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042-1090-20-400
Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM County: St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 579021 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. State Plan ID No: Permit Holders Name: City Village X Township Parcel Tax No: B'ornstad, Adam Warren, Town of 042-1090-20-400 CST BM Elev: EM ev: BM Descripltio Section/ Town/Range/Map No: TANK INFORMATION 32.29.18.497A40 TYPE ' ELEVATION DATA MANUFACTURER P CITY STATION BS HI Septic ` FS ELEV. Benchmark tV t TZ Dosing 1~ + `'OM Alt. BM Bldg. Sewer Holding{ 1 Z t Inlet ` J TANK SETBACK INFORMATION $I Outlet 10 72' v TANK TO P/ WELL BLDG. Vent to Air Intake 0 ( ROAD Dt Inlet Septic lJ IV / Dt Bottom Dosin 0 Q'G~ eader/ an. v DD Aeration ✓ ~0.~ Dist. Pipe ~ Holding 2 Bot. System 5» 44»'{ b.z to, b ~ 9S'] PUMP/SIPHON INFORMATION Final Grade Manufacturer Z . 91 Demand St Cover r Model Number GPM III A ~ , I)~ TDH Lift N 5 3 ~ ~~J'~) `f Friction Lo System Head TD Zt Forcemain Lengt O) Dian Dist. to Well + SOIL ABSORPTION SYSTEM BEDPiRENCH Width A~ Length No. Of Trenches DIMENSIONS PIT DIMENSIONS No. Of Pits i Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL INFORMATION T e pf st LAKE/STREAM LEACHING Manufacturer: CHAMBER OR V (j o N UNIT Model Number: i ION SYSTEM v j L1 St Header b Id Distribution ~ e / f' ~ Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake ength Dia~ Length / 6 it- is spacing C• D/7d SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only De Sre f I Depth Over Be ~ xx Depth of en r Bed/Trench Edges xx Seeded/Sodded Mulched t . / Topsoil / es [H No s ~ No COMMENTS: (Includ code discrepencies, persons present, etc. Inspection Inspection #2: / Location: 686 104th Street Roberts, WI 54023 (NE 1/4 NW 1/4 32 T29N R18W) NA Lot 4 / 1.)Aft BM Description Parcel No: 32.29.18.497A40 / 2.) Bldg sewer length = ~~1 U?dp' /"A~,/~~n" - amount of cover 7b A){ ~ ~ li'/f (Q~ I ~f Yl fNl A Vim' r ')LIZ'' c~natl SgSft,N\;Srl Mvwj WN1 4Of Plan revision Required? 0 Yes No ' n Use other side for additional inform; ion. 41if SBD-6710 (R.3/97) Date / y"~ D t es.lnsepctor's Signature i o ' ' ~ l JqS4~Cove red hS F LGQ~~ r~ ec h Cert. No. PROJECT Adam Biornstad Soil Test and System PLOT PLAN ADDRESS 1060 Cottonwood Rd. Hudson Wi 54016 NE 1/4 NW 1/4S 32 /T 29 N/R 18 W T N Warr COUNTY ST. CROIX SYSTEM ELEVATION 96.5/96.4/96.3 3.5' below grade r / 8/6/15 4 CONVENTIONAL DATE BEDROOM IN-GROUND PRESSURE C VENTIONAL LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 933 # of chambers 45 BENCHMARK V.R.P. Top of grade at lot line stake ASSUME ELEVATION 100' Filter Lifetime Filter DBOREHOLE O WELL * H. R. P. same as benchmark All piping shall be ASTM SDR 30/34 within 10' of tank, piping shall be ASTM F891 490' Property Line 104th St. 102' 100' Scale = 1/4'1 -10' -2 B.M.* 60' 7% Slope 5' B-1 250' 40' 3 B-3 W ents Huffcutt Combo Tank 7% Slope _ x lf-l+ 20' Pro 4 bedroom house I I rl ce d ~b X 2+4 Gtr J ` btlovJ Vklvt e-&` Hal i~ "Asyn1 5'S/ Vent ~~nno t-016 f'h;j o/~d) >6" Quick4 Standard J/ of Cover Leaching Chamber Q✓1 with 20.0 ft2 of Area ~d~ t fi onr 4' Long 12" 5.tft^2/pair of end caps lb6e I'A r" 34„ Grade at System Elevation 4 EIVED Safety and B D sion County 201 W. Washington Ave., R Sanitary Permit ,mbcr (io be filled in by Co J A= K AUG 0 6 2015 Madison, Wa=-G 7162 T. CROIX COUNTY StateTramsactionNuwb2r T' 9M i1it Application /VA_ 1, accordance with SPS 38321(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 Project Address (if different than mailing address} the Department of safety and Professional Servies. Personal information you provide may be used for secondary ses M accordance with the Privacy Law, s. 15. l m , Stars. L A lication Information - Please Print All Informs ' arcel # Property 's N e l, cA - L p pF~ Prop Owner's Mailing,Address Property Location ! 7A - -7 6 / Govt Lot City State Ip Code Phone Number Section fcircle T~N; R/ C) E~ Type of Building (check 211 that apply Lot # 1 - Subdivision Name or 2 Family Dwelling -Number of Bedroo 1 Block # r ❑ Public/Commercial - Describe Use ❑ City of P `a"-- CSM Number ❑ tllage of / ❑ State Owned - Describe Use own of 1WW (leas w ham er 52 -;am q W. T of Permit: (Check only o box on line A. 1 e . e B if applicable A. ❑ Replacomerit System ❑ Treatinci t/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) 3- 31X Zt List Previous Permit Number and Date Lssu B. ❑ Permit ermit Revision ❑ Change of Plumber 11 Permit Transfer to New Before Expiration Owner (J IV of WT'S S stem/Com onentlDevice: Check all that apply) .4 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 (explain) V. Dis rsaffrea entArea Information: / ign Flow (gpd) Design Soil Application ds~ Dispersal ea Required Dispersal Area Proposed (sf) S Elev U) 1 VL Tank Info Capacity in Total # of Manufacturer B Gallons Gallons Units a ? 3 New Tanks ~Exuting Tanks r- I / ~ p 2 V~ Lc to v Septic or Holding Talc Dosing Chamber X -7n VII. Responsibility Statement- L the undersigned, ass responsibility for installation of the POWTS shown on the attached plans. P `beg's Name (Print) Plumber' ignatme MP/MPRS Number Business Phone Number Plumber's Address City, State, Zip Code) ~ l / / J'C ounty/De ar gment Use Onl Approved ❑ sapp Permit Fee Date Issued tssuing Agent Signaz ❑ Owner Given Reason for Denial $ V✓ * / DL Conditions of Approval/Reasons for Disapproval Jf+ nar 4 b ',Sys L 1 SYSTEM OWNER: t~ n 1. Septic tank, effluent filter and dispersal cell rust be Serviced / maintained i , as per management plan provided by plumber. 1a ry(tt4- /V a- 012 W-bw k • bmit w t County only on paper not less than S to z 11 inches in size as per applicable code/or inances. SBD-6398 (R. 11/11) 0,d a o, Ck&Ai -t~ bYl a CST- 1v P ravi & otxL q vah rt p lau Septic-Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer Pump Manufacturer Tank Model Number 510 Pump Model Number ~,7 Total Tank Capacity y -1 6 Alarm Manufacturer c Max. Bury Depth Alarm Model Number Switch Type , Filter Manufacturer k; j IQ, Total Dynamic Head (TDH) - Feet Filter Model Number 1 Elevation Head l Distal Pressure Network Loss E2_1 ~0 / . Minimum Pump Performance Required Force Main Loss GPM @ A Ft TDH Total 77 Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade Sealed Watertight Securely Mounted With Locking Device Weather-proof 1 Junction Box D Finished Grade Depth of Cover Vent Min. 12" Disconnect Ft Above Grade Means With Vent Cap F:~ {}t 't Outlet Outlet Filter Inlet Inlet Baffle iY{ II > Y { { - - JtY YS} S K > { } t ti A > } y i }s} Switch Settings and Reserve Capacity t't ,4„ } Tank Volume = GPI C` <;< - Weep YS> { t >i ]Dimension Inches Volume Gal. g Hole eserve) A d . { { (alarm) B 2 Off Elevation 7- Ft (dose) C p2 i;{ ys~ (dead) D Jz Bottom - t'{ D YS Elevation YS> y,---- -7 `S- t_ Total Ft } } } y } } } > } } } } y } } y } } } } } } } } Y } y } } y Y } > > } Y } > y } } y y }i >'S{StYtYt}t>{Si>;S~y;yt3{Y{y{y{}iy~y°yty~y{yi,;yt>~Sr>tyi>t>i>ty<>ty<Si>t}iY{SK>{}{>{>{>{Y{>{>{>{y4Y{>{X Y{}{>{>i GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 LJ Page of A" CAPA1-jV -P 25 i rs' z - 1- I l I i 40 TEP - - - - - i/ 3 ; 1 D 1 t,/.I N: V T. 009897 Variable level float switches available. Variable level long cycle systems available. T^\ Available with special cord lengths of 15', 25', 35' and 50'. Alarm systems available. ` - Duplex systems available. i , H ~(L SK858 SingleSeal_ -.-I T Co - - Model - Volts 1 Phase Mode ntrol Selection Listings _ _ Amps r-Simplex _ _ Duplex CSA UL 1. Integral float operated mechanical switch, no external control r,:quired. M53/55 & M57/59 1 15 1 Auto 9 7 r1 Y Y 2. Single piggyback variable level float switch or double piggybar k variable level N53r55 & N57/59 i 115 1 Non 9.7 2 3 or 4 & 5 Y Y float switch. Refer to FM0477. BN53 115 1 Auto 9.7 Y _ Y - - - 3. Mechanical alternator "M-Pak" 10.0072 or 10-0075. BN57 _ 115 1 Auto 9.7 N Yom; r ` BE53 57 T 230 1 Auto a a . - y v 4. See FM0712 for correct model of Electrical Alternator. L Db 55 & D5759 230 1 auto a e ; 1 Y v 5. Variable level control switch 10-0225 used as a control activato', with Electrical E5 3l55 & E5, - 1.- 230 -1- 1 Non 4.8 - 2_-_. r 4 & 5 Y Y Alternator (3) or (4) float system. - ' Single piggyback switch included. O CAUTION For information on additional Zoeller products referto catalog on Piggyback Variable Level Float Switches, FMO477; - Electrical Alternator, FM0486; Mechanical Alternator, FM0495; Sump/Sewage Basins, FM0487; and Single Phase Simplex Pump Control/Alarm Systems, FM0732. For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. KY 4025o SHIP %jo Manufacturers of. . Run Road it e, 3649 Cane KY 40211-1961 /7 ~,NCE (502) 778-2731.1 (800) 928-PUMP QU4UTY PUMPS , /i~ j,9 http://www.zoelleccom FAX (502) 774-3624 - © Copyright 2002 Zoeller Co. All rights reserved. RECEIVED ~a~.ssy Wisconsin DeAF,;6nQoQ" SOIL EVALUATION REPORT Page J- of 3 Division of Safe r~idd ST. ~I~OI~ Cu~~((d'M1 Y in accordance with Comm 85, Wis. Adm. Code -QMMUNITY DEVELOPMENT' County < Atta complete site plan on paper not ess than 8 1/2 x 11 inches in size. Plan must r 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. Q Please print all information. Revi Y Date / Personal information you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). I 7~ l Property Owner Property Location V l I AAA-- 0/ n Govt. Lot 1/4 /4 S3Z T2 N R E ( j W Property Owner's Mailing Addreds Los #lock # Subd. Name or CSM# In 6 o ~o A4,-,,a-h1rr7 ~ d aQ !U j UTY State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ew Construction Use Residential / Number of bedrooms Code derived design flow rate 1642, GPD ❑ Replacement ❑ Public 7mmercial - Describe: Parent material t~ FJPod Plain elevation if applicable / g General comments 06,-&tu fb- and recommendations: j P~ J• '~J iYc~ 'fie J System Typed YYf System El ox evation t t t Boring # C] Boring g[ 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 Boring # ❑ Boring ~it Ground surface elev/! 11/ 2 ft. Depth to limiting factor/_~/-- in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/lf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •E 2 -fo - Z Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < • Effluent #2 = BOD. < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) nature CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 5467/ 9- -01" 715-246-4516 Property Owner _ P I ID # Page 2-,5 ❑ Boring Boring # 13 (-5 ❑ 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/M in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Z 141 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication 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 ❑ ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 1150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. S81)-8330 (RAW) Property Owner _ P~cceI ID # Page 2- of L3J Boring # ❑ Boring ❑ Pit Ground surface elev ft. Depth to limiting factor in. Sail 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 F-1 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 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon 'lepth 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 = BODS > 30 < 220 nVL and TSS >30 < 150 mg/L ' Effluent #2 = BOD, 130 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. SBD4330 (8.6/00) Soil Test and System PLOT PLAN PROJECT Adam Biornstad ADDRESS 1060 Cottonwood Rd. Hudson Wi 54016 NE 1/4 NW 1/4S 32 /T 29 N/R 18 r:D rr COUNTY ST. CROIX SYSTEM ELEVATION 96.5/96.4/96.3 3.5' below gra8/6/15 4 E BEDROOM CONVENT IONAL IN-GROUND PRESSURE L LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 933 # of chambers 45 BENCHMARK V.R.P. Top of grade at lot line stake ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL * H. R. P. same as benchmark All piping shall be ASTM SDR 30/34, within , 10' of tank, piping shall be ASTM F891 490 Property Line 104th St. 102' 100' kale = 14" = 10' -2 B.M.* 60' 7% Slope 5' B-1 250' 3 B-3 40' W ents Huffcutt Combo Tank 7% Slope x LIV 20' Pro 4 bedroom house t if Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 5.Sft^2/pair of end caps Grade at System Elevation ~v County 1 1 ECEIVED Safety and Buildings Division^ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) PI 1-W ' 99 7-7152 51 I ~Z s JUL 13 2015 r v rVIMUNITY Stale Traasactionly emit Application NN In accordance with SPS 38321(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 Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary se5 in accordance with the Privacy Law, s. 15.04(l m ,Stets. Q L Application Information - Please Print All Information l~ Property ame Parcel # -0 u- n f) r in Property Owner's Mailing Address Property Location j f 7 /060. Pr, 44-,.,,1 LjDtl Govt. Lot J J city. State Zip Code Phone Number Section T N; R E tw) II Type of Building (check all that apply Lot EL ,Type Subdivision Name amily Dwelling -Number of BeirN - dk ~aA Bloc W__ ❑ Public/Commercial - Describe Use ❑ City of CS ❑ Village of ❑ State Owned - Describe Use _ J Town of LJ V- ~ / jNemw III. Type of Permit: (Check only one boz on 4ine A. Compl [iu i applicable A g tam Replacement System ❑ Trealment/Ho g Tani: Replacement On❑ Other Modification to Existing System (explain) ❑ permit Renewal Permit Revision ❑ Ch v: f PluList Previous Permit Number and Date Issued Before Expiration Owner Z-9. ..Typc of POWTS S stem/Com ones evice: (Iwcw that apply) 11V _Prassur=d in-Ground El Press -Ground Al-Grade El Mound > 24 in of suitable soil 11 Mound < 24 in. of suitable soil ~,Wlo l - - explain) ❑ Pretreatment Device (expla jjDgn Holding Tank ❑ er Dispersal Co is rsanrea ent Area Informati_5 e Flow (gpd) Design Soil Application ds Dispersal Area Acquired (s Dispersal Area Prposed Elev n a Tank Info Capacity " Total # of Manufacturer Crallons Gallons Units New Tanks Existing Taa1-s / f t 0 5 p Septic or Holding Talc I i ~JrS Dosing Chamber VII. Responsibility Stateme - the undersigned, ass a possibility for installation of the POWTS shown on the attached plans. Pltmtbe/r's Name (Print) Plumber amuc MP/NTRS Number Business Phone N r Plumber's Address (Street, City, State, Zip Code) ~ 2- f~0 4- fi t J1 f~d VIII-County/Department Use Only Approved i rov Permit Fee Date sued Issuing t Stgnat= oo, /0'1 eason for Datial / IX. CouditiZns ii(l@P approval 3l dispersal cell must all be ssnttoTs t maintained f 4~+ P 4L lls per management plan provided by plumbef, ~pp~ NG Z yp:~ roqutr~tnalttlF must rl tluFtt (F d 1 Tom- ' bls cods I W*41+oa. Attach to complete plans for the system and submit to the County only on pa of less than 8 it x 11 inches in size SBD-6398 (R. 11/11) PROJECT Adam Biornstad PLOT PLAN ADDRESS 1060 Cottonwood Rd. Hudson Wi 54016 NE 1/4 NW 1/4S 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX SYSTEM ELEVATION 90.5/89.8' 5.5' below qrade 7/12/15 DATE BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of spike in 10" pine ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark All piping shall be ASTM SDR 30/34 within 10' of tank, piping shall be ASTM F891 Scale _ 1/4 11 _ 10' 104th St. Leaching Chamber jT34" Quick4 Standard with 20.0 ft2 of Area 5.6ft^2/pair of end caps 140' Grade at System Eleva n 490'Property Line % 15 2-3' X 90' cells with >3' spacing 30' -3 10' 8% Slope 94' Pro 4 40' 0 Bedroom House B-2 96' 92' B-1 Vents 20' B.M. * ~dc' 0 Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 7/12/15 Owner: Adam Bjornstad Location: NE /4 NW1/4 S32 T29 N,R18 686 104th st. Warren Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross S ion 4-6. Maintanance Contingenc Plan 7. Filter Cros Signature Licens n ber #226900 PLOT PLAN PROJECT Adam Biornstad ADDRESS 1060 Cottonwood Rd. Hudson Wi 54016 NE 1/4 NW 1/4S 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX SYSTEM ELEVATION 90.5/89.8' 5.5' below grade 7/12/15 BEDROOM 4 DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of spike in 10" pine ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. sameasbenchmark All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Scale = 1/4" _ 10' 104th St. t jT Quick4 Standard Leaching Chamber with 20.0 ft2 of Area , 5.6ft^2/pair o f end caps 140 34" Grade at System Elevation 490' Property Line 150' 2- ' 0' cells with >3' spacing B 30' 10' 8% Slope 94' Pro 4 40' Bedroom House B-2 96' 92' B-1 Vents 20 B.M.* POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page__ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: ❑ NA Permit # eptic ❑ Dose ❑ Holding Volume: ~;SS (gal) DESIGN PARAMETERS Tank Manufacturer: >1a NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: A Vertical Distance Tank Bottom(s) to Service Pad: //(ft) Horizontal Distance Tank(s) to Service Pad: (ft) Estimated (average) Flow : IV(g ~ (gal/day) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): Y7 6n (gallday) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gauday/W) Effluent Filter Manufacturer: ❑ NA f r Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) s30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA A Total Suspended Solids (TSS) !150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BODO >220 mg/L A 171 (TSS) >150 mg/L Mechanical Aeration ©Peat Filter ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODO 530 mg/L Soil Abs Lion System (TSS) s30 mg/L A and (pressure) El NA Fecal Coliform (geometric mean) s10' Ground (gravity) ❑ In- ❑ At-Grade ❑ Mound Maximum Effluent Particle Size 'a in dia. ❑ NA ❑ Drip-Line ❑ other: Other: 214 Other. NA ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) O'When combined sludge and scum equals one-third ('h) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: month(s) (Maximum 3 years) ❑ NA ear(s) Inspect dispersal cell(s) At least once every: ? ❑ onth(s) (Maximum 3 years) ❑ NA ear(s) ❑ NA Clean effluent filter At least once every: CVnonth(s) ear(s ) Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ year(s) Flush laterals and pressure test At least once every:. ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) NA ❑ year(s) Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems 'shall be made by an individual carrying one of the following licenses or certlfi tions: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servidng Operator (p mper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks o leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third (ys) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 5512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02105) 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, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be=discharged to the soil absorption system in one large dose causing an overioad that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette'butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sani4ry napkins, solvents, tampons, and water softener brine discharge. 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 s. Comm 83.33, Wisconsin Administrative Code`. • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. c Name, 5l Name Phone Phone SEPTAGE SERVICING OPERATOR UMPER LOCAL REGULATORY AUTHORITY ~j f r p Name Name Phone Phone jj This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. .3 wy3 11 N 3 a n f G~~~..[ - - i o4 3 c ~ ~ Q d N ~ ~ i u y CIO 3 Q U to cry I ST. CROIX CC)L1NT'i' SEPTIC TAIN" AlAIl`vt"I 3NAN('I:i Y ~GRFFMI NT AND t.)WN1aI2, IJH' C`. ,'R-TIFk'AT11-:N I-ORM Owner/Buyer e5 Gec_ Jj tt? Cfi " Mailing /Vddress A® v ~v Property Address Verification require( (torn l'lanniu r f, br %onnth Depart' nent for ne.w coils, irac txiri.) City/State Parcel Idezati (-tcation is leer LEGAL DESCRIPTION Pro ert Vocation-~ ;7 1, 1/i s cc SL?Ud1V1610l1 Lof Al" sue- ~i) Certified Survey Map # V< Itum, _ .1 age # Warranty Deed Page TIJ Spec house yes nit lot lint; identifiable OnO SYSTEM NIAINTLNAN'E ANI) QWIriI?-R C"1EC27'I1,IC'ATl()1`4 Improper use and ;rtaintcriance of your septic system could result in its pr'nultme failure to handle wastes. ,l''roper maintenance consists of pumping out the septic tank every hired years or sooner, it needed, by a licensed pumper- What you brut into the systern can affect the function of the septic tank aS a treatment stage in the waste disposal sysi:eni. Owner maintenance responsibilities are specified in Wonun. 83-52(1} and ut Chapier 12 - St. Croi>; County Sanitary Ordinance. The property owner agrees to subrrtit io .St. Croix County Planning & Zoning Depai-Imem it certification form, sigricd by the owner and by a master phunber, Journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condiiion and/or (2) after inspcc:ion and purnp fig (if necessary), the septic tank is less titan 1 /3 full of sludge. read standards set we, thetmdoi it an s h-av the ll he abod nrrof L?orrnrails a rl ai we to m3irtain lie priti ale sc-ovage. disposal systern with tlic and the 'Depar inc- rt ot'Natuial ltesoan es, State of Wisconsin. Certification stating that youur septic System has been marniamed must be complete, l and r warned to the Sr. Croix Cotritty Planning Zoning .Department within 130 day ; of-the three; year expindion date, l%we certify that all statements on this form arc true to 111• best of illy/our I uowledge. I; we a[It1are the owllei(s) of*tlle property described above, by virtu(: a warra ty deed recorded ill Register of Dee, Is Office. Number ' be ooms SIGN 1 E, Of ULAN l - TF- **Any information that is inisrepresented may result in file sanitary permit being o-woked by the l'laruung & zoning; Department. Include with this application a recorded warranty deed from the 'Register of' Deeds 'Alice and a copy ofthe certified survey snap if reference is tirade in the warranty clc:ed. (REV. 08/05) [ ~g0 IF OTS e`~ 8 N m f E E 1 c? F w ~~¢o s°sg = N F, TQ ^53F`:s€~€ SAEu€§a3 9~i `tyGE"e~3~ i , a t z . W I dW ci dQ J FT 2 7`177 1 ~ ~I 1C I I LT?1 LMU 77 a 1 I4 L ~ m L_, HH o a€Emg ~I ~ ~d¢~g o0 ITC P t~ r 0 i qq `v€R y~k o n zl I - - I I w>'" I! 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O ~la „ ~ o 119 P: _g711~ A 9N .r., s @YA e8 O ,iii( b 33 0 ® of Cl F+~ o O I € I .mss-: n~~,,,.M aaav„a li I I I ~ Ej I ;a8 _ AJ I I aj yI ~ 5[ .L,x i~ ~ kk• &I j y~9 Mni3n o3„nrn 1 i S ~m _ xlil TP I 5 ° ' I I ~Ig I E W I n~ ,n n "Y a 88 ~a S Wisconsin Department of Commer So T Page -.l of 3 Division of Safety and Buildings RE El in ce with Co m 85, Wis. dm. Code colmy St. Croix 1 /2 x irtc in per„ ~I n T at 0 Attach complete ft plan on r not ;rr 2006 include; but not Iilftd to: verti nce poln (BM), o P I I.D. percent slope, scale or dimensions, north n d istelce to nearest road. ate x P/e"s prir+t all flrlfo ST. CROIX COUNTY Re i W~~ a q Posonfri infoRmation you provide play be used for seooWarysurposes / roperty Owner Property L P Richard Stout Govt. Lot' /Vl 1' 1/4 ~,10/4 S 3 T, ~ N R D E (or) GV Property Owner's Mailing Address Block # ,S,lubd. Name or CSM# 5 1353 Awatukee Trail 4 NW ~ m S 7 City State Tip Code Phone Number 12elty village ■ own Ne ad Hudson Wl(, ( 7)52-549-6731 70th Ave. Nfew Construction UseE] Residential Number of bedrooms 3-4 Code derived design flow rate 450-600 GPD Replacement El Public or commercial - Describe: Parent material Outwash Flood Plan elevation if applicable NiA. ft• General comments ys~ewj_ 1~--ce~_ and recommendations: v - L S!~ ~~~rZ~/ ~j cryY t Intl SGyytl~ ~S Boring# 11 Boring q Q pit Ground surface elev. ft. Depth to limiting factor 115 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. P.4 1 *Eff#2 1 0-12 10yr3/2 sil 2msbk mfr cs lc .8 2 12-38 1 r4/4 sicl 2msbk mfr cs lvf .6 3 38-115 10yr416 s Osg ml 1.2 ~t 2 Boring # ❑ Boring 120 ❑ El 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 1 0-21 10yr3/2 - sil 2msbk mfr cs lc .5 .8 2 21-53 r4/4 sicl 2msbk mfr cs lvf •4 .6 53-120 10yr4/6 s Osg ml .7 1.2 f 2u * Effluent #1 = BOD > 30:5 220 mg/L and TSS >30:5 150 mgA- * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L. CST Name (Please Print) ure CST Number Adam Schumaker 253309 Address Date Evaluation Conducted' Telephone Number 1679 89th Street New Richmond, Wl 54017 04_.27-06 715-760-0279 e Property Owner StQ*t pt el Ili Page of. 3 x Boring # 13 Boring 118 pit Ground'surtace elev. ft_ Depth toIimitiplaiwor. in, r Soil Application R Horizon Depth: Dominant Color FWox Description,*W ' Texture Structure Qpnsistence YBound Roots ropwf v in. Munsell " Qu. Sz. Cont. Cam"- Gr. Sz. Sh. *Eff#1 *Eff#2 1 .0-11 10yt3/2 - sil 2msbk mfr cs lc .5 .8 2, 11-53 10 r4/4 - sicl 2msbk mfr cs lvf .4 , .6 g -53-118 10yr4-6 s Osg - 3 l a VT Tr- 1 0 ❑ 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 ❑ 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. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 * Effluent #1 = BOD5 > 30 < 220 mg& and TSS >30 < 150 mgA- ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mgA- 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. SM-MOTest (R.07/00) Property Owner stoat ? PACCeI IL# r Page of 3 Bonn # € c, K . ¢1t t. g 13 Boring i~ Pit Ground surtace elev.4 ! /1 ft. Depth to limiti n2lactor 118 in. s Soil Application Raft Horizon Depth Dominant Color Fodox Description-*W' ' Texture Structure Qonsistence ,Bound Roots QPl3ff in. Munsell ° Qu. Sz. Cont. C6oT - Gr. Sz. Sh. `Eff#1 '!Eff#2 1 ` 0-11 10yr3/2 - sil 2msbk mfr cs lc .5 _8 2 I1-53 10 r4/4 - sicl 2msbk mfr cs lvf .4 6 1 53-118 10yr4-6 _ s Osg ml .7 12- F-1 Boring Boring 0 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 ❑ Boring # Boring 12 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 L I Effluent #1 = BOD$ > 30 < 220 mg/- and TSS >30 < 150 mgA- " Effluent #2 = BOD$ < 30 mg/- and TSS < 30 mgA- 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-8339rmt M07100) 1 PAG E OF NAME > v~ LOT# LEGAL DESCRIPTION ~J 1/4A)uy4,Sj T N,A E(OR SCALE: I" = go ~ BM i ELEVATION /60, O BM 1 DESCRIPTION Sjo,'k-t lO " SM 2 ELEVATION /00, O 1 ` r BM 2 DESCRIPTION S~' ~'t a ~O f'` SYSTEM ELEVATION ~1JC~ r/ e~0-cJ &,1'2c=~. SYSTEM TYPE (C,11 L)4 ✓k~ b✓L ILA- De 0 a / ~2s >~,GU SIGNATURE ' DATE Y 7;?