£tse.tx ^n. ... � ... .'" r � - ort oq"?W + L ._.��' hi►wl ID r fa t +v Pape awty x a Pool 40 gmdw IWAW In. �+ ++ Depth E l l ' nvtnt Cabr a�ew,c paanrl ti � 'raxtun �+� 4no� aouitdaly oo tn. GN, 3x, . Cd1w (3r Bt 6h, 'EM s lz 3 Ir; .. i ► Z:wa bF� Yri C � �� , . 8 � sort � ❑' +�+� r - -- - - -- - - -- G Pit cuai,a.e:reme. few, .�� n Dept, 14 ft" raawr In. Via+ Doom paminant COkx Dw**dptl4n Taxwre 81ruc+1►�ra � in. M t]UD ft CWL Cabe CanNSa� ry � Or, BBC. >!h. 'llftlt! 'EtM2 a 6ortnp p ❑ �� ' PYt GmUnd "ft** aim►....,,, fL t�plh I Q lwmr*Q bow ---- - in, wlr C Cothlfiant Color Aadopl x Uxwh Stnl�ma t«�ea goundNiS► R,00ta Nt, MNU1fal1 QN. 8 Cont. CQ W' Ctr, sot• 8h. 1 u !'IAt1a11t L30D� ;► a0 a ?20 ingA. and T$8 �O 1D(1 n1�„ " E*Jtm 02 0 so "Pa and res s 3p a*& rho DOPSM"crit of Coirat mme is an equal opportunity mvkV provider and amployor. if aced rastatial itt art altarnaie format, plapet coatoct Ute d Y°" mead assLtautao to Iloceaa set'Y1gW or cparelsent •t 60B -26G -3151 ar x'T'Y" 2648777. w�a�ca,wo, SESE98175T'LT 2T:LT 90OZ/Tn/AT. Qrvlsfanolsaf® _nn ",., -DUIL hvAL.UATION . REPORT � al In accor4oned WRh COMM es, W IS• Cam, Cod. Pyg. *na" Complete site plan on paper not toms mart a 112 x 9 I Cocnr/ IAC17eS in sire. Plan must ^ J Indv4e, but npt ilrrtited to vertlrstl and AOritortlal retR�ncc PaIrif (i'MI, QlrectlGn and , C Percent slope, agte or d1mensfons, norM Mrmw, and ICCOU and dlatgnoa t0 nearest rrc. pane[ t,p, Ploaa:� pPlnt 81 !!/ 7 fe 17 t7at1oA. ����' �� Qerfarel fWd"ation Revlowea by Di is Pro �'� PtOvhh ntny De uxaC rqr SoWndary bur -clot IDnvgCY Law. (m)b Cefty QM'n9Y f'roDer(y Lvcitkn � P 5'� 4 /61J 1 rapany a Ownr'a M311109 AOdreta '11A .s • T N R 1 E Lot I Block rt SU Ndrmt or C9Mg A d4 aria ttmCer U h1 S>; j" v 1 k�V —Z) 9 New Coneau Use Ft+atdenU T Y al / Number of bedrooms ReDltic�rnenl -- = CaCr+ dedveC dexfpn flow rate _ - � Public or wR►theMlol • geeoribe: Pst►ant nistsNal G t �y L. GenttnOl cpmmenta � '��` Mood PiAln e1MUCh If a N ant' recommandatiana: h.t M eA1b 3 ;,,%j L 1 ' ) � -LLS r.. I.....:..J earinp tt gtlrmfl Pit O►vuna Surface Hcri pe Ceafh to flmlCnp faCor p Dominant Color Redox Deecnpaon Tnz;um stu'ure Scn A=;Cai on Rare In. Muneall U. Sz. Cont. Ccicr Consistence Bcurte ry Or. S� stet Raara dPp� q�'lrL '" ey ^ Yf ►y1., -,� .,.. ® Pit Grouna sutitica ar$v. 10_ 6 Z d m umlMng ractor > 1 t n ►tzon 1],rrrpth Dam }Rant Color Redox Dosoodon Texture Cortafetenc. . Oil A loo on r;a s (Nunelfl Qu. Sat COAL Color r. 8z. stt. rN UCUr1 9ountlary Rwta C;po cir• 'Eiht�1 `Etfe2 t Z 5 1a k h t'rj— 12 "M Y/f6 I �Bluet►t �Mt ti s 30 s 220 "%PL WO T88 x3o K 160 d Mia h u•r •, � • . • 30 myt, antl TSB � : • �ure e r e r �. 0 3 �-Z, � S ... 3 � rvwnl�► A4 4rtasa We$eter Soil, TestIng Sc Design Ee>r•Vice n w 220 54 GI 41 n , St. Riv - Z — ndut�ct .F 8 7 5 U T �+Mm. rtumem $�oz2 ► X2_ 3 715 -425- 0165 f 639NISS129 gNVF{ CrrCn0"nTt T �T • , T I PLOT PLAN Pace - of 3 Scale 1'= 50' 1 . �I 3y I ��-7 m� �I w i o 1_3 ° o . S �J\ LN 1 4 l 20J`i l.0 T �4� L--10� -- \Z - -03715- 425 -0165 220254. 03 — Z�s -3 CST Signature Date Telephone Ito. CST No. Job NO. � t oa o�Q zo�G3 N 00_4216 "W 271.61' I CO L \ co 1 Q �� �'� E—, L obi cri C O to C C z CIA OD Q W pry j \. 3 r. Oa r, C'a \ —, �-- — — — �.► p ci o�N 152.8b' 244. 0 ; o , a Re. oo � ci co ao NI W40'41 V F-I co f coo r+ u u C C )) _ j J L ^_ -__ W ! in DRAINAGE Q 1 EASEMENT ap a ~'. N 00'04'31 "W 347.31' 3 aW wl -- I r-4 o ! N I to co vi 6 4 !CD z N N o o 1 E--4 ,� o I .n �n O c o A ' O J Z ti Q L, - - - - - -- — -� , ptn2! cn w 7 Z to 0 - w - 6 L . zt c 3..ti0,5Z.00 N I v �Z W a co (N �' —_ — _-- - - --I (n =3 � o p: Q� ogQ t > rn to Wf I ,,, , - \ot,et � �►W. 1 �w ye- ,.. 4� O .O �3' � b •S � n &fil �t �i0!i b�k p . �e�iwvti 1�ev �il: �~ ,�Qa►vtc� PLOT PLAN scale 1' x Sn' I L hv2.i� S I 3 G o-o ►-kc y1°iO � i co O�n 4'O 04- �O"L elk Sshe �1 a l �. . -..GL l O4. o ' cr, t " I Z'Wy 01 f(%Z tai^ 0 -0Vt-%,J kzM, 1k LP►- `r}�,, POWTS OWNER'S MANUAL MANAGEMENT PLAN Page of 3 FILE INFORMATION SYSTEM SPECIFICATIONS Owner ������Z <C Septic Tank Capacity gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 7 ❑ NA Number of Bedrooms 100 d/bedroom ❑ NA Effluent Filter Model crt= ❑ NA Number of Commercial Units NA Pump Tank Capacity al ®-NA Estimated flow (average)* al /day Pump Tank Manufacturer ty NA Design flow (peak), estimated x 1.5+ u\o' gal Pump Manufacturer L a NA Soil Application Rate S o, g al/day ft Pump Model p NA Pretreatment Unit ❑ N.A Influent/Effluent Quality (NA ❑) Monthly Average - ❑ Sand/Gravel Filter X[3 Peat Filter Fats. Oil & Grease (FOG) < 30 mg /L '� [3 Mechanical Aeration Wetland Biochemical Oxygen Demand (B.ODs) ✓ Total Suspended Solids (TSS) 5 220 mg/L O Disinfection 5 250 m V Manufacturer: Other: Model: Pretreated Effluent Quali Monthly Average*** Dispersal Cell(s) Biochemical Oxygen Dema (B s M In- ground (gravity) ❑ In- ground (pressurized) S 30 mg /L ❑ At -grade ❑ Mound Total Suspended Sol' S) Fecal Coliform (geo etric mea _< 30 mg /L ❑ Drip-line ❑ Other: 10 + cfu/100m1 ❑ Leaching Chamber Manufacturer \o o, v C- rrt Maximum Effluent Particle Size 1/8 inch diameter Model 'CA Q_C_ - S (_ i Stipulation `Wastewater Flow Verification on and calculations: Soil Application Rate 6 ),W gpd/ft Area Req. `65 t ft' (Other than bedroom based) Absorption Area Credit per unit ft`' Minimum Number of Chambers 3 t ❑ Aggregate Desi n Flow/Loading Rate= ft min {• Values typical for domestic (non - commercial wastewater Materials: all materials must comply with W1 Adm. Code and septic tank effluent. COMM84 and be installed per manufacturers specifications `Values typical for PTetTeated wastewater. and approval letters. DESIGN CRITERIA ❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.al.1990) ❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler. Publication 15.22 ❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6 ❑ "Design of Conventional Soil Absorption Trenches and Beds ". R.J. Otis - ASAE Publications 5 -77 and "Design Manual - Onsite Wastewater Treatment and Disposal Systems ". EPA 625/1 -80 -012 October 1980 ❑ SBD - 10570 -P (R.6/99) "At -Grade Component Manual Using Pressure Distribution" ❑ SBD - 10567 -P (R.6/99) "In Ground Absorption Component Manual" ta� SBD - 10705 -P (N.01 /01) "In Ground Soil Absorption Component Manual" Version 2,0 ❑ SBD - 10628 -P (N.6/99) "Recirculating Sand Filter System Component Manual" ❑ SBD - 10656 -P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual" ❑ SBD - 10572 -P (R.6/99) "Mound Component Manual" ❑ SBD 10691 -P (N.01 /01) "Mound Component Manual" Version 2.0 ❑ SBD 10595 -P (R.6/99) "Single Pass Sand Filter Component Manual" ❑ SBD - 10657 -P (R.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10573 -P (R 6/99) "Pressure Distribution Component Manual" ❑ SBD 10706 -P (N.01 101) "Pressure Distribution Component Manual" Version 2.0 ❑ Drip -line Effluent Dispersal Component Manual for Multi -flo Onsite Wastewater Treatment Units MAINTENANCE AND MANAGEMENT MAINTENANCE MONITORING SCHEDULE Service Event Service Frequenc Ins ect condition of tanks At least once every ❑ months ER year Maximum 3 s.) Pump out contents of tanks When combined sludge and scum equals one -third 1/3 of tank volume �-- Inspect dispersal cells At least once every 3 ❑ months Ca ears Maximum 3 s t Clean effluent filter At least once every 1 2r months ❑ year (s Inspect pump, 2ump controls & alarm At least once every Vonths ❑ ear7 NA Flush laterals and ressure test At least once eve ❑ - NA Valves At least once eve r-1 ❑ NA Other: At least once ever ❑ ears p NA t. START UP Page z of 3 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 cells If high concentrations are detected have the contents of the tank removed b ( ) y a septage servicing operator prior to use. System start up shall not occur when soil.conditions are frozen at the infiltrative surface. OPERATION The property owner is responsible for the operation anid rnitintenance of the'POWTS and submission of required reports. The quantity and quality of the wastewater stream will affeofthe performance -and lotigeVity of your POWTS. The installation of water- saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should a discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc, This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable /fruit peels and seeds, bones, and food solids such as those roduced b a g arbage disposal p y g g p I should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system, Chemicals such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up, ❑ Valves Valves shall be operated in the foil o g manner. i I C3 Alarms Alarms should be tested on a regular basis by a home ner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve rider regular op ng conditions, however water should be conserved until any problems with the system are corrected prevent back -up of sew a into'the dwelling or surfacing. INSPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). CWeptic Tanks Component Tank inspections must include a visual inspection of the tank 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 backup or surfacing of effluent . Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective locking device to prevent accidental or unauthorized entry into the tank. When the combination of sludge and scum in any tank exceeds one -third (1/3) 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 NR1 13, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. ❑ Pump Chamber/Treatment Tanks Co onent The inspection must include a test electrical equipment such as pumps, alarms and floats. A visual check must be f Litt made for leaks, backups, suraci g or broken security devices and other hardware and the condition of the filter. Any service needs or repairs 11 be �promp taken care of. Page of f] In- Ground Gravity Component Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. O Mound, At- Grade, In- Ground Pressure The inspection shall include recording the 1 is ofponding, if in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any charge to ground surface must be promptly reported to the regulatory author Ponding greater than 75% of the height the mponent may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. The pressure distribution system is provided w' an opening the end of each lateral to be used for flushing. The laterals should be flushed at least once every three years. Pressure the s of systems with multiple laterals should be done to ensure that equal distribution of effluent ' occurring to promote the longevity of the system. REPORTS Reports for maintenance"spection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative Code. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code. t / 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 ith soil gravel or other inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil 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. • Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrate\ e 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 GASES 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 i POWTS INSTALLER POWTS MAINTAINER Name 1 \4 4a�_\i, -(L I I Name Phone 7 4-\S- Z85- 6'RT1 Phone SEPTAGE SERVICING OPERATOR Pum er ) LOCAL REGULATORY AUTHORITY Name Agency S� , G2o1 x o_t_4�r4 " batt.t 6 Phone Phone --�5— 19'6 - 6 �? 0 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND `,� 1 OWNERSHIP CERTIFICATION FORM Owner /Buyer j C �► ` l L � " M C4 O`` V W Mailing Address S 3 &v 1 �: � Irs.- �) r.. V\ V � S % V w Property Address 4 13 Y r N L a. y To w Y\ % l rm q W 1 (Verification required from Planning & Zoning Department for new construction.) City /State 0C W 1 Parcel Identification Number n !j '� ' 3 d " 3'1 " ° a LEGAL DESCRIPTION Property Location SW t /4 , N IE t /4 , Sec. $ , T N R I) W, Town of Subdivision S y VN ky Lot # 3 L l . Certified Survey Map # , Volume , Page # Warranty Deed # V Z� 3 6 �- , Volume 0 , Page # 0 e Spec house yes no Lot lines identifiable Q� 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. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 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. I/we 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 _ IGNATURE OF APPLICANTS) DATE I ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application 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. (REV. 08105) V - -2934 P 626 KATHLEEN H. WALSH REGISTER OF DEEDS State Bar of Wisconsin Form 2 -2003 ST. CROIX Co., WI WARRANTY DEED RECEIVED FOR RECORD Document Number Document Name 11128/2005 18:00AK WARRANTY DEED EXEMPT # THIS DEED, made between B & L Development, Inc., a Wisconsin Corporation REC FEE: 11.00 TRANS FEE: 329.70 ("Grantor," whether one or more), COPY FEE: and Michael McCollum and Diane E. McCollum, husband and wife CC FEE: PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is A v r needed, please attach addendum): Lot 34, Plat of Sunset View Development in the Town of Troy, St. Croix County, Wisconsin. 040- 1306 -34 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptionsto Easements, restrictions and rights -of -way of record, if any. Dated (SEAL) (SEAL) * * nc. Roger n Revers (SEAL) Pf- rf' />h S/T SEAL) * Notary Public �►�iI1�itDO�ISl11 ACKNOWLEDGMENT Signature(s) authenticated on STATE OF �[.y/ ) ) ss. COUNTY ) * TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on /U //� ,3 Z00" !r— (If not, the above -named & Development, Inc. a Wisconsin authorized by Wis. Stat. § 706.06) Corporation 44 to me known to be the person(s) who exe ted the foregoing THIS INSTRUMENT DRAFTED BY: instrum t a nowledged the same. Attorney Kristina Ogland Hudson, WI 54016 Notary Public, State of My Commission (is permanent) (expires: Lke 41& (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO -PRO Legal Forms 800.655 -2021 www.infoprofom)s.corn 413j©rdyn lane Q ED 0 60' -d Ord„ 1 - 55' -0" 0 M1- v