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HomeMy WebLinkAbout008-1055-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 563803 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: Gunderson, Blair Eau Galle, Town of 008-1055-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 16 /0 ! GAT 18.28.16.276B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. f Septic ` ~ Benchmark l,J ll z 15a 3.75 X03. /.b6 Dosing ( : ► 766 Alt. BM Cow„b a 1A I 0~'; I ~f• • $ Bldg. Sewer <'4 e s 11,15 l Z . (p Holding St/Ht Inlet #TZ I/ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ~ Dt Bottom 7160 46 zY rG.341 17, Dosing z Header/Man. 7/6 145 '1 7 Aeration Dist. Pipe 3 97 $`j, A79 Holding Bot. System ~ g9~ PUMP/SIPHON INFORMATION Final Grade Manufacturer JO Demand St Coverer q oul~ GPM / 7 "y 7 Model Number /`j' n 65 Ile, 97. TDH f~ Friction Loss System Head T~Ft . 164, -5 1 & a . lQ Forcemain Length / Dist. to Well Jb~S SOIL ABSORPTION SYSTEM /a•94 BEDITRENCH Width A Length No. Of Tlenc PIT DIMES No. Of Pits Inside Dia. Liquid Dept DIMENSIONS to 4/7L SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of Sy tem: / CHAMBER OR w/1 a 7/6676 UNIT Model Number: DISTRIBUTION SYSTEM C! 44 Header/Manifolyo i( Distribution (%J j t x Hole Size / x Hole Spacing r Vent Air Intake Pipe(s) /.Is Length 5.4 Dia Length S/ 7 Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded Iched Bed/Trench Center \ Bed/Trench Edges Topsoil Yes ®No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ! 9 / r3 nspection #2: / / Location: 320 220TH ST Baldwin, WI 5/40002 (SE 1/4 SE 11//4 118 T28N R16W) NA Lo~tr1 L pjp~ Parcel o: 18.28.16.276B 1.) Alt BM Description = U rr`~ c~,~po0 2.) Bldg sewer length = - amount of cover P(p~ CP aw CQ_ Plan revision Required? ❑ Yes No /Tj L5_ Use other side for additional information. 1 (!/I uL=VL ~I~/~ Date Insepcto s Signat a Cert. No. SBD-6710 (R.3/97) S¢~9 e,0 ::e u3 • County Industry Services Division S 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P.O. Box 7162 :?r•; >:!4r Madison, WI 53707-7162 `d Sanitary Pe pplication Z State TransactionNumbger (g D In accordance with SPS 383.21(2), Wis. A C s of this form to the appropriate governmen alvZ SC / is required prior to obtaining a sanitary p plicati forms for state-owned PO re ubmitted to Project Address (if different than mailing address) the Department of Safety and Profes ' al ' s. Perpuff mformation you provide may dr~e¢yg purposes in accordance with the Z. IN, s. 1 m , Stats. << 7 ~ C~` I. Application Information - P e t All htf afion ST dp 32 J Property Owner's Name ' COUryry Parcel # 1d r h der a vo 8 --409 -rya o Property Owner's Mailing Address Property Location 3 ao d ~-r,~ Govt. Lot 2-7 City, State Zip Code Phone Number ,/a d , f f~ /a, Section -BaA tlk w i h I 400 (circle one "52 -p - T ~S N; R /!p E or TJ II. Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling - Number of Bedroo 4 Subdivision Name Block # ❑ Public/Commercial -Describe Use ~ ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of .Town of ~C~k Ggrl i ~ ' l Cleo I ~ (q.w,( O✓ V° Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ❑ New System ~ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued / Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) V ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil A Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Trea nt Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required Dispersal Area Proposed System Elevation moo , a fv4~U o~° ~oZ gq . /3 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks D ~ /~k- 62 U n W U G Septic or Holding Tank ~ 15e 41? Jr0 l "e- S C-_ r Dosing Chamber 7 C-50 11601 / ~fe- SF:r X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum 's Signature MP/MPRS Number Business Phone Number a 9~ -7.--? :Z'7 S' Plumber's Address (Street, City, State, Zip Code) / t/ /V 7&417 Hai Y has' S rin U~~f` e~l W. ~ C7l0 VIII oun /De artment Use Onl Approved rsapprove Permit Fee Date I sued Issuing A Signature rven Reason for Denial $ ' IX. Contli3rli~fTrEflitA M Measons fof Disapproval 3 / ~f>4oti~j r r t 1'. Septic tank, effluent filter and dispersal cell must all the services /•inair>tatTred as per management plan provided by plutllCit. 2. M, se*WA requirements must be maintik6d n per applieable Code t ordinances. (ll a ~jPZ?.y1 Pa cr, (~a,~t ~6► Attach to complete plans for the system and submit to the Coun o Cry paper not less than 812 x 11 inches in size SBD-6398 (R0313) Rot P(a-\ P I C., .1 CW I/1 tr IV I,,.. l r•. ( U h 2(rSOc~ f.l K e ci~~~r-: .~cv►v► <-e N~ges~ 5C-1Y o51= sec, 18N A k. y c 7, 7.3 Eleu. 7. -y 3 9,573 I ~ `I. tiro oSec~', r~5-~ CreLl 9Sa G~/, p~ Sc ~-r ,Des 7✓.,k sus- i M. (01,37 `role ~ We It ~ \ I To 6.,- F,Ite d tj,M , I oo, a ~ SoI{tsu~. e r, FX, pIAS Q si eM~ 9 y /O'^A `e- !`rVt ~m YTARTjf DIVISION OF INDUSTRY SERVICES x`19 ~TO~ 3824 N CREEKSIDE LA HOLMEN WI 54636 Contact Through Relay 3 www.dsps.wi.gov/sb/ ~Z www.wisconsin.gov O tiL A ~ ~o55roN~ls~ Scott Walker, Governor Dave Ross, Secretary June 12, 2013 CUST ID No. 220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/12/2015 Identification Numbers Transaction ID No. 2256962 Site ID No. 791616 SITE: Blair Gunderson Please refer to both identification numbers, 320 220TH Street above, in all correspondence with the agency. Town of Eau Galle St Croix County SETA, SETA, S18, T28N, R16W FOR: Description: Mound / Four Bedroom / Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1432414 Maintenance required; Replacement system; 600 GPD Flow rate; 14 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter 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: Reminders This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. COND111 o Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. P PPR Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and OEpT OF S dispersal are prohibited. pROFESF 1N The pump chosen for the design is at the limits of its capacity. If the total dynamic head is calculated to be VNIS10% higher, at the time of construction, a pump that meets or exceeds the system flow will need to be installed. ® The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c 5EE co ® 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. f BENNIE W HELGESON Page 2 6/12/2013 ® 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. Stat Q SPS 383.22(7 A copy of the approved plans specifications and this letter shall be on site during construction and open to inspection by authorized representatives of the Department which may include local inspectors Owner Responsibilities: SPS 383.52 Responsibilities. 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. SPS 383.54(1). o SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4) shall be considered a human health hazard. ® SPS 383.55 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. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/instal lation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, _ Fee Required $ 250.00 112 Fee Received $ 250.00 4 Balance Due $ 0.00 4 Charles L Bratz POWTS Reviewer II , Integrated Services WiSMART code: 7633 (608)789-7893 , 7:45 am - 4:30 pm Monday - Friday charles.bratz@wisconsin.gov _ r t v,~ 3 DECEIVED JUN T 3 2013 INDEX SHEET INDUSTRY SE-FiViCES PROPERTY OWNER: BLAIR GUNDERSON 320 220TH STREET BALDWIN WI 54002 PROJECT NAME: BLAIR GUNDERSON PROJECT LOCATION: SE'/4 , SE'/4 , S 18, T 28 N, R 16W MUNICIPALITY: TOWN OF EAU GALLE COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N. 01 /01) MOUND COMPONENT MANUAL VERSION 2.0" SBD- 10691-P (N.01/01) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: W1250/750-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 ~►LL.Y Page 9: Payment Voucher ,VED -TETY AND Name: Bennie Helgeson Sign d: f AL SERVICERV' Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 Date: 05-30-2013 RESPONDM Rot p(Qv P Cx.~ 1/l ~e Ir (Q l l3 (.l v~ G~V'SOv~ - Jar arf - L 1 h e- 1, J_AeRFE s fc©~~-~--7 Eexa C-a-lie'rb. ns k,*P 5 C- o-(- 5.: -4 sec., 18'm R (A ry Ek., 99 ~ ~>eu. 97.3 ~ Cleo, 95:3 Q 1 a I i a I ~ o 0 I I ~ Sc,,,,~~p~-c c f ,DasG 7R•► /C WELL p ~vrH, Pply!ak S'~s- ~ ~s B ~ F lftr- h r3 M. (01137 Too use It FA, $o{{ou~. o ~ ~X' in9 r I V lj )Jj E±_J \ ✓ l G~1 i(` C '7 r N A lp i' Se% Y, 1 Pa ge 0 Synthetic Covering ASTM (1 33 Distribution Pipe Medium Sand kle o poor 95- Topsoil G Sy % ku 3 J t E N ,I , D • Eleu g7~ S~ °/e Slope. CUOf z= 2 i2 (Force Main Plowed Aggregate From Pump Layer D /.$3 Ft. Cross Section Of A Mound E .39 Ft. F• Ft. G , S Ft. Signed: A . LDFt. M /,-0 Ft. B 6 O Ft. License Number: K Z1, Y Ft. Date: L 83.6 Ft. J V.D Ft. T 3. Ft. WFt. Observation Pipe 8 K JL 0) PUC- '~.Distribution 2 2 2 Pipe Aggregate I Observation Pipe 86t6al 74keA- Plan View Of Mound r K Perforated Pipe Detail Cleanout Access Threaded Cleanout End V1.w PO(Iofoif° j PVC Pip( No"" • End Manifold Holes Located. on Bottom R Are. Equally Spaced i Force Main From Pump Y~ S First Hole Next to Manifold P ~ Cleanouts Distribution Pine Lavout P R 7' S x ~i Y Hole Diameter Inch Lateral " Inch (es) Signed: Manifold " Inches Force Main Inches License Number: Date: Invert Elevation , to 3 Holes Per Lateral 3 7 Number of Laterals Total Holes / Q~ 1 yr ; r k~ e.~ Sor Page_!f Of_l_ SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS v" ftX..VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF > 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED _ FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER 61-6cnn r- J W1 PADLOCK 6 ~G~C _ ----WARNING LABEL lie MIN. 18" IN. ' %.X. b. y i~~8 MIN• INLET WATER TIGHT SEALS GAS- _A SEALT /APPROVED FILTER , JOINTS WITH APPROVED =O` - ALM APPROVED PIP,f PIPE 3', . B ON 3' ONTO ONTO SOLID So, 5011 SOIL PUMP OFF ELEV. .OFT. OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE ._TotZL I r a.1!L Lg Ldp ~ TANK MANUFACTURER: l~UIcse-r /4v X S 80 Gci1. TANK SIZES: SEPTIC 10SO GAL. DOSE VOLUME INCLUDING DOSE `76"O GAL. Q. 7g&/, -PFLOWBACK: 89', 79 GAL. ALARM MANUFACTURER: -SXE RV, o,,,.t~pci5 CAPACITIES: A : o~S INCHES = GAL. MODEL NUMBER: S'e.rtes D " SWITCH TYPE: M.echan F/aaf B = 2 INCHES = 3a• ~9-GAL. PUMP MANUFACTURER: c, cis C = 7 INCHES = / GAL. _ MODEL NUMBER SWITCH TYPE: c -moo-- D = /3 INCHES = 6~ y sb GAL. REQUIRED DISCHARGE RATE jl,a GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 11,43 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . S' FEET + _ FEET FORCEMAIN X 3.7 FT/100 FT. FRICTION FACTOR a.PP FEET TOTAL DYNAMIC HEAD = FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID D EP'I`A- tt " ~/Paste- See Ta.~ ~c ~pec ; SIGNED: LICENSE NUMBER: DATE: 1/88 a z 0 rLn-q $ j o z C:= n a 'A Wj~ U uQi LLI V I ~E~Hf f' Z WW J l.! U') Liz O FO ~ d (n ! Fa N ~ 1 00 w m i Q ~p w~ ~0+► N Od\ o- J= z z I~,-~~7I o_ I o 0 a o WW aU JJ Q 0 0 Nam N 0 a- ^m °Q _ja ) mm ? ~ °o v o ~W o o O a =ooo~~~, 1 wwcn 0)N _ FLr'Jl _ Q N(A N o=I o rn N m N Iri co W 04 to F- n n O \MIOWCO~rozW.- -iwU wvN N~ ^ 3 Y F- z c1i_ip~=tF= 3p= 0Mm 4 0 U N zJF-WZ20 050 N N~ 0. w OQOOaWWOWa- Ds Q p O D N3mc~Q~rc~ zQ~.. Q z o z LLJ 1-- c~ J J O Q o z z J O "£S F- W Z 4N N t , 1 j 1 1 I .i 1 ~ 1 I I , I• I , L-LI 1 I N •r I V/ N 1 Z "9 i i "L5 \k 1 ~ , i i I I F- D 0 "99 "og "99 MOODEL 3871 .v - Submersible Effluent Pump r1 j E t T I .a j d e er GOU METERS FEET e MODEL' 3871 2S 20 x Y - EP05 0 3 10 2 s . ~POr 0 00 10 20 30' 40 60 US 0?M 0 2 4 8 0 10 l2' .In1Ai/.. , CAPACITY Pump-Specifications. Features and Benefits Vie end 1/2 HP • EP04 impeller- semi-open design Up to 60 GPM . with pump out vanes.to protect Maximum head to 32' mechanical.seal. Discharge size 11/2" NPT • EP05 impeller enclosed design Solids: % 'maximum for improved performance. Motor •Rugged glass-filled.thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase: 115V resistance. Materials of Construction 'Cast iron motor housing for Cast iron efficient heat trahsfer, strength, Thermoplastic and durability. Stainless steel *Corrosion resistant threaded stainless steel shaft. *Available for automatic and manual operation. • CSA listed models available. operation and feature stainless steel hardware. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 9_ FiLIW, INFORMATION I . SYSTEM Sf?EGIFIDATIONS . [0 wh r BLATR GUNt71;R5U1V Perrr.it # Tank-Manufacturer: .1.►ieSe ~r O NA LJ Septic p Dose_.:p Holding Volume: 1250 (gal) DESIGN PA ETER3 Tank Manufaoturer NA Ntrmbei of Bedrooms 4 p NA, ❑ Septic Dose O Holding Wolume: 750 Number of Public facility Units: dsaq ER NA Vertical Distance Tank Bottom (a) to Service Pad: (n) Estimated (average) Flow : 400 00 (gal/day) Horizontal Distance Tank(s) to Service Pad: (h) Design (peak) Flow = (estimated x 1.5): 6UU (gal/day) Specific servicing mechanics must be provided if vertical is >IS feet or If horizontal is > 15o feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gsl/daye) , . Effluent Filter Manufacturers Poly lok Standard (Domestic) ihfluehVEffiuerit onthly average Effluent Filter Model: 1=] NA Fats, Oil 8-Grease. (FOG) s30 mglL Pol lok 525 Biochemical O ix Demand, (BODE) s220 mg/L• 0 NA Pump Manufacturer: Gould's 7`Dtai Sus ?t a~alids. Ss'. -:srso L . -Porno Medel•: . NA High Strength Influent/Effluent Mogthl aver"e ' y g Pretreatment: Unit (FOG) >30 mg/t' . Manufacturer. {BODs) >220 mg AL 0 NA SS) >150 m A ❑ Mechanical Aeration 0 Peat-Filter Q NA Pretreated Effluent: Monthly average ID Disinfection D Weiland :1 (130%) s30 mg/L San 'Gravel Filter ❑ Other. (TSS) 06 mg/L C1 NA Soil Absorption System . Fecal Collform. (geometric mean Sue ' ❑ In-Ground ra Maximum Effluent Particle Size t O At-Grade vity) O In-6round (pressurq). p NA in ilia. [3 NA 11 Mound Other: ❑.Drip-Un:e ' t] Other: O NA Other: • ❑ NA MAINTENANCE $GHEDULE Service Event Service Frequency Pump out contents of tank(s). When combined sludge and scum equals one-third of tank volume O When the high water alarm is activated Inspect condition of tank(s) AtJeast once every; Z O. month(s) year(s) fMaximunt 1 years) p NA Inspect dispersal cell(s) At least once every: 2 month(s) C$year{s). (Maximum 3.years) p NA Clean effluent filter At least once every: 1 month(s) ~ Y88Ks) [3 NA Inspect pump, pump controls & alarm At least once every: 13 " O month(s) t'year(s) O NA Flush laterals and pressure test _ At least once every: ; 3 mon`ahls) CI ar Other: NA Ai least once every: Y onth(s) t] ;NA Other: C7 ea s D NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by en individuat carrying one. of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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.grdund 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 treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing; Operator (pumper) and disposed of In accordance with chapter NR 113, Wisconsin Administrative Code: All. other services, Including but not, limited tc the servicing of effluent filters, mechanical ©l',Pt0s8urized -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 30 days of completion of any service event. ' GMW-005 (02/05) s Page is of y START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may Impede the treatment process'and/or damage-the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will bedischarged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent. and. damage W the system. To avoid this situation have'the contents of the pump tank removed by a Septage Servicing Operator (pumper) priorto•rdstoring power tothe pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil- absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption .area. Reduction or elimination of the following from the wastewater, stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipe8, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drgIn (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, *and water softener brine. discharge. _ABANDONMENT . > When the POWTS fails and/or Is permanently taken out of service the following steps shall be taken to:insu.re thatithe system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin AdniinistratiVe.6. odd.': • All piping to tanks, pits and other soil absorption systems 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. (pumper). • 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 falls 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 and`site evaluation to establish a suitable replacement area. 'Replacem'ent systems must comply with the rules In effect at the time of their permit issuance. .p A suitable replacement area is not available due to setback and/or soil' limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. O The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soli and site.evaluation must be performed to locate a suitable replacement area. If no •eplac ement area Is available a holding tank maybe installed.as a last resort to replace the failed POWTS. f] 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISON4US GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE, NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY kSSum EgCA rn RESCUE FROM THEINTERiOR OF ACTANK MAY NOT BE POSSIBLE: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS-MAINTAINER. Name Bennie Name johnson Sanitation Phone 715/772-3278 Phone 715/273-5811 SEPTAGE SERVICING OPERATOR PUMPER- L CAL REGULATORY AUTHORITY Name Johnson Sanitation Name St. Croix County Zoning, Phone 615.'273•-5811 Phone 715/366-4680 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(l),(2) & (3), Wisconsin Administrative Code. a ~l PC, STATE OF WISCONSIN j . << 5a, Department of Safety and Professional Services sPS Fiscal Plans PO Box 8602 Madison WI F 53708-8602 Govemor Scott Walker Secretary Dave Ross Payment Voucher If you are requesting to be invoiced for your plan review, DO NOT use this voucher form. Transaction ID: (Leave blank if this review has not been pre-scheduled) Check # 12269 Dollar Amount: 250.00 Payer Name Helgeson Enterprises (Individual or Company name as printed on first line of check) Payer Address N7649 Hwy 128 (As printed on check) Payer City Spring Valley. State WI Zip Code54767 Phone 715/772-3278 Plan Submitter Name Benni P HP1 geGon (If different from Payer) 1. Mail your check (payable to Industry Services Division) and this completed form to: DSPS Fisca[,Pians PO Box 8602 Madison W1 53708-8602 2. Send a copy of this completed payment voucher form along with your plan submittal documents to the office that you select below. Plans submitted to: (circle or check one of the offices) Madison ❑ Hayward ❑ LaCrosse/Holmen ® Green Bay ❑ Waukesha ❑ Madison Hayward LaCrosse/Holmen Green Bay Waukesha 1400 E Washington Ave 10541 N Ranch Rd 3824 N Creekside La 2331 San Luis PI 141 NW Barstow St 53703 Hayward Wt Holman WI 54636 Green Bay, WI 4t' Floor PO Box 7162 54843 54304 Waukesha WI Madison WI 53707-7162 53188-3789 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND / OWNERSHIP CERTIFICATION FORM Owner/Buyer 46! e i IrO r.) Vc-do- C t4yiac - rS oy.: Mailing Address 3 _qG '-?'a3 &rf i l y S-Y 00 a Property Address 5 C~ e A ; (Verification required from Planning & Zoning Department for new construction.) City/State bmA L'-' h h3 j- Parcel Identification Number yd $ - fG S5 IG -6v n LEGAL DESCRIPTION Property Location 3L- % % , Sec. , T ~FZ N R It, W, Town of Subdivision A//A - Lot # - Certified Survey Map # -7 y 3 ci Volume , Page # "41 Warranty Deed # ~l ~ / S✓ Volume 7 S- I , Page # Spec house ❑ yes X no Lot lines identifiable )k yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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. Uwe 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 dee recorded in Register of Deeds Office. Number of bedrooms -4 1A 97 1,3 SI NATURE OF APPLICANT(S) S DATE E ***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. 08/05) 9 0 FILED N OV 2 ,11981 co MmI a eo> s 1I,~ at D"ft 3'74 30 . o .°~~1'• ti CERTIFIED SMIEY MAP $ THOMAS SI: II1DN Part of the Southeast 1/4 of the Southeast 1/4 of Section 18, Township 28 North, Range 16 West, Town of Eau Galle, St. Croix County, 'Wisconsin., o Indicates 1" x 24" Iran pipe weighing 1.13 lbs./lin. ft. set E 1/4 COR. SEC. 16,T28N. R 16W (COUNTY N LINE SE 1/4 SE 1/4 o SURVEYORS MON.) G' UNPLATTED LANDS M R! W x 1 3. 1 3 $ Bd• 588.90 1.- aso dom. 33.06• I E COR S E 1!4 S E 1 /4 ti 4 a ~ ODD `g. w 111 o g3 O O O O - ~ W DO a SHED 1 E LINE S£ 1/4 0 l ^ s is: 1.- 2 owl >t ~ q = YtJ ' J •IS` 0 W 2 ~ ~ p0 Lu SHED t- O ~ ( I ar R LOT 1 = 6.930 ACRES OJ O w I - 369 z ~j F ® t ~q NET = 8.406676 ACRES 10 p~ 66' TOWN ROAD ~ ~ ~i .p N It 366,247 SO- FT. l•_ - O 1- 0 SCALE 1"= 200' Z Op.. APPROVED D " `~l,W}rillitpl}H/IIJJJJJ y A OS • SG~N • °a 9A 803.39• SSo ' T 2 9 1989 yes ~`'y N 6$•09'22"W JAMESL 336-43 - -7f y 1j3 ST. CstQiX Cv~:+i Y z MURPHY CO vJ.Idcs ruarNws S- 1 0 4 2 F~ ` w AM ZONING courrES RIVER FALLS, UNPLATTED LANDS WISC- di ~ip'•+...__..•-''J4~.~~ SE COR. SEC. 16, T26 N, '4'o' *lei 1 ilLA. T SURVEYORS "ON.1 D7SCRIPTION That certain p~ivicel of land located in the Southeast 1/4 of the Southeast 1/4 of Section 1R_, Township 28 North, Range 16 'West, Town of Eau Galle, St. Croix County, Wisconsin, more fully described as follows; Commencing at the East 1/4 corner of said Section 18, thence S 1° 001 0011 W (assumed bearing along the East line of the Southeast 1/4 of said Section 18) a distance of 1315.68' to the POINT OP BOGINI-UNG of the parcel to be herein described; thence continue S 10 001 00" W 715.941 on said line; thence N 46° 091 2211 W 536.431; thence '1 000 13' 161/ W 719.87; thence S 85° 50' 41" E (on the North line of the Southeast 1/4 of the Southeast 1/4 of said Section 16) a distance of ;-51.95.• to the POINT OF BEGINNING, containing 8.950 acres, more or less, being subject to easement over the 'asterly 331 thereof for Town Road purposes; also being subject to easements of record. State of Wisconsin) County of Pierce) I, James L. :4zrphy, Registered Land Surveyor, do hereby certify that by direction of the Owner, Thomas Simmor:, I have surveyed end divided the lands shown hereon in accordance with official records, Chapter 236 of 'w1sconain Statutes and the Ordinances of St. Croix County; and that the above map and description are a -trLie////~~~~and correct representation thereof. Dated: 14 September 1981 Vol. &_Page 1121 1 Certified Survey baps Jams L. Mavpbyr Jt. Croix County, Wisconsin Registered Land Surveyor - volume 4 Page 1121 t`- _ Y 17t1 {j THIS "ACE RESf RVEO FOR Rcc-'.v DATA OOCUMHNT NO. jI WARRANTY DEED i jiSTATE BAY. OF WISCONSIN FORM 2-1982 ii j` it M "A = it RE<515T ERS C7Er'iC.,C --'Thomas A. Simmon and Nancy J. Simmon, ST. CROIX Co., WI& hus..................... aran ife, as joint tenanis Rec"d. for Record 26 t h e _ !>QY Qt s 7 IF V_ r a (:utl[]er~.On aiiCl ':ter:. t 1 :k~ A ex Conveys and , Irua-inii ~..i Lu _...,-r...-.... . a ......._..J... _C.unsiex's.ar_..... us_band.. an.d..e?l.ze.,. a~------------ +i - 1 s:Iar~rixs~.r_ship---Irfazi.tal ..p.rs~p~r.ky li . . - ij . - j'ReTURn ro l; ! i. iI tii0 Patate in Ct Cro>X County, State of Wisconsin: Tax Parcel No: Part of Southeast Quarter or SoutheassL Quarter (,SV° - SE11) of Section Eighteen (18), 'T'ownship Twenty-eight North (T18N), Range Sixteen West (R16W), St. Croix County, Wisconsin described as as follows: Lot 1 of Certified Survey Map filed November 2, i1 1 li 1981-, in vol. 4, Page 1121, Doc. No. 37423(). 1 i it H TNSF'~R II S S& ~f u jj i~ 1. This 1 S homestead property. f (is) (MANOW i~ Exception to warranties: easements and restrictions of record II 1 Dated this day of Au nt.. , 19. 6 'I ° -.........._(SEAL) SEAL) it « _Tl?o . mas...A .r...S,immon it (SEAT') ! ? .(SEAL) II * ; iVartc ._•J.,.•,~_ilru-nUn AUTHENTICATION ACKNOWLEDGMENT ~l ~l Signature(s) STATE OF WISCONSIN ji as. C'r O.l.X........... County. _ authenticated this day of 19....__ Personally came before me this P II ...........day of I , 10.38 the above named If L~ - ml r,a c a nd Nancy J . C rn rn r+n TITLE: MEMBER STATE BAR OF WISCONSIN It (If not, authorized by § 706-06, Wis. Stats,) " ' w to nra k to be the pcr on Windeteettted the i forego' g i n en ~n ovule samD 1 THIS INSTRUMENT WAS DRAFTED BY ij Thomas A. McCormack ^ j a.._- '------L€: zo~~/-.. Stnrl~y- _ ~•ir~ in t win, WT 54002 No*_a:v Public .._St,. craj tr i~ Ipn f (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If nu1~ 'sy'~.p~ r ;4- nct necessary.) - - date. I 'Names of V-- PfRmng in any Capa_ity should be Leven - pn.~t^d Frio.r ch^ir rimnacu re». WARRAZITT nx:=D STATE BAR OF WISCONSi'S N'1. •nn.in i..-rsl ltln 1 FARM NO. 2- I'J.42 .n. Wisconsin Departmdnt of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings r `'G G in accordance with Comm 85, Wis. Adm. Code G~~ County S?: C /eCS / K Attach complete site on paper no ss than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical aq izontal reference point (BM), direction and Parcel I.D. percent slope, scale or;! n , north arrow, and location and dis 4c riease qo~~infotmation. ~ Re 7ya Date Personal information you proVQ18:; Rd for secondary purposes (Privacy La 1 (m)). / I Property Owner Property Location /dF / 1~` V u"i C~ hSb Govt. Lot S E 114-SP- 1 /4 S g T Q N R 6 E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2AD City State Zip Code Phone Number ❑ City ❑ Village gg'Town Nearest Road wr syoO ( 15-)A►6g4l - y 4~ta i ~o s ❑ New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate w GPD eRRepiacement ❑ Public or commercial - Describe: Parent material 4neSS 6 0 T I t Flood Plain elevation if applicable ft. General comments GIs c 1 3 'San cl ct v1,(e,- u c.- and recommendations: F 7 Ca.L1<oct~ 9 7. moulvb Boring # a B~g Ly' 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/fl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 o - wt 1 t t I 3 q o faD .s ~L D LA-) sb i`n Lv ' y .~=q /0'1/Q, ht~D 7.S d /Oy C of 3 Boring # Boring F51 U Pit 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/fll in. Munsell Qu. Sz. Cont. Color / Gr.`Sz. Sjh-. *Eff#1 *Eff#2 6 -7 / 02 7 ~fc t~►l V' (-LA.) irn CO '8 -/7 s~/ bh 4; tI ~d f- /7--2S-10-1P- ~1,P 75-YK 66L- rr m 1co , y C- t? Lj S-S b`i2 + SL if Io © o * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print r Signature CST Number Address ( Date Ev nation Conducted Telephone Number N74 9 ~ ffw 1~ 0nt UcJ U31. $_/e 13 7/5- 77P ~3~7e rs Y'.. Property Owner ~~LLri' (TL.tf/1G~t°hS ~ Parcel lD# Page of 3 Boring # ❑ Boring p Ground surface ele4, 2 IL Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Des iption Texture Structure Consistence Boundary Roots GPD/f' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 \f 9 v►1 t r v . Co F1 o .3 a lob CL v►~s - rl ~,vf b (Z 3P 7!r2 4-Lovk- C L ( Uc bk -2' .3 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/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # 1:1 E] Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = 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.07/00) Property Owner &&! f ~r~ vu ~~S p vl Parcel ID # Page A of 3 Fal Boring,# Boring 2 plt Ground surface elev. 95( to ft. Depth to limiting factor b - in. Soil Application Ram Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 rt ~-rof , ~3 G~-a loY CL Akksllcl 95 o_ 2 3o cL 1u~ dr tub .3 ❑ Boring # Boring Q pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 ❑ Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP QM In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 •Efr#2 • Effluent-#1 = BODE > 30 < 220 rng/L and TSS >30 < 150 mg/L ` Effluent #2 =.BOD6 < 30 mg/L and TSS < 30 mg& 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. ssD-8330 pe.mroo> 1 I Wisconsin Department ofComrrierce SOIL EVALUATION REPORT Page ( of -3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code p Courtly S T C /l 61 X Attach complete site plan on paper not less than 81R x 11 inches in size,. Plait. must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 00-- /UU - 5570 -00d Please,p►tnt ail Information. Revlewed by Date Personal information you provide may be.used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner -n Property Location /et7U~ l3u►'l ~1(ehSo Govt. Lot SE IIXSJ! 1/4 S fl? T Q N R ~b E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 3AD Sao-k S~, City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road LOI ' W r Syoo c. ) 68y - tau l - a6 S' ❑ New Construction Use: ❑ Residential / Number of bedrooms y Code derived design flow rate F._.. GPD eRReplacement ❑ Public or commercial - Describe: Parent material Guess B oer- 'Ti Flood Plain elevation if applicable ft. General comments GC$E~' /.Y3 ' ,stne/ ct4 ter cWes- ecl~ L o ^F ccA and recommendations: Oft C o n- fri c v,- 9 7. -7 M.~ ~ Sys~,ro~r ~.~ev, y9.~3 Ft~ Boring # ❑ B9 /Pit Ground surface elev. ~ ft. Depth to limiting factor- ~Y In. - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#l •Eff#2 - wt )1 0 a O Yle 3 y d 4F 15 .s -`~t .c L c 6bk .10 11CZ 3 S=y to ~lR r4-kD 7,s +/oy c sbk vvv it Boring # ring Pit Ground surface elev. 9-7-6 ft. Depth Ito I(miting factor in. Soil Iloation Rate Horizon Depth Dominant Color Redox }Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 -50 +-A IF 6-7 O-YP- l r f. o . (9g' -/7 Wlk 9q - S% n t~ lr cJ t i 41 ~ d 3 7%2 ~oyR XP 7.5Yg- $cL c ,r it) l , y • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Pri ~ S(gnature _ CST Number y~Vl'I f n Z)aaa a Address f f r Date E uation Conducted Telephone Number Z A ~ Flo" 'PICI- t 3 0 3 8.9 4aEs ,VPares~" 7ti Lln~ L~ J?~0~,~~ ro / o urr T" Sc~, /8 N R l4 t~ gk~. E/cu , b-lev It q9 ~ <ca 1 QI- _ I I C ~ ~ ER F~ p ~ Mouh d ~a 7e p 'I ~,Jooodr I UXLL \ Ex~s s~,~,~ T0.h k N1, l 4l . 3 7 ~ ~ `CoP m-(- we-it C)o ~X%s ~~5 136-(~"a of ousc 51j to , Ho vY+ ~ 3~o d - - c • o O Q r p u°9 v 00 4 0° V ` M Q N I M i ! 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