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018-2011-94-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix . Safety and Building Division Sanitary Permit No: INSPECTION REPORT 578904 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)j. Permit Holder's Name. Village X Township Parcel Tax No: Felicity City Homes Hammond, Town of 018-2011-94-000 CST BM Elev: Insp.BM Elev: BM Description: , !� �- _ �l- Sectionrrown/Range/Map No: TOP 6F EG�'�� ED, ,cr/C�'— 30.29.17.1101J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /Zrn Jop of kl �� �%-3v 1/0.l� 7� Dosing Alt.BM Bldg. Aeration g• Z. Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet (p•QS /03•,.,/9� Septic }�� �n Dt Bottom pi� l�8y /0D-0( Dosing 4 '" Gt u Header/Man. 3.33 /D7•S7 A11,4 Aeration Dist.Pipe 3-?j3 167 S7 Holding Bot.System /' 106.00 Final Grade 12.30 1.,$.190 PUMP/SIPHON INFORMATION Manufacturer Demand St Cover Z.6z 108 Zg 616W GPM 001 T ac. Model Number h 5-0 �oS�9Q TDH Lift �, Friction l oss System Head TDH Z Ft ^ @ p, t1afo $.3 0 l oz.(j 0 ' • .L YrRQ� lForcemain Length, Dia.Z„ Dist.to Well LS SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 7J! SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer: �- INFORMATION CHAMBER OR Type Of System: 7v 7! N/� N/n UNIT Model Number: yNiuNArD /' DISTRIBUTION SYSTEM Header/Manifold Distribution f x Hole Size x Hole Spacing Vent to Air Intake rr Pipe(s) f ��' (�! S/�2N Length Dia _ Length Dia Spacing '�+' i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedrrrench Center Q ` Bed/Trench Edges D !I Topsoil X Yes Ej No Yes 0 No COMMENTS: (Include code discrepencies,persons present,etc.) In ectio #1: s / !_/� Inspection#2: PL r )a63D Location: 1506 78th Avenue Unknown(NW 1/4 NW 1/4 30 T299.30 N R17W) Emerald Acres Lot 94 Parcel No: 30.29.17.1101) 1.)Alt BM Description= f 5) Z �✓ ��3 2.)Bldg sewer length= �/ -amount of cover=� yryi /�� � .�j Plan revision Required? Yes No Use other side for additional information. Date Insepctor's Signature Cert.No. SBD-6710(R.3/97) PLOT PLAN PROJECT Justin Leach ADDRESS 1403 Ctv RD GG New Richmond Wi 54017 NW 1/4 NW. 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST.CROIX SYSTEM ELEVATION 103.6' DATE 3/26/15 BEDROOM 4 CONVENTIONAL IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none Ilik BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Property Line B.M. All piping shall be SDR 30/34,within 10, fi T of tank,piping shall be Schedule 40. B- 1 Scale _ 1 /4'1 = 10' 7% Slope Area 15' below systeh is in undis urbed B-3 B-2 15 Grading is to be done to 101 ' divert run-off away from system 102' 10 .6' 103' +P 104' V Huffcutt Combo Tank Wet is/to all DNR setbacks Tank is to be porperly bedded and provided with Pro 4 Bedroom lockdown covers with House approved warning labels 400' Property Line Z n J �b Town Road copy K`l „� 0, Safety and Buildings Division d L s A le r. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) P '� ' a. Madi 5 162 al a tf)" �t�_% 0.:',c•ff Lr S -. Y Y State Transaction Number �$ t1 hermit Application 25 21 a(0 5 In accordance with SP 38 V+ s Aden Code,submission of this form to the apprupiiate governmental unit is required prior to a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of S ety and Professional Servies. Personal information you provide may be used for secondary 4) purposes in accordance with the Privacy Law,s,15.04(1)(m(,Stats. 5-f 16 —1 B ft" Ave v`()6 kkkit'� I. Application Information-Please Print All Information J lJ /1 Property Owner's Name O%.�� Parcel# %.�,/e/ Ll✓C �/ �,8— 26. — 9 °°° Property Owner's Mailiness Property Location Govt.Lot r 1 I b!LT) City,State Zip Code I Phone Number M,t.'-. ) f' /14... y,, Section 7�? 7 ib tC_1 ('Au 1/0\ i ", ')] 7 7� N; RE rR1 U. ype of Building(check all that apply) Lot# 1-or 2 Family Dwelling-Number of Bedrooms Subdivision Name Bloc # / rat /r'�i�.�„CT 4/e-d ❑Public/Commercial-Describe Use 6' - t I ❑City of �� CSM Number ❑Village of ❑State Owned-Describe Use 0 E3 'x 5, 0 fJ (-L ,e-Town of rat tvLt/1�/- Ion ND CL AFT ISo..:. i _•, ' • (Check only one box on line A. Complete line B if applicable) - New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only I ❑Other Modification to Existing System(explain) lam. '' i ; B. j List Previous Permit Number and Date Issued ❑Permit Renewal ❑Permit Revision ❑Change of Pi ❑Permit Transfer to New Before Expiration Own er i Co Vl//�, // Z (P1 IV.Type of POWTS System/Component/Device: (Check all that a t ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gra.e al.I Mound>24 in.of suitable so' ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) - eatment Device(explain V.DispersaVTreatment Area.Information: GttiCl /ill--: /7 if grr Flow(gp9 Desipnt S91 Applicati P,* (gpdsf) Dispersal Area Re wired(sf) Dispersal Area Proposed(sf) System Elevation _y 9 ,6'‘ro,lifi _ /e'-', b' VI.Tank Info T acity in I Total #of Manufacturer u v 3 Gallons Gallons Units o � v New Tanks Existing anis 1_ , © ” J ° v g ki �e r b// it Z �Pun�th Septic or Holding Tank // Dosing Chamber K I /6 c / I . � X. I ! C Lit `f tl�L�� /� I VII.Responsibility Statement-I,the undersigned,assu„I es,i nsibility for installation of the POWTS shown on the attached plans. Plumberr''s Name(Print) Plumbe y..∎ure MP/MPRS Number Business Pholne N bier/ / Plumb 's Address(Street,City:State Zip Code / / - " - .(---71- A- --e-c-(._,.../C-/ (2_4 (,(' A ,_.5V1)i ( VI ounty/Department Use Only Approved ❑ :'. . roved Permit Fee DateIssued 4 6 1 Issuing.Agent g • ure ❑ •.•: riven Re. ..for Denial S 6 2 y OD / /VI.. !' / 9v,4narslEA, DIVISION OF INDUSTRY SERVICES 77', • ro,,, 10541 N RANCH ROAD c" a ;m HAYWARD WI 54843 s ,y, Contact Through Relay http://dsps.wi.gov/programs/industry-services K,„ ti �o' ssrov www.wisconsin.gov Scott Walker,Governor Dave Ross,Secretary April 02,2015 CUST ID No. 226900 ATTN.:POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/02/2017 Identification Numbers Transaction ID No.2527865 SITE: Site ID No. 811289 Justin Leach Please refer to both identification numbers, CO RD TT above,in all correspondence with the agency. Town of Hammond St Croix County NW1/4,NW1/4, S30,T29N,R17W Lot: 94, Subdivision:Emerald Acres FOR: Description:Mound,4 bedroom residence Object Type:POWTS Component Manual Regulated Object ID No.: 1529942 Maintenance required; 600 GPD Flow rate; 33 in Soil minimum depth to limiting factor from original grade; System(s): CO 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 DEPT The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes PROFES' and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed DIV1SlON OF 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 —,--1 requirements. JJ No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, SEE C(i' stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • 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.In addition,the owner must insure that the operation,maintenance and monitoring duties as described in section VIII of the mound component manual are complied with.A copy of this information must be given to the owner upon completion of the project. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. • Limit activities in the area 15'beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384.10.No fixture,appliance,appurtenance,material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system,unless it 1 SHAUN R BIRD Page 2 4/2/2015 is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(i). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. 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. 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 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 This Amount Will Be Invoiced. When You Receive That Invoice, Please Include a Copy With Your Patricia L Shandorf Payment Submittal. POWTS Plan Reviewer,Division of Industry Services WISMART code:7633 (715)634-7810, Fax: (715)634-5150,M-F 8:00 a.m. -4:45 p.m. pat.shandorf@wisconsin.gov cc: Edwin A Taylor,Wastewater Specialist,(715)634-3484,Monday-Friday 8:00 am To 4:30 pm Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 3/26/15 Owner:Justin Leach Location: NW1/4 NW1/4 S30 T29 N,R17W Lot 94 Emerald Acres Hammond Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section :DITIONALLY 4. Pipe Cross Section/Pipe Layout )F ROVED )F SAFETY AND 5. Pump Chamber Cross Section aIONAL SERVICES 6. Pump Curve INDU i� RVICES 7-8. Maintance and Contigency plan 9 Yp 9-11. Soil test )R:ESPONDE 12. Filter Specifications a • ross section Shaun Bird ,F Signature �� License num.- '6900 PLOT PLAN PROJECT Justin Leach ADDRESS 1403 Ctv RD GG New Richmond Wi 54017 NW 1/4 NW. 1145 30 /T 29 N/R 17 w TOWN Hammond COUNTY ST.CROIX SYSTEM ELEVATION 103.6' 3/26/15 4 BEDROOM DATE CONVENTIONAL IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND )0(X SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none ■ BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H,R,p, Same as Benchmark Property Line BEM. NIL All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. B- 1 • _/ Scale = 1 4" = 1 0' 7% Slope �h Area 15' below system is to remain undisturbed VA /(.3 B-2 Grading is to be done to 101 ' divert run-off away from system 102' 102.6' 103' 104' Huffcutt Combo Tank A Wel is to meet all WDNR setbacks Tank is to be porperly bedded and provided with Pro 4 Bedroom lockdown covers with House approved warning labels 400' Property Line • Town Road - Mound System Cross Section and Plan View �• _.fin _ - _ �.. �• �• �• �. �. �. •� �.. •� Dimension Feet r ♦ - A.•::H:::::::::::::::::::::::::::::::::::::::::H::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::: ::::::.. I 1 B 17. 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L, ::::::.:::;:.: W 5- i �.•. G t I H t? I I - i J J I. K I L U ■ - ' W •• • ' �1 K T B + Z 1 53 Slope L I- 1 =Topsoil =ASTM C-33 rr}r��} = Clean aggregate = 4 in. sch. 40 pvc I I s}r.r}• rr}r}r} Cap Material sand fill ,,;" 1/2 to 2 '/2 in. dia. • L) observation pipe • Geotextile � H Fabric ,r�:., y�y�1r1r.;.r.r.r.. + r}.h. J�:�r ,r�:,rrr:,}r�' F r}l• r.r.r.r.r.r.r•::::':':':.:.'. '03 -6o r•t f•r•l.; L•1• 4.4•M1•L•1•M1•1•M1• D•:ii i PWAVAi IVA ii►'� its .:.*044;140 ::: : : ; r11 .ti 11 �►t,�, i► 111 11�,i' . � aA�- `111�ti11►11ar ,;1� 11111��_f 111 1'"1 1111 .: .... -a+ti tittitit�12 Plowed Surface " ' L ti�iitiii�itiyiii»:» j 02% It Contour ---•.mAglIkutiii�itil Slope Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x W) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a 1/4 inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flange. 10/07lgj Page of Pressure Lateral Layout . Two Laterals -- End Manifold f--- `Threaded Cleanout Lateral Turn-up --► Plug Manifold 1-1 —. I --'-------+411k. . \ 4, M \)11, . .1. ...--3:k 1 1 l i X --; I lJ Long Force Main / Sweep 90 Bend Distribution Network Specifications � Pressure System Construction Lateral Diameter 2 In. Manifold Diameter In. Laterals are constructed of Schedule 40 PVC Orifice Diameter 51-327 In. pipe. Orifices are drilled perpendicular to X(Orifice Spacing) a q In. the pipe with a sharp drill bit and face down. L (Lateral Length) 2. Ft. Lateral turn-ups terminate with a threaded M(Manifold Length) q Ft. cleanout plug and are enclosed in a 6-8 inch Main Diameter In. diameter lawn sprinkler valve box accessible Force Force Main Length gQ Ft. from finished grade. • • • • • Grade • • • • • • :::::::::::::: . . 6-8 Inch Lawn dB Sprinkler Valve NI Box m OF Page of 03/05 lgj Septic-Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer 1A;k4_ Pump Manufacturer 228 i Tank Model Number ( 1.so I'l Pump Model Number g / 45 Z i — Alarm Manuufactuuer ve,e,7� 57 Total Tank Capacity "�- ��-s 5 "1 � � Alarm Model Number JL,/ Max. Bury Depth , � 9 Switch Type . n? e 4- Total Dynamic Head(TDH) - Feet Filter Manufacturer l Filter Model Number j Elevation Head / 0 Distal Pressure 3, S Network Loss / Minimum Pump Performance Required I Force Main Loss Zr 2 LJ 0 GPM!1 @ I / „j' Ft TDH Total /6 3 Outlet Manhole Min.4"Above Grade With Manhole Min.4"Above Grade Looking i?euice. Inlet Manhole all Securely Mounted With Locking Device <�"Below Grade Sealed Watertight Weather-proof P 1 ► E ? Junction Box "f' 'ter r r r -• Finished Grade `i l i l ��' rrr Vent Min. 12" ! [r � ! i Disconnect ( . _ Above Grade ■liuM } Means IIII . With Vent Cap r:i.` <•a::`art`�•::sr : •r .. s .•r•r > Y a r MIN • N Outlet Filter ___.,_,.,4._ =f� _____ -l■ MN inlet Baffle ` Inlet : , �-- ,. ,.rr 1 a nNJ+i .4, A 1/4)S •+ and Reserve Capacity ........ iiAii a. � , Switch Settings ' GPI I� Hole Tank Volume= / g `; Inches Volume Gal. ' Dimension. .. :'r Off 1 vation C (alarm) B ��� Ft ! Bottom < a> .. (dose) C /off �, D �� Elevation :> (dead) D �� ``a, ` sums '' Total : Ft :::: ` a`::a i•<`.:a`: :a•:aY:.Y::+r a:fY:rsY:ra:+>+Y.r{•:•aa•:;::;;< a >• • .:. <e.a a s•`><:<�t: raaraYaY�YrY�i i�.`:.`: :.<a:.; it septic/dose tank is bedded and back filled in�u��re with not GENERAL INSTALLATION: The septi depth of bury as specified by the manufacturer's val ifiications. Maximum dep device (pay not be a ceede without prior ao exposed to grade have an effective locking t fittings,s and be exceeded without�pt'tox appmv�• Manhole covers expo roved material, connected to the tank with watertigh g installed. Piping at the inlet and outlet is g app The force main is sleeved with 4"Sch.`w PVC to bridge the tank laid on stable soil to prevent settling or fig' complies with NEC NO and Comm lb.2x. excavation and the sleeve.is sealed Watertight. Electrical service comp Page of 02/05 LI • - TOTAL DYNAMIC HEAD/CA?ACJ(Y PER MINUTE CURVE EFFLUENT AND DEWATERING •HEAD CAPACITY 1,----c,i MODEL 152/153 � __ i W MODEL 152 153 t 50 Litrs I — 15 69 1 29 —- I I 231 0 231 I 12 4efI , 5 i 4.6 T i 20 1 6.1 I 44 167 I 52 i 197 z I I 75 , 34 129 42 ;. t_y 30 ;C j 2z % 8 j 25 20 i I __ I _�i i 42 I — — ' o {� kvo 138.0 44 ( .4.r� — c 4506 4-1 10 _� — I i , I I 0 20 41 60 80 100 GALLONS 320 5i8 •-� LITERS 0 80 160 240 2;i z FLOW PER MINUTE /ft,. ai'` � _7/ CONSULT FACTORY FOR SPECIAL APPLICATIONS , � . �-J ; 2, •Timed dosing panels available, supplied with �' 1- •Electrical alternators,for duplex systems,are available and supp ; an alarm. •Variable level control switches are available for controlling single phase i systems. j — — , ■ •Double piggyback variable level float switches are available for variable level long and short cycle controls. },-x,`� •Sealed Qwik-Box available for outdoor installations.See FM1420. - •Over 130°F.(54°C.)special quotation required. z 1 ,V �- ,� I - , 1 --r",,—Fi 1521153 Series d I 1521153 MODELS Ccmtrol S_ __election.--"I , 5 t�o I Model Volts•Ph Mode Amjs Simplex_.ii 0uplex_; f 8.5 1 2 or 3 j s c20en N152 115 1 None j Inciuie _ z f -� �'' h u'a: �-L 6N152 115 1 Auto 8.5 � � - ' E 152 230 1 Mon 4.3 1 I 2°r 3 8E152 230 Auto 4 3 Inclined 2 or 3 Non 10.5 t SELECTION GUIDE L BN153 115 t0.5 inclined 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float �BN153 115 1 Auto 1 i 2 or 3 � E153 230 1 Non 5'3 8E153 230 1 Auto 5 3 Included r2 or J switch. Refer to FM0477. 2. See FM0712 for correct model of Electrical Alternator E-Pak p CAUTION 3. Variable level control switch 10-0225 used as a control activator,specify duplex{ ) All installation electrician.n. Abele el ectrical and safety codes should d be followed including the most or(4)float system. licensed N eional El Ali Code(NEC)l and tY recent National Electric Code(N and the Occupational Safety and Health Act(OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAlL TO: P.0-BOX 16347 Marufacturersof. " A - /5O2tz .1(aoo)9281'0MP Louisville,KY 40256.0347 ° wS ` yg- E t `- Ql/QUTY PUMPS /NCE Zo �� � L X(502)FAX 24 hip;//www.zoetl er.corn ©Copyright 2000 Zoeller Co.All rights reserved. ST. CROI.X COUNTY SEPTIC TANK MVIAIN'CENANCE AGREEMENT AND OWNERSHIP CERTIFICATK.N FORM e Owner/Buyer c„( 4-70, •Mailing Address / b Property Address 5-No o 7 U h A/c (Verification required from Planning&.Zoning Department fur new construction.) Ut8 - 2011 - yL - a60 Cit y/State it_b_e1/}"S ,51-/b23Parcel ldeittiicatton NISI bet 4 # LEGAL DESCRIPTION Property Location n' 30 'I' Z N R L 7W, Town of /N Subdivision fn,r✓_ Certified Survey Map # Vc lu rtf; Page /J -- • Warranty Deed �C� l� �--- t3' Dd # .._._� t✓ / ' V volume Page re #r` Spec hous yes no l.ot lint:. identifiable yes no • SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its pr:amatu.re failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, it 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 wasie disposal system. Owner maintenance responsibilities are specified in§Comm. 83.52(1) and ian Chapter 12-St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zo.n nng l.)eparlrnent 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 inspcc ion 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 completes l and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all s rents on .is form are iru.e to the best of my/our:k nowledge. I/we andare the owner(s) of the property described above, by virtue of a wan my deed recorded in Register of Deeds Office. Number of bedrooms • SKiNAftIR OF APPLICANT(S) UA,1I, ***Any information that is misrepresented may result in the sanitar y permit being o woked by the I Iarning &Zoning Iepartmenx..r , Include with this application a recorded warranty deed from the Register of Deeds :Alice and a copy of the certified survey map if reference is made in the warranty deed. (REV.08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE`INFORMATION SYSTEM SPECIFICATIONS Owner -I a..,4 f r/ - k P � Septic Tank Capacity gal ❑NA Permit# Septic Tank Manufacturer e,,,ej❑NA DESIGN PARAMETERS Effluent Filter Manufacturer ��12_ ❑NA Number of Bedrooms l ' ❑NA Effluent Filter Model ❑NA Number of Commercial Units - A Pump Tank Capacity 7,1,..5- qal ❑NA Estimated flow(average) 900 g auday Pump Tank Manufacturer ,� NA Design flow(peak).(Estimated x 1.5) COO gaVday .Pump Manufacturer i,� ❑NA Soil Application Rate /i 0 gal/day/ft2 Pump Model &j`.)/,5 Z ❑NA Influent/Effluent Quality Monthly average* Pretreatment Unit A ❑Sand/Gm/el Filter ❑ Peat Filter Fats,Oil&Grease (FOG) 530 mg/L ❑Mechanical Aeration ❑Wetland Biochemical Oxygen Demand (BODS) 420 mg/L ❑ Disinfection ❑ Other. Total Suspended Solids SS) 5150 mg/L Manufacturer Pretreated Effluent Quality A Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BODS) g 530 mg/L ❑ In-ground(gravity) 0Jn-ground(pressurized) At-grade ound Total Suspended Solids (TSS) 530 mg/L ❑ 0 Fecal Coliform(geometric mean) 510'cfu/100m1 ❑Drip-line _ Maximum Effluent Particle Size Y inch diameter • Values typical for domestic(non-commercial)wastewater and septic tank effluent ' .** Values typical for pretreated wastewater. MAINTENANCE SCHEDULE . Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third(Y,)of tank volume Inspect dispersal cell(s) j At least once every 3 ❑month year(s) (Maximum 3 yrs.) Clean effluent filter At least once every / [ ❑ months ' ear(s) Inspect pump,pump controls&alarm At least once every '7 ❑months years) ❑ NA Flush laterals and pressure test At least once every �')❑ months earls) ❑ NA Other. At least once every 0 months ❑year(s) ❑ NA tother. At least once every ❑months ❑year(s) ❑NA MAINTENANCE INSTRUCTIONS of the following licenses or s of tanks and dispersal cells shall be made by an individual carrying one Ins n o Septage ti Sewer,POWTS Inspector, POWTS Maintainer, S p g Sewe p� certifications: Master Plumber, Master Plumber Restricted , Servicing Operator. Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware,identity any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up l cells shall be visually inspected to check the effluent levels or ponding of effluent on the ground surface. The dispersal ( ) aril on the Po 9 in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. accumulation o f sludge and scum in any tank equals one-third(Y,)or more of the tank volume,the When the combined accu 9 NR entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with 113,Wisconsin Administrative Code. . The servicing of effluent filters, mech nical or pressurized POWTS components, pretreatcment components, and any other maintenance or monitoring at irervals of 12 months or less shall be performed by a certified POWTS Maintainer. A servicf report shall be provided to the local regulatory authority within 10 days of completion of any service event. STARTUP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s)for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s)removed by a septage servicing operator prior to use. Page of , START UP AND OPERATION painting products or other chemicals that For Impede the treatment pto rocess use of and/or POWTS damage the dispersalt ell(s)) if high concert ations are detected have the contents of the may impede the treatment process an tank(s)removed by a septage servicing operator prior to use. System power r shall not occur when soil conditions II above normal highwater levels. When power is restored the excess�a ;�arge to of ew will by discharged power the pump tanks may large above power to U7t. e is of the pump tank removed by a Septage Servicing Operator p for otostrestore normal levee discharged to the dispersal cell(s)in one large dose,overloading the cell(s)and may result in the backup effluent avoid this sir cont ct have the contents operating the pump effluent pump or contact a Plumber or POWTS Maintainer to assist in manually op within the pump tank. s over tanks and dispersal cells. Do not drive or park over or otherwise disturb or compact,the area within Do not drive or park vehicles at-grade soil absorption area. 15 feet uc ion down slope a any mound or at g and fat; foundation the T5: of the following from the wastewater stream may improve dentalefloss�diapers; disinfectants;prolong the iife othe P od ct�s; antibiotics;or baby wipes; o condoms; cotton swabs; degreasers; (sumptipu; baby wipes; cigarette butts; gasoline; grease; herbicides; meat scraps; medications; oil; painting (sump pump) water; fruit and vegetable peelings; 9 pesticides;sanitary napkins;tampons; and water softener brine. ABANDONMENT r is permanently taken out of service the following steps shall be taken to insure that the system is propelly When the PC}WTo fails and/or p Wisconsin Administrative Code: and safely abandoned in compliance with chapter Comm 83.33, i e openings sealed. • All piping to tanks and pits shall be disconnected and the abandoned sad of by a Septage Servicing Operator. • The contents of all tanks and pits shall be removed and properly d • After pumping, ail 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 compl ant replacement system; replacement soil absorption systelm. p A The suitable replacement ant area should be protected from disturbance and ecompaction and should not be infringed upon absorption required Tee rck froment lot lines and wells. Failure to protect the replacement area will result�e fe�ineed for setbacks from existing evaluation proposed structure, for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply effect at that time. ❑ A suitable replacement area is not available due to setback ked/oOs�Smitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace site has not been evaluated to identify a suitable replacement area. Upon failure othe e a POWTS tank may steinstalled at On ` mint be performed to locate'lea suitable area. replacement a last resort to replace the fa and and at-grade soil absorption systems may be rewconstrructed in in plaeet following 1e,moval of the biomat at the infiltrative surfa . Reconstructions of such systems must comply with «WARNINGS? SEPTIC, PUMP AND PUMP OR TREATMENT TANKS HE T TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT.RESCUE OF A ENTER A SEPTIC, PUMP OR OTHER TREATMENT T PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE, _' ADDITIONAL COMMENTS POWTS MAINTAINER I- POWTS INSTALLER Name � � 'J ' Name �/ L! _,� Phone ' �-- Phone • • LOCAL REGULATORY AUTHORITY SEPTAGE SERVICING OPERATOR(PUMPER) Name a '' ` Name I/ _,_. Phone pzS 0.2.--r— Phone �� 3 MN/ ce with chapter SPS 383.22(2)(b)(1)(d)&(f)and 383.54(1),(2)&(3),Wisconsin Administrative Code. This document was drafted in compliance 911 savioH All113d :.., ti izzs 3 i .., .A 020EAOke SDNIMY1,0 a •7 in 31Yel NNW& NOWArti053a ACI agalivtai Atiel L.66 1 MEE .9itiL E-4. A A AIL 1.-.1.1. t-=- j le ,\,,. L) -•,, IL.1' i ![ /./ k:, 1 '‘ RI ;,17 7//...tt- vow ,- `..- . .., i '_,./ A /\ , i .u,a ■ a 4til:9. • . 6,-, ' a, te. 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 08/18/2009 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner 0-STOUT, RICHARD 0 RICHARD 0 STOUT C-BAST, KERNON J KERNON J BAST 1353 AWATUKEE TRL HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *= Primary Type Dist# Description *1506 78TH AVE SC 2422 SCH D ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.270 Plat: 5648-CSM 24-5648 018/2009 SEC 30 T29N R17W PT NW NW FRL BEING PTS Block/Condo Bldg: LOT 94 EMERALD ACRES 1ST LOTS 36 ,38, 39,40, &42; NKA CSM 24-5648 LOT 94(2.270AC) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 30-29N-17W NW NW 1 Notes: Parcel History: RETIRED 2009 FOR 2010; LOTS 36, 38, 39, Date Doc# Vol/Page Type 40,&42 EMERALD ACRES 1)ST 08/18/2009 902245 24/5648 CSM (018-2011-36;018-2011-38, 018-2011-39; 06/16/2004 766092 2597/300 WD 018-2011-40&018-2011-42; (1051, 1053, 1054, 1055, & 1057)TO CSM 24-5648 LOTS more... 2012 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/11/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.270 43,600 0 43,600 NO Totals for 2012: General Property 2.270 43,600 0 43,600 Woodland 0.000 0 0 Totals for 2011: General Property 2.270 43,600 0 43,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category .Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 r Whcorlsin Department of Commerce SOIL EVALUATION REPORT Page_l_of 3 Division of Safety and Buildings in: ..• • ' -. rain 05,Wis. Adm. Code cc'',,''CC�� County SA-- C - Mtactt com tnrte site plan o pnperf�EADE(11 in i rz: Plan must �- Indude,turf not limited to:v: ttcal a I orizontal reference p•,�j'''+r.' Al' to ar Parcel I.D. ��/ percent r lope,scale ordirne sfons,north arrow,and�location Id , Fr .-tole ad. Q/ �' 02U// - -S7 -Oa Pt ,se PO. all AfrfrP�atlon. L ft 1 ` [Dale Personal Infonrrallon you povrd may be used tor sec. :.r , poxes,•rivacy inn,a.15.04(1)(m)). •/ iyV}�-_ 7 /S 6 Proper ty Owner ONIN OFFICE Property Location Govt_Lot 114 14 S 30 T 2_9 N It (00� 17 E( Property Owner's Mailing ddress L yeck# Subd.Nance or CSM# 1` Pv.�o�1V, r - afraid 1 5T ti City State Zip Code Phone Number ❑City Village Or-town Nearest Road t.ad )r)1-01 I���I li6)5 -� I(y)roor d a/ . . ,1-New Construction Use:I1Residential/Number of bedrooms_3-`i Code derived design flow rate 4`Ja1_4_oo___ _GPO ❑Replacement ❑ Public or commercial-Describe: _ __ —__-____.__ -- r Parent material_-�1 4f _ _ _ —___-----____ Flood Plain elevation if applicable --R. General comments C -e e,, enJ /6e. -5—C)and recommendations: ✓t i Cn16-c4111 1J X102.o t1 Boling I I ni Boring# Q !Pit Ground surface elev._ c,LOO R. Depth to limiting factor__ I 5___-in. — - - __ Soil Applic:alion Rate horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f_ In. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Hitt 'H#2 I (2)-11 Icyr3I2 311 2-110N: c 3 I v-C .5 . a 11-45 (Qyr4 l- 5;0 Z m.gbk_ m- r c., — . 44 . , 3 1[5-.5) 10yrg1a C.I 0.7.Sy r4 i(' v-C-3 On-. ,r-n-r — • Boring# E Boring 2- pit Ground surface elev.tmc�l-'a ft. Depth to limiting factor_433_in. Soo Application Rate Ftorizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots r r GPDIfe in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Efflt2 1 O--((p 10 yr 3(Z .5r 1 Zrmsbl; vric- , c 3 I v.1 . 5 ,.8 Z I(03) 10yr4N scI21n512kCe c 3 - , ti - <0 .3 3-50 I O yr3-/I °7.Syr,- l& L-C.3 3n--).4k mC-; — — . q • C, •Effluent#1=BOD$>30<220 mg/L and TSS>30<150 mg/L •Effluent#2=BOD$<30 Ing/L and TSS<30 mg/1 CST igdarc,Name(Please Print) LX--1 Siyn jJw7 Address Date Evaluation Conducted Telephone Number 21 i 3 g o y , 3Y-r ( >�� d 7 - _ (j),)7(00-0279 1 Parcel ID 11 ( Page — of Property Owner_ !v — — ,: --- [J Bonny 3 —IC) _ I Boring# Of-pit I AC) It. Depth to limiting factor _in. Ground surface elev., I Sul Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots AirmAirmen 'EIIIfGPDIIFE#q2 in. uen Qu.Sz. Cont.Color Gr.Sz.Sh. 0-1'f (Oyr31 - 5r.I 2.1n5bk nor_ c 5 \\/- - 5 _.g 2 1429 inyry. 14 — 51 e1 2m .11.01 c 5 _ LA — .3 td) tb dio SCf LII__�_i1. CS — • - `V 4 --10'�yr8 2- `� v-P Om nn-C► 4 In e'�w, d -- — < -- Boring# ❑ Boring 1 ❑Pit Ground surface elev. —_ft. Depth to limiting factor____ _in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIIF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. _'Elf#1 ¶11112 1-1 ❑ Boring Boring# Ground surface elev.__ ___ft. Depth to limiling factor___________in. ❑ Pit I Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfl in. Munsell Qu.Sz. Cont.Color Gr_St.Sh. 'Eff#1 'Eff#2 • •Effluent#1=BOD5>30<220 rny1L and TSS>30<150 mgIL 'Effluent 112=BOD5<30 tny1L and 1 SS<30 rnyll • The Department of Commerce is an equal opportunity service provider and employer. If you aced assistance to access services or need material in an alternate format,please contact the department at 608-266-3151 or TIN 608-264-8777. snD-Nlo rR.ormmo) L . . . 3 1)AGE3 01,3 NAME: Sk-cy Li 4— 1,()Ill 3& I,VA;AI, DES(_:RIPTIOtTANAJII)fLuti,;, ;3cir0,1,R, R (m 00 SCALE: 1"----: VO 61/k -- ELEVATION: 100_, 0 .. .. ------ •.:<: \,, 7. 0 i BM 1 DESCRIPTION:.10_pc2..E. I 'rue_pop-iz — 1 -- BM 2 ELEVAI ION:_ _ cf et ZO A - --- - - 1-- -- -- (-3q- —- BM 2 DESCRIPT101,14,4 64-- i. pvc- p_eig-e... SYSTEM ELEVATI■it i: /0Z, S .. . . . SYSTEM TYPE: Co Atityvb.,t3A04 4.9 14 10\P 1/F I t -F IN\i 1 • 6-1 0 4,. 0 ,.. -..; • (01' v. f) 3 .67-5 6--7- J ( . SIGNATURE: ...„--- )ATE:• _z .., • - --•(1)44" . . .