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HomeMy WebLinkAbout042-1084-70-500 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578935 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Dalton, Steven M. I Warren, Town of 042-1084-70-500 CST BM Elev: Insp.BM Elev: BM Description: n Section/Town/Range/Map No: 1st^ f—s.. .��a�-1�� 30.29.18.475E30 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER e,•,1 CAPACITY STATION BS HI FS ELEV. 1 Septic �✓►- Benchmark Dosing Alt.BM / 9� gs F;I i ri b 4....Gd 1.$5 Aeration Bldg.Sewer -7. 6 2Y. -• Holding St/Ht Inlet 1•3 (?3•4/ TANK SETBACK INFORMATION St/Ht Outlet 73 .Z.5 TANK TO �/L i WELL BLDG. &nt-0 Air Intake ROAD Dt Inlet Septic ) Z 5 A)A' `� �6 l 7 Dt Bottom Dosing Header/Man. $,�jrj 93• Aeration Dist. Pipe Holding Bot.System Trial Grade , W PUMP/SIPHON INFORMATION Fin S• �� ' C Manufacturer Demand St Cove GPM ; Model Number TDH Lift Friction Loss System Head TDH t Forcemain Length Dia. Dist.to Well I SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pit Inside Dial Liquid DIMENSIONS : '7/< '7 �fG�( - ,� \. SETBACK SYSTEM TO U P/L JBLDG WELL LAKE/STREAM LEACHING Manufacturep INFORMATION Type Of System: r $ CHAMBER OR Mod I r: DISTRIBUTION SYSTEM 6�Lj (`7 3-a = 3 us Header/Manifolll t/ Distribution x Hole Size x Hole Spacing Vent tc}Air Int ke Pipe(s) W 2b Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed(rrench Center 4 Bed/Trench Edges Topsoil �� Yes � No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 712 99th Street Roberts,WI 54023(SE 1/4 SE 1/4 30 T29N R1 8W) NA Lot 5 Parcel No: 30.29.18.475E30 1.)Alt BM Description= ` '� � ^ GaJ.a� ��� L be;� 2.)Bldg sewer length= G -amount of cover= 0 �/ Moo, � 18 d� �I�L�C Plan revision Required? ❑ Yes KNO 1i 5 3 Use other side for additional information. —- Date Insepctors Signa Cert.No. SBD-6710(R.3/97) Industry Services Division C.�.o;k Q {f j ' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) P.O. Box 7162 3Y07N yyo1 FW,. ison,WI 53707-7162 p9� SSION n ow nitary Permit.Application State Transaction Number In ac a g ' .Adm.Code,submission of this form to the appropriate governmental unit is red R"o% & permit. Note:Application forms for state-owned POWTS are submitted to Project Address If different than mailing address t ment of Safety and Professional Services. Personal information you provide may be used for secondary ( g ) purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �� I. Application Information-Please Print All Information 717— Property Owner's Name / Parcel# 546 vG t'd 0 0y7_-/,q0q --70 - roo Property Owner's Mailing Address Property Location 9:5.0 64.,l✓L 0'.- Govt.Lot <# / City,State Zip Code Phone Number f£ '/4, S£ '/4, Section 3 b C7on-ta f-A-4T 95 �"�r J �d �r T Z 9 N R l8(circle C70 II.Type of Building(check all that apply) Lot#Q `-'lor 2 Family Dwelling-Number of Bedrooms 3 S Subdivision Name ❑Public/Commercial-Describe Use Block# [I City of ❑ State Owned-Describe Use E] Village of CSM Number Za -Y-635 [9-Town-of �CcA,A.�� III.Ty a of Permit: Check only one box on line A. Complete line B if applicable) • A. [RNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑ Permit Renewal ❑ Permit evision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration 1 Plumber Owner t moo_ �L IV.Type of POWTS System/Corn onent/Device: (Check all that apply) ` ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil Ff Mound<24 in.of suitable soil IOS, ❑ Holding Iank ether Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatment Area Information: —2 - £ J_ X G $ .3 Y Ta 4 d 1 N k t -'z'S Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Di spersal Area Propose sf) System Elevation 4y'5-7) Rate(gpdsf) -7 & 'f 3 VI.Tank Info Capacity in Gallons Total #of ° 2 = C U U y Gallons Units Manufacturer A` c Y E 2 New Tanks Existing Tanks / f / p U tic Holding Tank Eg- ❑ ❑ ❑ ❑ Dosing Chamber T ❑ ❑ ❑ ❑ ❑ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PONVTS shown on the attached plans. ber's Name t) Plumber's Signature MP Number Business Phone Number C Lt 'e"" 1 Z_Z_z077 71�'vq�-338 ' umber's Address(Street,City,State,Zip Code) f. v . a kuGk- s �.s3 VIII. ounty/De artment Use Only Approved prove Permit Fee Dateissuef Issuing JVt Signature J5 ( iven Reason for Deni ts ()✓ �� (/ L /5 L- IX.Condit i a fgxdisapproval 3 d n -- )C-- it •SST � I bP n : . , iumbe� �Q,i r I ie rnalntair n a pK�pplicabia + ,*rrgilld�l&ss, , ` �Q✓�d�C.c. /9 e Attach to complete plans for the system and sub it to the County only on 6aper not less than 1/2 x 11 inches in si - a I SBD-6398(R03/14) I O v a„ J QL. tru J t � n's � Rn1� o z � x � h M 4 2 3 � a A W Q. s ID � o ..d w 2 Soil Absorption System Cross Section 4"Schedule 40 Final Grade PVC Vent Pipe 9 3. With Vent Cap / ft Leaching -� Chamber 9.1 , 3 ft d— System Elevation ft S ft Soil Absorption System Plan View --- ft ft ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4"Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model Qk ;C.ki �/ s EISA Rating i 0 sq ft per chamber Soil Application Rate gpd/sq ft ` `t`Jy gpd Design Flow_ -7 1 Soil Application Rate : 2-0, 0 EISA Chambers 2 rows of ?chambers each. Page of i Wis.Dept.of Safety and Professional Services SOIL EVALUATION REPORT Page f of 3 Division of Safety and Buildings in accordance with SPS 385,Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. v percent slope,scale or dimensions,north arrow,and location and distance to nearest road. O YZ '/VU Y—70 —J-.0 U Plea" print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). 6tif 16, >N-0(A/ -2, 9 Property Owner 1 Property Location ft(I c D a2 ` 4 0 /✓ Govt.Lot S 6 1/4_j-£1/4 S 3 d T Zq N R /8 E(or)W Property Owner's ailing Address Lot# Block# Subd.Name or CSM# 130 p QA AL" vti- �`-� V. Z0 City State JV; Zip Code Phone Number ❑City/ ' -❑Village ©Town Nearest Road 7/Z R—New Construction Use:[f Residential/Number of bedrooms 3 Code derived design flow rate YJ-0 GPD ❑Replacement ❑ Public or commercial-Describe: Parent material Flood Plain elevation if applicable General comments and recommendations: 7 Boring# E] Boring Qp pit Ground surface elev. 96, o� ft. Depth to limiting factor O O in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft a in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. :ff#1 -' ff#2 05A ( - - -7 a- ❑ Boring# Boring ® Pit Ground surface elev. ` O ft. ',Depth to limiting factor V "7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Y in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 -ff#2 8 J OL11-117- s x a 'mss I D 1Z f/ st Effluent#1 =BOD >30<220 mg/L and VS>310 <150mg/L *Effluent#2=BOD <30 mg/L and TSS <30 mg/L CST Nam (P ase Print) Signature CST Number OIL C, w £ `� w�� �- � Z-2,Z 817-- Address t Date Evaluation Conducted Telephone Number Property Owner Parcel ID# Page of 3 P Y F Boring# ❑ Boring 9� 8 Pit Ground surface elev. U ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft : in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 sow 2 /o`t�T/3 S 1 36 'V F-1 Boring# El Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in EEooiI:A:pplication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft : in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 Boring ❑ Boring# Ground surface elev. ft. Depth to limiting factor in. ❑ Pit =Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 402 Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L `Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L The Dept.of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay. SBD-8330(R 11/11) i a N r � r Ch CA � h �.9 w C� a � � Vo / N 1 � - 4 3 I i SOIL PROFILE DESCRIPTION Owner: �/�LTb� S/Gv� CST: Sri GQ uE kI W V,IA) System Elev. Proposed: 92-3 ft Syst. Range ft to ft Ld Rate: , 7 # Elevation: 71'0.2- # z Elevation: 95 . #3 Elevation: o Boring o Boring o Boring 14 Pit Pit ¢A Pit --- ----- ----- ----- 5 , ---- ----------- ----- 92- ----- >'i bSE7 S YS'� `----------- ----- QZ f ----------- so/t�S ffS T�!✓S��raF� - -- ----- Sqw ----- 7 - - ----- - - - - - Industry Services Division s�'• ��t,o X 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) S P.O. Box 7162 Madison,WI 53707-7162 � iots�`� "e^'k 2 71 Sanitary Permit.Application State Transaction Number r `' /Ui>� In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to tl ,�pprdpriate(g��a`�nmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information yo$JT;o011lO%4.ikkkkl3'oYsecondary Project Address(if different than mailing address) purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. -.0MMUNITY D EVLLQFJMENT -"17 -7 Z .I. Application Information-Please Print All Inform // Property Owner's Name Parcel# -�- L., D 012- - 76 - SCb Property Owner's Mailing Address Property Location /3 d 6A-4 v /j�A Govt.Lot , ( -715 6- City,State Zip Code Phone Number Section 30 1 i (circle one) f/L�f W J~YvZ'J T N Rle Eore II.Type of Building(check all that apply) Lot# [�-1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name ❑Public/Commercial-Describe Use i Block# °v`5-t� � "� ❑ City of ❑State Owned-Describe Use CSM Number Zb 5635 ❑ Village of RI Town of Q,c-��..�-�✓ III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. (t New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner N.Type of POWTS System/Com onent/Device: (Check all that apply) r n-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank Other Dispersal Component(explain) ❑Pretreatment Device lain) V.Dispersal/Treatment rea Information: "- G''f >' 'X (, ' o-fd i c Y T Design Flow(gpd) � � �3 8� Design Soil Application Dispersal Area Required(sD ersal Area Proposed sf) Systemm Elevation Y�a /� Rate(gpdsf) ✓ /! • 0.64- 8 -' (� � VI.Tank Info Capacity in Gallons Total #of h � b v Gallons Units Manufacturer c H n 4 New Tanks Existing Tanks 2 E w 7 ��� U in 0. eptic r Holding Tank 1 J-A-A w ❑ ❑ ❑ ❑ Dosing Chamber ❑ ❑ El El ❑ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. P ber's Name(Print) lumber's Signature MP/! ?R Number Business Phone Number —/P c: lee 461 f I 2_Z7-87;-- P umber's Address(Street,City,State,Zip Code) f 6, t2 k,,(,t k�j: J y VIII.Coun /De artment Use Only Approved Disapprov Permit Fee Dalle ed Issui gent Signat re Ow ven Reason for Denial S 'T�� ' J IX.Conde a nk ar Disapproval r4r � a i'3 na llisOmal cell must all be servk ( esspest management plan provededbyplumber, C .-at M-�� �, �1"sc�c raguir'e :ans�stbe•mslntalned (�- es>s par appllcabla code 7 ordir>wgoas: `1 61-to re- a ,i ,,-,:,� �� F Attach to complete plans for the system and submit to the County only on paper not less than 8 r x 11 h4s ij size 16/ Orbs SBD-6398(R03/14) J All r4 qL-- JCS Q61 3 ,kAk 1%J ri -44 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Owner's Address: �3 0 D&. �O✓��+ fiLS L-- � 1/l�� J y�z J Legal Description: - se- 5cr, 36 T Z 9 /eL--? Township: W ac.t. ,Jr., County: Sf- d,,-d , jC Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test& House Plans Designer/Plumber: w� N��•ki in- s License Number: LL S�Z Date: Phone Number Signature Designed pursuant he In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 i -i II o ter. v 1 s `-h a J � U w VIA Iz �,- nn Soil Absorption System Cross Section 9S. D ft k4'V' 40 Final Grade pe -�Z, ft p Leaching —fl Chamber ft �— System Elevation 3 ft ft Soil Absorption System Plan View ft 3 ft ft Leaching ambers Trench 1 Vent Or Observation Pipe � Ch 4"Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model_(7�) 4 C_J s EISA Rating 7- sq ft.per chamber Soil Application Rate 7 gpd/sq ft gpd Design Flow= 7 Soil Application Rate 2 d U EISA= 3 Chambers 2 rows of--17 chambers each. Page of ' [:31. ifetime "filter Installation and Maintenance Instructions Installation Step 1 Dry fit the filter case onto the outlet pipe going to the drain field. Ensure it is centered directly under the access opening.(if outlet pipe is already in a fixed position,additional pipe may need to be added) Step 2 If utilizing the additional single side support and the two bottom supports: While the case is still dry fit to the outlet pipe, measure and cut 1"schedule 40 pvc pipe to the length needed to extend from the hubs that are pre-molded into the case to the side wall and the inside floor of tank. solvent weld pipe into the hubs that are pre-molded onto the case. Step 3 Solvent weld the case to the outlet pipe. Insert the filter cartridge into the case pressing down on the cartridge until it locks into place at the bottom of case. Step 4 if utilizing a vertical read switch: Insert switch into the hole pre-molded into the top of the filter. Press straight down until it locks into place Maintenance 1) Remove the access lid of the tank. Note:To ensure undesirable solids do not exit the tank and into the drain field,the tank should be pumped out until the level of effluent is below the outlet level of the tank. 2) To remove the filter cartridge from the filter case, pull up firmly on the handle of the cartridge dislodging it from the case.(if utilizing a vertical read switch,removal of switch is optional) 3) Using an ordinary garden hose, rinse the filter cartridge ensuring all visible septage material is removed. 4) Place the filter cartridge back into the filter case pressing down on the cartridge until it locks into place. 5) Place the access lid back onto the tank ensuring it is secure. Lifetime filter has a lifetime limited warranty: Lifetime filter LLC warrants the filter will be free of manufacturing and workmanship defects during normal use for the period of time the original purchaser owns the product.Lifetime filter will provide a replacement filter in the event that the original filter was not damaged during the installation or maintenance process.Damage to this product caused by accident,misuse or abuse will not be covered under this warranty.Improper care or malfunctions resulting from product not being installed,operated or maintained properly will void this warranty.Lifetime filter assumes no responsibility for labor charges,removal charges,installation or other incidental or consequential costs. Contact:mike @lifetimefilterllc.com Phone:502-724-2231 Page of START UP 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. 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 cell(s) 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 in 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 slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the 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; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS 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 chapter Comm 83.33, Wisconsin Administrative Code: • All 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 with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name �t w/'f, f"f Sf f;C Name Phone ?� �f 4/ �-3f'8 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name a 'T K a— Name Sf- eA, a/X Zd A_4 A- Phone 215-- '?Ts- -V yv Phone 71J - 39&-9(o84 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1), (2) &(3),Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 5.f£v£ D +d) Septic Tank Capacity 1,04`0 gal ❑ NA Permit # Septic Tank Manufacturer S"j A w ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 4IrITY ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model GF1.6 ❑ NA Number of Public Facility Units (ANA Pump Tank Capacity al —0-N+4 Estimated flow (average) gal/day Pump Tank Manufacturer E4-MA Design flow (peak), (Estimated x 1.5) 67 �� gal/day Pump Manufacturer A Soil Application Rate . -7 gal/day/ftz Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) :5220 mg/L J;HTA- ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 15150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) :530 mg/L .,fin-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L 2KA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :_10°cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y8 in dia. E?NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 0 month(s) (Maximum 3 years) ❑ NA cP -a year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (W3) of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: CP 49-years) Clean effluent filter At least once every: ❑ month(s) ❑ NA�, 1 .-ayear(s) ❑ month(s) ANA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) B•NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once ever ❑ month(s) G3-NA❑ year(s) 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 (Y3) 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:_12 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. GMW(4/01) Page of START UP 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. 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 cell(s) 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 in 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 slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the 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; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS 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 chapter Comm 83.33, Wisconsin Administrative Code: • All 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 with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name a ,��'� �„� �� C Name Phone ?� — ��/r �38� Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name sKQ. Name Phone 2 1 — �� t�}� 7 Phone -7 to e0 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) &(3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S`'£t,,,r Da Mailing Address g3 D 6/l,u,vt l�„_ �oirn t��t A-, Property Address w z' (Verification required from Planning&Zoning Department for new constructi .) City/State Parcel Identification Number 6y Z - 1 v9y -7v -J-06 LEGAL DESCRIPTION Property Location -5'6 '/4 , S6. '/4 , Sec. 30 , T N R / W, Town of Subdivision Plat: , Lot# Certified Survey Map # o ZD �j�3 5 , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house pLyes no Lot lines identifiable j,yes t-1 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1)and in Chapter 12-St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber, restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2) after inspection and pumping(if necessary), the septic tank is less than 1/3 frill of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein, as set by the Department of Commerce and the Department of Natural Resources,State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning& Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on thi form are true to the best of my/our knowledge. I/we am/are the owner(s)of the property described above,by virtue of a warr my deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNATURE OF APPLICANT(S) 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. (REV. 08/05) r Property Owner_ Parcel ID# Page of ® Boring# Boring Pit Ground surface elev. ft. Depth to limiting factor 0 in. Soil Application Rate If Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 I - r - S-2 F-1 Boring# E] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 •Eff#2 a Ong# Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 •Eff#2 I Effluent#1 =BOD6>30<220 mg1L and TSS>30<150 mgA_ `Effluent#2=BODS<30 mgA_and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(8.6/00) L D � Wisconsin Department of Commerce RT Page of Division of Safety and Buildings in accordance with omm 85,Wis. Adm. Code J ounry Attach complete site plan on paper not less than 8 1/2 x 11 i ches ir4R P n u O 5 include,but not limited to:vertical and horizontal reference int(BM),dirred6r>�n�U anal I.D. percent slope,scale or dimensions,north arrow,and locatio and slta�rS�X earest road. U COUNTY Reviewed D;7Z Please print all informatio ZONING OFFICE Personal information you provide may be used for secondary purposes(Privacy Law,s.15. S 6S Property Owner f_ / Property Location v U ��✓ e �- Govt.Lot.�� 1/4 S a N R g E(o(W Property Owner's Mailing Address Lot# Block# Subd. Name CSM# �, �' �- aL s� 3s City State Zip Code Phone Number ❑City ❑village Town Nearest Road ST. New Construction Residential/Number of bedrooms Code derived design flow rate --) GPD ❑Replacement ❑ Public or commercial-Describe: --- Parent material .L/l "' Flood Plain elevation if applicable ✓�� ft. General convnents and recommendations:,j�,� `g�£�'��i/► ` �/ �� 9� Boring# O Bo' it Ground surface elev. ✓f ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Cu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 I 'Eff#2 D- -7 i Ong# C1 Boring L� 8 Ground surface elev. / ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 ff#2 Zn Effluent#1 =BOD >30<220 mg/L and tSS>30<150 mg/L 'Effluent#2=BOD 130 mg/L and TSS<30 mg/L CST Name(Please Print) Sig CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 !�� ��-� 715-246-4516 }a{ o 6 1e'o' eb• •---------------- --------------- j u &,:OR Hawn P&2-O.C. COVOW r 4 I ! � •� 3 a - 1--------------- 4 6 —------------------- y •• — ——— 4� tr .` ----------------- —I ! f -- nrm..w= Ilk 4 = r I t o s � � a�.i ti� Yd• _ _\ �> -}� - rc - iS Fr + m t z e La, a ti6• ,h F I I I q � t � a� --- lu•oe, toveau --_ ___—_- --------- _ -__---------------------------- _-_--_-------' ------ ___________ --__--_---_-_----_ e'aN' YAK' It�pnj�I II'd• 7-0' S!'b• F a� o�A Z 1 ' i ji FTmm 24 4tl- 1. L--_j FtA" ft Ell WA�l ak Ftm .OMN OLD.,. ire• i Property Owner Parcel ID# Page of 13 Boring# Boring Pit Ground surface elev.J ft. Depth to limiting factor in. Soil Application Rate II Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 `Eff#2 Boring# ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. -go-i—lApplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 `Eff#2 ❑ Boring# ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate. Horizon Depth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 -Eff#2 Effluent#1 =BOD_>30<220 mg1L and TSS>30<150 mgA_ 'Effluent#2=BOD,<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(8.6100) Soil Test Plot Pl Project Name John Pearson aun Bird Address 992 70th Ave Roberts Wi 54023 STM #226900 Lot 5 Subdivision -------- a 4/7/05 SE 1/4 SE 1/4S 30 T 29 N/R18 W Township Warren ❑ Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation 91.8/90.8 *H R pSame as Benchmark Alternate Benchmark Top of survey Iron C 96.8' aeis1" = ' unless otherwis noted 277' Property Line Pro Town Road to 70th Ave B-2 40' B-1 14% Slope 30' 212' Property Line AL 45' 60' B-3 90' 92' 96' 326' property line B.M. Parcel #: 042-1084-70-500 07/30/2007 11:22 AM PAGE 1 OF 1 Alt. Parcel#: 30.29.18.475E-30 042-TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 08/03/2005 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-PEARSON,JON&CHRISTINE M JON &CHRISTINE M PEARSON 992 70TH AVE ROBERTS WI 54023 Districts: SC= School SP= Special Property Address(es): '=Primary Type Dist# Description "708 99TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.000 Plat: 5035-CSM 20-5035 042/05 SEC 30 T29N R18W PT SE SE FKA CSM Block/Condo Bldg: LOT 05 14/3991 LOT 4 33.215AC FKA CSM 17-4441 LOT 4(32.966 AC)FKA CSM 19-4901 LOT 4 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) (33.150AC) NKA CSM 20-5035 LOT 5 30-29N-18W SE SE (2.000AC) Notes: Parcel History: Date Doc# Vol/Page Type 08/03/2005 802224 20/5035 CSM 12/29/2004 783721 19/4901 CSM 01/09/2003 705153 17/4441 CSM 07/23/1997 1213/258 WD more... 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/31/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 37,500 0 37,500 NO Totals for 2007: General Property 2.000 37,500 0 37,500 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 37,500 0 37,500 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