HomeMy WebLinkAbout040-1289-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERIAM State Plan ID No 57 T V S
Personal information you provide may be used for secondary purposes [Privacy Law, S15.o4 (1)(m)3.
Perm older's Name: City Village X Township Parcel Tax No:
v ar~..~ ~ ~ro 6tif0 /Z$9 ~ Zo
CST BM v. Insp. BM Elev: BM Description: Section/Town/Range/Map No:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER n. 5 CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
18-1 163. MCI,
Alt. BM
t o ~ a lz S ~'l1~ Ga 1. t. /6 j . t, tp
Aeration Bldg. Sewer C
Holding St/Ht Inlet + 7 , 41,13 -74,A7
TANK SETBACK INFORMATION St/Ht Outlet 7, 62. 9 4v, 2%
TANK TO rr P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic I c / Dt Bottom
J -33 3b' 7
Dosing Header/Man.
Aeration Dist. Pipe L
ws ~S•~
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM ~"r ~.t~. L4~ ('T 1 ~S • (O
Model Number
TDH Lift Friction Loss System Head DH Ft
Forcemain Length ___ra~ I Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 74 (rd.a. ( _ `
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer.
INFORMATION Type Of Syste CHAMBER OR 'xr{ F,'It ~•f.~
l
C S~ l / UNIT Model Number
e IQ~o
GO 46 c7 _ I /v . 5
DISTRIBUTION SYSTEM /1Jar ~l--3 = S
Header/Manifold li, Distribution x Hole Size x Hole Spacing Vert lo Air Intake
Pe()
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/Trench Center S' Bed/Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / /
Location: ' - • Parcel No:
1.) Alt BM Description 6A-
2.) Bldg sewer length = '3 D Q~__ `
- amount of cover = 120 144,Q
64-
4g et,(L,ct w A
Plan revision Required? ~ Yes
Use other side for additional informations. 1
SBD-6710 (R.3/97) Date Insep rs Sig re Cert. No.
-
f
2Y Z-
~ J
dEe"aa+r r+rVED In ry
Services Division County
A S~ C t3~jl _
K 1 E Washington Ave Sanitary, Permit Number (to be filled in by Co.)
~5} q7 4g y P.O. Box 7162
U~ 10 2015 n, cal 5707 71s2 `j c~j S
-0 PAIN=
D t ennit Application State Transaction Nu
^gM'UMTY
In accordance w th SPS 393.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 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 you provide may be used for secondary Project Address (if different than mailing address)
purposes in accordance with the Priv Law, s. 15.04 1 m , Stats. / ri n ' I r L / 0 u✓_"
1. Application Information - Please Print All Information tp L ,3 ,1 C_
Property Owne2 NM e -P% a 4- Parcel # XVrfmr r~)9 o4o , Z-0 -Wo
Property Owner's Mailing Address Property Location
Govpt►~''ot
City, State Zip Code Phone Number ~ PE Section 8
/461k50-43 ki I v1 (circle one)
wT Zg N R jq E
Type of Building (check all that apply) Lot #
La4 or 2 Family Dvmlling - Number of B:P)om 2 Subdivision Name Cr
❑Public/Commercial-Describe Use 0,% Pt. ~ St~Mc~k Block# iJ(~L(Sil
hOtjS-(- ?I&,.. '1 ❑ City of
❑ State Owned -Describe Use
b¢p, CSM Number ❑ Village of /
6E .Town of TKOy /
gil1&-noii W ~U ~ V
(-RA j
HL a of Permit: Check only one box on line A. Co fete line B if applicable)
A. jlg~m ❑ m ❑ TreatmentlHolding Tank Replacement Only ❑ Other Modification to E . 'ng system (explain)
t, IV al`/b ea
B. ❑ Permit R al Permit Revision ❑ Change of ❑ Permit Transfer to New Lcst Previous ermit Number and Date Isstkd
Before E)q) Plumber Owner t X / _ t
lP
N. Type of POWTS System/Component/Device: Check all that apply)
No - Pressurized In-Ground ❑ Aveade ❑ Mound > 2tk of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatmen icelain)
!'an tYAfI1 ~
V. Dis rsal/Treatment Area Information: b
Design Flow (gpd) Design Soil Application Dispersal Area Requir Dispersal Area y~ed (o System Elevation
5
-75D v/ Rate(gpdsf) , 7 / 67) 7 X 071 ✓ /O~C~ (:M.7
VI. Tank Info Capacity in
Gallons Total # of M d
New Tanks Existing Tanks Gallons Un' IJ - / ~0 ~I pq
i V cA n V! W 'U a
Septic or Holding Tank 'S IS6517
Dosing Chamber Q
VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Pi ber's S' store MP Business Phone Number ~44
-:UV z~3Zy~ 715°755- 2%
Plumber's Address (Street, City, State, Zip Code)
T` V DggWtr
c.J
oun /De artment Use Oni
OApproved ❑ Dis roved Permit F Date Iyd Issuing Agent Signature (SA_
Z. n for Den $
, J
DL Coudttion$WkMw#0Rsons for Disapproval Z)h/e(I 114US - M&4
f PO12, /
1. Septic tarik ffluent filter and
dispersal cell mu$t be_$eryiced / maintained ~ ~
as per management plan provided by plumber. -l. f e f u.t, W4- QA'YG, 7% 1l~"C
2. All setback requirements must be maintained A AA A'P.-t/V
88 Pei tseft system and submit to the County only on per not less than 8 tn:11 inches in sin
It~fD~~c.~~'n.
SBD-6398 (803/14)
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OW De*n Flaw,, .'7 Sell AppNmdkm Rem 4. ZZ) E M / Chambws
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Pape or,.~„_..
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RECEIVED
Wis. Dept. of S f rofessional Se G EVALUATION REPORT Page ~L of
Divisiong tafx=dings 0
with SPS 385, Wis. Adm. Code
A~ Rp CO County
Ab~WilD ~er not less than 8 1/2 x 11 inches in size. Plan must
iml ed to' vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Revie r Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(l) (m)). -711y124 /S
Property Owner Property Location
Govt. Lot 114 1/4 S N R / E (or)&?
Properfy Owner's Mailing Add re Lot # Block Subd. Name or CSM#
. ~S
City State Zip Code Phone Number ❑ City ❑MIlage .Town Nearest Road
1 .01
New Construction Use: 0 Residential / Number of bedrooms S Code derived design flow rate 7S"G GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material r<f,.~r l~rs,~ Flood Plain elevation if applicable ft, _ X/41
General comments f
and recommendations:
4LAjjm:d4, 4af:, Lat y:/
Boring # Boring
F/-1 r
® pit Ground surface elev. 9 ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. ff#1 102
s
3 _ 4 R
•
Boring # E] Boring
® Pit Ground surface elev. &9 ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 102
Effl ent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L E pent !,ROD < 30 mg/L and TSS < 30 mg/L
CST Na P Signatu CST Number
Address Date Evaluation Conducted Telephone Number
(JY ' ' S S /Jr'
SBD-8330 (RI 1/11)
of
' Property Owner Parcel ID # -;p -4Page
~
❑ Boring
Boring #
t~v Pit Ground surface elev. 9e 2 ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
'_2 41
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ft#1 * ff#2
❑ Boring
❑ Boring # Pit Ground surface elev. ft. Depth to limiting factor in.
❑ =Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure ansistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 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 (RI I/11)
Property Owner T~ia/ 1t~7~ Parcel ID# Page of
®Boring # ❑ Boring a
( Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
'Zj
S m
e
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil A-pplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
❑ Boring
17 Boring # El Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 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-9330 (RI 1/11)
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RECEIVED County
Industry i Div' '
~ST
$ + 1400 E st1' on e
R $ JUN 1 0 2015 P.O. Ox 1 sanitary Permit Number (to be filled in qbyCo.)
Madiso r C
ROIX COUNTY n 17zz 5746 / S J
-OMMUNIT9 ermlt Application State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 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 you provide may be used for secondary Project Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. 15.04(1) m , Stats. ;
1. Application Information - Please Print All Information AEG z f~j st, Cw
Property Owner's Name ~ ft' a
Parcel #
PA~L em-iZ6q- w-env
Property Owner's Mailing Address
Property Location ~ 4(o
S i l 114 S Govt. Lot / ) City, State Zip Code Phone Number N M/ X14,
Section 8
one
T4 N ; R tq (crE oi&
)
I~. Type of Building (check all that apply) Lot #
1211 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
❑ Public/Commercial - Describe Use 6 G~ Block # 0?,*L )50 i✓v~'T/~~ ~S
❑StateOwned-Describe Use nCity of
3 CSM Number ❑ Village of
i..~ C "et aTown of TROY
III. T e of Permit: Chec onl one box on line A. Complete line .B if applicable)
Q
A. 'KNe~ w System ❑ Replacement System ❑ TreatmentfHolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number an Da sued
Before Expiration Plumber Owner
~
IV. e of POWTS S stem/Com onent/Device: Check all that a 1) ~ 3 ~ 77
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil
Holding a Other Dis ersal Com nent a lain ❑ Mound < 24 in. of suitable soil
p po (xP ) ❑ Pretreatment (explain)
V. Dis ersaUTreatme Area Information: ~ ~
Design Flow (gpd) Design Soil Application Dispersal Area Require Dispersal Area Prop d (sf) System Elevation
-7 Rate(gpdsf) .7 16 7
? iL 71 ~o C5.
VI. Tank Info Capacity in
Gallons Total # of
New Tanks Existing Tanks Gallons Units l I M ufacturer
Septic or Holding Tank 56 S ❑ ❑ 0 ❑
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plan ❑ ❑ ❑
Plumber's Name (Print) S' ature~
`F'F F tuber Business Phone Number
Plumber's Address (Street, City, State, Zip Code) ',3~58
VIII. un /De artment Use Only
Approved tsapprove Permit Fee Dat Issu Issuing Y@6 Signature
r tven Reason for Denial S Z, 5
IX. Condi$~~QWeasons for Disapproval 1
r $epgc'ta e mustt finer and ~J Q ~GQ, IAtiG GL✓PR
dis rsal c cell must all e s . A- I
p
ae W management plan pro ' ed by plumber. \ 1
2. All s ttrse~i regvireri de Must
li milntalined l~ 1
ss cads / ordlrianaa. J rJ ~ C.JU[~
Attach to complete plans for the system and submit w the Coan
ty outy on paper not less than 81/2 a 11 inehes in size
SBD-6398 (803114)
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Fho L R-ut-;,Fez`r
Owner's Name:
Owner's Address: 5/3 q r 14
S`r N
d yasop wl
ol:
Legal Description: _ni VlJ ICE ,~Y S/8 ` r z8 o K / °l Yv
Township: T/Z0 y
County: G -T (3&011
Subdivision Name:
Lot Number..
Parcel ID Number. OBI p- / ZPY -LCD QaC)
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: F-Q'/ License Number rn Zz,3ZyZ
Date: ~,~y1J5 Phone Number 715.j/- 3158
Signature
77-7 N
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD40705-12 (N.01/01).
Page 1
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tra~ar
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M ntuftmarAM Model q)lCK-Y XA7LT-RA-NK
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-7 60 gpd Desire Flan a -7 90 APPOeWfm Rain 4 Z U_ MA Chambers
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Installation and Maintenance Instructions
Installation
Step l 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 fitter 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 fitter 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
or other
property-will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal charges, installation
incidental or consequential costs. .
Contact: mike(alifetimefii ic.com Phone: 502-724-2231
FUZ INF 1RMATION SYSTEM SPECIFICATIONS
owner • Tank gmac±L gal S D NA
Perntit # Septic Tank Manufacturer vV CI NA
DESIGN PARAMETERS Effluent Filt>er1Vlanttfacturer 67iw C3 NA
Number of Bedrooms 1 DNA Effluent Filter Model NA
Pump
Number of Commercial Units A Tank Capacity b NA
Pump Estimates flow (average)* SOD Uda T NA Pump Manufacturer PNA
Design flow (peak), estimated x 1.5* 75 0 gal/day Model NA
Soil Application Rate , da Pretreatment Unit NA
lnfluentlEffluent Quality (NAO) Monthly Average"' p Sand/Gravel Filter D Peat Filter
Fats. Oil & Grease (FOG) 5 30 mglL Q Mechanical Aeration Q Wetland
Biochemical Oxygen Demand (BODs) < 220 mg/L p Disinfection 0 Other.
Total Suspended Solids (TSS) Modek
250 mg/L Dispersal Cell(s)
Pretreated Effluent Quality D Monthly Average*" hirground (gravity) D Ia-FOUDd (per)
Biochemical Oxygen Demand (BODs) 5 30 mg/L ❑ At grade O Mound
Total Suspended Solids (TSS) < 30 mg/L Q Q Other.
Fecal Coiif rm (geometric mean) <10 cfu/IOOml D Leaching Cumber Mamifacturer
Maximum Effluent Particle Size 118 irtch diameter Model Laying I.eagth/Chamber
*Wastewater Flow Verification and Calculations. Soil Application Rate polfl Area Req. ft
(Other than bedroom bred) Infiltrative Suds cWCbamber-ESIA fe
Minim Number of Chambers
to Dea~p FFlow/Loading Rate min
p Aggrega
Values typical for domestic (nors-commercial wastewater Materials: all materials moist comply with WI Adm. Code
and septic tank effluent COMM84 and be installed per mmitiftwonva specifications
***Values typical for pretreated wastewater, and approval letters.
DESIGN CRITERIA
E3 "Wisconsin At grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et aL 1990)
p "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and EJ. Tyler.
Publication 15.22
Q "Design of Pressure Distribution Networks for Septic Tank-Soij Absanptian Systems" Pubbcabm 9.6
C3 "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Maul -
Onsite wastewater Treatment and Disposal Systems". EPA 625/1480-012 October 1980
C3 SBD -10570-P (R."g) "At-Grade Component Manual Using Pressure Distnbutice
„SBD -1050-P (P-&W) "Im Ground Abse> "on Component Manual"
p SBD -10705-P (N.01101) "In Ground. Soil Absorption Component Manual" Version 2.0
D SBD -10628-P (N.6199) "Recirculating Sand Filter System. Component Mannar'
p S8D -10656-P (N.6199) "Split Bed Recirculating Sand Filter System Component Manual"
E3 SBD -10572-P (8.6199) "Mound Component Mannar'
p SBD -10691-P (N.01/01) "Mound Component Manual" Version 2.0
Q SBD - 10595-P (8.6/99) "Single Pass Sand Filter Component Manual"
C3 SBD -10657-P (MM) "Drip-line Effluent Disposal Component Manual„
❑ SBD -10573--P (R 6/99) "Pressure Distribution Component Mammal"
❑ SBD -10706-P (N 41/01) "Pressure Distribution Component Manual" Version 2.0
p Drip-line Effluent Dispersal Component Manual for Multi flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORIlYG SCHEDULE
Service Event Service FreqMq
❑ months s (Maximunt 3
Inspect condition of tapWs) At least once every
Pump out contents of s When combined sludge and scum equals on-tlrird 1/3 oftank vohtme
s At least once $ 3
❑ $
Clean off knew filter At least once ever
Inspect pnE, pump controls & alarm At least once every CJ moms s NA
Flush laterals and Zesmire test At least once every D months s
. _ _ At I"-tt nsanr tvPrv ri mouths VeeI(s) 13A
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
OPRRATION
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The gttmttity
and quality of the wastewater stream will affect the performance and longevity of•your POWTS. The installation of water saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetaNdfivit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be mimmmed. Toilet tissue is the only
paper that should be discharged into the system. Other non-biodegradable *ms such as baby wipes, tampons, sanitary napkins
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint,
disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week, Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
E3 Valves
Valves shall be operated in the following manner.
CS Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
INPECMMS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Phumber, Master
Phunber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
D Septic Tub Component
Tank inspections must include a visual inspection of the tank to identify any missing or broken hwdware, identify any cracks
or leaks, meersure tare volume of combined stodge and scum and to check for any backup or ponding of effluent to the ground
surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unau&mmd entry into flue tank.
When the combination of sludge and scum in any tank exceeds one-third (1f3) or more of the tank vohurne, the entire contents
of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin
Administrative Code.
The outlet filter(s) shall be inspected and cleared to remove any accumulated solids according to manufacturer's
specifications. Provisions are: to be made to retain solids in the tank. Filter cleaning may be necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
Ct Pump ChambertTreatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms affil floats. A visual check must be
made for teaks, backups, surfacing, missing or bmlom security devices and other hardware and the condition of any filters.
Any service needs or repairs shall be promptly taken care of.
M In-+Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
au ity. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending
hydraulic Mure necessitating more frequent monitot*.
Pagce of
y .
❑ Mound, At-Grade, In-Ground Pressure
The inspection shall include recording the levels of pondmg, if any in the observation tubes and a visual i tion for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic f d1we
necessitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flu diing. The laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done bQ
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
UZORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 53.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails andlor is permanently Wm out of service the following steps shall be taken to ensure that die system is
properly and safely abandoned is compliance with Ch. COMM 83.33, Wisconsin Administrative Code.
- All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed
- Ile contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
- After pining, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or other inert solid material.
CONTINGENCY PLAN
If the PONM 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 beprotected from disturbance and compaction and should not be infringed upon by mquired
setbacks from existing and proposed shudure, lot lines and wells. Failure to protect the replacement area will result in the
need for a new soil 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. Replace systems must
comply with the rules in effect at that time.
❑ A suitable replacement arcs is not available due to setback auftr soil limitations. Barring advances in POWTS ten hn IW 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.
«WARN1NG>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN 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
Aiame~lE tmby Nam
Phone - ? S- Z'16/
Phone
SEPTAGE SERVICING OPERATOR QP"Veo LOCAL REGULATORY AUTHORITY
Name Arney 3't l z 101 fJ6
Phone Phone I - to -
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer P o►u k &.r d MA e g oa r% C~ P P r+
Mailing Address (o O( D i ci vv% a n d n e i V -C H V d S 0 n, W 54014
Property Address 3 6 2 E 1 S h C o u r+
(Verification required from Planning & Zoning Departm for new construction.)
City/State H u d S o n, Parcel Identification Number O 4 O- I Z$ 9 2 S- O 0 O
LEGAL DESCRIPTION
Property Location N W 114 , NE 1/4 , Sec. It , T_28 N R 11 W, Town of Tr 0 y
Subdivision Plat: Encai S ti ES t Ate $ , Lot # 2
Certified Survey Map Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house 0 yes 0 no Lot lines identifiable 0 yes 0 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 §SPS. 383.52(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 113 full of sludge.
Uwe, 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 Safety And Professional Services 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
Colony Planning & Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of mylour knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warn ty deed recorded in Register of Deeds Office.
Number of bedrooms
SI A URE OF APP "IT(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. 04112)
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Wisconsin DVartment of Commerce SOIL EVALUATION REPORT Page 1 _ of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pending
Please print all information. a wed by Date
Personal Information you provide may be used for secondary purposes (Privacy law, s. 75.01(1) (m)). J:YA
3
- n-4
Property Owner Property Location
Thmas 0' Leary Govt. Lot NW 1/4 NE 1/4 S 18 T 28 N R 19 rx(or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
389 My. Rd. 'IF" 2 na En lish Estates
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Hudson WI 54016 1(715 )381-5590 Troy urt
C k New Construction Use: IZ Residential / Number of bedrooms 4 Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material outwaah Flood Plain elevation if applicabl a
General comments
and recommendations:
1 reT l~X _
trenches @ el. 95.40', spaced to code 4.00' below grade
tp~~c
- T
❑ Boring
Boring epth to limiting factor 100 in.
1 # D Pit Ground surface elev. 99.40 ft D
ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
1 0-6 10 3 3 rione L 2c cs if .5 .8
2 6-32 10yr5/4 none sil 2csbk dsh if .5 .8
3 32-10 7.5yr4/6 none MS Os na
9 .D
l~ 110
Boring # T~-I Boring
F2 Pit Ground surface elev. 98.40 ft. Depth to limiting factor 100 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 'Effff2
1 0-6 10yr3/3 none L 2csbk dsh cs if .5 .8
2 6-30 10yr5/4 npne sil 2csbk dsh if 5
3 30-10 7.5 4/6 none mS 0S ml Da -na- -1-2
8
• Effluent #1 = BOD > 30;s 220 mg/L and TSS >30:5 150 mglL uent = OD < 30 Tk~ and TSS < 30 mg1L
CST Name (Please Print) Signature CST Number
Gar L. Steel ~ i~ 02298
Address Date Evaluation Conduote Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 8-30-2001 715-246-6200
I
Property Owner Thmas O' Leary Parcel !D # Pendinq Page 2 of _3,
Boring # ❑n Boring
3 pU Pit Ground surface elev. 96.60 ft. Depth to limiting factor 100 in. Soil Application Rate
Horimn Depth DominantColor Redox Description Texture Structure Consistence Boundary Roots GPDff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
1 0-6 10 3 3 none T, 2csbk .5 .8
6-24 10yr5/4 none sil 2csbk fish 1f .5 8
3 24-10 7.5yr4/ none ms QS9 nn na .7 1.-2--
Boring # Boring
F-1 ❑ Pit Ground surface elev. III. Depth to limiting factor in.
Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfP
in. Munsell Qu. Sz. Cont. Color Gr. SL Sh. •Eff#1 •Eff#2
a Boring # Boring Ground surface elev. it. Depth to limiting factor in.
❑ Pit
Soil Apaication Rate
Horizon Depth Dominant Color Redox Description Texture Sbuctu a Consistence Boundary Roots GPDiff
in. Munse9 Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 -Eff#2
• Effluent #1 = BOD, > 30 1220 mg1L and TSS >30 < 150 mgA- • Effluent #2 = BOD, < 30 mglL and TSS 130 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 608-264-8777.
SBD4330 (86/00)
r ~
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Thanas O'Leary New Richmond, WI 54017.
MPRSW-3254 NWJNEI S18-T28N-R19w (715) 246-6200
town of Troy
lot #2-English Court
i
This sail evaluation vas conducted to satisfy a zoning requirmAnt, it may or wsy
not be suitable for your use. "n location of the test may or may not be as oft
as persansnt lot lines vets not established at the time the test vas conducted.
N
1"=40'
BM.= top of 1" pvc pipe @. el. 100.00'
alt. BM.= top of 1" pvc pipe @ el. 101.80'
tSo
t~
(V
A'
~9b
l
Gary L. Steel
8-30- 01
l