Loading...
HomeMy WebLinkAbout012-1031-30-050Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal mlormabon you provide may be used for secondary purposes IPnvacy Law s 15 04 , 1 hm1l age Tonnsn,p Permit Holder's Name City Robert L. and Kathleen M. Frydenlund TOWN OF ERIN PRAIRIE TANK INFORMATION TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION to JVIL AbbUIRPTIUN SYSTEM ELEVATION DATA IDt Inlet SI Cover n BEDrTRENCH DIMENSIONS Width Length No Of Trenches PIT DIMENSIONS No Of Pits Insde D,a Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WFI I LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturer Type 01 System. Model Number HeaderiManrfold Distnbubon x Hole Size x Hole Spacing Vent to Air Intake Pipe(sl Length Dia Length Dia Spacing Depth Over Depth Over xx Depth of xx Seeded Sodded xx Mulched Bedi Trench Center BediTrench Edges Topsoil Yes No Yes No 61LIMIALN I J: (Include code discrepencies. persons present. etc ) Location: 1645 200TH ST 1.) Alt BM Description = 2 ) Bldg sewer length = - amount of cover = Plan revision Required? Yes No Use other side for additional information. SBD-6710 (R 7/97) Date Inspection #1 Inspection #2 Insepctor's Signature Can No us S A& Division _! adis11 Yards W> Ma(`(>T1l di 705 _- .O. Box 7162 Madison, W153707-7162 Sanity P it Application In with S1?§�31[3Qisubmission of this form to the appropriate govermkntal unit is tcgtnited 'or to t�l((ypgqus r. Application forms for state-owned POWTS arc subu ittod to the Departm t rofessiouai Services. Personal information you provide may be used forstazuMary u�t uses in cuxdence with the Privacy Laws 15 04(1)(m). Stars I. AppHntion Infotvtatitm - Please Print AH Information [eroperty Owner's Nernc Property Owneu's Matting A City, State Zip Code Phone Number NEtel /cVlyo JJ W1 Syo/7 11. Type of Building (check all that apply) Lot a 1211 or 2 Family Dwelling - Number of Bedrooms .3 ablirKominercial - Describe Use Binder # hate Owned - Describe Use _. 64q-7g /6 Parcel N l! d /1-/Q3/ - 30- Osro Prop 1,Oa000 . l -t . I 'B Z 8 Gov_t.ILot NrJs-' sr✓ Y, swoon 12 T 30 N R / % c ..-Z ) wmr.umocr AW vluageol 20 Z -7 Z1 E]fntrlr of I-X/ij /le/E M' Type of POWTS Permit: (Cheek dMw "New" or "Replacement" and other oppHeable on Has A. Check one box on Hoe B. Complem Me C a HpWe ) A. ew System ZR t S IBC pceplacernca ystem [Dptker Modi(icatiem to Eeisting System (explain)]Additiaoal lhronnatment Unit (atplam) B' � Wdi Tank Z ng a (cmvc ti at -Grade �Mmnd Individual Site Design Other Type (expiam) (convcnriotul) C. Renewal BeforeRevision ange of Plumber aransfer to New Owner u Previous Perm'Nam yI Expiration and Date Issued u l / ;a M Dispersal/freatment Area and Tank Info Design Flow (gpd) ign Soil Appl' so DuspersaI Area Required (af) Dispersal Area Promised (so Ekvmm So 7 Cy3 ✓ 50 9/ 3 t 90.5r Capacity in Total fl of Mamufaeoner Tank Information Callous Gallons I Units Orcnc D o Ncw Tado Exining Tanks U x Septic or R,J��L Dosing clumbcr /aao l - !✓/ESE.e La.,u, '- � �• � .r v w -- h --- -�,R• ti .sewme zesPaamam Or tmflnanoa of the POWTS shown an the attached phut Plumber's Name (Print) Plumber's s' �t:MP/Nita Number Bufirnea Phase Number Al twr A14KAr a.?y/99 7iS W-2-y/sS s Add Pltltttbct'= (Snm City, Slate, Zip Code) - Po. 41" AO fex. GJI .T973o �Q Approved ❑ Disapproved Pemut Fec Date Iswcd Issuing A ignature / \ S O Owner Given Reason for Denial S-ow • t7 a Conditions of Approval/Reasons for Disa�roval SYSTEM OWNER: �'�G1/`C e� �(��'s t!YJ� 0t✓Yh 1. Septic tank, effluent filtef and dispersalC411must byso etf/maintimad LI/ �Cirut r �Yto �I/`��sU L /s ✓fit %%•fG(f 1(�1'�yt as per management plan provided by plumboc ) �j 2. All setback requlremenls must be maintained ai per applicable code/ordinances. Attach to complete plan far thcryzbm sad mbmn# ,too theeCounty owly a Per a" ku than 9 112s11 ietin e In th SBD�i398 (R.0321) Nv`rQ Yl 3 /ors -- goo c� Sr, r � A - Ado. a 64 rro,y ex 6cd. ya appr'� !J/rse.c 0 am tr o 'sr 3 �9�0 . i Pt 0 00 24 PLOT PLAN � 9r fiE[o c VOVCY'k Fi yClanh" v5 ,toorN Sr, Nt✓, sue, so N, 1741 y aF Et/✓ 10A'mit', sr. /, ., Co. Ptrft / Ogia' 0 �Za riu/r AAs cY) Ururl�Is(7,4 9Ya` c 9u >/7"Poc ScN,V4 91.ar Y"Ax 9aS ,-'Aa5-s-,SEGr/ems+ �iJa sc�ci� LISE EL f[ou /.703 ,S/ bt cdOtls (/ xd + /a�= Ay /S 6u r11Es x 50.0 ce a 75-4o .iY bF[ov L.r.uF 75 3� 0 3039( 6 UE.vr �i�isC�� , 0 /f o 3 / L/N aI dd StAtl� N 3015 -f-ifctr car .gu S/S 383. VS Srr4A4.&s 'YFr EK, //ou rs re 6r 40Ajr A1!/, Fy,y/r/ oar f Fiuco ry Page 1 of ¢ Private Onsite Wastewater Treatment System Index and Title Page Project Name: Owner's Name: Owner's Address: /6 , ,dc10 & Sr 6-yo/7 Legal Description: Nal� St,/ /,74 ioN /7 G/ Municipality: Town, Vi%ge, City of E,ci r /�,r Ii ciE County: Sr, Lot Number. / Block Number: CSM Number: C/w/ Subdivision Name: /�ys ,lam & Sr Parcel I.D. Number: O/7- /a3!- �a oSo Page 1 Index and Title Page Page 2 Plot Plan with Cross -Section & Plan View Page 3 Septic Tank Specifications Page 4 POWTS Owner's Manual & Management Plan Page 5 POWTS Owner's Manual & Management Plan Page 6 Filter Information Name of Designer. License #: Signature: Date: 5_-/6-,76a2 Designed pursuant to the following POWTS Component Manual and D PS 381 385: SBD-10705-P (N.01/01, R.10/12) "In -ground Soil Absorption Component Manual" Version 2.0 Attachment: Soil Evaluation Report r/ pro 17// / J oo "I^fAl '"Iwopr oy !D' °1 tl 0V0/ x-:7 �3.✓ sy»9flS fh'F8F ;IS 77SV ' or `/ tN „ y �lrr7 °�+• rr� r7 Np 717/ r 0 !f o l0I Y7' r*o7l9' /i £�j =Nl/3d '7rYl SP'/ 'XY!✓ T f�F/f/ i�• OS/j - l7�%' /�•/irk _ =Xs 0 4orz a=A> O.OS X t37p rnq s/ i F,r / J fl70/`np' Y FOr/ rvo7/ 7-9 3t�j �.rsros oC� ro/s7�'S' -ftvY� •y3 S �£ f slo 6 py•N25' vndNC/t * lrr6 �f/< �Nf/f 0 7y .4 74 �) 010V 1S /o1 rYr� > v /I Z/ ivoi ",C/ 'r757 717N �F Ft"o1' Sb7/ 'Cod r Or9,� ro6_a� '°f60£ s ei6_•� \ r ° 61,4N7f .lrN brio/s >° x°11 cq /n Ov/ 1 ~pf n7j n d N DOLx !/ TuFna pia v� a 4" CAST Q) a ACTURED TO ON I I � < 11) PUMP PAD SIDE VIEW 3 ED ASTM C-1227 REOUIREMEN CAST -A -SEAL WLP1000—MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1 /2' a BOTTOM: 3' COVER: 5' MANHOLE: 24" I.D. PRECAST CONCRETE RISER i HEIGHT: 53 1 /4" ° LENGTH: 8'-8" WIDTH: 7'- 2' BELOW INLET: 42' z LIQUID LEVEL: 36" o WEIGHT: 6,790 LBS. 1 INLET AND OUTLET: E g o 4' CAST -A -SEAL BOOT OR EQUAL GASKET Y g INLET AND OUTLET BAFFLE AND FILTER: m o c o � 4 WISCONSIN, SEE DETAIL /10 (OTHER STATES SEE CHART) W N LIQUID CAPACITY: 27.83 GAL/IN W HOLDING TANK: OUTLET HOLE PLUGGED G.7 u ACTUAL CAPACITY: 1,085 GALLONS 0 �° LOADING DESIGN: 8'-0' UNSATURATED SOIL v N TANK CAN BE USED AS: Z o SEPTIC / HOLDING / PUMP OR SIPHON o _ COVER: MIX DESIGN /8 (NO FIBER) CO W TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE J 3 I O Z <� $ REVIEWED BY U REVIEW DATE d DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: SHEET N0. APPROVAL DATE: j PRODUCES NEEDED BY: / OF ' POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORM TION Owner Permit # DESIGN PARAMETERS Number of Bedrooms 100 oom Number of Commercial Units - Estimated flow (average) 30ogal/day Design flow (DWF), estimated x 1.5 ySogal/day Soil Application Rate 7gal/day fl2 Influent/Effluent Quality (❑ NA) Monthly Average Fats. Oil & Grease (FOG) 5 30 mg/L Biochemical Oxygen Demand (BODs) _< 220 mg/L Total Suspended Solids (TSS) _< 150 mg/L Pretreated Effluent Quality (® NA) Monthly Average Biochemical Oxygen Demand (BODs) :5 30 mg/L Total Suspended Solids (TSS) - /L 30 mg [L Fecal Coliform (geometric mean) _<]0 cfu/1 Maximum Effluent Particle Size 118 inch diameter Calculations: Soil DM t Application rate = ySo - 7 = DESIGN CRITERIA ezv4TFM RPFCiF1CA1rI0NB Septic Tank Capacity 60D gal 0 NA Septic Tank Manufacturer 4//J-36x E3 NA Effluent Filter Manufacturer OXE-;co E3 NA Effluent Filter Model fro 0,79-/ 6 Cl NA Pump Tank Capacity M NA Pump Tank Manufacturer ❑ NA Pump Manufacturer ❑ NA Pump Model ❑ NA Pretreatment Unit (®NA) ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer: Model: Soil Absorption Component (❑ NA) ® In -ground (gravity) ❑ In -ground (Pressurized) ❑ At -grade ❑ Mound Drip -line ❑ Other. ® Dispersal Units — Manufactuer E Z iidrJ ❑ Aggregate Cell(s) Model 1,?4311 Dispersal End Cap (Dispersal Unit EISA) or Area Required - EISA + (Trench Widthl = # Units or Total Len o c G'/3 fr` - - Soo Fr' _ /S /3�rat[s �71rd fr+ ❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publication 9.6 ❑ "iCC Flowtech Mound Component Manual" Version 1.2 ❑ "EzFlow Mound Component Manual" Version 12/152017 ❑ SBD - 10854-P (K1/12) "At -Grade Component Manual Using Pressure Distribution" Version 2.0 SBD - 10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0 ❑ SBD - 10691-P (N.01/01) "Mound Component Manual" Version 2.0 ❑ SBD - 10657-P (R.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0 MAINTENANCE M0N1'1'ARiNG SCRF.D1i1.F. - MAMTF.NANCF. AND MANAGEMENT Manual) Service Event Service Frequency Pum ect tank(s),inspect dispersal cells clean filter At least once every: 29 13 months 83 years Other - Inspect pump & pump controls slazin, pretreatment unit At least once every: months Q 3 yews 8 NA Flush and pressure test laterals At least once every: ❑ months ❑ 3 eats NA START UP AND OPERATION: For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity 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 be discharged to the ground surface whenever possible. Note: this does not include laundry waste, sbowem dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fiuit peels and seeds, bones, and food solids such as those produced by a garbage disposal 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, Page yof4; 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 fi=c up. INSPECTIONS & MAINTENANCE: 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). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify arty cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (113) or more of the tank volume, the entire contents of the tank Shall be remaved by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. if an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system ate corrected to prevent back-up of sewage into the dwelling or surfacing. 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. SPS 383.33, 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 Seplage 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 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: �1 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 render it unusable. Replacement systems must comply with the Hiles in effect at the time of replacement. 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 infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. «WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAIN Name K/ENT O/Ze ^0- h /99 Name Phone y/S 9e l - Y/-r-T Phone 71A Li - Y/3*1r SEPTAGE SERVICING OPERATOR um er - LOCAL REGULATORY AUTHORITY Name Agency a Sr.r6*/r w yAra r Eu�t. Phone Phone 71.jr 3 L YZJ6 Page 5 of 6 A. CMG Maintenance Instructions t-e00tii18-9613 Biotube6Effluent Filter How to Clean Your Effluent Filter 7o ensure your effluent filter is functiomnc properly, it should be nspectea every year. Urder normal conditions, your effluent filter will'unction for severe; years before clearing is necessary. The filter should be cleaned when it becomes clogged erough to restrict normal Flows out of the septic tank. A: a minimum, :he filter should be cleaned whenever the tank s pumped. Most people ore-W -W have a sep is tank service provicer ta+ce care of'iaer .me ntenarce and cleaning. You car, rand a septic :ar<se,v ce prahrder it the Yellow Pages, a^der 'Septic Tanks S Systems.' Or you car contact your county health :eoam-m-t'or a Gat. Jr you wis- to inspect and/or clean you, effluent %her poursetf, ne sure :o dress orooery. wear fL4i-length parts and shLK. shoes. gloves, and gogcles or glasses 7rer follow ti;ese astructio-s I. Remove the access lid to your septic tank by unscrew- ing the Rainless steel lid balts with hex nead wrench provided. If your lid is above ground, a will be easy to find. If it is buried below ground, find the marker that indicates its location. 2. Remove the fitter cartridge by grasping the tee handle and lifting it out at its housinc (see photo f). 3. Spray the catrdge tubes wits a hose to remove any material sticking to them .see pnoto 2). Ensure the three onf:ces in the opticnal flow modulation plate insiae the filter are clear of any debris. Make sure the rinse water runs back into the tank, but do not allow solids material to fall into the open fiber housing. a. Firmly olace the cartridge back into the housing. 5. Some effluent fitters come with an alarm that activates whey the filter needs cleaning. If you have an alarm, check to make sure 4 is working by liftirg the float with a stick. An audible horn should sound The alarm panel is normally mounted on the side of t►re house or M the garage. Note: If your effl ient!ker doesn't have an alarm system and you would like one, call your local septic system Installer. B. Record the date that you inspected and/or cleaned your filter on the form that follows. If you checked the alarm or made any other observations about the tank or system, include that information under -Notes_ 7. Attach access lij by placing it on the riser, matching the openings in the lid with the bah catches. Insert lid boles info catches and tighten with hex head wrench provided. Photo 1. Remove the filter cartridge by lifOng it out of its housing. Photo Z Spra y the ca.rrndge tubes with a hose. p. _44 I Wlsoonsln DapadmentcO Safety and Professional Services Division of Industry Services SOIL EVALUATION REPORT InaccordancewltltSPS385,Wls. Adm. Code j County 5t _to Page _ of Attach compiew sits plan on paper not Was then 8 112 x 11 Inches in size- Plan must Include, iparcel I.D. but not limited to: vertical and horizontal reference point (SK, direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Into, matlon. RevlrNad by I Date Props OYYMf 1 Property Lccetlon ❑ GovL Lot Y. %. S T N R E (or) W Property ownefe MeilingAddresfi Lot # 810bk# Subd. Name orCSM# City I t State zip Code . Phore Number []City QMIlege 4.Town Road � 16rsaeo QNewConstruadon Use: J.ReaidentlaUNumber ofbedrooms Y Code derived design form rateyjL0GPD !T Replacement �I Public or commercial — Describe: Ar� Parrot material /A aLr�� Flood Plan elevation It applicable tL General comments recommendations: �- an-,�s`-�.� -M- a v-s3`('�-br,)���.� llo�ocd—(o�o�ca-ss Ir4- < .`1� G,r �o. !aX'r2�-L r�'4--u`t ^Olc�ro FT Boring M ❑ Boring Pit Ground surface slev. Depth to limiting factor!) �fn. � Cwx AwwllwwAww O..L -Qu.Az. Cant Color ��Fiwilwjjse Ml M I a 0 AIM., 1� �WAWOM�AM _ MISS I L I Boring#. Boring Cl PR Groundsurfaceelsv.. Depth to limiting factor h. Soll Application Rats Horizon Depth p In. Cominant Color Munsell Radox Des anptlon ' Qu.Az. Cont. Color Texture ( structure Or. Sz Sh. Consistence Boundary I Picots QPDIFt` '1t 'Etf#2 3 r 7 Y14 LIS^. i r" iLf BOO, > > n >so s and sLo s 1 go MUL CST Name (Pleas Punt) n rti � r '' � .' CST Number 7/ Address \N-M el Road mloc on Co ucte veI 6z-1— Telephone Nunn 5" Mondo�579 ;715) Boring ��r Depth to tUnalnafecto'Z= epdnQ• i pd Ground eurtace elev. 1 0. p n G DO }fin I p ; pornhunt,Calor RedDx Deaedg�n' 7e�duns St:ttcture ; Consawaa Boundt�Y 4 � p�ianelt Cu. Az Cont, Boi> or. 9z Sh. ) ' O— l z k Usorina s Bor1rD P3 �murd wrhas elev. It 8 Depth Go wdftfacwr--t-:e. r Ike or moo*,,QaA� , Daminamcotor : RedcxDewip:+r Taduro Stmctuns ,x i •� !n 1 Mansell C.. As. ConL Ct;x 8r. St St, i r � 1 i l ' r—^ BoPo7p# pit fi Gmumdeurfmalev._ 7epdttat6nitlng'a�o•'_ru Hortron Oepth 1 Dominant Colcr iiedox Deatriptle ti Tern Stvcwfm f Consmoce I Bauadary Roota G?� i r � ism i in. I Mansell CLi. Az Cont. Coltr Gt. sz Sk. t � 1 t . i - EBi..er!o = BCD, > 3 , s 2.r �y _ erd Tss > 30 s I00,T IL • EfAltentNt = BCD, ;p 30 s 22C TWL and —138 > 30 s .,s .0 rQl-t vo F� o lA/ b856-6L9 (SL) ti 99,Lb9 IM. . piaoH �ooiw@H COSCM OiuilsOJ IioS 1pl;9H WM, EON 04 �,7 =�'fgf? s " � SG 5/27/22, 10:11 AM 20220527 062453.1pq SE CROI.&COUNTY �. SANITARY SYSTEM OWNERSHIP/ADDRESS FORM File #: — Office Use Only Crr ated 212021 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. If you would like to view your issued sanitary permit online, you can do so by using the _. -, .. weblink OWNER/BUYER INFORMATION Owner/Buyer 1Aobeeer >! Mailing Address )i -u� - �r'h City/State/Zip 4v n Phone Number (required) I i5o12-0 la�1-1 Email Address (required) 1 Parcel Identification Number �f-t .. ' r ' `� 12 >31 5irp (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location V, , Lid t/. ,Sec. LA. T,jON R W, Town of _ Slchltrtn 6fJ D Wu Subdivision Plat./'l i �M-�� ., iai�f _ Lot#�_. Certified Survey Map # I -Ufa(` Volume . Page # _— Warranty Deed # _(before 2006)Volume _ Page # Number of bedrooms cz� Spec house 13 yes Ono Lot lines identifiable JW yes O no New Property Address (Verification of new (Stiff initials) (Date) OFFICE USE ONLY required from Community Development DeperCnent for new corm raction ) This form must be submitted with all Private Onsite Water Treahrrent System (POINTS) applications. New System: Include with this farm a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey mop if reference is mode in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center _ 1101 Carmichael Road, Hudson, WI 54016 715-245-4250 Fax https:llmail.google.coMmaitlui0t#inboxlFMfcgzGpGBGPjbrtmDBY,ZrvggpmfdpdF?projector-1&messagePartld=0.l 1!1 ♦ Wisconsin Division of Attach complete i but not UMNed to, Bede or dinwnsla _ CST .a daa - 6 51 at Services t" `Y Page of _ SOIL EVALUATION REPORT APR 2 5 �022 In ccordanoa w@h SPS 355, Wis. Adm. Code County on paper Qctiswilin 1 x 11 Inches In Size. Plan must include, Cr led he nt (Bluff, direction and percent slope, Parcel I.D. cation and distance to neareat road Z - 3 — Please print all Irfformatlon. Revs d by J / 3vids may be used for ssoondary ouroosed (Pdvaev Law. a.15AU11(ml). h /if 4" Props owner Property Location I J Oovl Lot IVI.Ys S W Y• 5 17, T 3 D N R rz (or PropertyOwner's MaitingAddres� Lot # Blo'rk# Subd. Name or C9M# Z7 Zl City State Zip Code , Phone Number ❑ City Omil"e 4,Town N reef Road Z QNewConstructton Use:JLRealderedW/Numberofbadrooma,T_Code derived design flow rate�PD 612; At Replacement ZI Publlo or com erclal — Deacrlbe: Parent materiel ' Wood Plan elevallon It applicable �a'R General comments V,recommendations: �-ap—�s'�>�-�.s�-s3r��-t��^a�J load—o%�r�s i I L Si 1 r44- < t"Av': e,r` � n _ l.A4e r-,t- r kb L,-t 11 I Boring # ❑ Boring Pit Ground surface Slay. 4 Depth to limiting faotor?4n. RIMMING Iffm © Boring #, Boring r Pft Ground surface slev. l th to Dior14 4r. _ Z.-7 } 6eIow ��f� =� GBAll Application Rate Horizon Depth Dominant Color Redox Description I Texture I b+fructure I Consistence BoundaryRoo opume in. Munseil Qu.Az. Cont. Color Gr. Sz sir. CST Name {Please Print} S nat 'r8 =va m •�aqV JV �.1Va lQYm L CST Number Z Address W M el rn�ock Road vel on Co ucts Zti Telephone Numbs "� r .n C Mond0v11 vv, . • . V nnu.eaau(wwia) (715) 579-9584 {-� , I 5 I Bortno N Baring Pit Ground surface eiay. 2Pt Depth to 1itn�inl�faetor'LZ.tn i Sou tiatlon t Redox i Domfner1tC01or I Descrip:ton Texture i MCWM i Consistence ; Gr. Sz Sh. Boundary Roots OPD/Fls 'fif1RI Norf an DepQr in Munetil Ou. Az. Conte faiar s ft J 9orirg 711, Boring S ] P5 i =0ZJOefolI'JLM.AF e®oM r � . DepM to limiting factor _.+,tn. i Sol[ Aot116eulCn Ra Hadmn Depth DrunlnentCofor i RedozCescrlpron Texture Structure Cansisteres Boundary Root t GPDfFt' In. ; ManeeU Qu, Az. Cant Gr. Sz. St. ! •Ellli4 t f l I i Boring# Pit Groundsurfeoea!ev.__R 7epthtpllmaingfaetor_1n Sofl AopUniton Rate Nortron Depth l Dominant Color 1, Redox Descriptic' Tweura Structure Consistence Boundary ; Roots OPDm` in. i Munsell 4a. Az. Cont. Color Gr. Sz. Sh. 'r 1 '8tflfg i EMUSntl/'t = SOD, > 3D 5 220 mWL and TSS > 50 s f 50 rrgt ' EhluSnt#2 = BOO, > 30 5 220 mgR and TSS > 30 5 f b0 MVL 9Y-0 s!\.Q- e- /o5- ;?Col -sr�.C� y -- e-r,4�nv, vo M . VVM Heidt Soil Testing W3503 Hemlock Road Mondovi, WI 54755 (715) 579-9584 ?0 z - 4f4c,enzA's -- couN-nr NO. 644781 STATE SANITARY PERMIT LLLKA�FE E571 NS AL P14FAff OWNER )26'leh /L*W// PLUMBER 4`)4ke LIC.# ZZ�J TOWN OF ' SEC,T?Z)N, R_Ll__E AND/OR LOT_BLOCK — G / Z/ SUBDIVISION CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and 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. (f) 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 the permit, please contact the county authority. AUT OR14ED ISSUING OFFICER -DATE Z THIS PERMIT EXPIRES S 8 Z.S UNLESS RENEWED BEfOlk THAT DATE POST N PLAINVIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)