Loading...
HomeMy WebLinkAbout018-1056-80-000Wisconsin~L~partmel'~ of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT ~O~,D~ GENERAL INFORMATION (ATTACH TO PERMIT) ~j, Z~ Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)}. Ot ~,.~ Permit Holder's Name: City Village X Township Niccum, James Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic l~r•- ~ Z.~.~ ~ ;-,.-. ~~'~ I o r~r~ ~~~G Dosing Aeration Holding ~~ ~ ya-- ~ TANK SETBACK INFORMATION TANK TO PiL it; WELL BLDG. Vent to Air Intake ROAD Septic ~ ~5 / '~! ~~, :-''~.5 '~., - Dosing ~~S ' '" ~3c, ~ ..-3 ~ ...... -~, - Aeration Holding } PUMP/SIPHON INFORMATION Manufacturer ~ ~ ~ Demand c ~ -5 GPM Model Number . r EPG~ . _.. ~a.7S TDH Lift ~~' Friction Loss., Sy rtT eat., `~. TDH F _... Forcemain Length Dia. pis3_'to-Vdetf--f SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 453341 0 State Plan ID No: Parcel Tax No: 018-1056-80-000 Section/Town/Range/Map No: 25.29.17.388A J'L u STATION BS HI FS ELEV. Benchmark ~ ~ ~ ~~~ ~~ wG ~ Alt. BM S.~I(7 y~.(oS Bldg. Sewer ~ Z ~ ~ .~ SUHt Inlet Iv;"3 ~0.~3 SUHt Outlet ~.~\ Dt Inlet Dt Bottom .~ r3:75 8`7 ~ Header/Man. S ,7 q 5 ~ ,~~ Dis P' a S'am' Bot. System Q /~ Final Grade ~7 Y'~'l is r K +t_,Za` O G }~ S ~ r~ ~ ~/ • ' ~p ~(~ `j~ St Cover ~ it iS+~/ ~~~~~~ ~•7 9y."3> BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Insid id Depth DIMENSIONS O ~j ~~ ~ SETBACK SYSTEM TO PIL ~ BLDG WELL LAKEISTREA LEACHIN Manufacturer: INFORMATION CHAMBER OR Type Of System: ,,, ....,-~r~C ^^2CU ` •'~'S (G~ "''" ~ y~7 Illl t~ A UNIT Model Number: ~ ., DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ~ Length Co ~ Dia_ pipe(s) S~ ~ / ~ j `i Length Dia_ ~ Spacing 3 ~ / ~Z~ Z.7 i~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over 5/~~t / Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 7 Bed/Trench Edges ~ r Topsoil ~j - S r 0 Yes ~ No ~'; Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / ~~ / r'`f Inspection #2:~~_/ ~` Q Lew ,t,,,. i .- Location: 2025 U.S. Hwy. 12 Hammond, WI 54015 (NW 1!4 NW 1/4 25 T29N R17W) metes & bounds Lot Parcet No: 2529.17.388A 1. Alt BM Descri tion = ~~ s ; ~t - ~- ~~ ~ ~~ `-~ G ~~ 2.) Bldg sewer length = L:t'.~ ~y.1cs ~~c3 e•Q~ -amount of cover = , ~~rJ~s Plan revision Required? 1 Yes '~ No Use other side for additional informati n. SBD-6710 (R.3/97) 'i~ a ¢ ,L r.L -1 v <j :..-t c t -~~c;.-'~ < <. ~ ~ S e lr~-e-gG C c., n~ z C J~ ~ C; i^ 6 -- -- - ~- 1 ~, ~ 3 ~~ ~-~- _ ~~ I ~ L i_ __ ~ __. ~ _ _ . _ ._-- _- - - - _ _. - __ _ --- ---..J Dat~j Insepctor's Signature Cert. No. '~~ .J~e~t- X : n{~ a c cca.~ fem.' ~ ~~ ~ ~~ r~,C,,L `.{~2s~ °'"i"~`3i'e~ -~ n.JL~"-d Safety and Buildings Division 201 W. Washington Ave., P.O. Dox 7162 <<~t~mY r /Y J ~ t~ ~6 i ~ 7162 Mad Sanitary Permit Numbs (to be tilled in by Ca ) iis~onsirin 608) 266-315! ( De artment of Commerce te Plan LD. Number sta Sanity Permit A lieation rovide ou rmation t i f d 1 3 r J / Q ~~~ Q'$~2'' p y n o e, persa ia , Wis. Adm. Co . In accord with Comm g may be used for secondary purposes Privacy Law, s15.04(1 xm) Project Address (if different than mailing address) 1. Application information -Please Print All Informal `"` `` """ ~" ~ ~ ~ ~" ~ J ~/~ /~ Propert Owner's Name .q. u_ 7 10U4 Jlaij Parcel tY Lot I Block N . property Owner's Mailing Address ' 2 b ~ ~l~ ~ ~ i . LI~uIX~.U~ ;V f .,i .t~NING OFFICE ProPG'tY Location ~ ~ ~GC~/ ~~C/ lt.'s, /~ 4.~i Z S~ C~ G S i 5 . . /,, . o .; ect Ciry, Statel ~~ / ~ 4r ,~ ~` t Zip Code S'L Dd 2 Phone Number q 7<~"- ~ ~'~ ;~s'3~ _ T ~ GfN: R ( "o~ ane) -3 ~s`~ ~ ` -~ ' ~ ' ' II. pc of Building (check all that apply) ~ Subdivision Name CSM Number or 2 Family Dwelling - Number of Bedrooms s~ `2 ~ S ~ f J Y _ n ^ Public/Commercial -Describe Use ~ 15T~ c- t / /'r ']~ J ~ ~~ ~1 ^Ciry_^ illage ov~nishipof ~-KcHt~+k ry~ . ^ State Owned -Describe Use ~ III. Type of Permit: (Check only one box on line A. Complete tine B if applicable) A' ^ New SYStem eptacement Stan ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New list Previous Permit Number end Date Issued Beibre Expiration Plumber Owner IV. T of POWTS S m: C all that a le Pass Sand Filter ^ ^ Sin d G ^ g ra e At- (~ Non -Pressurized In-Ground ound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil Constructed Wetland ^ Pressurized [n-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Rxitsttlating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leachi Chamber ^ Drip Line ^ Gravel-less Pi ^ Odter ( Isin) Y 1 V. Dis rsal(I'reatment Area Information: Design Fiow (gpd) Design Soil Appl' Dispersal Area R iced (sf) Dispersal Area Pro ed (Sf) System Elevation i ~ r . '~j ' q ~ - ~ oj~ , ~ ~~ S v ~ t ~ s-v ~ ~ 5 gg3 VI. Tank Info Capacity in Total Number Manufacturer fab Site Stcel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Fxistiog Tanks Tanks Septic M Molding Tank / (~ (,~ ~ ~' i- LS `s AerobicTn~tmentUlrit Dosing Chamber (~ 5'(f i VIT. Responsibility Statement- 1, the nn igaed, ale responsibility for installation of the POWTS shown on the attached pleas ess Phone Number i B ~/~~ us n Plumber's Name (Print) Plu 's Si RS Number ,F ~-~.~ s~,~L, ~~ 3~~ s 7~~ -C~~f-s I Plumber's Address (Street, Ciry, t e, Zi ode) VIII. unt ;' pproved De artment Use On ^ Disapproved Sanitary Permit Fee ('ncludes Ground`~ter Date Issued: I i g A en gnatu o ) Surcharge Fee) ~ 3~ ~/ j ~ , ` 22 ^ Owner Given Reason for Denial J IX. Conditions of ApprovaUReasans for Disapproval ~~iJi ~~1 .S ~,,~,~ ~ ~G~(~ SYSTEM ~~~:i~'~tl//L Qom- N~. -''~ II r 1 Septic tank, effluent filter and ~~(iu.o~;2~e~vj'n.J~ ~ / ~ ~/,,_ dispersal cell must all be serviced /maintained ~rLUuinr^-a'uc-~ as per management plan provided b ~ ~/S~'1~1 l , y p umber. 2. All setback requirements must be maintained ~~~ yy~yr 3 3 ~' 3 g ~ , as per applicable code/or ' ~__ a,» _ „ ,~, ~ ~ ..~ -Q.. s, w At41ch eoapiete plan (~ ibe caar~y amr) wr r.e sysnmr w tom' ~ ~ •••••• -••_ _ .............. SBD-6398 (R. 01/03) ~~ 1~-- YtQ~GLQ-d ti ~--- ~- J T ~~1 _~ -~--- d S d ' `~ l"? ry 3 L ~ ..-0 +- s ~ n -s'-r ~~ o ~n o ~. ~ ~ d s c~ 2 ~ I ~~ ' J J a ~ D ' ~ L N J ~~~ 3 ' .~ ~ ~~ ~ _ d ~~ c,, `' s O o V li ~ V~ ~ ~ ~ ~ . 0 ctl-~' ~ v 9. n ~ ~ O O uv~ u ~ ~ - ~i m _~ . ZS 0 o ~ O ~ o ~3 ~~~ ~% 1_t'~ ~~ ry y .~ o -- .~ - s dl I u ~ C~ j P ~' 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.state.wi. us/sb www.wisconsin.gav Jim Doyle, Governor Cory L. Nettles, Secretary June 08, 2004 CUST ID No.223475 JOE STANG STANG PLUMBING & ELECTRIC PO BOX 263 WOODVILLE WI 54028 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/08/2006 ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 SITE: James Niccum 2025 US Hwy 12 Town of Hammond St Croix County NWl/4, NWI/4, S25, T29N, R17W FOR: Description: Three Bedroom Mound System Identification Numbers Transaction ID No. 1005952 Site ID No. 684593 Please refer to both identification numbers, above, in all cones ondence with the a enc . Object Type: POWTS Component Manual Regulated Object ID No.: 962000 Maintenance required; Replacement system; 450 GPD Flow rate; 31 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (R.6/99); Biofilter 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 Departtent per s.145.06, CvraG stats. ~~ The following conditions shall be met during construction or installation and prior to occupancy or use: pE ~'TMEI General Approval Requirements: OF • This system is to be constructed and located in accordance with the enclosed approved plans and with the SEE COIZI "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD-10572-P (R.6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" ~ • - ~ •~ °~--~ SBD-10573-P (R.6/99). • The~hanees made to this plan on 6/9/04 by this reviewer were acknowledged and approved by the system designer. ~___---- • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • 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 JOE STANG Page 2 6/8/04 • 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 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. Stat • Comm 83 22(7) A copy of the aporoved plans specifications and this letter shall be on-site durine construction and open to inspection by authorized representatives of the Deparhnent which may include local inspectors. Owner Responsibilities: • Comm 83.52 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. 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. • Comm 83.55 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/installation/operation. 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 may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shalt 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, ~i~G~LZ~C:~o ~, ,,0'G - . J Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday cbratz@commerce.state. wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 . , PROJECT NAME INDEX SHEET JAMES NICCUM 2025 HWY 12 BALDWIN, WI 54002 JAMES NICCUM JAN ' 2 2004 sq~E~' ~ B~~GS DIV. PROJECT LOCATION: NW 1/4, NW 1/4 , S 25, T 29 N, R 17W MUNICIPALITY: TOWN OF HAMMOND COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6199) PROPERTY OWNER: CONTENTS: Page 1 Page 2: Page 3: Page 4: Page 5: Page 6: Page 7: Page 8: Name: Joe Stang Address: PO Box 263 Woodville, WI 54028 Credential Number: 223475 Plot Plan Cross Section and Plan View of Mound Distribution Pipe Layout Septic Tank & Pump Chamber Cross Section & Specifications WLP1000/600-MR Zable Tank Specifications Pump Specifications POWTS Owner's Manual & Management Plan - Pg. 1 POWTS Owner's Manual & Management Plan - Pg. 2 Signet Date: May 27, 2004 ~~ ~' C014lMERCE ~0 QINGS ~PONDENC~ _ ~_ ~. T ~~ o~ V ~'~ -+-- ~-- JI '~ i ~ N _ .~ 3 S o ~ ..o }- S ~ ~~ ~~~ ~ O CY CS . ~1 ~ 0 .~ a ~ 0 ~ ~ S G ~. 1 - ~ ~ s p2.~ .~ ~i ~.. d J ~ I 1 a ~ V emu- D ' ~ ~ i 1 ~~ ,Vj~+ _.1 0 -- .1 - f 91 ~ ~~~ w p ~~ \ 3 s ~ ~~ ~ ~~ ^~( O J ~ y ~o ~O A L ~li~ ~~~ o .~~ ~ ~,~- ~ ~. {^ ~ ~: ~' 3 0 ~~ u ~ /~ 'r v ' \/I al 0 O ~ ~ 0 o n ~ O lm Di~ayt ear ~ ~lav>1e,s iy ~ c c~.-v~ Synthetic Covering A57'M C 3 3 Medium Sand Topsoil --J ~ E 3 j % Slope C r--_ ~.~.0 f 2y- 2 %2 Aggregate _ Cross Section Of A Mound Signed: License Number: Date: Page ~; )istribution Pipe c s~st~ ~. ~-s~'' F D Grote cQ, Elev, Q_ y Force Main From Pump Plowed Layer A $ Ft. n B ,j'~.25 F t . ~ a~' ~ ~.S'Ft. C~~3'~ ~g ~ y. ~ Ft . I ~.- Ft . W ~2 I_ Ft. D , s Ft . E ~ Ft. F , ~0 Ft. G S' Ft. H / Ft. ' -- L ---" Observation Pipe J B K r - --- - ---j-----_-_-----___ ~ '~._______________ _ ____ ---- -' ... ~ K~ w G ~ -- I . __.T - .._._ .._._ , - -- -- - - - - - - - - ~ 2 ~~ 2 Distribution ~`~'t" Of ~ - Z Pipe Aggregate l _ C~' ^S~ rcct. - /~d. Observation Pipe ~as~~ A Plan View Of Mound ~ ~p.o.o~ 1r ~G~rsC ' C. ' (E'nNa~`-~ PelfololnA hlPe Onlo{I ~ ~ .~ Eno Vlew Per(orotau :. ~ I of Holes Located on Bottom are Equally Spaced ~u PCyI e1 ~~ c 1 L - ~- IL it ~ t lC ~ "[' t7 /' / /2 <n, ~O~w ~ I~~ P~De Distribution Pipe Layout Signed: License Number: Dace: R ~~~ ~ Y -~ ? .r S X ~ ~ ~~ Y ~~" ~ Hole b~.ameter ~ Inch Lateral ~ Inch (es) Manifold " ~ Inches force Mein " ~_ Inches No IQs AeF 1.~~-.era.) ~ ~ s' LS.L~.d.-s ~~ n t/t e S -V I G C c.~, v~ Page~O f~ " SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS .~UC..VENT PIPE 12" MIN. ABOVE GRADE E > 2 S' FROM DOOR , WINDOW OR FRESH AIR INTAKE C-~-b~.wcQ C~V. g3. ~ ~l/ - 18" IN INLET ~- WATER TIGHT SEALS -f-- FILTER _ A APPROVED Z~ $E~- B PIPE 3' (a "x l (," ~"- ON70 SOLID C SOIL PUMP OFF ELEV . ~~ SIFT. ~" D SEPTIC / DOSE TANK MANUFACTURER WEATHERPROOF JUNCTION BOX WITH CONDUIT Zy'" S. D. '~ ~ ~~ I ~, GAS- ~ ~, TIGHTS SEAL ~ ;. ~ r, ~ ^ I ' 3" APPROVED BEDDING UNDER TANK APPROVED MANHOLE COVER W / PADLOCK r; WARNING LABEL -4" MIN. • u 18 M~N• /APPROVED JOINTS KITH ALM APPROVED PIPE ON 3' ONTO SOLID SOIL OFF CONCRETE PAD SPECIFICATIONS L_~t~~ r Ic T~ ._ ~ X s ~, s G~;I. ~~~ I e'S c' ~~ TANK SIZES: SEPTIC ~ GAL. DOSE ~_ ALARM MANUFACTURER: _ ~"' -"- MODEL NUMBER : I C~ ~ ~`~ ~ - L SWITCH TYPE: - -~~c`I PUMP MANUFACTURER: `yv -'Epoy~~ F MODEL NUMBER : `Z ~~~ C H TYPE • /LI r < < ^- F" I ~~.~ ~' DOSE VOLUME FLO BACKG c ,~ S- GAL. i{ ~-c.~~S .E.-~ • 1 ~ INCHES = `~n~GAL. CAPACITIES: A = B 2 INCHES = ~.? GAL. C ~ INCHES = ~~GAL. D (Ci INCHES = 1~~AL. SWIT 16.23 wAc S" GPM PUMP E ALARM WIRING AS PER ILHR REQUIRED DISCHARGE RATE 3C~_ ~ ENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.'r~'`3~ ~ FEET VERTICAL DIFFER .~/3 FEET + MINIMUM NETWORK SUPPLY PRESSURFT/100 FT. FRICTION FACTOR FEET + ~ FEET FORCEMAIN X ~_,G'l TOTAL DYNAMIC HEAD = -- i -fa' 7 b' WIDTH _; DIAMETER ~_._. LENGTH INTERNAL DIMENS/IONS OFf/ PUMhP TA}-NK: LIQUID 6j~-~`_y- I ~(C. ~ ~~ C~'<il_ ~"f'~ . 1v~C') I"/F'G-~$ L .S P~ /een~ S~~C ~ /1 E'er LICENSE NUMBER: DATE: S IGNED: 1/88 . ~ Q V" O 4 ~ U o ° a vi 0 .~ N~m -°O°~~' c rD ,^ \VI O F-Jr ~ N O ~ r- ,d. J r- M t t ~W 00?J ~ Y Z .. ~~ ..~~~ ..30-- Z~~~Z~c~~O~~ r ta.. ~3mov~0~~mQ~ O (} _~____._'T I I I ~, 1 i I O U Z W Q `w a F- W Fo i Y ~ o°o ~m oa ON h- I ~, a H ~N J ~ U Q ~ W o~ m ~~~ J Z o~ ~,Q ~_ U W W W O (n m N ~ W Z F- ~pW o~~ ~~o J z Ua vWi a vv zz ~~ ~~ ~ ~ lD cV ~ H U Q Q U O 0 J J O 0 d' Q to Z 0 t~ Z C9 N w 0 C~ Z O Q w ,.lt' J a po ~ n J~ ~ m U ~~`Co Na ~ ~ ~ ~ ~~ ~ Q i ~a I°~~~ °~~ c I oVa ~ ^ °~~ o (?S~~oo ~vo L -'~ ~ J ~ ~ O 3 0 I ~ ~~ 1 W ~~ l ;_ o w ~ J ~ ~" U N 1 1 I 1 ~ ~ M I k !~~ i _`\ I I-- - --I W W ~_ J U N F- w o= „6£ „9 N~ Submersifile Effluent Purnp METERS FE' Sf 7 w 6 s U g 5 Q Z ~ ~ 0 J -a' 3 O f- 2 11 o' ~: :. .:~ . M0DEL:3871 ~~~ SIZE: 3/4" SOLIDS, ~ ~~~~~~ RPM:1550 , H P: 0.4 . .,a Ef(~ctive t)ctobar,1988 •, PRINTED W U.SA. _. ,__ SPECIFICATIONS ARE SUBJECT TO CHANGE WRHOIJT NOTICE , j. •1Niscon~~nDepartmentofCommerce SOIL EVALUATION REPORT Page ~ of~ Division ~f Safety and Buildings In accoraance t l Att h l it t l 8 1/2 th va.+.cu~-aarrr+~~wi~`~ f~~~i~: f~~a 1 inc st -- Couniy s~ ~~D~X x ac comp e e p an on paper no an e s ess inGude, but not limited to: vertipl and horizontal referen point (BM), direction and Parcel LD. ~ ~ O1,-/ _ C/,~ ~ ercent slo e, scale or dimensions, north arrow, and to p p lion an to qe~ms{{ st roa ~ ~~~~ J to lXJ LUU ' Please prinf all infor 'on. e Date Re Personal information you provide may be used for .._ oses~!ri~~llbdvs~ h~itid (N) (m)) 'L2 d Property Owner ion AA ~~ ~'~ ;~,,~ e 5 ! V t C ~, [~ vti Govt. Lot ,/J l.(~ 1 /4 ,11 ~ 1 /4 SAS T ~ `~ N R l 7 E (or W Property Owner's Mailing Address Lot # Block # Subd. Name CSM# r / Zip Code Phone Number t e City ~ n Sta ^ City ^ Village Town Nearest Road l1 ~tCYcly r ~t l~J~ ~"~G~G~o~ (~ l S~) ~cv$ ~ - ~ ~ 3 ~ ~Q vr~ r.2 ©~ ~ {-f `.i' ^ New Construction Use: residential / Number of bedrooms ~_ Code derived design flow rate ~SC~ GPD placement ^ Public or commercial -Describe: .r Parent material ~ r5~s,t c~ tie ~-- ~i ~~ Flood Plain el//ev/ation if appligble n ,/l,zr ft• General comments i~.5~ . ~ ~ X ~-L . ~5 ~ C~ ~ ~ W i T l1 ~ ~~ s~ h C~ C_c.v~ ~e ~- (,(~p~-e s- ~C~~ -2 and recommendations: r I d vL C o vt ~f 6 t,c V ~/ S/, ~3 S ~M ~""~~ sy ~ -~~~ r- i~~. = 9U. ~s- ^ Bor' Boring # Ground surface elev. ~-3 ~ ft. Depth to limiting factor ya in. Soil A lication Rate l C ri ti n d D R Texture Structure Consistence Boundary Roots GP D/fF Horizon Depth in. o or Dominant Munsell p ox esc o e Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 I V -f 3 -3.? ! v `! 1Z 6 `-- S c ,L ~ c 5 b k ~ r C~ /' , y ~~ S~ ~o~~ I~ '-~(~ .s ~3 5 ~ ~~ s~ ~k ~v~ . ~ . 3 Boring # O Boring ~ ~3 °~ Pit Ground surface elev. ~ U ft. Depth to limiting factor in. Soil A ication Rate i H th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'• zon or p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 ~ b . c~ y 12 ._._ ~ ~. ~ , ~ w - ~ , ~ 1- 4 v ~ , sY c l._ o ~ h.. ~{ ~ u D o " Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 =BUD < 3U ~u ana i ss ~ su mg~~ CST Name (Please Print) Si ature CST Number `'- ~~ 2i c-~ /rte (' L Address ~ 1 // ((,,11 Da valuation Conducted Telephone Number 76 Property Owner ~D.w~~,s ~) 1 C Cl.uw` Parcel ID # Page d of 3 Boring # ~~ Boring _ ~ Pit Ground surface elev. ~~ 35- ft. Depth to limiting factor 3 ~ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I -lo ~ ~ ~ ~-- s ~~ ~ ~ S 'c ~ I f=U~ _~o , ~ ~ k a -ao ? c~ ~~ ~ , / ~ t ~ ~,~ ~ ~ o b ~ ~ 5- old y ~ i f s f~ sr. d s ~ l u g . 4 ~~ ~ 6 ~ ~ 12 ~ ~' ~r ~- ~ a Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor ~n• Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soit A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Gont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 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. '- t y- 0 M 4> ~b a ~~ ~~ y -~ ~~ ,~ ~S `~~~ L s S_ N ~, z ') v'~ ~ Y s o . y --~ ~- ~~~ ~ w ~~ .. 3 a 3 d ~ ,~ ~~ .s ~~ ~~~ f a L ~' ' ` `~f ~ -~ ~ o 1 ~ W M Z o a~~ 1 ~ ~~ ~ ~'~ s ~~ l ~ ~~ ~ oa ~ -~ -------~- ~ .o ~- ~~ a -- ~ ~ (j k ~~ ~ ~ ~ ~; d"'y f°7 3 111 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 FILE INFORMATION Owner JA1v1ES NICCUir1 Permit /i ~ ~ ~? DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ~ NA Estimated flow (average) 3UU al/da Design flow (peak(, (Estimated x 1.5) 45U al/da Soil Application Rate U.5 al/day/ftZ Standard Influent/Effluent Quality Monthly average " Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOOS) 5220 mg/L ^ NA Total Suspended Solids (TSS) 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. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. cvcTFM SPECIFICATIONS Septic Tank Capacity lUOU al ^ NA Septic Tank Manufacturer WIESER CONCRETE ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model A-100 12" x 2U" ^ NA Pump Tank Capacity 6UU al ^ NA Pump Tank Manufacturer(y*IESEK CONCRETE ^ NA Pump Manufacturer GOULDS PUr1PS INC ^ NA Pump Model 3871 EPO 411F ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: NA Dispersal Cellls! O NA ^ In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade gKMound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCt SGHtIJUt.t Service Event Service Frequency Inspect condition of tank(s) At least once every: Z ^ ear( )(s) (Maximum 3 years) ^ NA Pump out contents of tank(s) When combined sludg e and scum equals one-third IY,) of tank volume ^ NA Inspect dispersal cell(s) At least once every: 2 ^ month(s) (Maximum 3 years) ear(s) ^ NA Gil month(s) ^ NA Clean effluent filter At least once every: 13 ^ year(s) Q month(s) ^ NA Inspect pump, pump controls & alarm At least once every: 13 ^ year(s) ^ month(s) ^ NA Flush laterals and pressure test At least once every: 3 ~ year(s) Other: At least once every: ^ month(s) ^ year(s) ^ NA 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 cell(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 (Y,1 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 shal- be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) OWNE1t: JAMES NICCUDI Paps ~_o(Y~ System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power Is restored the excess wastewater will be discharged to the dispersal cell(s) in one.large dose, overloading the caU(sj and may result In the backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Matntainar to assist in manually operating the pump controls to restore normal levels vrithln the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Oo not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soli absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the Ilfe 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; herbkidea; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMIVIENT When the POWfS fails and/or is permanently taken out of service the following steps shall be taken to Insure that the system is properly and safely abandoned In compliance with ch. Comm 83:33, V>risconsin'AdminlstraHve Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.• • The contents of all tanks and pits shalt be removed and properly disposed of by a Septage Servicing Operetor. • After pumping, all tanks and pits shall tie excavated and removed or theft covers removed and the void space filled with soil, gravel or another inert solid mater(al. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, t0 provide a code compliant replacement system: ' O 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 compacUon,and should not be infringed upon by required setbacks from existing and proposed structure, lot Imes and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a 'suitable replacement area. Replacement systems must comply with the rules in effect at that time. O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POVVTS ` technology a holding tank may be installed as a last resort to replace the failed POWTS. I~~~ O e site has not been evaluated to identify a suitable replacement area. Upon WTS e s e ev aG n mus erfomted sate a suitabl cement ar no replacement area available a ho Ing tank a insta as a last re apiece the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that ttme. «WARNING» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND10R INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRC,UMS7'ANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS onwTR INSTGI 1 FR •. A IAITA IAICG IE Name STAN ' P a' ' Phone 715/684-5166 r V ~f 1 J IYl Name nll. . ABC SEPTIC SE1tVI~E •1`1EtdOr10 Phone 715/235-1666 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY ' ' ' ' ~ ' Name ABC SEPTIC-SERVICE =AiENUi~lONI Agency ST. CROIX COUNTY ZOiV~ING Phone 715/235-1666 Phone 715 386-46$0 ` t This document was drafted by the staffs of the Green lake, Marquette and Waushan County Zonlny and SanMatlon apsndps. This doaansnt mssb the minimum raQUiremants of ch. Comm 83.22(2)(b)(1)(d)d(i) and 83.54(1), (2) & (3), Wisconsin Administrable Code. Uss of thb documsnt dos! rtOt guarantee the performance of the POWiS. GAA4V(?/01) ~N~! W ~,g ~- .~- 2 5 'u. __..----_.. _. ~2 . .~ ~. ____ ~..~_--_.._._._.r~..~.___-_ I-l w . U ~~~~_~. _._..___,__~..~a_~___.._ _~...n..,._.~. a O,~~T'2! ~:,3Rit?31'i rCL~L413'C'.t! rI't}Til ~i8RAIII~, PleUU3 U11vtt~ IOT X1EC~ G~17]5T5UCLi'F2,1, ~~%~~~_.u ~•.,~..~-_`__,.._... ~.~ ~ r G~~'1Qs" ,~i't..A'~„'}M•S L'S+' 7.. t.}L..d ~it?S~: ~....Y---`- ", ~,x ~ _Y M .u 4 A; ~~i~~~V ~/ ~~ t /ry .,..J-.... ~ _. , __ ~G ~ t'~2 ~ l~ ~~~~ . ~Jc~le~rne _____-_----------~ --------_, ~""ail ~;5' L' £~ ci ...._._ .....____ _..____~__---.,.T.._._.__ ~._ ._...____. - ~ ~It3's1S~ ~ ,y~ti~'= r .1~ ~;~~+'I'~~'1 MAY~F`~ET'd~~ ~ ~ ure~aih.2L~iai;e~~ic~~r_stes.s'~,,cruxaintet~_ -•,: p -- 1^xipropcruseanama?ntenanceofyatsrsen#ics}xr~~ncou?d:esuizird3~_. ~~.;_., Zt;!,r_tya~~siit.in,cichasy: -. R - ~T~1?w7S.;'? x3 ids 3.~ ..i=~t+~ ~1L"~ C+,retil?r 3SCP ?dC1TS Efi fiCJQXLC7, k`i Lr£~C~C ~cI Y 3. xhlE.71.4CG '~t1~`t50C. ~ ~? trL'»iITU'Y°~~ >!:~{r C, iex c~l+. e3+. 5i°~ x~ _ y{ 99~~ }}~~ ~P: 'iu `til~A S4 _l= f }Y.~. ~,'~ ~ Qi9. tlll: l.'. LI U~, +..r. tiic oK~~aer ~FUa `~'xC propczty csw-ravr r~~s tc s~bmit,Q St. C~r~4x T-,ona^~ t~e~artQ.~~~F ~' ccrtific:~ti~~ fa~t~, si~:;d u} .. W C~^ifl~^?3i!?fI"17Ci; #'[.SfI'YCi~?3~ULT]~~f t3F 2?IC~flSCu i}itE23Q'=f xd~? rxr`ch„i~i i::~i r x ()Y-Sii:: ire'~S~CR'&[CSCS25jiO5t1~ S` ,.~ ., ~~cecs~ d;, s ~ sP,..dv ~:~= ~ leas ti=n 313 ft?ll e; Sl,;t~ ~.~astcrrl* ra~cr, ioda~n ~; ici vro~er =.i,erati.i*~ ec -:-_ t nia and~nt (~1 ai~zer, ari:~ec~a~ atld ~L*Trdt~t~3 tkt .... r ~ x f ~ £ w~ .,a ~" 1i . n r r* _ , a iuc; t rig ?x*t1L ~i? ~~.ftC' ~° :: ' _ :}; ?"6cr :.", ~'•.Itfl.t"S7~E;Flt.~ w.?1. L~ 5ut~.4,T' ~• f ti 3 s~P x i F "~, 14,d Qi..k C~C.ti`}_~~ '~..:.F~y t t~11r.,~' ~ttLLi.LS .: ... "er'-~, ~3..~_.3 _ "~.a 'SLt U~' ~.1f z~'c.prs_~£±xl£.'1t uT f.a3193I33~SrC sm,..~'FL~ r~:.U i~3j3cTSiF}-~lv 7i tii ~r~z.l'i" r c Sttrf='i ~iflS ~iPC;C2 T31:i1i211ir1°if ~ELS~ ~3£ ~0?I1t7i~tCt~ ~~ CLi'»,.+._~ u" Lttc' ~.~~ c~,~ cif ~~e rhzem dc~dr ~:Yn~,~Jr~Fi dat^. ~ : - C..G `'~ e n ~~ d ~. ~(T..,......- ? - _ -ad~ & ~ai ~. »~ 4 t 1. ~ j` ~:i2 ~.i ~iiL °) t; 3T}-' L~2 f ~~ Si,3ierSL2Ai." 4I t~2lS iCii.+' xt~. ~'~~, I;s i i "Sz tx d1~ ~ r . r r ~ r ~}v ~ ~~: Ch tr'+_- .,i -.-.,~,G }" 'X'1f£?'.C. ~~ ~, w°3^"3II~"~, L`~C:.~ t~'C~Cl3.~~ LTt tL£t~I.. _ ~~, co :. / G . ~ 'c ~- ~~iin~ ~en~rtx-,cac. ` t1..Fd~' Lt7ia`:~iT71T=i'. ' ;'-x..15 iFliS-a'l`~3Tf'S~".ll`'"fktf'.F2,' z.:'Stt~~.23SLikC ;.";k~ZT<"~ f` r;".~".>r':"y31}T_.I'C~'4~:~Cit1J t,~i='~ ~~xewm~ . ~..>~' Tt3~3Ci~ W$T.T3.t`t~r'~ Cite--~ fCf3i"x" €it{; ~' i. T'LSt"r £ } )' <'C~ q~C~ ~M . ~ ' ~° ~$}.C~lgiuf-"'aF'7~f2 ~.iBBS E.S"•li.2t'.t~Y.~fSi$` ..,itTlGk...{;„ , Si:..''-` 7,i: fLCt k:Ftail ljT t"j".~,(. .+, •,~ iapu o~ tE1c Lertificd st~~'ey ,.ae3 if . ,_s,: KGrrw.c.,v.v OCCtlMENT Ii10~ 3ti4942 voi 613 ~ACE4$2 Notep S. iQicctts and Ellenore Niccum. husband and wife, as ioiat tenants. oonreya and warrants to amea ccum an , u y C. Niccutg, husband and wife, aa'joint tenants, tM following dsscrlbed real estate In S r _ ('rn i x County, Stag of W!sconsin: Comtaencing at the Northeast corner. of Northwest Quarterf of Northwest Quarter (NW 1/4 of NW'1/4) of Section Twen ty-five (25), Township Twenty-nine (29) North, of Range Seventeen (17) West, St. Croix County, Wisconsin; thence West 320 feet; thence South 190 feet; thence East 320 feet; thence North 190 feet to point of beginning. .~ ~` STATE BAR OF WISCONSIN -FORM 2 wAaaANT,r ot:Eo TNNI SrACE RESERVED F011 RECOROINO DATA REGlS7ERS OFFICE ST. CROIX CO., W t5t, Recd for Record this 1st ;lay. of_ July A D. 19 80 at 2:00 P ,~, •obr. u..a. RETUIIN TD H/tROLD D. OISON ATTORNEY AT LAW BAl.DWIN, WI 54002 Tax Ksy No. = its ~ ~~ ~- ~xs ~ ' ~° ,~~: ~~ Said real estate is subject to municipal and zoning ordinances and easements of record. is not Thta homestead property. Ilsl (IS not) Exception to warranties: ated tnis 24th day of June csEAy (SEAL.) AUTHENTICATION Signatures authenticated Chia day o! ,19 TITLE: MEMBER Sl'.iTE BAR OF WISCONSIN lif not. - authorized by § 708.08, Wis. Stets.) This instrument was drafted by to 80 °~'~'`~- lsEaW Nolea S. Niccum Ellenore Nicct~ ACKNOWL.EDQEMENT STATE OF WISCONSIN ss. St. Croia County. Personally came before me, this 24th _ day of June, ~ ~9~ the above named Nolen S. Niccum and Ellenore Niccttm, hus- band and wife, as joint tenants, Harold D. Olson, y, ~~~~`~ ~, -. J ' •. Baldwin Wis. 54002 ;~ v ` =^ ~ ~- s _ „~. ~ ~f ~ tdmsknown to be the person ~ who executed the foregoing in- • rL ~ !~ sirnftibnt an k~nj9~wledged the same. } ~i - ~ f- /mil / ~~9.~Q~_./~~~ (Signatures may Ce authenticated or acknowiedge8. Beth a~~ql, ~ .~ ~ p necessary.) ~ ' Harold D. Olson