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HomeMy WebLinkAbout008-1048-40-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township Johnson, Ter Eau Galle, Town of ST BM Elev: Insp. BM Elev: BM Description: 1 .~ Co~,~~ ~g • 3 g M ~ C.ST !~ TANK INFORMATION TYPE MANUFACTURER ,~~ CAPACITY Septic v~ l~J ems--- / o do Dosing ff Q~• ~ / ©~!O (7 ~~ ~ F; ~ Pd f~, ~~S Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 7 /~/ 7 /Qp~ 4~ ~ `f'g Dosing ~ `~ ~ 7 /6C~ ~~' ~ ~ i Aeration Holding ~,. \ DAMP/CIPHC]N INFARMATI~N <.~ Manufacturer /~, ~c. ~>~ c43~ errand GPM Model Number ` (~ ~ ~ ' ~ ` Zcl, Z J TDH Lift iZ.z9 Friction Loss x•55 System Head 3•Z5 TDH Ft i ;a9 Forcemain Length ; 38 Dia. ~ Dist. to well y ~~ CAII AQCl1DDTI~lN1 CVCTFM ELEVATION DATA County: St. Croix Sanitary Permit No: 499123 0 State Plan ID No. Parcel Tax No. 008-1048-40-000 Section/Town/Range/Map No. 16.28.16.247A STATION BS HI FS ELEV. Benchmark i3d as io1.35 Bg • ~ Alt. M n Rio anti ~C :Si~;,n o,~., fi 2 ~5~. `l~ . 9'S Bldg. Sewer 9,7~ I SUHt Inlet /b . yo . 75 SUHt Outlet Dt Inlet ~ Dt Bottom ~ 5 L`l ~(m ` ~ Header/Man. -+ Dist. Pipe ~ ~ ~~• 3~ Bot. System 3 .~ ~ 7. ~ ~' Final Grade 7•~ fy.3S St Cover ~;1.~v._. C~ ~ ~-~ ~ ~~ , ~~ t/b~oJ~ 5.3~ BED/TRENCH Width ~ Length No. Of T the PIT DIMENSIONS No. Of Pits Inside Dia. pth Liquid De DIMENSIONS 3 ~ ~ `~ ~~; ` ~ ~ i SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer. INFORMATION / Type Of stem: ~ Ibp ~ l % 7 /~ ~ N& UNIT Model Number: a nIG•T~IO11Tlflt.l CVCTCIIA Header/Manifold Length~_ Dia Distribution J ~y Pipe(s) ~~ Z \ Length Dia Spacing x Hole Size ,j ~/4' x Hole Spacing `/ Z~ Ve-ntrt-o Air t1ntake -1--v~. `~..'~ c•~u nwro __ .,____..__ ~.._._...,, n..~.. .,., AAr.unrl flr Af_Rrarlu SvcTams Only Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center f ~ s Bed/Trench Edges ` Topsoil ~ ~ s "' No ~1'es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1 Location: 2372 30th Ave ue Baldwin, WI 54002 ( 1/4 SE 1/4 16 T28N R16W) NA Lot ~~e,~, e~ 5~,",. G~,~.;~~ d- 1.)Alt BM Description = ~ ~ ~ Q~,S a ~ 2.) Bldg sewer length = (p - amount of cover = ~ ~ 1 •~SJ~c,Jar•~ow UJ`~ ~f~1v+ U Plan revision Required? Yes , Use other side for additional information ~ No ~ ~ ~( _ _ ~-_. _ , _ --~-0.. ~ _ - Date I SBD-6710 (R.3/97) b / ~/ Ulf Inspection #2'. ~OW ~ Parcel No I t; ir3 t b ~t~ 7A ~~ J ld`6-~`-f ?~ Cert. No. Safety and Buildings Division County ,` 201 W. Washington Ave., P.O. Box 7162 St. CfOiX isconsin Madison, WI 53707 - 7162 Sanitary P 't Number (to be filled;n by Co.) (608)266-3151 /2~ Department of Commerce Sanitary Permit Application State Plan I.D. Number Trans. Id #1307432 In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(lXm) Project Address (if different than mailing address) I. Application Information-Please p ~ 23~'Z 3p~ 4V~~ RE / , Property Owner's Name Parcel # Lot # Block # ( l TERKY JUHNSUN UG 6 006 J - Property Owner's Mailing Address `, Propel cation 2372 3UTH AVENUE ST. CROIX COUNTY ~ SW SE Section 1 tJ '~< '~" City, State Zi Code a Number , ~ HALDWIN, WI 54002 715/634-3991 T 2$ N, R 16(circli one) II. Type of Building (check all that apply) / 1 ^+ 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name CSM Number Pubfic/Commereisl -Describe Use A ^ State Owned-Describe Use ^City QVillage t=lrownshipof Eau Galle III. Type of Permit: (Check only one bog on line A. Complete line B if applicable) ~ - d - 0 - t?o0 ~ 2 ~ ~/~{ A' Q New System ^ Replacement System g ep y ^ TreatmenUHoldin Tank R lacement Onl g y ^ Other Modification to Existin S stem B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner It - a IV. T e of POWTS S stem: Check all that a 1 X = i ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil 0 Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ~ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber 0 Drip Line ^ Gravel-less Pipe ^ Other (explain) ~ V. Dis ersal/1'reatment Area Information: ~ Design Flow (gpd) Design Soil Application R ate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 150 n X69 1.0 ci~Ol 150 1 SD 97.67 VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 1 ~~~ 1000 1 Wieser Concrete X Aerobic Treatment Unit Dosing Chamber 500 500 1 Wieser Concrete X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu er's Signature MP/MPRS Number Business Phone Number Bennie Helgeson 220292 715/772-3278 Plumber's Address (Street, City, State, Zrp Code) W1229 770th Avenue, Spring Valley, WI 54767 VIIL Coun /De artment Use Onl Approved ^ D' appro Sanitary Permit Fee (' Ludes Groundwater Date Issued Issuin Ag t Signature (N Stamps) Surcharge Fee) ~ _ ~~ er Reason for Denial LX. Conditions f A al SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / rr-eintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach complete plans (to the Couuty onty) fo the systeA~m^wonnnpapDer not le-s`s thae Ml/Z z 11 inches iu size SBD-6398 (R. 01/03) _~m. _n ~" ~' . ~ S• ~ ~ .~ehh~-e~.Sszo2 ~3~a~ Iv \!~-1-~-.----- VVV - Z,~s;~l~~-~ M, toac~o\ C'C~ c7l h~L'~ ,J 4c~L V Y! ~~~~y ~~ ~r o PpSe t~- ~o ~~ ~.`~ ~~ ~ ~~ ~•~U E ~e~,roovti ~ - 1 - - ., . ~~ ~`' ,~ N c I aF n py ~ '~, 1 ~ 4 a Q3 ~~ _.~ J1 ~ ' ~, ~~1- ~. ° B i "~ J C~ I~V/J ~~~ ISCc 1. ,~f;r~ Tit./ ~~s~ ~C~ ~t Ft l~~O~7 ~O~ ~S~S~ ~. ~~cr 'V ~~ C Sca I~ 1 = `f Cxc~r~t .A~ <~~a~~~, B.l~t. 84~ 3, _- -rte of ~/`~, S ~-P f~ 1 F ~~ \, S(~v-V Q~ ~ (~rtly~~- l --- 1 %7~ ~o o~ ~cf~~~-. ~ c ~J ~~ ~~0~1/ os~ c~ ~o ~c rt S ,~f-~ ~ ~'~ T~o E,A~ ~Au..E ±' ST. c..eZolX Go, 1 W a T; _ 3 ~ ~ ------- -- __ __ <. ~, pY Co i _c -~c commerce.wi.gov ^ ^ isconsin Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD . LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.wi. gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary August O1, 2006 CUST ID No. 220292 BENNIE W HELGESON HELGESON EXCAVATING W 1229 770TH AVE SPRING VALLEY WI 54767 ATTN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIItE5: 08/01/2008 Identification Nun3bers Transaction ID No. 1307432 SITE• 7e,rr ~ Site ID No. 716336 dertJohnson Please refer to both identification numbers, 30th Avenue above, in all cones ondence with the a enc.....:.. Town of Eau Galie St Croix County SW1/4, SE1/4, S16, T28N, R16W FOR: Description: Proposed One Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1089793 Maintenance required; 150 GPD Flow rate; 16 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual, SBD-10572=P (8.6/99), Pressure Distribution Component Manual, SBD=10573-P (8.6/99) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be located and constructed in accordance with the enclosed approved plans and with the component manual(s) referenced above. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular traffic or soil compaction in this area is prohibited. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the tanWfilter for maintenance purposes must be provided per Comm 84.25(7), Wis. Adm. Code • Comm 83.22(7) - A co~v of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. P.O.W.T.S. Conditionally A~PRO~~D DEPARTMENT Of COMMERCE BENNIE W HELGESON Owner Responsibilities: Page 2 8/1/2006 • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • Comm 83.52(1)(a) -The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or. component. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, /~~ erard M Swim POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon -Fri, 7:15 am - 4:00 pm j erry.swim@wisconsin.gov Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 ~ • ' INDEX SHEET PROPERTY OWNER: JON JOHNSON 2320 20TH AVENUE BALDWIN, WI 54002 PROJECT NAME: JON JOHNSON PROJECT LOCATION: SW 1/4, SE 1/4, S 16, T 28 N, R 16 W MUNICIPALITY: TOWN OF EAU GALLE COUNTY: ST. CROIX ~~cFo S ~~'~ 2 ~~~ qcF~~ ~ ~~~06 S~j<~C ~~S' DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section and Specifications Page 5: WLP1000/500-MR Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Signe Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: July 24, 2006 (VISION Ut JHttl 1 Mnu Du~~u~"~~r SEE CORRESP ENCE , ~ ' ~__ I _ ~s. ~ ~chtn~~e~~~.S_Q~1 ~3~a~ I~ ~~..~-.-~--~ IvVJ ~.M, l oCtoo ~~~ o~ ~ ~~et~ ~d~~`5 _k~s~~~y ~1~~ u Py ~~ 98~c __ _ __~- - - ~ 1 '~ 4a ' S~~~/ ~~ _/ . .-- ~'G. ~ - -- '~~ ? '~ -- Z~s;~la~~- ~ oB- ~, ,~ ' ~ ~oP©s~~, ~ot~ w~~~ ~,1~~~5 1,~-fl,~~o~,,, ~_ _ - l ~`, ~ ~~ ~.~ ' B.Nt. 88.3 f -f.,,p of ~' S fPc 1 P ~0.~ ~~ ~.i~~ - i 1J G1 . c ~ vF B3 -- - --- Sys _ -- J e~0~ S~c~ C<« 1. ~- ~ / ,~~s ~ TQ ~~ ~t t~ ~~1 I~ _ , S~I~ 1~~. ~~, Cxc~~t A5 :~~o~,,~v ~rc~DGSe~ ~O ~ rc S t f-e ~~~, sw, s~,s ~b,'t"2~t~t, K ~ 6W ~, ~ ~'~ T~o EAR fsA~.~E ~' ST: G.RolX Co. W ~~ ~r ~ __ _ -- --- ------- ~, 3~~ 4, ~I~ -~ Page o~ Of Cross Section Of A Mound Using A Trench For The Absorption Area F~.,,s~ fiF ~~ _. ~9, S ~ ~- Medium Sand Fill ~1 ° F - 6" Topsoil ~~~~ (ASTM C33) ~ D ~ 3 E ~" ~a o~_~.__ - -~'on~ou.!-~l~v. y~~i: Plowed Layer Trench Of '2" - 2~" Aggregate, 6" Below Pipe, Covered With D ~~107 Ft. t'~= Synthetic Fabric E / . g.2 Ft. ~ .. 5 Ft. F d gs Ft. H / Ft. Plan View Of ;found Using A Trench For The Absorption Area .~ " ~ol«. ~ a~~~l J Distribution Pipe ~!__.__-_ Observation Pipe B ~ K `Trench Of ~" - 2i" Aggregate _~~ 1 L A _ ~ fit. ~ I //~ 3 Ft. K U. Ft. B ~ C;, Ft, J ~_ Ft. L 7L~• Ft. W ~,~ ~.3 Ft. r~ ~~ ~ License Signed: Plumber: Date: Distribution Pipe Detail For ' ~~~ PVC Force 'lain }{oles Located On Bottom Are Equally Spaced 1 ~ '~~. o~ C ELI ~~E-~~noc~~ ~ ~ ~-s $ _ ----~~ /~ ~ . !' U ~X'1 ~ PVC Distribution Pipe ' C'~{<<"c!c~~ «•,tl~ P ~}'l r e= a c ~E r~ Ply: ~. * Last Hole Should Be Next To End Gap 4ap ~2~ FRoM END ~F Ge.!! ~~ ! First hole to be tz'~ from maai~e-ld end of bed P ~ Ft. Hole Diameter V Inch X ~~_ Inches Lateral Diameter --~-a Inch(es) ~i+~S~r" ~r~l~ - Force Main Diameter _~_ Inches ~,~~~' tc I ~-~-~o ~~c~~ ~ Of Holes/Pipe ~s ~~,r~e- M~~~ Invert Elevation Of Laterals ` ~•/~~~ Ft. Page ~? Of c~ Lateral Network d4.3/?~r ; ..j c,~ ~J d ~ -~ ~~ ---, Page ~ Of ~ SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS u" .P(J~,VENT PIPE 12" MIN. ABOVE GRADE E >_ 25' FROM DOOR, WINDOW OR FRESH AIR INTAKE I ~(~, y~ v 18" MI INLET APPROVED PIPE 3' ONTO SOLID SOIL 'aEATHERPR00F JUNCTION BOX WITH CONDUIT _. ~ r Zyu r.fl. ~~, ,~ ~ ~. ~ , `WATER TIGHT SEALS ~' TIGHT ~ ~, FILTER - A SEAL Po t~./o /~ S"~ S e i ~ A LM ~_ ~ O N p C PUMP OFF ELEV . ggC~~FT • ~ OFF D APPROVED h1ANHOLE COVER W / PADLOCK E WARNING LABEL ____4" MIN. ~~ 18 rniN• APPROVED JOINTS KITH APPROVED PIPE 3' ONTO SOLID SOIL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS _ _`Cs~.~~ r ~. ~ s r ~ t~ S. SEPTIC / DOSE ~ _Z, SJ~ _X_5 = 3 `r~ ~ CG~~I. TANK MANUFACTURER : (~leSe~- TANK SIZES : SEPTIC ~LC~X~ GAL . DOSE ~QQ_,_ GAL. ALARM MANUFACTURER: a ,~,~ '-"-~ MODEL NUMBER : b 1 W SWITCH TYPE: LsxL~ PUMP MANUFACTURER : Ou-(tt' MODEL NUMBER: F 3~~t~ SWITCH TYPE: /~•ercw~, '~ REQUIRED DISCHARGE RATE ~9, ~SGPM DOSE VOLUME INCLUDING ~.5~.1 ~f, -~FLOWBACK: y S ~ ~ a GAL. CAPACITIES: A = ~ I2~CHES = $ , 3~ GAL. g = 2 INCHES = 1R~GAL. C = g INCHES = 7~.7~ GAL. D = (~ INCHES = ~I g~_~a GAL. PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ~~' ~ 7 FEET + MINIMUM NETtiJORK SUPPLY PRESSURE ~ FEET + ~_ FEET FORCEMAIN X ~FT/100 FTOTALIDYNAMICAHFAD •_ / ~~ FEET WIDTH DIAMETER _ INTERNAL DIMENSIONS OF PUMP TANK: LIQUID 6I`Pf`FI- ~$1" '` ~, 25 ~I (3Q. ~. ~t'r l v~ c ~ i"`/~E'QS t' Sc ~ ~z ~. ~~ ;S~ar c . S ~2 -~' <,~ SIGNED: LICENSE NUMBER: DA•i E: ____ 1/88 ,~I aw-oos ooo~M~3~i~ gS~B-SZ~-008 ~ooz ~.avnNVr ~31vo OSL4S N1 'r~02f N301Vrv OIAMH Sn 9lLCM W MS~AB 3MV~a ~13N~UO~ ~~s~~m © ~31vd 'ON n 3a U Y ~ 1 f Sc r rJ S ^~ W 3 N Q I U ~ U ~ W O ~', 0 O Y ~K O' C w J Z w O _J O W ~ ~ J Q .. U^ to W O ~ U a w d~ ° ~ z J = ~a ~ ~ ~ ~ ° ~ oF va ~ w o zz_ ow ~ ~ Q J U \~ Q ° o o a as z zo ° O O m ~ w w c~ c~ ~ W 3 ~ ~ Ox m ~ ~ j~~J ~ J Q Li°N a WN _~ c0W ° W Z : \~~~ 0 I ~ ~ m~FW--- ~~ ~ ° M ~ U M J ~ ~ U ~J W ~ ? J !y W ~ N Z Zd' U N S 3 ~_•. J ~;_ = Z FO ~~ ° U OOH Q ° Y =~ Z UQOOQww°wow Qd a`to v ° z~a Q ~'_'; ~C~U~SJ~mJ~s ~ Z ~ I- J F- J Q O Q Z z z J U ~ 3 ~~ w_ 5~ O W J V ti a a U a ~ O (~ _ Q Lj d O ~" N N W U ~ ~ 1- W U W m H (/1 Q N O V Y Z c ~OOZ 'Nb'f 'n 3N ~yf1NdW OIld~S NW-OOS/OOOIM o\ w N o o ~ w ~- ~ '~' r U z ~,, ~ Z O W ~ ~. ~_ ~ ~ C ~ ~: ~~ w , ~ Z N U `t N I U z o ~ v N o Q "' N o ~ O W w X U7 w .. ~~ Y ~- Z ~ ~ Q U O 0 w Z o rv Q w ~ ~ `- O cn ~ c ~ U Z C S ..J Q Y Z .t ui 6V 3 w S °d w Q W _ J ' ^ Q V / ~ J r. ,~ ns~ Submersible Effluent Pump METERS FE 81 7 O = 6 U g 5 Q Z >- 4 D J H O 3 F- 2 0 . MODEL: 387 DS SIZE. 3/4 SOLI RPM:1550 . H P: 0.4 ~ 2 4 6 g 10 12 m'/h 0 CAPACITY ~, GOULDS PUMPS, INC. se~u F+w.s rFw ~ aae Elfectivo October, 1988 „___.r..._,_,,,. ,,,~~,~aicrtrYOCF1ANGEWRHOIffNOTICE PRWTE~WU.SA. '0 1 U '-" - POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 FILE INFORMATION Owner JON JOIiNSUN Permit Ar r~ ~' ~Z>? DESIQN PARAMETERS DNA Number of Bedrooms 1 Number of Public Facility Units ~ NA Estimated flow (average) al/da Design flow (peakl, (Estimated x 1.5) 1 - al/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average ` Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ~ NA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L [~ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size Ya in dia. O NA .Other: O NA 'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity lUUU al ^ NA Septic Tank Manufacwrer~~ieser Concrete ^ NA Effluent Filter ManufacturerpOlylok O NA Effluent Filtar Model pL 515 ^ NA Pump Tank Capacity SUU al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer Goulds Puftr ~s Inc ^ NA Pump Model 31371 EPU 411E ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland O Disinfection ^ Other: ~ NA Dispersal Cellls) O NA O In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Gracie (~ Mound ^ Drip-Line ^ Other: Other: O NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency ^ month(s) (Maximum 3 years) ^ NA Inspect condition of tankls) At least once every: 2 W earls) When combined sludg e and scum equals one-third (Y,) of tank volume ^ NA Pump out contents of tankls) Inspect dispersal celllsl At least once every: 2 ^monthlsl (Maximum 3 years) 4~ year(s) ^ NA ® monthlsl DNA Clean effluent filter At least once every: 13 ^yearls) ® monthls) O NA Inspect pump, pump controls & alarm At least once every: 13 ^ year(s) ver : 3 ^ month(s) ^ NA Flush laterals and pressure test y At least once e (~ year(s) ^ month(s) ^ NA Other: At least once every: ^yearls) Other: ^ NA MAINTENANCE 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 call(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 lY,l 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. GMW (4/01) , , , . OWNER : JON JOIINSON Page_U' _ol__ tS-- START UP AND OPERATION For new construction, prior to use of the PO W'fS check treatment tank(s) for the presouce of painting products or other Chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations arc detected have the contents ofthe tartk(s) removed by a scptage servicing operator prior to use. System startup shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above rtorrtta! 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 contcnis of the pump tattle removed by a Septage Servicing Operator prior to restoring power to tha effluent pump or contact a Plumber ar POWYS Maintainer to Assist in manually operating rho 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 otharwise 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 betaken to insure that the System is properly and safely abandoned in compliance with ch. 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 Septago 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: ^ 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 front 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 arcs 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. O 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 maybe installed as a last resort to replace the failed POWTS ~ Mound and a!-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 o$'ect 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 INSTALLER ' Name I Phone 715/772-3278 POWTS MAINTAINER Name •Phone 7I5/~73-5811 ' SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORYAUTHORlTY Name JUHN 0 A ~ Agency Phone 715/273-5811 Phone 715/386-4680 This Ooeum•M was drsMd by Uto ataHs of Iha Grsen lake, Marquette and Wausharo Counfy 2:on4tp and SankaUon aDOntd}a; Tali fiOaYtW1f ttaiili u» rrtirtYnum nauiramanta o! eh. Comm OJ.22(2)(b)(1)(d)6(Q and 8J.54(1), (216 (9), Wisconsin Adrrlktlilratlvi Coda. tJai of thli dopYpiQt tttoM ao< gwranta• tha parfortnsnu of U» POWYS. G~~u QR~GINAI. RECEIVED Wisconsin Department of ommerce OIL EVALUATION REPORT Page ~ of Division of Safety and Buil 'ngs q~ G 1 6 2006 in aWVraance wnn wnun ov, YVIS. /1u 111. IiVVG county ~ ~ C R ~ i k Attach complete site pla on pager pR@t:~ ~~/~ x 11 ches in size. Plan must . include, but not limited to vertical and horizontal reference int (BM), direction and parcel I.D. percent slope, scale or di , an location and distance to nearest road. Please print all information. R sewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~~ ~~ Property Owner ~,CrPt, O -'~ Soh Property Location ', Govt. Lot ,5 ~ 1 /4 5 E.1 /4 S ' ~p T ~ g N R~ (o E (o W Property~9wnet's Mailing Address .a-y ~ ~' Lot # Block # Subd. Name or CSM# ~ 320 ~ d f ~ hie-- . -- -- City State Zip Code Phone Number ^ City ^ Village own Nearest Road 1'~lcQwt~~ (~I S`/rx~~ ( )~8y-3491 ~'~. C~-Il~ o'+~. Avc. (New Construction Use: residential / Number of bedrooms ~ Code derived design flow rate 1~© GPD ^ Replacement ^ Public orcommercial -Describe: Parent material ~O~e 5 S O V e 6- ~~ ~ ~ Flood Plain elevation if applicaable /V fl. General commer>ts u 5 ~ , 3 ~ k SD ~ G 6L L w r `f-~, a D " Sa.-. ~Q l„~~C~.er c~-~/0{ ~- t `~ ~.- and recommendations: O-ti C o ~ ~-o w- 9~ , D ~p c.~v~ c~~ Sys ~-1,.,., ~'/e~ , 9 7. ~ 7 Boring Boring # Q p t Ground surface elev. / S ~ ft. Depth to limiting factor ~ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 / o- ~ .~ L s t~ I ~; ~ . ~ ~ 8 .5 ~ r ~'CL 1 L ~~ - ,~ r~ a Boring # ~ Boring !/ pipit Ground surface elev. 9~°' 7 ft. Depth to limiting factor _~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 _ •S ~' 3 s jv~~ Ernuent iF1 = tsc~u > 3U < zzo mgn_ and I ss >;w < ~ ou mgiL - tmuenr sz = esw < su mgn_ ana I ss < 3u mgn_ CST me (Please Print) ignature CST Number ` ~ 6~ 9~ ~ l'{ r ~~ Address Date Evaluation Conducted Telephone Number (,~1a~9 `77 D -f-~ ~(Je _ ~r~•~ ~a-~ ~e Lt.?~ ~-/ y_ o~ -7j~ - 3a7J c~e~ ~ So -. To (~ vts Property Owner r~rK JbhnS~ ParcellD# Page ~ of 3 3 Boring # ^ Bonng ~ p t Ground surtace elev. 9~ . ~ ft. Depth to limiting factor ~ I in• Soil A placation Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistenc Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~ b-Ib v 3 -- L ~. s c ~~~.~ ~~ 3 I -i - w, b ~~ ~~.~ ,~ 1. a ~ - ~ ~` . y ~` r b- ,.~ ~bk ~~ ~ t . ~ ~ • a ~ r~ _ v S 6s - ,y .~ ^ Boring ` Boring # ~~ 2 ~ ~ . I~ pit Ground surface elev. ' ft. Depth to limiting fa r in. Soil Ap lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Cons Boundary Roots GP D/fl~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~" l0 3 L ~ ~ cP ~ tW i u ~ g ~ SQL ~ II ~ 6 8 .s~K "`3~ s cL b ~ , ^ Boring Boring # Ground surtace elev. ft. Depth to limiting factor in. ^ Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fi= in. Munsell Qu. Sz. CoM. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 =BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 =BODE < 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.0'1/00) ~i o~ PI ~~, ~ t.c~ N ~e w '. e r ~' ~ ____J o ~ n s o,-~ ~/ ~9 9~ o .~ -,._ - - ~ - ~y~~_ S~op..~ ~~-9.~ 3 a f 3 fit- av5~ ~y ~ 7 ~ _ ~ _U S 1 /''= Div' < a ~. ~~ce~~ /-~s ~41ow~ 3 6~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AG is EEMENT AND OWNERSHIP CERTIFICATION l~ (ARM ~~ Owner/Buyer ___.o+~ ~d ~, h ~ o n __ Mailing Address a ~ ~,2 ~O~` pUC V~~t~ , ~~~ e~ t~ i vt , ~ ~ I S~UU 2 ~ Property Address ~3't a ~-~~' (Verification required from Planning & Zoning Departnu~:~°. (or new construction.) City/State~~ ~, ,.,,,` I~ 1 , Parcel Identification Numh, r tag- JO t(~- ~0 - Opp (Z y~) LEGAL DESCRIPTION Property Location ~~ `/ , SE '/a ,Sec. l ~a Subdivision Certified Survey Map # Lot # Volume ,Page # Warranty Deed # ~-- ~~/ / J ~ , Volu~~te ~pl "7 ,Page # ~~__. Spec house ^ yes I,~no Lot lines ictcntifiable~yes ^ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its preiii~~ture failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if t~~ .:ded, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the wastr .iiposal system. Owner maintenance responsibilities are specified in 3Comm. 83.52(1) and in Chapter 12 - St. Croix Coun~ ; Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoninz Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licenscc~ pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspecti~ ~~~ and pumping (if necessary), the septic tank is less than I/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maint~ii~i the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Departme~„ of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed <nld returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 1/we certify that all statements on this form are true to the best of my/our knowledge. I/we arn/aze the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms I G U E OF APPLI T(S) />~/~ DATE ***Any information that is misrepresented may result in the sanitary permit being rc •. , eked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds (~ ~ ice and a copy of the certified survey map if reference is made in the warranty deed. 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