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040-1306-17-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 579053 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: Village X Township Parcel Tax No: Creative Homes, Inc., c/o Nathan Hidde City Troy, Town of 040-1306-17-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 08.28.19.1844 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss I System Head TUP Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dip Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of d/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx Seede 51 Yes ® No ® Yes F No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 446 Jordyn Lane Hudson, WI 54016 (SE 1/4 NE 1/4 8 T28N R1 9W) Sunset View Lot 17 Parcel No: 08.28.19.1844 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? { Yes FS-1 No 1 Use other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) t 63°q.~'~ ® Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) $ Madison, Wl 53707-7162 SEP Q 8 201 State Transaction N IoM ( pplication NJX In accordance with SPS 38321(2), Wis. Ada Code, submission of this form to the appropriate govtxnrnental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to P ojcct Address (if different than trailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes m accordance with the PT* Law, s. 15. 1 m Stats. ~tJ Vp L A lication Information - Please Print All Info on Parcel # Property Owner's Name rc y 7 y, fe UC - Property]~l ocat;on / ! /~j~'1t c property Owner's Mailing Address n C , 2 D Aor Ire Govt Lot C' State Zip Code Phone Number N r Section city, y~ cle 47 IL Type of Building (90a all that apply) Lot Subdivision Name 2 Family Dwelling-Number of Bedmo 6k 41 0(i Block# ~SLr/JS ❑ Public/Commercial - Describe Use ~ ❑ City of `/~,0 JSt_ I w CSM Number ❑ Village of ❑ State Owned - Describe Use owr of 7_Z-'rLZ r 1II. Type of Permit (Check only one bo on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List of Plumber ❑ Permit Transfer to New Previous Permit Number and Date Issued B. ❑ Permit Renewal Permit Revision ❑ Change Before Expiration Owner IV. of POW I S S stem/Com onent/Device: Check all that apply) / Gln~e Non-Pressurized in-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Ho ding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsal/Treat ent Area Information: / Desipi Flow (gpd) Desigt~APPlication f) Dis Area Required (s) Dis o (sf) SystemElevati 101" co 0 VL Tank Info Capacity in Total # of Manufacnuer Gallons Gallons Units 2 0 a3 0 New Tanks Existing Tonics Septic a Holding Tank Dossing Chamber VIOL Responsibifity State t` 1, the undersigned, responsibility for installation of the POWTS shown on the attached plans. PI s Name (P m) PI ignature MP/MPRS Number Business Phone N ber Plumber's Address (Street, City. State, Zip c VIII Coun /De artment Use Onl Permit Fee Date Issued ISSnin ent Signature proved ❑ $ lven Reason for ial U ' 7116115 lK Cond" ' ns for Disapproval w ',-effluent filter and dispersal cell must all be services / maintained Fier management p provided by m enis rnust.oorl PK ePP code i ordieancss. Attac3 to eompkte plans for the system and submit to the County only oa paper not less than 8 in x 11 inches in size SBD-6398 (R. 11/11) Soil Test d ~ystem P OT PLAN PROJECT Creative Homes ADDRESS 7 Comm e Drive suite 410 Woodburv Mn 55125 SE 1/4 NE 1/4S 8 /T 28 N/R 19 0 N Troy COUNTY ST. CROIX SYSTEM ELEVATION 93.0/92.9 5' below grade DATE 9/7/15 BEDROOM 4 CONVENTIONAL XXXX IN-GROUND PRESSURE NVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons IFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of foundation 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 ca I e = 1/411 = 10 Vent Jordyn Lane >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps Long 12' Grade at System Elevation 34 Pro 4 Bedroom House 10' 130' B.M.* 10' S B-3 15' 50' Vents 30' 100' 30' B-1 0% Slope B-2 20' 2-3' X 90' cells with >3' spacing Property Line Soil Test and ystem PLOT PLAN PROJECT vCreative Homes ADDRESS 7 Comm e Drive Suite 410 Woodburv Mn 55125 SE 1/4 NE 1/4S 8 /T 28 N/R 19 O N Troy COUNTY ST. CROIX SYSTEM ELEVATION 93.0/92.9 5' below grade DATE 9/7/15 BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE NVENTIONAL LIFT HOLDING TANK SEPTIC TANK SIZE 1255 gallons IFT TANK SIZE DOSE TANK SIZE MOUND HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 Ilk BENCHMARK V.R.P. Top of foundation ASSUME ELEVATION 100° Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark All piping shall be ASTM SDR 30/34, within ~ ~ I ~ - 10' of tank, piping shall be ASTM F891 " - 10' Vent Jordyn Lane >6„ Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12" 34" Grade at System Elevation Pro 4 Bedroom House 10' 130' B.M.* 10' S B-3 15' 50' AL F1,411 Vents 30 100' 30' B-1 0% Slope B-2 20, 2-3' X 90' cells with >3' spacing IN Property Line A. Wisconsin Department of Commerce SEp SOIL EVALUATION RE _ Page of Division of Safety and Buildings in acx og~n Il t ti /is. Adm. Code County J Attach complete site plan on paper not Iesgt hNIJAl"ll rcnehes insiz#.` 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. Q '70 ^ / .3 7 - D6 Please print all information. Revie ad by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 9 ~6 Property Owner Property Location 0 ( el~ 0-, a 'a-0 Govt. Lot 1 /4 1 /4 S T N R E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name CSM# , (n . @ 1 14 Y1 Y 0) Cud City State Zip Code Phone Number ❑ city ❑ Village own Nearest Road )OAUJI-L J.D New Construction Llse,® Residential /Number of bedrooms Code derived de gn flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments ~'jy~Ct JG-~' and recormtendationss: l System Type CLN-" )O, System Elevation i 01P.2. r Boring Bori Mng # Iff-P' It Ground surface elev. ft. Depth to limiting factor 1112_ 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 b Qs-, Boring / Borl C] ® ~ # apit Ground surface elev?9- d ft. Depth to limiting factor Gl 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 mg/L and TSS >30 < 150 • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 54017 715-246-4516 Property Owner _ Parcel ID # Page of Boring # ❑ Boring pit Ground surface elev. A, Oft. Depth to limiting fad/L!2 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Z 12- e- / t 70 1 L - Boring # ❑ Boring F-1 ❑ 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 ')epth 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 mg/L and TSS >30 < 150 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. SOD-6330 (8.6/00) Property Owner Parcel ID # Page of Boring # ❑ Boring ® APit Ground surface elev. -N ft. Depth to limiting fad [l j( in. Soil Application Rate Horizon Depth Dominant Color Redoz Description Texture Stricture Consistence Boundary Roots GPDiff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'IC s 1 ,L 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 # Ground surface elev. ft. Depth to limiting factor in. F-1 ❑ Pit Soil Application Rate Horizon ')epth Dominant Col Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD6 > 30 < 220 mg/L 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) ECF-1 V D - CountY~~ Safety and Buildi ivi I - 4 N13 201 W. Washington Ave., P.O. 1 anitmrY Permit Number (to be filled in by Co.) Madison, VVI 5 162~a ~ /be~~ T IX COUNTY 7/ ostELOPMENT State Transaction Number Sanitary Permit Application In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate goveminental unit Note. Application forms for state-owned POWTS are submitted to Project Address (if ditlerem than mailing address) is required prior to obtaining a sanitary pewit the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 00 ~C sat in accordance with the P ' Law, s. 15. 1 in Stats. `7 ' ``y , L A lication Information - Please Print All Informa- / Pared # property Owner's Name o l-- 6 ~ / 3 o 6 - Cr Property Location Property Owner's Mailing Address l Lg M of i n n r i /0 Govt. Lot CC U Zip Code Phone Number SE '1+a_ soon City, state ~ `4/ 00 TZ N; R W II. Type of Building (c all that apply subdivision Name uckor t or 2 Family Dwelling-Number of B Su S, v r•( 6k Ah p l w.•~. ❑ City of ❑ PublidCommercial- Describe Use CS ❑ Village of ❑ State Owned - Describe Use own of f'i %5+" 2Ztt-Z 5 III. Type of Permit: (Check only one oz on line A. if applicable) Z6 A ❑ Replacement system ❑ T g Tank Replacement Only ❑ Other Modification to Existing System (explain) New System ❑ Permit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 0 Before Expiration IV. of POW TS S gtem/Com nent/Device: Check all that apply) Non PressurizedlO4,,ound ❑ pressm=d In-Ground ❑ At-Grade ❑ Mommd ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil p/.)s 5 ❑ Pretreatment Device (explain) I Holding Tank ❑ Other Dispersal Component (explain) P V. Dis rsaUTrea el S~ii Information: n: dst) DzsP Rolwred (sf) Dr Propose s~ System mevatio jkrea Design (gpd) u ~U(/ q S. Capacity in Total # of Manufacauer 8 ~ .S VL Tank Info Gallons Units Gallons ' p~o " Z 8 New Tanks Eluting Taniz ri✓ r ~~M e, ` a U vi v C7 w Septic or Holding Tank 5S Dosing Chamber VII. Responsibility Statement- I, the naderaigoed, a responsibility for installation of the POWTS shown on the attached plans. Pl Signature MP/MPRS Number Business Phone Number Plumb/ex's Name (Print) Z7 6 r,J--~ . m t Plumber's Address (Street, City, State, Zip ) VIII. Coun /De ailment Use Onl Permit Fee Date Issuing SignatuQe Approved ❑ isapp ~7J • bD ~I :anon fo DL Con ' ns for D~~'&&approval 3~ l f~ Q re5e, l ✓e 1 : y ep tanks affluent f fter ails I dsdersal ceft must all R°^'te°a ! `maintained as per, management plan provided by plumber.. 2. A1kSAWkfiqu emer s mutt **0144 japer appw able coda / ar" w , Attach to comple* plans for the system and submit to the County only on paper not less than 81x1111 inches in we SBD-6398 (R. I l/11) PLOT PLAN PROJECT Creative Homes ADDRESS 707 Commerce Drive Suite 410 Woodburv Mn 55125 SE 1/4 NE 1/4S 8 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX 95.8/95.6 5' below rade 8/13/1 SYSTEM ELEVATION a 5 4 DATE BEDROOM 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 survey iron 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 ca I e = 1 /411 = 10, Jordyn Lane 75' I I 40 Pro 4 Bedroom B-1 House B-; 100' 30' T .5% Slope 15 Vents Vent 2-3' X 90' cells with >3'spacing >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12" 34" Grade at System Elevation B-2 15' Property Line B.M.* Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 8/13/15 Owner:Creative Homes Location: SE 1 /4 NE 1 /4 S8 T28 N, R1 9W 446 Jordyn Lane Troy Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cro ection 4-6. Maintanance a d Contingenc P` n 7. Filter Cross Se on Signature License num t 226900 PLOT PLAN PROJECT Creative Homes ADDRESS 707 Commerce Drive Suite 410 Woodburv Mn 55125 SE 1/4 NE 1/4S 8 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 95.8/95.6 5' below grade DATE 8/13/15 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 survey iron 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, ca I e = 1 /411 _ 10' Jordyn Lane 75' 40' Pro 4 Bedroom B-1 House B-3 100' 30' T .5% Slope 15' Vents Vent 2-3' X 90' cells with >3'spacing >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area " 5.6ft^2/pair of end caps 4' Long 12 -411 34" Grade at System Elevation B-2 15' Property Line B . M. * Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 101.0' Vent ACI Grade Vent 31 4„ 3 $ ,A;~30/34 Septic Tank g 1 „ 5' Long 119 5 5 Lon Grade at System Elevation 3619 Grade at System Elevation Spacing 5' 2-3' X 90' Cells Same on other end Observation tubeNent At end of cell A 22 chambers per cell B System elevations: A_95.8' B-95.6' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS % Owner Tank Manufacturer: ❑ NA Permit # Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: -)2~NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: A Vertical Distance Tank Bottom(s) to Service Pad:` /1(ft) Estimated (average) Flow : 0 t) (gal/day) Horizontal Distance Tank(s) to Service Pad: •°7 (ft) Spec'itic servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) If horizontal is >150 feet. Specific Instructions to be provided on back. In Situ Soil Application Rate: , (gal/day/ft=) Effluent Filter Manufacturer. i~ f ❑ NA 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 jVA Total Suspended Solids SS s150 m L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. > (BODs) >220 mg/L El SS) >150 mg/L Mechanical Aeration ❑ Peet Filter ❑ Disinfection Pretreated Effluent Monthly average e ❑ Wetland Y 9 ❑ SandlGravel Filter ❑ Other. (BODs) 530 mg/L. Soil Absorption System (TSS) s30 mg/L NA Fecal Coliform (geometric mean) 510` n Ground (gravity) ❑ In-Ground (pressure) ❑ NA Maximum Effluent Particle Size Y8 in dia. ❑ ❑ A - Grade ❑ Mound t~A ❑ Drip-Line ❑ Other. Other: A Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third ('X) of tank volume ❑ an the high water alarm is activated Inspect condition of tanks At least once eve month(s) every: year(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: ? ❑ month(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: month(s) ❑ NA 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. ❑ month(s) At least once every: 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 certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 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 (X) 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 <12 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 (02/05) 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 overload 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: adds, antibiotics, baby wipes, -dgarettelbutts, 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 reply ent system: 94- ble 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. Name J ~1 c~ 1 Name ~/1 rt u 1 Phone 72 J-, Phone 71 j d v 6- SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name a, Name Phone 7 ~ lad-5- ~~j Phony lJ--:. 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) 8 (3), Wisconsin Administrative Code. 4, lk" a. a v 0. LL- 01 f: m C.. t~V R r- x,, LU ST. CROIX COUNYY SEPTIC TANK MAINTENANCE AGREEMENT ANII OWNERSIJIP CERTIFICATICN FORM Owner/Buyer C e, _,,)e, ~ - wl- Mailing Address 7D 6,17 /,W e/ c!L Property Address 'j~ /Y V-6 319 r ri / 4 n_~ _ (Verification required from P ng & Zoning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRIPTION Property A✓~ Location Sec. T Z 9N RZ? W, Town of bv Subdivision SL , sg~v) Lot #17. Certified Survey Map # Volume Page # _ Warranty Deed # Vo[time Page # Spec house es no Lot lines identifiable yes 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 §C:omm- 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 full of sludge. Vwe, 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 Departrnrnt 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. 1/we certify that all statements on form are true to the best of my/our knowledge. I/we andare the owner(s) of the property described above, by virtue of a wa'my deed recorded in Register of Deeds Office. Number of bedrooms SIGN F APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being r~::voked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. 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Plan must County S c~ < include, but not lim ed to: ref ence point (BM), direction and SG rig percent slope, seal or dimen Ow ocation and distance to nearest road. Parcel I.D. 3U~O ' /-7-0Z P/ nt all information. Revi ed by Personal information o may Date y provide ma be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner` , Property Location 1/4.K~E1/4-S e~• T Z.8 N R Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# E ( ) W ~ • o , Sox ,3 3 _ City State Zip Code Phone Number 1~ IS Ste- ❑ City Village JS Town Nearest Road t3 pr~-~M lR~~ tiv ~ 5 ~18~I 0 l ) ~gS .33 S ! T~~. ~ New Construction Use: ® Residential / Number of bedrooms Replacement Code derived design flow rate 00 Public or commercial -Describe: GPD Parent material G Lie) ~4 L Flood Plain elevation if applicable r`1 General comments and recommendations: n4-`~Y~1 ti ft Lvt D (-Z- BLS >,~/~/v i~L~n~2 l~ Cti-{~"~+•tg ~ s_ i Boring # ❑ Boring ® Pit Ground surface elev. OZ~--7 U' ft. Depth to limiting factor -2 in. Horizon Depth Dominant Color Redox Description Soil Application Rate P Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color t p. 31 Gr. Sz. Sh. J Z D~` 'Eft#1 'Eff#2 O 1 - / 0~ I I~ Z 'S1 -30 ri~M 2:1 - ~S- S 3 3D.~`b io7rz I•~ i Sb'~ ~ y El Boring # ❑ Boring ® Pit Ground surface elev. lib- Z ft. Depth to limiting factor R g in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate in. Munsell Qu. Sz. Cont. Color GPD/ft2 Gr. Sz. Sh. 'Eff#1 'Eff#2 I I o - t o 10-l rZ 3 t z - s i t Z c-w Z'r s s Z S. I- b 3 -QS ) (n L V/6 S-Zi Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 CST Name (Please Print) - mg/L ' Effluent #2 = BOps < 30 mg/L and TSS < 30 mg/L .Arthur L ✓Wegerer L Sig tore CS Number 03-Z1S - 1`1 220254 0254 Add" W e g e r e r Soil Testing & Design Service Date Evaluation conducted 421 N. Iiain St. River Falls, UI 54022 1 Z_ZZ 3 Telephone Number 715-425-0165 r.- a s Property Owner N'~ Et (Dv-r- Parcel ID# (S Page of Boring # ❑ Boring ® Pit Ground surface elev. ( Do. 8 ft. Depth to limiting factor '7 1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color ~Gr..~lSz. Sh. •Eff#1 •Efff#2 0-)0 )0`123!- S1 I L.1 S~~Z !Yl 1 _ Z~ -S fU Z lb-'s 3 1~y R 3/c, s 1-1 Z trt s b IZ7 m 3 a`? )off YIL - S CDs - . 7 . Z t b F 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/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F-1 Boring # ❑ pit Boring ❑ Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODE < 30 mg/L and TSS < 30 mg/L . I I7ie 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 (R.6/00) Property Owner P/✓~~~Y Parcel ID # Page Z ' of Boring # ❑ Boring ® Pit Ground surface elev. 0c). ft. Depth to limiting factor 7 q In. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil AGPD/ftxn Rate In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0-10 )0'12.312 ~ s j I Z~SI,~.z m`F1. ~ Z`~' ~ 8 Z 10 -3 3 ~~~-r cz 3L~ - s i t Z ~1 s b m e S l ~ ~ • `3 3 33 -°lc? ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil A GPD/fton Rate 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. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate in. Munsell Qu. Sz. Cont. Color ry GPD/f Gr. Sz. Sh. 'Eff#1 * Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD3 < 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. S©0.8330 (R.6100) Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page of in accordance with Comm 85, Wis. Adm. Code r _ Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County I S7 2-0 include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel LD.~,~ ~G Please print all information. Reviewed by ^ "Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ■ Property Owner Property Location n ~x..t~ V Z(5 L ~U-~ f~, H1` JC 1/4! 1/4 S.E • T Z (5 N R E (ot W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P o_ 3oY, 3 3 1~ - ISurvs city State Zip Code Fhcne Number FT v F-I City F-1 Village ~ Town Nearest Road +3 Prk r'1 g Z 0 1 T 1Z-0`7' ~ ~ 11) ~S _33 4 i 21 New Construction Use: Residential /Number of bedrooms Code derived design flow rate ❑ Replacement - GFD Public or commercial -Describe: Parent material G LAC.) 1 r L ~ 7tiv1`) ~4 Flood Plain elevation if applicable 1~ F1 General comments ft. and recommendations: , ~ - --S ~y^~J U)= t°2t~J 1~ fit` ~1 ~Z.V , a o . S ' Boring # ❑ Boring ® pit Ground surface elev. J v ft. Depth to limiting factor - in. Horizon Depth Dominant Color Redox Description I Texture Structure I Consistence Boundary Roots yo'I Application GPD/ft Rase 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 ~ 'Eff#2 O -q `0` l tZ ! z I - S 1 J Z`ts, Dr. I 1- C 1,Q Z~ • S I - 8 Z ~ -30 tp~ 2 316 1 CIE. a Boring # ❑ Boring ® pit Ground surface elev. 1 ub- Z ft. Depth to limiting factor g in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -10 1 O`2 IZ 3 L Z - S j 1 Z `FS b ~c Z ) D~ ~p~~ 3 L 6 - s i f Z M s b~ vrl'f'~- cg l • S . S 3 6-Q8 1rnLV26 - S ass 1 - Z • Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOO, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sig tune CST Number -•A:rthur L aWegerer C~i,~. 03-Z1S - 1`1 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N Hain St. River Falls, WI '54022 1Z-Z Z-O 3 715-425-0165 ` PLOT PLAN Pace 3 of Scale 1' =SO ' I ~ O V O t5o$ ~Gi )Dp~ / o S a° lob 3_- ~ 1pp 3 1 Lo T LS 1 \-137 _g Z=--CSZ, IOU . 7 CIJ a IOU D Su1Z.t=fl-CQ Fff- wr CUYZKit~R >Z-u-o 3 715-425-0165 220254 03-1 _ S 7 CST Signature Date Telephone I-do. CST No. Job NO.