HomeMy WebLinkAbout261-7000-17-001 17-1
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
563850 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: Village Township Parcel Tax No:
City of New Richmond, airport properties X City City of New Richmond 261-7000-17-001
CST BM Elev: Insp. B Elev: IBM Description: Section/Town/Range/Map No:
6c> &A G5 T- 24.31.18.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic -1;'- ~ Benchmark
J Lam. vv\ l dZ .
re. Alt. BM S471 97, Z$
Aeration Bldg. Sewer (P,3:9 '76-52-
Holding St/Ht Inlet
4.7 qG . z-
TANK SETBACK INFORMATION St/Ht Outlet ~o• 9 'S•'5FJ
TANK.TO P/L WELL BLDG. Vent to Air intake ROAD DtInlet
Septic Dt Bottom ~
Dosing Header/Man. 71 Q`
Aeration Dist. Pipe ,7--6 9~;-
Holding Bot. System S ,G~ L -7z/. 4.58 PUMP/SIPHON INFORMATION Final Grade 98. 3
Manufacturer Demand St Cover,
GPM 1~n C4 (p Z
Model Numbe
TDH Lk,ft Friction Loss System Head TDH Ft
Forcemain Leu~gth Dia. ist. to Well
SOIL ABSORPTION SYSTEM
Liquid Depth
BED/TRENCH Width / Length No. Of Trenches PIT DI ENSIGNS No. Of Pits Inside Dia.
DIMENSIONS 3/ I fe~c
SETBACK SYSTEM TO W P/L BLDG WELL LAKE/STREAM LEACHING Manufacture
r:/+ /
INFORMATION CHAMBER OR 't aQ
Type f System: 7 L A f UNIT Model Nu er.
'VAveA~141.11 -dC 1-7 73
404,
DISTRIBUTION SYSTEM 4.) S
Header/M~ifold Distribution x Hole Size x Hole Spaci Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx DeptW xx Seeded/Sodded xx ulched
Bedrrrench Center 3. yZ Bedlrrench Edges Topsoil \ Yes ❑ No Yes N No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: Row 17 Hanger 1 New Richmond, WI 54017 (SW 1/4 SW 1/4 24 T31 N R1 8W) New Richmond Airport Lot 17- Parcel No: 24.31.18.
1.) Alt BM Description= 2.) Bldg sewer length = OF, cJ
- amount of cover = Qr✓~
Plan revision Required? ❑ Yes No
Use other side for additional information. lJ ~4~ Date Insepctor's Si nature Cert. No.
SBD-6710 (R.3/97)
County
,/y
Industry Services Division API R-00 •Y(
v 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.)
r~ p P.O. Box 7162
Madison, WI 53707-7162 2 ~i S
J o
State Transaction Number
0 Application ZZ gbZZ.
In accordance with SPS 383.21( is. Admy ~ ion of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-ownedl i are submitted to Project Address (if different than mailing address)
1i
the Department of Safety and Professional Servies. Personal information you provide ma~)99 ary 1-7
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. Q6r,_j r / .1v1
1. A lication'lnformation - Please Print All Information
`7
Property Owner's Name 2013 Parcel # 4
l~4__ C`4- t~C,.,. o z - '7606 ~7- do j
Property Owner's Mailing Ad ress - 14 COUiVrY Property Location
v ~~~T/ t✓ Govt. Lot
City, S to Zip Code Phone Number /4, Section 01 T
(circle on
Tta/ N; R~EoCV
II. ype of Building (check all that apply) - Lot # -
~a ti i- a Subdivision Name
❑ 1 or 2 Family Dwelling -Number of Bedrooms
e-C
Block #
-Public/Commercial -Describe Use 47/t / ~ [City of l~
CSM Number ❑ Village of
❑ State Owned - Describe Use
❑ Town of
U'em- Ll t,~ I Ge.
III. Type of Permit: (Check my 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)
List Previous Permit Number and Date Issued
Transfer to New j
B. ❑ Permit Renewal E) Permit Revision ❑ Change of Plumber PEI.Per7
s°(
Before Expiration er b
IV. Type of POWTS System/Co m onent/Device: Check all that apply)
9-14-On-Pressurized In-Ground ❑ Pressurized In-Ground. ❑ At-Grade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank 11 Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat ent Area Information: Proposed (sf) System Elevation
Design Flow (gpd) Design Soil Application Rate(~Pd ~ Dispersal ~~~quired (sf) DisP ersal Area
7 f
Total # of Manufacturer
VI. Tank Info Capacity in c
Gallons Gallons Units u N
New Tanks Existing Tanks CE U In in V) p„
Septic or Hykhn.+.,Ik J
Dosing Ch.nber
VII. Responsibility Statement- I, the undersigned, ass a espo or installation of the POWTS shown on the attached plans.
um MP/MPRS Number Business Phone Number
Plber's Na (Print) Plum 's 'gn
/D~v L ~N~ tT Z~ ~
Plumber's Address (Street, City, State, Zip Code) /
VIII. County/Department Use Only tssuinA t inature
Permit Fee Date I sued g g g
Approved ❑ D' appro $ , `7 / Z ~
❑ 0 even Reason Denial L/!
t tine / e
IX. Condi easons for Disapproval
'WO, pftlt
H aa'f~ter 61W
d r l ts3 t
l~,W all>t2e services / malntatl d N.dr~"~C-~ f A A-
tnent plan provided by"plumber.
t # ra "wirli3rrte(lti t„t~t 6e rriairttalued ; 7-1 /3
4) ALI'( r' oK /a o~
Attach to complete plans for the system and submit to the Co my only on paper not less an 8 I/2 x t 1 inches in size
SBD-6398 (R0313)
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9FyARrvrFV DIVISION OF INDUSTRY SERVICES
~5ti~ ~oA 3824 N CREEKSIDE LA
0 9 HOLMEN WI 54636
3 ` 0 S K Contact Through Relay
P www.dsps.wi.gov/sb/
9 1, S w www.wisconsin.gov
2a tiL
S
~ss1 oNA1 Scott Walker, Governor
Dave Ross, Secretary
July 16, 2013
CUST ID No. 139462 ATTN.- POWTS Inspector
TODD L SINZ ZONING OFFICE
TL SINZ PLUMBING INC ST CROIX COUNTY SPIA
E5609 708TH AVE 1101 CARMICHAEL RD
MENOMONIE WI 54751-5520 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 07/T6/2015
SITE: Identification Numbers
Eric Segler Transaction ID No. 2269022
County Road CC Site ID No. 792545
City of New Richmond Please refer to both identification numbers,
St Croix County above, in all correspondence with the agency.
SW1/4, SW1/4, S24, T3 IN, R18W
Lot: 17-1
FOR:
Description: Non-pressurized In-ground POWTS / -l% slope / Commercial
Object Type: POWTS Component Manual Regulated Object ID No.: 1436289
Maintenance required; 152 GPD Flow rate; 90 in Soil minimum depth to limiting factor from original grade
System(s): In-ground POWTS Component - Ver. 2.0, SBD-10705-P (N.01101, 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. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code CONDITI
requirements. APPR
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06 DEPT OF S
stats. OROFESSION
The following conditions shall be met during construction or installation and prior to occupancy or use: DIVISION OF INDU
Reminders
• 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. 4 SEE ORP,
• Inspection of the private sewage system 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.
• 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 filter for cleaning must be provided
per SPS 384 product approval conditions.
• All POWTS component piping material shall be SPS 384, Wis. Adm. Code compliant.
• A copy of the Uproved 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.
TODD L SINZ Page 2 7/16/2013
Owner Responsibilities
• 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.
• 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).
• 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 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, e- Fee Required $ 250.00
Fee Received $ 250.00
Balance Due $ 0.00
Gerard M Swim
POWTS Plan Reviewer, Integrated Services
(608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WSMART code: 7633,
jerry.swim@wisconsin.gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with
"SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to
x the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered
d addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed
b~ SPS Chapters 360-366.
~ ~-^soPF „r..vxV
TODD L SINZ Page 2 7/16/2013
Owner Responsibilities
• 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.
• 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).
• 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 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
Fee Received $ 250.00
Balance Due $ 0.00
Gerard M Swim
POWTS Plan Reviewer, Integrated Services
(608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WSMART.code: 7633
jeny.swim@wisconsin.gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with
A_ "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered
r d addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed
r c SPS Chapters 360-366.
.g3 tC
fit-', I:.II.+ s r a
III
.T
RECEIVED
JUN 21 2013
1NDUSTR- Y SERVICES
Construction Materials & Techniques
All materials must comply with Comm 84 and be installed in accordance with manufacturer's
specifications. Construction methods must comply with the following Component Manual:
In-ground Absorption (v. 2.0) - SBD -10705- P
Location: SW1/4-SW1/4-S24-T31-Rl8W
City of New Richmond
County: St Croix
Date: 6-18-2013
Owner: Eric Segler
)NANCY
Address: 236 Danriver Ct )VE0
Marco Island FL 34145 F SCR NO
ERVS
YSCES
CES
Plumber: Todd Si
G)tNCE
Signature:
License # MP 139462
Attachments: 6748 Plan Approval Application
SBD-8330
Page l: Cover
2: Design criteria and sizing
3: Plot plan
4: Plan view/system cross section
5: Maintenance
Page 1 of 5
Design Criteria
Yes Wastewater Contaminant Load: 30 mg/L < BOD5 < 220 mg/L
Anticipated septic tank effluent 30 mg/L < TSS 150 mg/L
Fecal Coliform > 10,000 cfu/100 mL
Fats, oils, grease < 30 mg/L
2FTE x13 x1.5 = 39gallons/day
3 Floor Drain for water heater x 25 x1.5 = 112.5gallons/day
Min.Design Flow =151.5 gallons/day
New Drainfield Design Flow =151.5 Gallons/day
Design Calculations
In situ designed loading rate 151.5 gallons/sq. ft. per day
Depth to estimate high ground water >90 in.
Depth to bedrock >90 in.
Cross slope at system Level %
New Septic tank 600 gallons
New Effluent filter Orenco FT0822-14BA
Septic Tank Sizing
Minimum septic tank size required for 3 years service frequency is 316 gallons by spreadsheet
Calculation; Using Huffcutt 600 gallon septic tank.
Trench Sizing
i
151.5 gpd/.7 per sq ft = 216.43 sq. ft minimum effective area for medium sands
Install 11 infiltrator, Quick 4-W shells which @ 20 sq. ft each EISA plus 5.8 sq ft for a pair of
end caps gives 225.80sq ft EISA. System loading rate is 151.5 gpd /216.43 sq ft =3 gpd per sq.
ft.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE(INFO.RMATION.: SYSTEM SPECIFICATIONS,
Tank Manufacturer J r~ NA.
Permit ft (Septic ❑ Dcse ❑ Holding vol Q gal.
Tank Manufacturer '
77777-7
;•N~imp~f of Bedrooms A [3 Septic [I Dose El Holding vol gal
❑ NA Effluent Filter Manufacturer (nej ED NA
Niiinbt~r b~ P`Ubilb f=adiUty Urnts
Qg~,~
Effluent Filter, Model
Egkirgated::(average).flow Q~` al/da
a;'dav Pump Manufacturer
Design (peak) flow = (Estimated x 1.5)
2 Pump Model
pplipahon Rate ► alldav'ft peat Filter ~A
Standard IIn uent/EfiidenfClUality Monthly average' Pretreatment Unit
Fats, Oil & Grease (FOG) s30 mg/L O Sand/Gravel Filter El Biochemical OxY9en Demand (BODt) 6220 mglL 11 NA ~ rvechanical Aeration O Welland
.
Disinfection E] Other
Total SuspendedSolids, (TSS) s150 mg,L
Pretreated Effluent Quality Monthly average Manufacturer
s} E] NA
Biochemical Oxygen Demand (BODs) 530 mg'L Dispersal Cell( s) (pressurized)
Total Sus~SarYl~t1'5tllld5'(T55) 530 mg;L ❑ NA' - arid` gravity
❑ Mound
,•a.•: ;Fecal Coliform (gedntetrl¢ mean) 00' cru/100ml ❑ At,Qrade ,
OfYie`r
Maximum Effluent Particle Size '6 in dia. ❑ NA ❑ Drip-Line ❑
0 her _ ❑ NA Other: ❑ NA`
-tank effluent Other. ❑
'Values typical for domesticwastie". rand septic
MAINTENANCE SCNEDU414
Sel'iiice Event - Service Frequency
me In(s) (Maximum 3 years) C3 NA
ear s
Inspect condition of tank(s) At least once every: .3
When combinedslgdge and scum equals one-third ('h) of tank volume O NA.
Pump tiut contents of tank(s) ❑ V'hen the high water alarm is activated
❑ month(s) (Maximum 3 years)` ❑ NA
Inspect dispersal cell(s) At least cnce'every. ear(s)
w ❑ month(s)'. Q~4 /ufC NA
Clean effluent filter At least once every ear( s)
❑ month(s) NA
Inspect pump, pump controls, alarm At least onceevery. ❑ ear(s)
i
Flush laterals and pressure test At least once every: m months) NA
ears
Otter` .Atleast onceevery'
NA
Other:
MAINTENANCE INSTRUCTIONS
tMspeotions of tanks and dispersal cells shall,be made by an individual;carry.ing one-of the following licenses. or>certificationsr Master
Plumber; Master Plumber Restricted Sew 6r,- POWTS Inspector POWTS Maintainer, Septage Servicing Operator (pumper
inspections must inchide a visual inspection of the tank(s) to identify any iiissmg or broken hardware identify any'cracks`dr 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
dispersal cell(s) shall be visually inspected to check t`1e effluent levels in the observation pipes and to c`'eck for any ponds^g of effuent•:
on he 9round surface. The ponding of effluent cr the ground surface may indicate a failing condition and requires the immediate `
L -
notification of the local' reg'ulatory authority.
a Se to^e Servicing an treatment ram tank equals one-third (h) or more offthe. tank volume the entire'
Whe"ri the combined accUfflUletitln of
and scum ~ an p and disposed in accordance wth chapter NR 113, Wisconsin
moved b sludge
e P u
.9ontnta„o(,the tank shall be re by
Adm'IhWr Live Code.
All:other. services,.inelu,:K g,b'.Ut ~tdt.limited..tothelse s icing nuiref do effluent mechanical or deed regard gpma ntenapc~e egm ementss recorded on the that require servicing
at intervals of 12 months •
A sere ce report shall be rov1,ded to the local regulatory auihcrity Nlthin 30 days of completion of an y service event. GMW (t2J02):
Page ~ot
STARTUP AND OPERATION
or touse of the PQWTS check treatment tank(s) for the presence of painting products solvents or, othor.
i n
a ,...chemicals that may impede the treatment process and/or damage the soil dispersal ceil(s) If high toncentrat ons are detected have thacontents of the tank(s) removed by a septa9e
servicing operator'pnor to use.
System start up.shalI h6t occur "66 soil condi(ions are frozen at the infiltrative surface
,r
i'DUring extended power outages pump tanks rtlay:fill above normal high water levels. When power is restored the excess wastewater will
`s be discharged to the dispersal cell(s),in one large dose and may overload thorn resulting in the backup or surface d scharge of effluent.
u t
to assist di in a Sepmanuallyta a Seoperatirvnglcii5the Op epumprator co prior s to to restore restoring power to'the
normal levels
!"to avoid .'effluent pumi p or contact a P umber for POWTS. Maintainer k're
within the pump tank` Do not drive,or park vehicles over tanks and dispersal oils. Do not drive or park over, or otherwise disturb or compact the area within
•
15 feet down slope of any mound or at ride scil,absorpt on area.
Reduction or elimination of the following from the wastewater stream may improve, the- performance and 'prolong the life of the POWTq:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers, dental floss, diaDers disinfectanls, fat, foundation drat"
s.
grease; herbicides; meat scraps; medications,: oil painting products;
p
(sump pump) diaoha pe`1friit anp vegetable eelin9s gasoline
pesticides; sanitary na kins; tam ons; and water softener brine
ABANDONMENa e; _r .n
When the POWYS, fail8 and/or Is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandori~ct' i3 bompliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed
! ;•The,contents.,ofail tanks and pits shall be removed and properly disposed of by a Septage. Servicing Operator
• Aker puff OMW 811 tanks and pits shall.be excavated and removed or their covers removedand the void space, filled with soil,
gravel or another•inert solid material.
CONTINGENCY PLAN
: .
If the POWTS fads-and -Cannotbe repaired, the following measures have een,, or must, be taken , to provide..a code compliant
'replacement system:
( A suitable replacement area has been evaluated and maybe utilized for the location of a replacement soil absorption
y. system: The. replacement.area should be protected from disturbance and.comgact on and„should not be Infringed 'upon by
Required setbacks from existing and proposed structure, lot lines and wells Failure to protect the reptacemenl area will
a,...
Ps'ie~i1i:'iri'tFie 11~Ef~"f~ii'•"S"t~eW sdif and Site evaluation to establish a'suitable repiacerrienY area".' Replacement 'systems must
ciirntijt"Jdflf#iilt iUi3 in effect at that time
-
A sUlthole106'011160r4i i)lllis not availablA dUe to setback and/or soil limitations. Barring advances in POWTS (ethnology
a holding tank may tie installed as a last resort to replace the failed POVVTS'
❑ The; .site'has.not; baait evaQted to identity 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.
O Mound and at-grade soil ahi brption 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 61 'time
<<WARlill
SEPTIC, PUMP AND OTHER TREATMENT'TANKS'MAY-CONTAIN LETHAL "GASSES °AND/OR INSUFFICIENT OXYGEN, DO, NOT
INTERIORT&FHER A'TREATMENT TANK UNDER, ANY[CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON ENTER A FROM SEPTIC, THE PUMP OR 0T4:
TANK'MAY gEDIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS........ : .
POWTS INSTALLER POWTS MAINTAINER
Name -774,- NZ Ll~i~'f$/I'1/ J/UL Name 7Z ,(JZ
,Phone ,Y - •,1.,~3"....- Ph"one
LOCAL REGULATOR.Y:>AUTHORITY
SEPTAGE SERVICING OPERATOR PUMPER
`i N
Nerve j. ~(itf~t/ Name
Phone Phone' ' a
This document was drafted by the Chippewa County Zoning Department in compliance with chapter Comm 83.22(2)(b)(i)(d)&(f) and 8154(1), (2) & {3)
Wisconsin Administrative Code-
S,Tl CRCTX'COUNTY.
SBP'I'IC TANK:MAMERANCL AGMUTNT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer l.~ aovlo 7'T`k-C 'V -S~C.._tr
Mai)ing Address V u q L~r}'G
1/
PropertyAddress- C ZS We5~- '1-~0~~Q( -42L\~o,r {-7 -
(Vetifcation required.from P ng & Zoning Department rnew construction.)
City/State Parcel laentification Number
LEGAL DESCRIPTION
Property Location r/4 , r14' ; See. T N R W, Town of
Subdivision Lod- LoW I - L ~1~0e;cyym~ fZs~~ Ni ~rA! Lot #
Certifled:Survey Map # , Volume Page
Warranty Deed # , Volume Page #
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND: OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the, septic; tank every three years or sooner, if needed, by a licensed pumper. What. you put into
the system can affect the 'function of the septic tank;as, a: treatment stage. in the waste disposal, system Owner maintenance
responsibilities are specified in:§Comm. 83.52(1) and?n 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 tieoessary), the septic tank is
-less than 1/3 full of sludge.
I/we, the undersigned have tend the ab:pVo requirements and agree to maintain the private sewage disposal system with, the
standards set forth, herein, asset by the Department of.Commerce: and the.Departmerit of Natural Resources,. State ofW4censin.
Certification stating that your septic system has been,m.4intained must be comp leted:and returned to tha St. Croix County Planning &
Zoning Department within 30 days pf the three year expiration date..
I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe arn/arG the. ownor(s) of the
property described above, by virtue of a warranty. deed recorded in Register.of Deeds Office.
Numb of b droo..
SI A OF " - PLICANT(S) DATE
***.Any information that is misrepresented may result in the sanitary permit being. revoked by the Planning & 7bnting Department,
Include with this application. a recorded warranty deed. from the Register of Deeds. Office.and a copy of the certified survey snap if
reference is made in the warranty deed.
Wisconsin Department of Gommerce SOIL EVALUATION REPORT K,•,.,. Page ( of Z
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D: t
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. f
Please print all information. Rev ed y C NTy Date?
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). `T
Property Owner Property Location
r' v C S Govt. Lot /4 1/ S dV' TZ,( N R G~ E (o6V-
Property Owner's Mailing Addr s Lot # Bloc or CSM#
9134, D~ ~l0G-a-, 0r 117, l
City State Zip Code Phone Number id-City ❑ Village Nearest Road
6New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate _ GPD
❑ Replacement Public or commercial - Describe: o("~ a2e+~, 5 + FCoz,
ft.
Parent material Flood Plain evation if applica le
General comments f^?GorrNr')Q> C~rtOe.,~ eav g~J 61in'd al`e's
and recommendations 0
r a5e~ S 4-
Boring # Boring
~.~'~~-Z-ft. Pit Ground surface elev. Depth to limiting factor in. 4E-E Horizon Depth Dominant Color Redox Description Texture Structure
Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 0 S'f123~ one 6 6-!9
126
riv
ing
2 Boring # Bor
pit Ground surface elev. ft. Depth to limiting factor Soil Application. Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff#1 'Eff#2
3 3 ~ `~2 Y S7
359 f4l~5yR y
sYr~ -'Cots ug cs "b J,~,
r
' 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 (Pie, ~lClt ~C1~ f? ({ji; Si nat e r TNumber
W3903 berniock RC' e~~7Z
Date Evaluation Conducted Telephone Number
Address t~Ot1C~G'df ~~/rr r 7
,
~ . .
715 „
Property Owner E~ v Parcel ID # Page Z of`Z-
❑ Boring # Boring
Pit Ground surface elev. g "Z ft. Depth to limiting factor 2:0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 7
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. " ff#1 ff#2
o'~~ ~~jll a 5
6a ~s 3/3 lt,~
3 30s`t2~ P
3 YR~ sl
3' Y-yo ~ s`P ~ fs
x`90
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
❑ Boring
Boring # Ground surface elev. ft. Depth to limiting factor • in.
17 F-1 pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 3
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
" Effluent #1 = BOD , > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = SOD , < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3 15 1 or TTY through Relay.
SAD-8330 (ROS/U)
Property Owner LrEe- S Q Parcel ID # Page ~of-L-
Boring
37 Boring #
Pit Ground surface elev. / g 'Z ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ` ff#1 ff#2
0 ~5`~~ll a 5
VN-x_
3 Yi2`~ sl
Y Yfl ~-s`~ ~ fs
❑ Boring
❑ Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
'
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ` ff#1 ff#2
Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor, in.
❑ Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ` ff#2
Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD s < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD-8330 (RO5113 )
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