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HomeMy WebLinkAbout020-1402-08-000 ~,Nisconsin~Department of Commerce PRIVATE SEWAGE SYSTEM safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Kolashinski, Kim Hudson, Town of SST BM Elev: Insp. BM Elev: BM Description: ~i7. (o t5 B- / c57J TANK INFORMATION , ~ TYPE MANUFACTURER , n.,' CAPACITY Septic 1 / 'r.~^l ~ W IrG~_ F.`I h.a+.. ~ /GG O Dig :~ o v ~t 525 ~~I Aeration Holding -, TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic } ~ ~ A f~ ,v `L ,~ Dosing - .-- Aeration Holding 7 Pl1MP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System H TDH ~Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 515068 0 State Plan ID No: Parcel Tax No: 020-1402-08-000 Section/Town/Range/Map No: 11.29.19.2519 STATION BS HI FS ELEV. Benchmark 5,`7 ~~3,5 97. ~a AltrBM G Bldg. Sewer ~ ' ~G SUHt Inlet 5 ..,.1 9 ~. SUHt Outlet ~ • t ~ „7' Dt Inlet ~ \ Dt Bottom ~ ~. Header/Man. '`' q~ 91~ 5/ Dist. Pipe f'' ~ / ~I' L~Y 7 Bot. System ~Z•~ g /~.S Final Grad M, ~~te.. ~~ Z St Cover r~; L ~-r. Z . ~ ~~ `r T J T J BEDITRENCH Width ~ Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth ~ DIMENSIONS ~ / _ Y~ "7 ~e~ L `~ "~~ '- SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~ ~, ~ ~ ~ INFORMATION CHAMBER OR ~J ri ~ 6, Type Of System: ~ ~ y ZJ ~~ `~ /~ ~~ UNIT Model Number: ~ ; ~ ~ ~~ J IIISTRIRl1TION SYSTEM Header/Manifold /~ / ~ Distribution Pipe(s) ~ ~ ~ Di S i x Hole Size ~ x Hole Spacing ~,~ Ven't^to/ Fyif Inta~Q Z a1 _ Dia_ Length ng pac Length a ~. SOIL COVER v Prcccura Svctams f)nly YY M~unri Or At-Grade Systems Only Depth Over Bed/Trench Center Depth Over Bedlrrench Edges ~ xx Depth of` Topsoil xx Seeded/Sodded xx Mulched ~ ~ ~ ~ Yes rte No Yes ~ No ~ . ~_. COMMENTS: (Include code discrepencies, persons,prese~ t e~c.) ``~ ~ Inspect on #1: / / Inspection #2: / / Location: 796 Starlight Ave Hudson, WI 54016 (SE 1/4 SE 1/4 11 T29N R19W) Misty View Lot 8 Parcel lNo: 11.29.19.2519 1.) Alt BM Description = F• ~ ~ G~J{..~- G ~4,;,,~ ~"` ~O G~ ~ 1 ~~ ( 1f-~-- ~c~ ~J~t.~ 2.) Bldg sewer length = Z~ - amount of cover = ~ Plan revision Required 0 Yes ~'No r_ ~g Use other side for additional information. 1L~ __ t Date SBD-6710 (R.3/97) x~~ - --- I epctor's gna Cert. No. ~' ~.tirll.~, piM Siafety scat Api4di,ngia Division County J 201 W. Washington Ave., P.U. 33avt ?l62 ~~j~ ~ Madison, W,f 5~707i,~6 ~ D S'~Crl p ~ ` .~~ p i N ~ a ~ j~~'' Y ,~rn t pm6enr(po be filled is lyCo.) S~ c.~ b(~, Sanitary Permit ,A-Aplication ~'"°°^'~ in ~ with ~ Cam, 53,21(2), Wis. Aden. (=ocla, submission of iha farm m dto approprlsra Awl unit in nagtritM prior m rtMtdning a sanitary pearrnit Nola; A iieati tb ' ' ' ~~ . pp ort rres for stato-owned ;i OIIV 1 $ are aub d t itt h i dd ' i rn r o t e Dapatgnont of Cmrpnq~cc, i'a8enal iafmmtwAr yar pArn~irih may be used ibr seeartdary P A ress( i d tfbrartdan a nlliling a drtr au) i. A iwdo ~rma~i~ra ~Ple~e Print AU l'eto~rrtwti4rA t ~ _. p ~ 1 C(~P ~ ~ ~~. I( Lt C I~~ r V'~ Prgpgty Owner's N~ree ~' > ~ G~ ~ sig. ` ' llhred ~ 620 - /502-• 68 - ~ nM~7 Qvvrter's Meifirrg Addtees t ~ Properly Larrlioe ~ 25 / `3 j1 ~ ST CRU~n.,.~~w I r ~...~ ~ Lt ' ~ Y: - ~.~' < (~rl, Lot City. 3rsta ZipGode C.L' y,, ~''~ '/~. Secgort ~G /~i'G l5 .tJ / ` 5"ycr " loa~ssa°wA! . .. , ~ ~ ~) L~ ii. "7i~ efBpii~aR (ebieclt ~ that apply) ~ Lot ~ cC.~N, R ~ / Q~ Mt ~1 c-r 2 Pamity DVVallir~ ~ IVumba- of 3 ~- ~i 3ttbdivision Name S~br..~ Ala ,.._. C~ PuWiclCamntaxiel -n U t ~ - ~ v,'~_ ~ eser pe se ~e~1'~ ; ~ ~~f ^ 9tste Owned -17ea<xibe 17Ae ~ CSM Numl>cr ii t ~ ~ `J k7a5P~2 ~ T trsnn of ~~ ~ ,' lxi. T ie nrtPena~: (ea~k osiy arse boa ®n ~nae A. craAlp~i~ee s uappifeaWe) A. New s3ystern ----- Replaa~rrxtl gyisem T~t+ealmdfag Tank ~t Only Otbet lriaditfadort W t3ubdag l~P~) lt. Permit t'Ct~tit IinvlAintt Chsnse of panAntTtarAfd'tlo Lid PrntriousPerwrhNuarberand t)rlte isrtled ttratevtntl Hefltte Plumber New Owrta' of POW'EISt 3 Ot1A3>1tIDt3YiP~ Check ail ttlAnt N~,r-Prrssuriad in-cc3rrmnd Pt~rrized ln~t3rarmd At~Ggtide Moond?~A in. ofsritablesol) Mound c?q fa. ofnrintblesoil r~t-kiing 'i nek ^ ~ ~lapersal Canpasene(exptairt) a _ y. n enraVR'rsats~t Area xMmanntloa; ' Desists Flaw (6Pd) laeaign 3p11 AppiiratMn gpdst) t3iapersal Ato4ltaquital( 1DispetAel Atm ofj 8ysAom Blavatian yso , l ~ ~r..~ ~ G' ~.~ ~S ' S", .3d~,~d ~ ~ Vi. Teak islfa Capacity in That ~ of ~ Materiel tie0pns (3allans thtirA Naw Tssks ESrigisg Twt*s ~/ o ~o ~ fir-' s' G~,,JG v-~a f Segdornr Holding Timk ~d4 ( ~j, f . ° t'. e'- _v' rawias ch.,»t~ ~'J~~~ ~~J~' ~s z= ~~ CO,,uC YG ~- i "~' Vti. aAibili BtateAtleAlt^ I, 1M~ fraddnrlpted, aASttke AYa flntfiAa oidre Pt)rYY'i"8 w Alreagaelted e N turr 1YIP Narteer Pitoae ersZ / plntntrer'g Name tPrhni, ~i k° fi~`ber'n~ .~=---~' v2 '~ ~ Q is CL~< G M .S i< <! ` S Phtmber'9 AddteAa (Street; City, State, Zip Cede} -V alt 1"LlAlislt Usk Qn lie lasxred faatittS Appmvrd _ a ed 1'arndt E~aa 8 _ L ner r~neniel $ ~~/ ~ 5-~- b9 T easons iior Eflsa~prarai iX. Cor>rail ~8RS1~'0 R ~aGQ./vle~ ffluent fiber and 3 ~ t k ,~J 5 ~- ~ an ; e 1, Septic ~ serv~. dispersal cell must all be services! maintainer! as per management plan provided by plumber. 2. Ail setback requifernents must bs maintained ~___ - AMseh beawsplerr pbw ~ thesyNua raid satmlr ra rlre CpuAly ep9 sw !'sM'r~ les rem ~ rl~ x A A MeheNa Ike 9~n-~sss tE;. oim~ vailtl ~t Ol!(~9 `~. c ~~ ~~ 0 '~. C ;~ ~, ~ ~ ti ~1~ ~ ~~n ~ ~ q~~ .~ ~ ~_ ~ .~ -_. ~~ o ~ K ~ b rV ,~ Z ~3 ~~ u ~ 3~~ t ~~ ~. ;~ ~~ . ~w ~~ ~~ ~ `~ ~~ ~ d ~ F~ ll ~ ~~ U ~~ ~ ,,~ - ~ ~ ~~ 1 i '3 s \ R' p. ~~. ~' Waxx~n DepaM~ent of Commence Division of Safety and Buildings ~d i~~zs~~ i r~ z~rz~? ~' 3 SOIL EVALUATION REPORT Page ~ of In accoroance wro1 c:omm fSS, vns. Hom. ~.oae t Pl 11 i i i h -_ County ~ ' ( an mus ze. nc es n s Attach complete site plan on paper not less than 81/2 x include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. p / ~ /,, ~ Z v' ~ Z ' ~ ~ `~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 (_X~ Q P/ease print all information. ~ by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~~ Property Owner Property Location ~~.~ Govt. Lot S/" 1/45 F 1/4 S ~/ T Z9 N R ~g E (or)®' Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 13 /~ e Trot ~ ~ ~ City Stake Zip Code Phone Number ^ City ^ village [$ own Nearest Road [~ New constn,clion Use: ® Residential / Number of b~rocrns 3 - y Code derived design flow rate ~ ~ GPD ^ Replacement ^ Public or commerclal - Descx~e: ~ ~'` '~ ' V v ~-c~+--S h Flood Plain elevatan if a hcable rU ~~ ft~ Parent material PP y ry €, General comments $ ?r S ~ m ~ / t / ~ •}o ~ 9 F/ ~ ~ ~ 9 ~ U ~ L. /'~q ~ - -~ 1j and recommendations: ~~ L ~ , >° (C ~/ . ~ P~Q Y~ ~,,, .re.. r- Q/ ' ~ ~ wD7 " ~~ / (.! . T ~' . ~ ', _ --{ ~B'rcvy: ~oc~d an a~.m - ~ ~c~~~ ~ ~~-- ,r eROi~ ~~1 ~~ ~, ~, ' -,- Bonng # ~ ~~ Ground surface elev. ~~' (! ~ ft. Deptti to limiting factor!S~ In `~ ; , ~ ._:--~: \ lion Rate Horizon Depth Dominant Color Redox Description Texture Sure Consistence Boundary Roots GP D/ft' in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. "Eff#1 'Eff#2 I o _g /z 5i 1 z -1^r~ ~ • ~ - Z ~~Z3 / ~ -- m k -~ ~- 5 - - `-~ - ~ 3 3-r~6 ~0 r~ ~ m5 6 rn l - J ~ 1, 2 1 'L• l tt l0 ~J L... Boring # ~ ~~ ®pit Ground surface elev. ~~' y ~ ft. Depth to igniting factor ly ~ in. Sod lion Rate Horizon Depth Dominant Cobr Redox Desfxiptan Texture Structure Consistence Boundary Rools GP D/fr? in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 I -I~f l~ r 3~2 - ~ 2 ry~r ~S l v-~ . 5 ~ 8' ~ I~-y~ s i/ 2 c 5 - . 5 . ~'' 3 ~-~ ID ~`tl~ -- ~ m 5 m ~ - ~ . 7 1. Z .3 92. ~ 'f~`' ' s rte' ~rccl~ /, , S '` ` Etfftlent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/l and T55 < 30 mg/L CST Name (Please Print) Signature CST Number h Z Address Date Evaluation Conducted Telephone Number 211 $0'' Sy0 ~ Cl 15) 241- yov 8 Property Owner ~Yf'(1t 1 t Parcel ID # Page Z of 3 U Boring Boring # ®P(t Ground surface elev. 9f1' ~ y ft Depth to limiting factor / ~ !y _ in. Sal jcation Rate t C l i Redox Descxption Texture Structure Consistences Boutxfary Roots GPD~ horizon Depth in. o o nan Dom Munsell Qu. Sz. Cont Cobr Gr. Sz. Sh. "Eff#1 "Efl#2 ~ a -9 I6 3 2 ~ I Zm m~ c v-~ . 8 2 -sue r- ~ -~ 5~ 1 2nrY~,.b ~ - 3 -rich ~ ~ `~ ~- mS s l - _ ~- ~ J U ~ y ^ Boring # U Boring ^ pit Ground surface ebv. ft. Depth to IKrri6ng factor (n. Soil lip6on Rate ri H ih D Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/ft' o zon ep in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'E1i#1 "Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate hor¢on De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fC~ p in. Munseii Qu. Sz. Cont Color Gr. Sz. Sh. "Eff#1 "Eff#2 " Effk3eM #1 = GODS > 30 _< 220 mg/L and TSS >30 < 150 mglL ' Effluent #2 =GODS < 30 rncyl_ and TSS < 30 mglL 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 60&264-8777. SBU-8330 (R.07/00) ~~~Y OMrt~er ~ ~ ~ ~ 1 ~ Pare ID # 1 "-' 1 ~ n ~ # a ~)~ C.rrn ~nri m afnr~n nln.. ~A • ~ ~ a n....a~, a.. r..._ .r_ ~~_- / / /.. ~ t Page Z ~ 3 ... - -- -- - _~~.....~ ..........n ......... ~ ..- .... SoN ~ Horizon Depth Dominant Cob Redox Description Texture Slrudure Consistence Boundary Roots GP DIft= in. Munsell Qu. Sz. Cont Cobr Gr. Sz Sh. •Eff#1 `Eff#2 ~ ° "9 I6 3 2 "I Zm ~ c v~ . 8 Z -~ r --~ Si 1 2-~h c -' 3 -~~c, r c7 `~ -- m5 5 ( - - Bonng # ^ ~~ ^ Pit Ground surface elev. ft. Depth to limiting tador in. Horizon Depth Dominant Cobr Redox Description Texture Stn3c~3re Consistence Boundary Roots won xauon Kal GPD/iF in. MunseN Qu. Sz. Cont Color Gr. Sz. Sh. "EB#1 'Eff#2 ~9 # ~ ~~ (1 p;+ Ground surface elev. ft Depth to lenity faclnr a., Hor¢on Depth Dominant Color Redox Descriptor Texture Strudure Consistence Boundary Roots Son li GP cation Rate D/fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 "Eff#2 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 =GODS < 30 rrxl/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 TT'Y 608-264-8777. SBU-8330 (R.07/00) PAGE~OF 1~T A MF Spa u ~ LOT# ~ LEGAL DESCRIPTION S ~ ~ SF_ i4 ~,S « T z R,~,R, 19 E(or)~ SCALE: 1"= ~~ BM I ELEVATION /UO.O BM 1 DESCRIPTION ~~ a-~ ~a ~ 3 ~ ~ /~, ~, c, _ --~---- BM 2 ELEVATION `~ ~• S S BM 2 DESCRIPTION •~r~,Q o ~ ja.~{- l~ Z ' ~ /~~_ SYSTEM ELEVATION ~Q 9'~• oU Coow ~.r q 3,0 0 ALTERNATE ELEVATION ~P ~fZ• `l~ ~~,.,e ~ 9/~ $d CONTOUR ELEVATION 9l, • ~ -- ~~ 7 C) TUR.E ~ ~~ ~~~ ~ ~~~ ~ ~ i ~ pod ~^- _ /,•,2 ~`" ~~ ~- •~~ ~ ~ \ ~ ~~'~ ~ lok 1'"~--• ~~.~ ~ f3'2 ~ ... -. ,,.. ~~~ „ G" N SPA. ! i - T ~ ~ ~~~~ :~ ~-~'. ~ TE ~G ' ~/ O/ ~w ~ ~~ • SEPTIC TANK E P[!MP CHAN:BiR CROS_5 S~:G~IO:~ ANA SPLC:1r1~Htswv~ ...~-.- - 4" CSC VENT PIPE' 12" ~~tfN'. 'ABOVE GRAD£ S >_ 25' FROM DQGR, WINDOW OR £R£SH AIR INTAKE FINISHED GRADE ~„ CI RISER ---~ 18" IN. 6ir MAX. ' NLET ~ ~~1 ff ~~ ~ WATER TIGHT SEALS ...i_... PPRDV~D B IPA 3' ~~"' OII. SALID FUMP OFF ELEV . .~ T • A 11EATNERPROOF ,7UNCTSON BOX WITH CONDUIT .~;, ~~ << l` GAS• ; ', TIGHTS SEAL ~ ~ ~ ~ r-' FF APPROVED MANHOLE OVER W/ PADLOCK ~ WARNING LAHEL -:+" MIN . ~~ JDIM'S WI=H APPROVED PIPE 3' QNTO SOLIO SOIL ~~ RISER EXIT P£RMITTEU ONL' IF TANK MANi,1gACTUR£R HAS APPROVAL 3" ,APPROVED. BEDDING UNDER TANK CONCRETE PAD gPECIFTGATIDNS SEPTIC / DOSE NtiMHER DOSE5 PER DAY: __~__- TANK MANUFACTURER : /. ~~~.-. TAN S : SEPTIC ,~„_„ GAT.. DOSE ,~,,,,~,~4 ._ GAL. AlaARM MANUFACTURER: ~ ~ t ~~~+-~ r ~~ __..__._._ MODEL NUMBER : '' ~ ~ .~ ~,...-. SWITCH TYPE; ,~ ~^,~'.~.._..~.~ PUMP MANUFAGTURER : ~+~ G~.c -`~'" MODEL NUMBER : _ _~,~.,~----- SWITCH TYPE: ~x~~'~ REQUIRED DISCHARGE RATE ,",~ GPM DOSE VOI~3ME FLOWSACKG ~ ~~" CAPACITIES : A = INCHES $ s ~^ 2 TNGHES C ~ r $ TNGHES p ~ INCHES ~~~~GAL ~,~ GAL ./,2, ~ -GAL GAL PUMP S ALARM WIRING AS k'£R TLIiR 26.23' WA VERTICAL DIFFERENCE BETWEEN PUMP GFF AND pISTRTBUTION PIPE + MINIMUM NETWORK SUPPLY PRESSUR~T11~t30•FT.•FRICTION FACTOR . • + ~~,/~_ FEET FORCEMAIN X .~:..,~. T.OTAL DYNAMIC HEAD ~z FEET ""1"' F£ET ~pF££T • D_I~AMETER INTERNAL DIMENSIONS OF FUMP TANK LIQUID ~~~ w.,- l~'.~`1~- ~.~•~~"~_ J ,,~, ~ ~~ ~-~./' LICENSE NUMBER : ?~G DATE SIGNED; ~3/? /o.~ 1/8$ ~GOULDS PUMPS APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: 3/e'"maximum. • Capadties: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'/s' NPT. • Mechanical seal: carbon- rotarykeramic-stationa ry, BONA-N elastomers. • Temperature: 104°F {40°C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: l0 fioot standard length,1613 S1TOW with three prong grounding plug. Optional 20 foot length, 16/3 S1TW with three prong grounding plug (standard on EP05). ®2000 Goulds Pumps Effective February, 2000 83871 • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic Semi-open design with pump out vanes for mechanical seal protection. Submersible Effluent Pump 30~ I EP05 ^ EPOS Impeller. Thermoplas- tic endosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover. Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. METERS FEE7 ................... _.....,._.._.;.._._._..._.._,..........._,..,.._.._......_.....,.... 10 _.. i 4 `~ _.! .__ 30;"'" ~ s . '.. i_.,... ...___......... t .. .... . ~~.........._ ............................e-......................................,M1,..._.,..........,.d- zs ~~ s i v 6 20 a , __ _ 5 0 , , -~~° ..._.. 15' 0 3 10 2 ,. _ _ ... s __ 1 ;. .__ _.. ~.....__.._....' 0 00 10 20 30 ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING ~' Canadian Standards Assadation (CSA listed model numbers end in "F" or "C".) Go~dds P~renps is iso Soot Registered. GPM FT - EPO4 Q...... 50 GPM 0 2 4 6 B 10 12 m~/h cnrnciTY Goulds Pumps ITT Industries POWTS OWNER'S MANUAL & M~I,NAGEMENT PLAN Page of FILE INFORMATION `m 1 S~ 'V 1~,~+J L- Owner ~~ t'c~ ~ 0..bh n5 ~L Permit # DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~.SQ allda Design flow Ipeakl, (Estimated x 1.51 ~'Q gal/da Soil Application Rate al/da /ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oii & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (RODS} 5220 mg/L ^ NA Total Suspended Solids {TSS) 5150 mgll. Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOOS} 530 mg/L Total Suspended SaGds (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size Y8 in die. ^ NA Other: ^ NA "Values typical far domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS ~, Septic Tank Capacity Q"©Q al ^ NA Septic Tank Manufacturer r'Cs~ ^ NA Effluent Filter Manufacturer 6 d /y ~ c ~. /~ ^ NA Effluent Filter Model Pump Tank Capacity ~"',~~' 4 al ^ NA ^ NA Pump Tank Manufacturer ~ shy ^ NA Pump Manufacturer ~D-!4 ~ ^ NA Pump Model ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Fiker ^ Wetland ^ Other: ^ NA Dispersal Cells} ^ In-Ground (gravity} ^ At-Grade ^ Drip-Line ^.NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency inspect condition of iank(sl At least once every: ~ month(s) (MaxMwm 3 years} earls} ^ NA Pump out contents of tankts) When combined sludge and scum equals one-third (Ys) of tank volume ^ NA Inspect dispersal cell(s) At least once every:. ^ monthlsl (Maximum 3 years) ~'year(s} ^ NA Clean effluent filter At least once every: month(s) ear(s) ^ NA y Inspect pump, pump controls & alarm At least once every: ,.--. ^ month(s} ^ year(s) ^ NA Flush laterals and pressure test At least once every: ' ^ month(s) ^- ^ year(s) ^ NA ocher: At least once every: ~ yea~j t(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 certffications: 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 obsewation 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 (Y3) or more of the tank vofume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page of 8TART UP AND OPERATION ~ a of painting products or other chemicals For new construction, prior to use of the POWTS check-treatment tanklsl for the presenc that may impede the~treatment process anchor damage the dispersal celitsl. if high concentrations are detected have the contents of the tanklsi removed by a septage servicing operator prior to use. System start up shall not occur when soil conditir.•ns are frozen at the infiltrative surface. During power outages-pump tanks may fill arove normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal ce111s1 in one large dose, overloading the ceillsl 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 Maintainer to assist ai manually operating the Pump controls to restore normal levels within the pump tank. Do not drive or ,park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slaps of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; degreasers; dental floss; diapers; disinfectants; fat; baby wipes; cigarette butts; condoms; cotton swabs; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; all; painting products; pesticides; sanitary napkins; tampons;-and water softener brine. ABANDONMENT shall be taken to insure that the system is When the POW'I'S fails and/or is permanently taken out of service the following ~~ properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • Ali piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled witl soN, gravel or another inert solid material. CONTINf3ENCY PLAN taken, to provide a code complian If the i'OWTS fails and cannot be repaired the following measures have bean, or, must bif replacement system: ^ A suitable replacement- area ha hobeenbevaotected f om disturbanice and compe~io~ ~finoe nfri gad ponr6 system. The replacement areas P nt area wi required setbacks (room new soil and s to ev a uat on reestablish as snud'ttabie replacement ares~RePiacemen~t~sY~e~ mug e~esult In the need f comply with the rules in effect at that time. advances in POW7 ^ A suitabia replacement area is not available due to setback and/or soil limitations.. Barnn9 technology a holing tattle maybe installed as a last resort to replace the faded POWTS• ,~~~sa.,~e_.~f~g PAWTC _a neil'attd Si _ a_ _..dilsb.la : s,~ hnlclkirJ tai Q '~ha Site h : ~ • e lar~an+ et arari if e d ^ Mound and at-grade soil absorption systems may be reconstructed in piece following removal of the biomat at infiltrative surface. Reconstructions of such systems must comply with the rules in effect'at that time' < <WARNINO> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN NETC RCUM TS ANCES ,ODEATH MAY RESUL~o~cUE OP ENTER A SEPTIC. PUMP OR OTHER TREATMENT TANK UNDER A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADD1110NAL COMMENTS - POWTS MAINTAINER pOWTS INSTALLER Name Name ~f ~ ~`1r. G( sa-+ yrs. s~B Y' PI10ne Phone 7 l ~ ~ -- .4 .%~ ' LOCAL RC~ULATORY AUTHORITY BEFTAOE SERVICING OPERATOR (PUMPER! Name 5~. p; !~ Go v w ' ^' Name ______- Phone 7/ ~ ~(p-y Phone yVisconsin vivo Code. This document was drafted in compNance with chapter Comm g3.221211b11111d1$If1 and 83.54111, 121 & 131, ,_ ~ ~~:, ~: ~ ,z ~~ t r ~ _ f>~ y x ~kYF ~k ~ t ~„t {. ". e ~.. ta, K r ~~ KA1• L ~' s! ; Y cp ~Qa~ a~~,C7~.1c7~1[r~ ~.ti~ . _ ; :~ ~Lg'9bZ N "~ ~ ~, ~ ~ ~ i ~~ I ~\~ `S . , ~ ~ `~/ 1 *.r 1 O J~~ N~ LL ~O Z _.. , a ~ o ,,Q ~ .. !~~ 95' ~ p- ~ 138• J ~ ~ ~ .~ g8.8o ~ ° 8~33~~ ~. ~ 12 N ~ ~ i~ 5 1 O \ / i - / ~AVENVE 0 8,33„E 26 080, ~ ~ ~ ~ ~ // 5 S _ 245 - G '~ .76'- - /. - ~ N 1~~0 / ~~ \\ O ~ ~ Or ~~ \~\ J O^ N W Z W~ ~a0 0°~ Jcva~o W~ ~VN ~ ~a~ n ~$~ N N~ W a O N O m~0 ~ OWN LL~U~=Z ~~WW~~ Z~~W?Q VHV~~~ i I q' M \M . N ( ~ ~9 9W I ~ ~ I `\ ~ ~ / \ I ~ \~~ ~ ~ ~ '~ . I,`~ _ ~ i ~,, Z 50~ ~ I ~ , N / I~ / ,~/ ~ . ~ ~ ~ ~~ ~ ~ ~. , ' / .-~ • ~ ,~ i ~ - , ~ . ~ ~~ ~ ~ W ~ ~/ 1A ¢ d i ~ / ~ b0 ~''~ \ OHO \\ N ~ 2i, ~~~ c'~o~ ~~ `S ~~ i O 11 JO 3 ri ti ~. _°~ t0 ~59~~ oour,~+rsu..w ur@TV U~I~IU - -- rig ~~-~-- .. N~~ ~ ..~ ~~ ~~ k ~~ 5T. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT WNERSHIP CERTIFICATION FORM Owne uyer _ ~YYt irh ~D IAS1n l r-S Ka Mailing Address _ 1~1.U3 1..t.~.~int?,~ ~t'tye. ~ 1~t Snot ls,Zl 5401(c ._ ._ _ _ Property Address '1 ~i(n SkG~' i'~ Gl~±~ A~>°n~lst.. - - - (Verification required from Planning & Zoning Department for new construction.) City/State ~ttc.~SOr1 r 1,01 5 461S,o parcel Identification Number OoZO - 190a - bB -~~ LEGAL DESCRIPTION Property Location-S~ 1/a , ~~i/a ;Sec. ~l , T ~~ N R l ~ W, Town of ~,i>s~ Subdivision _ Mts+,~ U~~ ,Lot # ~. Certalfied Survey Map # ,Volume ,Page # Warranty Deed # ~~~ y6~ ,Volume ' lq~ ,Page # 45a Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and mairnenance 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 l2 - 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standanls 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 returtud to the St. Croix County Planning & Zoning Deparament 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. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms `~ k~mn Y.~E'J1~~u1v~A1`.~.. SIGNATURE OF APPLICANT(S) .Sly oL DATE ***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. 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