HomeMy WebLinkAbout004-1044-95-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
579042 0
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)]. 2.5 Permit Holder's Name: Village X Township Parcel Tax
No:
Hampton Trust City Cady, Town of 004-1044-95-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/pA'•oO i A1,49 /W WI/ er `140 19.28.15.306
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI.14 FS ELEV.
Septic (~79r- Benchmark
S`1~~ 1Cs• /Od
W
ArAftow,
Dosing iw Alt. BVIL Z
u C.o
Aeration T-9tr g• s• S 3 to 2411,
Holding St/Ht Inlet 9,ff
TANK SETBACK INFORMATION St/Ht Outlet 4 'p
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
G~ Dt Bottom / •uy , yti
Septic 70
Dosing / Header/Man. l / vZ
/C 5 7
Aeration Dist. Pipe
Holding Bot. System Z ~q
a y~ Z
PUMP/SIPHON INFORMATION Final Grade 14,6.
Manufacturer Demand St Cover
GPM
Model Number 04 c?4j
66A4-60 r
TDH Lift' f Friction• LQ System Head TDH Ft
7 g94
Forcemain I Length_~ Dia. i/ Dist. to Well fAa
SOIL ABSORPTION SYSTEM uU
BED/TRENCH Width Length No. Oflrench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ,(/~1
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type ystem: 47 7& 7 UNIT Model Number:
O d / n/
DISTRIBUTION SYSTEM
Header/Manifo~d `N Distribution i I x Hole Size x Hole Spacing / Ve to Air Intake
Length _Dia Length 74. ' Dia A ~ Spacing .3 ~ 3• / v~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only w.
Depth Over Depth Over y xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges \ Topsoil Yes 0 No es No
#2: t/ S / 5
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspecl
G.1 o
6 use G
4
I.
Location: 212 CTY RD N S ring Valley, WI 54767 (SE 114 SE 1/4 19 T28N R1 5p) 40 acres Lot
~,K(zs` , ~ou& (v"~ uND'F2
1.) Alt BM Description Z*,I If pl P 60t
2.) Bldg sewer length =i~aN 1 5,,,,~, ~ypg r►~/e ✓~C 0016
~
- amount of cover =~rc~lj 4)'A
0
Plan revision Required? ❑ Yes )<No
Use other side for additional information.
Date Insepcto Signat Cert. No.
SBD-6710 (R.3/97)
RECEIVED Z_
y
b, 0 Z~ iJ Industry Services Division Count
Ott 1400 E Washington Ave
~ , ~ $ Sanitary Permit Number (to be filled in by co)
Sf f jX COUNTY P.O. Box 7162 UNIW DEVELOPMENT Madison, WI 53707-7162 5-79 oLlz
Sanitary Permit Application State Transaction Number
In accordance with SPS 383 21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit -259 Z7,5
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
"purposes `
in accordance with the Privacy Law, s. 15.04(1)(m), Stats.
1. Application Information - Please Print All Information L
Property Owner's Name Parc #
~~M mss: boy ►oNq- q5- oD
Property Owner's Mailing Address Property Location
D_ CO.., V_t>" 11,4 N Govt. Lot v
City, State Zip Code Phone Number
L cL \6-11 CliS (circle one
E of
II. Type of Building (check all 6 at apply) Lot #
91 or 2 Family Dwelling - Number of Bedroo s _ Subdivision Na
Block #
❑ Public/Commercial - Describe Use r
❑ City of
❑ State Owne - Describe Use CSM Number ❑ Village of
x '7 UUAI G~- "Town of
1111. Type of ermit: (Check onl a A. Complete line B if applicable)
76 New System El Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
Y\ t * 0404
tttl
B. ❑ Permit Renewal l7fePermit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous rN ntber and Dates ue
Before Expiration / Owner 1rTf 'l -7AD ' t
IV. Type of POWTS System/Component/Device: Check all th ✓ I i~
❑ Non-pressurized In round ❑ Pressurized In-Ground ❑ -Grade 'Mound > 24 in. of suitable soil ❑ Mound < 24 in. of su'tabl , 11
'Mold ngTan-k~ her Dispersal Component
(explain) Peat evice (explain)
V. Dispersal/Treat ent Area Information:
Design Flow (gpd Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) DispersJ al Area Prised (s I) System Elevation
'7 A
VI. Tank Info Capacity in Total # of n fac r
Gallons Gallons Units inS~u~ ~I 2015 4 c
New Tanks Existing Tanks Ca n
I l~✓ w C y 2
a` U vt ~ rn ii C7 a
Septic or Holding Tank
Dosing Chamber
VII. Responsibility Statement- 1, the and igne assn responsibility installation o the POWTS shown on the attached plans,
Plumber's Name (Print) Plum is S nature PRS Number 7G-7
ess Phone Number
aa-~ 4 4
Plum
ber's Address (Street, City, State, Zip de)
V 1. ount-v /De art ent Use Only
Approved: roved ermit ee Date Issued Issuing Agen na
even Reason
IX. C1~~~~on t iq6WWAI/Reasons for Disapproval
l
: 3,x►5fin s~sfcm be a~andbne pe-r
1. Septic tank, effluent filter and ~ p
dispersal cell must be serviced/ maintained / nn,A,,,', 1J 1t
as per management plan provided by plumber. 60, Id/,
2. All setback requirements must be maintained
as per app Ica r the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size
SBD-6398 (R0313)
r 9tiPAR DIVISION OF INDUSTRY SERVICES
10541 N RANCH ROAD
4 9~ HAYWARD WI 54843
3i D S' Contact Through Relay
~ P http://dsps.wi.gov/programs/industry-services
www.wisconsin.gov
'ssror~yS Scott Walker, Governor
Dave Ross, Secretary
September 02, 2015
CUST ID No. 227548 ATTN: POWTS Inspector
TIMOTHY H MITTLESTADT ZONING OFFICE
BOWMAN PLUMBING ST CROIX COUNTY SPIA
2819 KNAPP ST 1101 CARMICHAEL RD
MENOMONIE WI 54751 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 09/02/2017 Identification Numbers
Transaction ID No. 2592734
SITE: Site ID No. 816730
Shirley Hampton Please refer to both identification numbers,
212 Co Rd Nn above, in all correspondence with the agency.
Town of Cady
St Croix County
SE 1/4, SE 1/4, S19, T28N, RI 5W
FOR:
Object Type: POWTS Component Manual Regulated Object ID No.: 1553490
Maintenance required; Replacement system; 450 GPD Flow rate; 31 in Soil minimum depth to limiting factor from
original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure
Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manuals referenced above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code
requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Abandon existing system per SPS 383.33 W.A.C.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction/installation/operation.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
~ S
TIMOTHY H MITTLESTADT Page 2 9/2/2015
Sincerely, Fee Required $ 250.00
Fee Received $ 250.00
Balance Due $ 0.00
Carl J Lippert
Wastewater Specialist, Division of Industry Services WiSMaRT code: 7633
(715)634-5035, M-f 7AM - 12PM
carl.lippert@wisconsin.gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
Tradesman Inc
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COMBINATION SEPTIC TANKlPUMP CHAMBER X-SECTIONS • S 9
(DRAWING NOT TO SCALE)
MANHOLE RISER & COVER - - -
FfNAL GRADE (Per COMM 84.25 {7) & (8))
(slope ground surface away from 4T went Pipe IMPt3F2 T AtU T
manhole(s) for proper drainage) B~ ~ Anchor tank(s) as necessary
IrMin, ar2anabove Pursuant to SPS383.4-3(8)(g)
Established Flood Elevation
(tyaicai)
UILDIN~r SEWER Approved end rani ole riser as necessar,..
Vent { p
per COMM 8230 (11)) ELECTRICAL Approved Loddng Wnhote
JUNgnoN Son ? *111 Wanting Label Fitlached
Se.ctdcal musel comply rr~h ! (typical)
SPS 318 and NEG300
iVfin. or o ii shove
~stab li shed Flood oad Elevation
} {typical)
t MANHOLE V LI
LIANHOLE `
18" mirt. MANHOLE
• y .i to a•a°- ~4.
BOTTOM OF INLET (inved elevation) j~$° a• plops
dy soa~d
+ whennotul
(tVaSteptalertetY'I) r i r
INLET
0 OG
SAS ~~rrlili/J//!/rY/ ALARM FLOAT
fit reA, a C
ON FLOAT
4" INLET PIPE FILTERED B
r (lee orba~e) APPROVED EFFLUENT FILTER EFFLUENT OFF FLOAT
REQUIRED ON OUTLET A elev qq=
MINIMUM OF 3" OF SUITABLE BEDDING BENEATH TANK PUMP PAD
EFFLUENT FILTER OR EQUIVALENT COMPONENT
Tank Manufacturer lJiF E,c t~o.✓c.cErd- DWF (daily wastewater flow) YS0 BPD
Septic/Pump tank model /aao/zoo Number of daily doses V.
(DWF / actual dose volume)
Alarm manufacturer S.T. E. ~l1oy.6rrS
Alarm model number y-A.v.C 4.e rAr / Forcemain volume 5! /
Type of float switch Actual dose volume (gallons) 88. /
(total dose volume - volume of forcemain) 9.7.,2- 41./
= 88. /
Effluent pump manufacturer Zo EL C ex
Effluent pump model number 98 PUMP TANK CAPACITIES
Reserve above alarm / inches = 3Sd gallons
Minimum pump discharge rate (GPM) ?4 y Alarm float above on float inches = 3.S gallons (C)
OnlOff float measurment J.5' incites = 92 ? gallons (B) - -
Vertical lift (pump off to distribution lateral) 7.o Off float above tank bottom 7 S Inches = /,ls 7 gallons (A)
system head (distal pressure X 1.3 feet) 3.3 TANK DIMENSIONS & PUMP CHAMBER SPECIFICATIONS
Friction loss in the forcemain as Y.o/6 , y W
Total dynamic head (TDH) /p Length /SO It Width 8y
Liquid depth .34 Gallons per inch /6.7G
-Rogow
Mighty-MatelRo -
Considered one of America's most popular sump pumps. This robust
familyof sump pumps is known for reliability, durability and performance.
The preset, integral snap-action floatswitch is engineered for one million
mechanical sta rts.The heat-dissipating cast iron body with powder coated
epoxy finish provides maximum pumping performance under the most
extreme conditions. With Zoeller's cool run design, the hermetically
sealed, oil-filled motor and non-clogging vortex impeller add up to a
long-lasting, trouble-free product.
NON
EtEER
APPLICATIONS:
• Water transfer
• Sump and effluent systems
• Light commercial
• New sump and residential construction
For complete product
SPECIFICATIONS:
• 1-1f2" NPT discharge information, VISIt:
• 3/10 HP (53, 55, 57,59),1/2 HP (98) www.zoeller.com
• Available in automatic or nonautomatic
• 1/2" (13 mm) spherical solids capacity
• Thermoplastic or cast iron base
• Thermoplastic or cast iron impeller
W
• Bronze construction available (55/59 series) w w
For more information, see Technical Data Sheets ~ ~ PUMP PERFORMANCE CURVE
FM2778, FM2779 MODEL 53/55/57/59 98
25
0
W 6 20
_U
Z 15
0 4
98
0 10
R 53/55/57/59
5
~ 1
0
10 20 30 40 50 60 70 80`
Nonautomatic model with GALLONS
Piggyback
LITERS 0
80 160 240
FLOW PER MINUTE 152655
6 0 All rights reserved. ZOELLER PUMP CO. 502-778-2731 800-928-7867 www.zoellercom
POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Qwner Ta.✓ Septic Tank Ca aci oG0 I ❑ NA
Permit Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer at Loc,r D NA
Number of Bedrooms (100 d/bedroom Effluent Fitter Model L - .SJS ❑ NA
Number of Commercial Units Pump Tank Capacity
GOG gal E3 NA
Estimated flow (average) 246 Pump Tank Manufacturer 6✓1E4&ra. Le.oc. ❑ NA
Design flow (DWF), estimated x 1.5 !Y3,-0 gal/day Pump Manufacturer ZaE[tE.t 13 NA
Soil Application Rate ~aUda Pump Model 8 13 NA
Infiuent/Effl lent Quality NA) Monthly Average D Pretreatment U Sand/Gravel Unit { Filter r NA)
Fats. Oil & Grease (FOG) ❑ Peat Filter
Biochemical Oxygen Demand (HODS) 5 30 mg/L D Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :s 220 mg/L D Disinfection ❑ Other:
150 mPJL Manufacturer. Model:
Pretreated Effluent Quality NA) Monthly Average Soil Absorption Component NA)
Biochemical Oxygen Demand (BODE) < 30 mg/L D In-ground (gravity) [3 In-ground (pressurized)
Total Suspended Solids (TSS) D At-grade Mound
Fecal Coliform (geometric mean) ::5 30 mg/L D Drip-line ❑ Other:
:SIG cfu/100m1 ❑ Dispersal Units Manufacturer
Maximum Effluent Particle Size 118 inch diameter D Aggregate Cell(s) Model
Calculations:
Soil Dispersal (EISA) or
DWF _ Application rate = Area Required _ (Trench Widths _ # Units or Total Length of Ttt nchfs?
SD _ D = DSO T = G 77 LI*7x 7 EFi~'aal'i✓E [6.~sr~v~
DESIGN CRITERIA
D "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems Publication 9.6 (SSWMP Manual)
❑ "ICC Flowtech Mound Component Manual" Version 1.2
D "EzFlow Mound Component Manual" Version 8/20/2007
D SBD - I0854-P (8.1/12) "At-Grade Component Manual Using Pressure Distribution" Version 2.0
❑ SBD -10705-P (N_01101) "In Ground Soil Absorption Component Manual" Version 2.0
V SBD - 10691-P (N.01101) "Mound Component Manual" Version 2.0
❑ SBD - 10657-P (8.6199) "Drip-line Effluent Disposal Component Manual"
X SBD -10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0
D Other -
MAINTENANCE MONITORING SCHEDULE - MAINTENANCE AND MANAGEMENT
Service Event Service Frequency
Pum ms ect tan s), ins act d' areal cells , clean filter At least once very, 13 months 3 ears ❑ Other -
Ins act um & um controls, alarm, retreatment unit At least once eve : ❑ months 3 ears ❑ NA
Flush and pressure test laterals At least once every. ❑ months
li13 years I NA
S'T'ART UP AND OPERATION: For new construction, prior to use of the POWTS check treatment tank(s) for the presence of
painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations
are detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity
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, vegetable/fruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only
paper that should be discharged into the system. Other non-biodegradable items 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,
Page 7 of 9
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.
throughout the week. Avoid vehicle traffic over all system components-
Maintain a regular steady flow by spreading taundty washing
Compaction of snow over the dispersal unit may cause it to freeze up.
INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or
certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing operator (per the attached
maintenance schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware,
identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the
ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings
greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks.
When the combination of sludge and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire contents of the
tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NRI 13, Wisconsin Administrative
Code.
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to ma specifications.
than stated in the Solids
washed from the filter sball be retained in the tank. Piker cleaning may be necessary more f1mquent
maintenance schedule to keep the system operating-
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service O he
There is normally a l day reserve under regular operating conditions, however water should be conserved until any problems system are corrected to prevent back-up of sewage into the
dwelling or surfacing.
AS NDONME T: When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure
that the system is properly and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Administrative Code.
Alt piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
The contents of all tanks and pits shall be -removed and properly disposed of by a Septage Servicing Operator.
- After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or other 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 struch e, lot lines and wells. Failure to protect the replacement area render it unusable.
Replacement systems must comply with the rules in effect at the time of replacement in POW TS technology a
❑ A suitable replacement area. is not available due to setback and/or soil limitations. Barring advances
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 are& Upon failure ofthe 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 mil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHERTREATMENT TANKS MAY CONTIAN LETHAL GASSES ANDIORINSUFFICIENT
OXYGEN. DO NOT ENTER A SE L13CM O A, PEPUMP OR RSON FROM THE INTERIOR OFAATANK MAYBE DIMCUL ORES
DEATH MAY RESULT. R
IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name 7'%M /'91 l'TYESTAi7' i!'PRS -,?.~7Sy8 Name /M R.0 r d Ar ~Qiac
Phone ,3 - yL 3 y Phone 7/S 3S- 6L 3
SEPTAGE SERVICING OPERATOR am - &4J aow~ LOCAL REGULATORY AUTHORI Y c 6
Name te 7 ~
Phone
page 8 of 9
INSTALLATIO INSTRUCTIONS
t L- L. 9aF 9
'N5 S
I
Center filter
with opening
! e
w uz-y
i1"s
i
Additional pipe or
poiylok Extend 8 Lok'° Glue
for centering.
Step 1: Step 2: Step 3:
(A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
is positioned so the filter can be housing, making sure the filter
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
E37R c
r~
I..'-,
y:
f µ -
8
Step 1: Step 2: Step 3:
Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back
if necessary. into the the housing making sure
(B) Pull the filter out of the housing. the filter is properly alighed
(C) Bose off the filter over the septic tank. and completely inserted.
USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover
WHFN CLEARING FILTER septic tank.
P A
Wisconsin R 0 Mty and Professional Services D
Division of l ustry Services 738 Page/ of 3
ST. CROIX COUNTY
COMMUNITY DEVELOPMENT SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, Sr ('mod X
but not limited to: vertical and horizontal reference point (BM), direction and percent slop
scale or dimensions, north arrow, and location and distance to nearest road e, Parcel I.D.
Please print all information. Reviewed Date
Personal information you provide maybe used for seconda purposes (Privacy Law, s. 15.04 1 m D
Property Owner Property Location
3 0~ ❑
IoTOi✓ TdUS~' Govt. Lot sLc S /9 Tag N R S E (or)®
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
®7/a? Lo. llo. /VN /
City State Zip Code Phone Number [may
GA49ge 91 Town Nearest Road
SCR/n!L Ui9LLEy
YA/
5'Sd6
❑ New Construction Use: Residential/Numberof ;;rooms 'y Code derived design flow rate GPD y56 -oCdd
Replacement ❑ Public or commercial - Describe:
Parent material 4-0s.5 Flood Plan elevation if applicableiUR ft.
General comments and recommendations: /You„ip A6.w,'rSC 4 " r sA-'O ZI-0 - G BASNL A44-W,
~Ed o~sy .u o -s. F- 8. S o v 98. o o u s ou~C
E Boring # ❑ Boring i
® Pit Ground surface elev. 98.4 ft. Depth to limiting factor 33 in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application
GPD/Fe Rate
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eff#2
.7 /S ~o d R S .t SCI
s /d G 8
3 do- 33 /o Y.c y/3 - S.l rr sdlc
33 - So /o Iad /6 xx s SW ! jjA A- - ly G
® Boring # ❑ Boring
® Ph Ground surface elev. 9- s-tt. Depth to limiting factor 33 in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP/F Soil A D1Ft plication Rate
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
Eff#2
O - /O /o Y~c -3*Eff#1 *
wr P u ~ Q S ~ 8
O - to o Y2 S/ - Sr a? sb/c 45
d lv 8
3-33 cyt y13 ."If 46k
Aff 20
45
o y2 caa/ ora S/8a S 1 ! sdk ry - -
ETE
* Effluent #1 = BOD, > 30 5 220 m /L and TSS > 30:5 150 m * Effluent #2 = BOD, > 30 5 220 m /L and TSS > 30 s 150 m L
CST Name (MWsWl J.Hmeft Signature
~ CST Number
150311 ~ah way S16 -
Address Date Evaluation Conduct d
Eau Claire, ~ 547U1 7- Telephone Number
/s
1)'715 -8610 - '
CST, MFRS-224974, D-1152 SBD 833o (RO4115)
~oF 3
Boring # J ///lIC6Y /~`q~vPTowl Boring
® p Ground surface elev. 9X O ft. Depth to limiting fa 3 / in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDJFe
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eft#1 *Eff#2
- /+lv ✓ g
/a Y2 31.2
a 8- s iota /3 - a s~k L 8
y 31-3~R /ora d a sa` i~ bk y
F1 Boring
F-1 Boring # pit Ground surface elev. ft. Depth to limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Fe
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
C] Boring
F-1 Boring # F1 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/Fe
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Effluent #1 = BOD, > 30:s 220 mg/L and TSS > 30!5 150 mg/L • Effluent #2 = BOD, > 30 T. 220 mg/L and TSS > 30:5 150 mg/L
t ' r
♦ d`B t
%
k } }
Boring # Sl//QLEY /Tf7n,PT-o,✓ ❑ Boring -
® Pit Ground surface elev. 976 ft. Depth to limiting fact 3/ in.
Soil Application Rate
EHornizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
*Eff#l *Eff#2
/e Y2 3 8-/S /0Yx
3 /5--.3! o roc s'/3 45 7e
v~ 8
eae/ o s'i / ~k - _ Al
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A iication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2
In. Munsell Qu. Az. Cont Color Gr. Sz. Sh.
*Eff#1 " Eff#2
Boring # ❑ Boring
L~ ❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary
Roots Soil AGPD/Ft nn Rate
In. Munsell Qu. Az. Cont Color Gr. Sz. Sh.
*Eff#1 *Eff#2
* Effluent #1 = BOD, > 30:5 220 mg/L and TSS > 30:s 150 mg/L * Effluent #2 = BOD, > 30!5 220 mg/L and TSS > 30:9 150 mg/L
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Pffiash"ingtol Ave., Box 7162 Sanitary Permit it Nt Nuun er (to be filled in by Co.)
S Ma i on
1U fl 2~1~a 7 7-7162
Ps ~r, 571 b~Z.
twin
State Transaction Number
'
Sanitary Permit:A' * MWELOPMENT
Pon
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govertunental 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
17- Ctj 4
purposes in accordance with the Privacy Law, s. 15.04(i)(m), Slats. /
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
Property Owner's Mailing Address Property Location
'd-a N~ Govt. Lot `/\J
City, State Zip Code Phone Number SQL y, Section
"l C-w -T~ circle one)
II. Type of Building (check all that appl Lot # T N; R E o
;I or 2 Family Dwelling -Number of Bedr ms Subdivision Name
Block #
❑ Public/Commercial -Describe Use ❑ City of
CSM Number ❑ Village of
El State Owned -Describe Use
Town of C A V -
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS S stem/Com onent/Device: (Check all that apply)
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Applicatic Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
Sv
VI. Tank Info Capacity in Total # of Manufacturer o
Gallons Gallons Units 2 c 2
C U
New Tanks Existing Tanks c 2 p
G, U V] V CA W U P.
Septic or Holding Tank
=0 7 D
Dosing Chamber 1- F~
VII. Responsibility Statement- 1, the dersigned, ass *e nsibility installation of th PO S shown on the attached plans.
Plumber's Name (Print) Plumber's 'gnature MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip ode) -~A
IV N
L' _-1 dr 75 /
'Of Lsg,
VIII. oun /De -C epartmetit Use Only
proved isa..... Permit Flee Date ssued Issuing t Signature
ner eason for Dem $ ' OD 7 31 /s
IX. MW 0M
qTfor Disapproval 4
c
3 /S CA.
~ , emue'1t tilhr af+el
dispersal cell must all aervloos / maintained L G C G t3
C
t~
as per management plan provided by plumber. ~r- Sot
11
"211oitr!9uisa►rlrttmaintained
n p` ' °t li odds / o tIft .M. w~ o ti $ k»-r 1_5 e vv f< <
Attach to complete plans for the system and submit to the Cou'n~ty aly on per not less than 81/2 x 11 i hes in size
0 3 . J 04- 44,x_ bf rwi is,
SBD-6398 (R. 11/11) fJ,q) 9,111 JA 7 'fe'&f
SEPTIC or HOLDING TANK SERVICING CONTRACT
Contract Date
UL C; r This contract is made between the
a wner(s) Name(s) and Pumper's Name cc ^
7- J r ~t.
We acknowledg the inst ilation of (a) septic/holding tank(s) on t e following property:
(Provide legal description):
Y4 sz
15 141
a e
1. The owner agrees to file a copy of this contract with the local governmental unit (St. Croix County
Planning & Zoning Department) to document maintenance by a certified septage servicing operator as
required in Comm 83.52(1)(c)2. Wis. Adm. Code and the approved Component Manual.
2. The owner agrees to have the septic/hold ng tank(s) serviced by the undersigned pumper and guarantees to
permit the pumper to have access and to enter upon the property for the purpose of servicing the
septic/holding tank(s). The owner agrees to maintain the access road or drive so that the'pumper can
service the septic/holding tank(s) with the pumping equipment. The owner further agrees to pay the
pumper for all charges incurred in servicing the septic/holding tank(s) as mutually agreed upon by the
owner and pumper.
3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the servicing of
the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the
monthly report:
a. The name and address of the person responsible for servicing the septic/holdingtank;
b. The name of the owner of the septic/holding tank;
c. The location of the property on which the septic/holding tank is installed;
d. The sanitary permit number issued for the septic/holding tank (if known);
e. The dates on which the septic/holding tank was serviced;
f The volume in gallons of the contents pumped from the septic/holding tank for each servicing;
g. The disposal sites to which the contents from the septic/holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a
change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a
new service contract with the local governmental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on this date:
Skjg y / ' Nr - `I n0~ - ~ 1 Today's Date
',.J
Pumper's Name (Print) 45 umpe 's S na e Notary Public Signature
m myr,or
Pumper's Registration Numb Commission Expiration
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