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HomeMy WebLinkAbout040-1306-17-000 (3) 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: City Village X Township Parcel Tax No: Creative Homes, Inc., C/o Nathan Hidde Troy, Town of 040-1306-17-000 CST BM Elev: Insp. BM Elev: BM Description: ~ 1 e t Section/Town/Range/Map No: 08.28.19.1844 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic A~F-oJ y, Benchmark Aj LA11. 6.00 se&ing t-C.~" ~d►ti-Q» Ir' - Alt. BM ~ ~ aJ Z • 9$ . Aeration Bldg. Sewer Holding St/Ht Inlet 5.5 TANK SETBACK INFORMATION St/Ht Outlet 5. 7 9 5 , TANK TO J P/L WELL BLDG. re!ntAir n take ROAD Dt Inlet Septic ~ / Dt Bottom Dosing Header/Man. 7. c~ 3 . Z Aeration Dist. Pipe -7-(-o T3. Z- 7.8 3 Holding Bot. System (p q Z , Z Z PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM ~~e... Ga Z Model Number TDH L Friction Loss System Head T Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z. 3 1 70, 1 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactu~+rer: I INFORMATION CHAMBER OR .n P; I Type Of System: ' 4- / ^ ' UNIT Modgl Nummber: y 66~~e v -io ti 3-3 1$ N~j~ [sip: t r r.0 DISTRIBUTION SYSTEM s / 73 A s l'! Z Z k Z Header/Manifold it Distribution Hole Size x Hole Spacing Vent to Air Intake n Pipe(s) Length -7 Dia Length `Dia \ Spacing ` e SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded 1xx Mulched Bedlrrench Center Bed/Trench Edges Topsoil Yes DE No s No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 446 Jordyn Lane H dson, WI 54016 (SE 1/4 NE 1/4 8 T28N R1 9W) Sunset View Lot 17 Pa cel No: 08.28.19.1844 /I L 1.) Alt BM Description = / GtS J 4J`~ ~ ~ 4,:.•-- ~ ~ 2.) Bldg sewer length = - amount of cover Plan revision Required? ❑ Yes No ~3 Use other side for additional information. C1 54 ~Of _~SBD-6710 (R.3/97) Date Insepctoes Si ature Cert. No. County t RECEIVED Safety and Buildings Division K 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 s SEP 0a 201 65 State Transaction n Nun ~ . :OM L ~plIC1t10II In accordance with SPS 38321(2), Wis. Adtn. Code~~ of this form to the aPP~~ governmental unit r to obtaining a sanitary pem~it Note: Application forms for state owned POWTS are submitted to oject Address (if different than mailing address) is required prior the Departmerd of Safety and Professional Servies. Personal information you provide may be used for secondary / 1 . ores in accordance with the Pri Law, s. 15. 1 m Stats. L ~h G 40 L Application Information - Please Print All Info on ffJJ Property Owner's Name Parcel # C~re lJ` ~ /3d (o - 17- 06 property owner's Mailing Address Property Location D ~ me ~R~ ~ r>,,>•4.. ~ Govt Lot CityState Zip Code Phone Number Section l / ie r~W~ 17 0 ""J~ 'uf r l jy~ ` d~ T2 N; RI E 1Z Type of Building ( k all that apply) IAt / ` Subdivision Name 2 Family Dwelling-Number of Bedroo A # ~Lrj~S ~ Or 1i Block ❑ Public/Commercial-Des-be Use ❑ City of CSM Number ❑ Village of ❑ State Owned - Describe Use >a-,Town of TIC2 ` ZLi-LL T III. Type of Permit: (Cbeck only one hot online A. Complete line B if applicable) p A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner Q` IV. of POWTS System/Component/Device: Check all that a 1 7 pp Non-pressurized in-Ground ❑ Pressurized 1n-Ground At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. Of suitable soil e ❑ Ho ding Tank ❑ Orb - Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsaUTreat ent Area Information: d Des' Flow (gpd) Desi Soil Application f) Dis al Area Required (sf) Dis o (st) System Elevaticia VL Tank Info Capacity in Total # of Manufacturer Y Gallons Gallons Units p o $ v New Tacks Faulting Tanks m v U 1 ` 0.V on m Ln n. C7 F. i r:4 Q P Septic or Holding Tank Dosing Chamber VII. Responsibility State t- f, the undersigned, responsibility for installation of the POWTS shown oa the attached plans. PI s Name (Pr~nt) Pl ignaturc MP/MPRS Number Business Phone N ber "OY Plumber's Address (Street, City, State. Zip e r0 VM, County/Department Use Only Permits Fee Date Issued Lssuim ent Signature proved $ v en Reason for W 15 . ( ~a M Conditi as for Disapproval 1'. >pbc tank, effluent filter and dispersal cell must all be services / maintained us,patManagement plan provided by plumber. must I~r:tpaiMaifYed as pK appNc~lblel' ttorde / oMinsnces. Attach to complete plans for the system and submit to the County only on paper not less than S W z 11 inches in size SBD-6398 (R. 11/11) Soil Test and yStem OT PLAN PROJECT Creative Homes ADDRESS 7 Comm Pe Drive Suite 410 Woodburv Mn 55125 SE 1/4 NE 1/4S 8 /T 28 N/R 19 f O N Troy COUNTY ST. CROIX SYSTEM ELEVATION 93.0/92.9 5' below grade 9/7/15 DATE BEDROOM 4 CONVENTIONAL XXX 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 AS TM F891 c a I e _ 1/4" _ 10' Vent Jordyn Lane >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area Long 12" 5.6ft^2/pair of end caps 3 4" Grade at System Elevation Pr 4 Bedr Ho e 10' 130' B.M. * ' S B-3 15 50' Vents 30' • a a 0, B-1 0% Slope 2 20' 2-3' X 90' cells with >3' spacing Property Line r Soil Test and ystem OT PLAN PROJECT vCreative Homes ADDRESS 7 CommPa 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 F below grade 9/7/15 BEDROOM 4 DATE CONVENTIONAL XXXX IN-GROUND PRESSURE NVENTIONAL LIFT HOLDING TANK 1255 gallons IFT TANK SIZE DOSE TANK SIZE MOUND SEPTIC 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 C a 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 4' Long 12 3 4" Grade at System Elevation 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 77 Wisconsin Department of Commerce 5Ep SOIL EVALUATION REPeR-T- _ Page of Division of Safety and Buildings in accog~n l _ omm 8 I is. Adm. Code County ` Attach complete site plan on paper not les$ell wlb ac i rinehes insize`iwan 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. e ~Q - 1,3 Q / - -C6 Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy law, a. 15.04 (1) (m)). 611 Property Owner Property Location Govt. Lot 1 /4 1 /4 S T N R E (or) W 0( a pz- r I Property Owner's Mailing Ad ress Lot # Block # Subd. Name or' CSM# rA ✓ 17 L) ) City State Zip Code Phone Nom ❑ City ❑ Village own Nearest Road New Construction Use;93 Residential / Number of bedrooms Code derived de An flow rate 9'0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material ou-f ~ 6-1,,q. Flood Plain elevati on if applicable ) ft. General comments and recommendations: System Type~iV Qw 11,J System Elevation 9Y, M Boring # Boring it Ground surface elev. l" ft. Depth to limiting factor. 1142- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 0-1 b -1/ 0 Boring # El Boring ❑ apit Ground surface elev. r ft. Depth to limiting factor Cl N 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 - 3lz ~ m C S ~ r 2 S t t V 00.1 -6 • Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 • Effluent #2 = BOO, < 30 mg/- and TSS < 30 mg/L T2Z CST Name (Please Print) W 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 ® X'Pit Ground surface elev. 9-1O-ft. Depth to limiting fadl~/~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDM in.yy Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 _5 r j I ~ - 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 F-1 Boring # ❑ Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDtlf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' 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. SBD4330 (8.6/00) Property Owner Parcel ID # Page of n Boring # ❑ Boring nPit Ground surface elev. A--Oft. Depth to limiting factWZ/ j in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1[ 1 ,L ❑ Boring # ❑ Boring l ❑ 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 ❑ 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 1220 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. SBD-8330 (8.6(00) RECEIVED-- Court q Safety and Buildi ivi 1 201 W. Washington Ave., P.O. 1 soitary Permit Number (to be filled in by Co.) s K IX COUNTY Madison, Wl 5 162 ) DEVELOPMENT y 7 f 7q / bJ,3 State Transaction Number Sanitary Permit Application -J A- 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 differem than mailing address) the Department of Safety and Professional Setvies. Personal information you provide may be used for secondary pmpoKs in accordance with the Privacy Law, s. 15. 1 m Stats. ~C L Application Information - Please Print All Informatioir / ` Property owner's Nam / Parcel # 41/1 / A Property Owner's Mailing Address Property Location a (0 A, M\,e! / ~ ► % Govt Lot City, State U Zip Code Phone Number ~I--- yti Section am V 'l 17 z I?Q ~C1 tLl C k N; R or w EL Type or e of Building (c sll that aPP1Y 1-1 2 Family Dwelling - Number of Bedmo Subdivision Name , f ~~l ✓1 s / d gtAl 6k aA keJ+Q B l 11 Public/Commercial - Describe Use / l n..1 ❑ City of ❑ Village of El state owned -Describe use r%& CS own of ~ _ Lj I ~2~-~~r S III. Type of Permit. (Check only one oz on line A. if applicable) ~p A' New System ❑ Replacement System ❑ T g Tanis Replacement only ❑ Other Modification to Existing System (explain) B. ❑ P4rmh Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner D IV. Type of POW I S S stem/Com uent/Device: Check all that apply) a Non-Pressurised In-Ground ❑ Pressurized In-Gmtmd ❑ At-Grade ❑ Mound > 24 in. of suitable soIl ❑ Mound < 24 in. of suitable soil Olds ~ 5 Holding Tank ❑ Otber Dispersal Component (explain) ❑ Pretreatrttent Device (explain) / V. Dis rsalfTrea ent Area Information: i' Design ow (gpd) Design Soil Application dsf) Dispersal Area Rcquaed (sf) D' Area Pro sf) System Elevatio Manufacturer c VL Tank Info Capacity in Gallons units New Tanks Tanks __e Exrsnng G✓ J ~i-.H-e tF'; w e 01 W cx v a Septic a Holding Tank ss _ Dosing Chamber VII. Responsibility Statement- 1, the undersigned, apoe responsibility for installation of the POWTS shown on the attached plans. 7 Pl signature MP/MPRS Number Business Phone Number Plumber's Name (Print) Z~ 6 C1-o 711 Plumber's Address (Street, City, State, Zip ) t t Z- l 5 ~ tJ 2 I ~cJ S5 VIII. County/De artment Use Only Approved ❑ F=-it Fee Date Issued issuing 46t signature on fo $ '475 IX Can ' as for approval ;11 fes~t✓e t s teal(; effluent altar 3) [.,a MCA few yb . tlisorsal cell must all !j s!l1y"* !`maintained as per management plan provided by plumber. W uiVnenta mush ¢a m itred. 2. 0 Attach to complete plans for the system and submit to the County only an paper not less than 8 in z 11 inches in Size 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 SYSTEM ELEVATION 95.8/95.6 5' below grade 8/13/15 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 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 c a f e= 1/4" = 10' Jordyn Lane 75' Pro 4 40 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 12 5.6ft^2/pair of end caps 4' Long 34" Grade at System Elevation B-2 15' Property Line B.M.* . d r i 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,R19W 446 Jordyn Lane Troy Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cro ection t 4-6. Maintananc** Contingency 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 8/13/15 BEDROOM 4 DATE CONVENTIONAL )OCX 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 c a I e _ 1/4" _ 10' I Jordyn Lane 75' Pro 4 40' 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 Long 12" 3, 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 Grade Vent 3' 411 3' ~~30/34 Septic Tank 199 Long 5' S' Long 1 36" Grade at System Elevation 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 f Tank Manufacturer: ❑ NA Permit # Septic ❑ Dose ❑ Holding Volume: sS~ (gal) DESIGN PARAMETERS Tank Manufacturer, -)eNA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: A Vertical Distance Tank Bottom (s) to Service Pad:` (ft) Estimated (average) Flow : 4100 (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Spec'tfic servicing mechanics must be provided if vertical is >15 feet or Design (peak) now =(estimated x 1.5): (gal/day) If horizontal is >150 feet. Speciflc Instructions to be provided on back. In Situ Soil Application Rate: , (gal/daye) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) Influent/Effluent Monthly average . Effluent Filter Model: Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA jA Total Suspended Solids (TSS s150 m L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. > (BODs) >220 mg/L NA SS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter Pretreated Effluent Monthly average e [3 Disinfection ❑ Wetland Y 9 ❑ Sand/Gravei Filter ❑ Other. (BODs) 530 mg/L Soil Absorption System (TSS) s30 mg/L ANA Fecal Coliform (geometric mean) 510` " __-En-Ground (gravity) ❑ In-Ground (pressure) ❑ NA Maximum Effluent Particle Size in dia. 11 t~A C3 A- ra ❑ Mound ❑ Drip-Lin e Drip-Lin ❑ 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 (f~) of tank volume ❑ en the high water alarm is activated Inspect condition of tank(s) At least once every: 32month(s) (Maximum 3 years) ❑ NA Year(s) Inspect dispersal cell(s) At least once every: 7? ❑ month(s) (Maximum 3 years) ❑ NA Year(s) Clean effluent filter At least once every: month(s) ❑ NA !I year(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 1:1 yean(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 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 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 512 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: acids, antibiotics, baby wipes, -cgarettwtutts, 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, sanity 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 repla ant system: Ipm "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. F ame Name 177` hone f_ Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Name 4, Phone 7 Phone 1?6 216 v 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. m k t.. Hi w 10 m o. r O C9 1 L of U ST. CROIX COUN'I'Y SEPTIC TANK MAINTENANCE AGREEMENT AN) OWNERSHIP CERTIFICATION FORM Owner/Buyer C r Mailing Address 70 1t 0 M jWe1 ca_' Dr ~-2- Property Address )~k /Y V-6- 3,2 r /t,/ G~ 4 y~Q~ (Verification required from P ng & Zoning Department for new construetion.) City/State Parcel Identification Nur:Iber LEGAL DESCRIPTION Property Location S/ 1/~ , '/4, Sec . , T 9 N RZ? W, Town of _ Subdivision su rt SLot #17. r Certified Survey Map # Volume Page # Warranty Deed #~-F- t Vattune f , Page # Spec house es no Lot line; 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 §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal systern with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on ' 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 ty deed recorded in Register of Deeds Office. Number of bedrooms SIGN AF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being ro.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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I Q ~ 1 _ I O E o I `r L Q ~ .0-' 12111 S ry 1 I ~•N I fit" I I I n I P I /I 4 IMMIRW Z 1O ~ v W O z EXAM VO Q i (f1 z 07, O =L;7 O 4 _O l 4 ;;r lu c ~J11L 11 In 4 W Q R ku- In I o I '15H aOW'M 4 - .4,Q oil I Wisconsin CGapartrta EO SOIL EVALUATION REPORT Page of Division of Safety r l{r~ccord nce with Comm 85, Wis. Adm. Code s Attach completeAt leUss than 8 2 x 11 inches in size. Plan must County S C~ t include, but not lid~~~(tal ref ence point (BM), direction and percent slope, scParcel I.D. O w ocation and distance to nearest road.7- L46 nt a/I information. Revi ed by Personal informatiDate y e used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner ZZ/ Property Location L 7~~~U~~ NNE`- J~ 1/4 ~1/4S T Z8 N R Property Owner's Mailing Address E ( ) W ~ , ~OK 3 3 Lot # Block # I Subd. Name or CSM# City State Zip Code Phone Number 1~ S U` Q Ste- V l ~ 7~ ❑ City Village Town Nearest Road t3 f}r~ ~Rke; Lv) 5 C-l l 0 l 33 5 1 T 1?-p`7' New Construction Use: ® Residential / Number of bedrooms_ ❑ Replacement Code derived design flow rate GPD ~ S - UO- - I Public or commercial -Describe: Parent material G Lie) y~ L- General comments Flood Plain elevation if applicable 1~ ~1 ft. and recommendations: RZ , Yv" - r r Boring # ❑ Boring a, 1131 13111) Ply, Zon -~j ® Pit Ground surface elev. -7 ft. Depth to limiting factor - in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate j in. Munsell Cu. Sz. Cant. Color GPD/ft G(c~ Sz. Sh. `r O I 131 Z S l~ Z`f3" D1Z YYL Tti 'Eff#1 'Eff#2 Z -30 1 p`1 2 316 Cyv Z ' _ 8 s) 1 z S b m`ft- cs 1 , s . g, 3 3D.~6 io,Irz L/A - S Asa 1 - z I•~ 0-st- 76 •Sa i Boring # ❑ Boring ® Pit Ground surface elev. lOb- Z ft q g Depth to limiti ng factor in in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda ;Roots Soil Application Rate i in. Munsell Qu. Sz. Cont. Color ry GPD/ftz Gr. Sz. Sh. 'Eff#1 'Eff#2 I o -L O to,j p z - sit Z`ps b ~ ?n3 t=.w Z~p s i Z M s b 77 3 L -ct8 )13`1 2 V/6 , b S mss1 - - EE] Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L CST Name 1, Please Print) - ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L Arthur L tdegerer C~~. Sig lure CST Number 03-21S - 1`7 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation conduced 421 :1. Bain St. River Falls, 141 54022 Telephone Number 715-425-0165 a f Property Owner Parcel ID #JY~ 1 G Page Z ' of Fsl Boring # ❑ Boring QQ p ® Pit Ground surface elev. oc)' 8 ft. Depth to limiting factor I In. Solt Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft: ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 •Eff#2 ~ •0-10 )O`1fZ3~Z S11 Z`Fsb1-c Yvt`~1,- L`1.v Z`F .g .b Z 10-33 NU`tR-3lc, s! I Zto sb M`{ eS l es •b b l 3 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/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 -Eff#2 HE I J I 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/ft= 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 = BOD6 < 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 lie department at 608-266-3151 or TTY 608-264-8777. SB"330 (R.6/00) Property Owner Parcel ID # hi (S ❑ Boring Page of 3 Boring # I ® Pit Ground surface elev. fl. Depth to limiting factor > Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Soil Application Rate in. Munsell Qu. Sz. Cont. Color Roots GPD/ft Gr. Sz. Sh. •Eff#1 •Eff#2 o-lo )o~2~1Z sj I ZCs1,Z M_F1 Z 10 -3 3 t~~r cz 3L~ s J Z s b M`- e S l 3 33 o Y~C S c~ s m 1 _ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Applicaft2 Rate in. Munsell Qu. Sz. Cont. Color GPD/f 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 GPD/ft Gr. Sz. Sh. •Eff#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODE < 30 mg/L and TSS < 30 mg/L T7ie Department of Commerce is an equal opportunity service provider and ernployer. If you need assistance to access services or need material in an alternate format, please contact die department at 608-266-3151 or TTY 608-264-8777. S© 9330(R.6/00) Wisconsin Department of Commerce SOIL EVALUATION REPORT 'Division of Safety and Buildings Page of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S 1 Cam) include, but not limited to: vertical and horizontal reference point (EM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Portal I.D. ~~~'cvG Please print all information. Reviewed by 'Date Personal information you provide may be used for secondary purposes (Frvac•/ Law, s. 15.04 (1) (m)). CQPV Property Owner Property Location t~ 3$ L k L U ;~..1` ZC 1/4~1/4-S.S• T Z.U N R E( W Property Owner's Mailing Address Lot # Block u Subd. Name or CSM# P o. Box 3 3 - ISurvs~- vir~ ~L"'v. City State Zip Code Phone Number City Village Town LR)LE ILV I 5 C~ 'tZ~ I (1 S) 14aS s 5) T~~ Nearest Road I 2 New Construction Use: ® Residential / Number of bedrooms - Code derived design flow rate S Q - OCR ❑ Replacement - GFC ❑ Public or commercial -Describe: Parent material G Lie) 5=r L Q1 j~~ Flood Plain elevation if applicable ~1 General comments ft• and recommendations:`-` -M 1't7 Boring # ❑ Boring ® Pit Ground surface elev. J -7 ft. Depth to limiting factor -2 in. [i]Soil Acplication Race Horizon Depth DColor Redox Description Texture Strut ure I Consistence I Boundary Roots GPD/ftz in. ll Qu. Sz. Cant. Color Gr. Sz. Sh. ,E f#1 I 'Eff#2 1 0-9 Z q -30 tp'l 2 :11 C w `u )Dviz V/1 a Boring # ❑ Boring ® pit Ground surface elev. ) yb- Z ft. Depth to limiting factor q 8 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 1 ~ 0-10 to~23LZ - sit Z~Fsb~` S i i Z M s b~- rrl`f'}- cS l • S . S 3 6 -QS ) o~ rz ~l6 - S a ss k "Z i Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L . CST Name (Please Print) Sig tune CST Number -A`rthur L. +Wegerer 03=Z)S - 1`7 220254 Address W e g e r e r Soil T e s t i n g & D e s i g n S e r vi c e Date Evaluation Conducted Telephone Number 4 2 1 .1. Iiain St. River Falls, 1-1I054022 1Z-ZZ_.O 715-425-0165 ` PLOT PLAN Page 3 of 3 Scale 1' =SO ' I ~ l ~j 01° ~ 0 t5 o$ 1000 / o L ~ BC- ~ ~V .~5 S` ~ ~ s} ao ~ Ipp 3 i i 1 LO ~ .~1~-'Z-- -(,'Z-. 1O U , 7 ` Q►V G~UVIW S~1Z.t-f~-C.E ~4?" l..q~ CUY?aV~ . >222-Z 3 715-425-0165 220254 03-Z1 S 7 CST Signature Date Telephone No. CST No. Job NO.