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032-2167-32-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix . Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 579098 State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village Township Parcel Tax No: Tom & Charlene Peterson TOWN OF SOMERSET 032-2167-32-000 CST BM Elev: \ Insp. BM Elev: BM Description: Section/Town/Range/Map No: • oo sG J lva v /yI f k- 26.31.19.1412 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark lri'/i L' P~GUD K~ lar.~l /oo. o0 Dosing Alt. BM G ~lO (o Aeration Bldg. Sewer Holding 14- S' St/Ht Inlet (41,/314 9`s f -741 TANK SETBACK INFORMATION St/Ht Outlet !6.0 8s. Ys TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. -?-5 70 70 Aeration Dist. Pipe Holding Bot. System /p,p Q~ y V. 'el *S y PUMP/SIPHON INFORMATION Final Grade ?S-, fs- Manufacturer Demand St C ver . noe r O y Zv GPM 92• Model Number TDH Li I q~ Friction Loss System Head TDH .39 Ft of &XETMA" ~•a~ / Forcemain Length Dia. Dist. to Well s z - SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length r No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~~~'I7J12 INFORMATION CHAMBER OR Type Of System: L o nl~ N~ AG 7 f UNIT Model Numtu ~ C • I DISTRIBUTION SYSTEM 17 Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Q1 Ili Pipe(s) Length ~-OO Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulchad Bed/Trench Center 'I S Bed/Trench Edges Topsoil 0 Yes No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: !d Inspection #2: Location: 640 196TH AVE -Y V0 to E LC- @ OvSQFGT D.4j i .0AXY F6 L,,4j?. }-n oA) ow A{O c4s,,;~. 1.) Alt BM Description= ^ Voo A(560-5 ON -ngA4, A-I,L 00.,-TVD -po jv Q tovw noA). 2.) Bldg sewer length= 9 1 - amount of cover = S 4- Plan revision Required? ❑ Yes 9 No Use other side for additional information. r 0 J2A AIPOW / G l Date nsepctor's Signature Cert. No. SBD-6710 (R.3/97) ~ #'/,00 Industry Services Division Couifty B 00 ashington Ave ,j p; ~jlo/1C S n n Box 7162 P~~ Q 1U 1 " 0 73~gfadison, WI 53707-7162` Sanitary Permit Number (to be filled in by Co.) - Rolx couNTY - ego 7 :.OMMUNIIY~ -y ermit Application State Transaction NN her In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit t 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 Services. Personal information you provide may be used for secondary u oses in accordance with the Privacy Law, s. 15.04(1)(m), Slats. 1. Application Information -Please Print All Information /9G r-// X-V e Property Owner's Name Parcel # %o y ~ ~iyAitla ~ErEaso.) Q3a-a~0-3a-000 Property Owner's Mailing Address Property Location R4.31. 1q, I ) a, o?e7,S 7 9.S ST. Govt. Lot City, State Zip Code Phone Number SE 1,V41 Section aG /Gw.,yo„ / p Z yo / 7 713- Q? y8 - 7Y13 circle one) IL Type of Buildin T 31 N, R E or W g (check at that apply) Lot # ~I or 2 Family Dwelling - Number of Bedrooms Subdivision Name 6k Block # lJin1E elv r"r ✓ 2 ❑ Public/Commercial - Describe Use 64 QJA, QEitraf ❑ State Owned - Describe Use U CSM Number image of 2 e_ ( 11-74- 1 0. r AfTomm of Sa/YEi1SE f ` III. Type of Permit: (Check only ne box on tine A. Complete line B if applicable) A, New System ❑ Replacement System ❑ Treatment/Hotding 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 IV. Type of POWTS S stem/Corn onent/Device: Check all that apply) r YNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soils ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Trea nt Area Information: Design Flow (gpd) Design Soil Application Rate(gpds~ Dispersal Area Required (sf) Dispersal Area Proposed !~f) System Elevation 3/6-10 dY3 ele? .2 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units y s ° u New Tanks Existing Tanks ^ U o 0 c U n cn 7 c Septic or 1 leldtng4;aedr /C►Od 7ooa Dosing Chamber zoo COd ~ p t► VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI mber' gna ure MP/Ietl?#6 Number Business Phone Number .l oiv~ f Z_1xE o? 3I 3 ~G 7/S e77 - S,1G Plumber's Address (Street, City, State, Zip C~de) Al G a 98 Sr, Y. ~S AWAX,~D 4J1_ 5-V73,9 VIII. County/ eartment Use Only pproved proree Permit Fee Date sue Issuing ent Signatu n Reason for ial 471' & 16 IX. Condi$Vwgf1A4"E#(Reasons for Disapproval 1. Septic tank, effluent filter and 3) Vb A.- 1~ a• . dispersal cell must all be saryhces !'maintained 1 as per management plan provided by plumber. 2 `l~q t?k rectcairertlatt►.lpl:tpNRl~tFl as per applkabls ~ / Wifimnp», Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R- 08/14) v ti o I M T. ~ -+---1 T y ~u v W ~ V II ti n Ira o h It W N 0°o n Q n~ `o< ti a v~ n p M V 44 ti 10 PAM o v h 0 e M ~ • u 10 e n a Q ti ~ y V y v `C o ~ a o~: o h ? Private nsite Wastewater Treatment System Index and Title Page Project Name: Ley 6yfef DE Owner's Name: /t Owner's Address: _ g?a57 9S'~` Sr /1/~w ~i~Hiycao t,~1I' Syoi7 _ 7rs ay8- 7yi.3 Legal Description: S E, /V A/ aG 31 Municipality: Town, V411age, gi(~y of Sor,E.cS~r County: Sr. oix Subdivision Name: /,✓E'e Lot Number: FBlock Number: Parcel I.D. Number: Page I F- Page 2 Lcr .y.✓ e116~440J s - Page 3 s►rit r4A"A" Page 4 Arx 110GIVIfw7G Ir~u2 yE _ Page 5 s ~ o s 4cJ.1:4f-A.'s XedfAl Page 6 Page 7 ,r~iG s-E2 xi.~r~.tlA,dcE Psge 8 Page 9~"j.~L'.y~,~r : ylo~GdiPLU.o r'.c,tf ~r'E,~'a.~ Name of Designer: _,J -6 w A.IxE License Number: /Jp- a313 i~G Signature: Date: Designe scant to the Following POWTS Component Manual and s,a 81-85: In-Ground Soil Absorption Component Manual for PO~~Ver 2.0) SBD 10705 P (N 01/01) Cx 'a A• " V, „ w ti h o Q w n It a o V a j J 1 l14 C a uu a ~ y a ~ a~ \ T 0. ~ h V °p n4 'In o V y \ 0 v IV i, 14 12. COMBINATION SEPTIC TANKIPUMP CHAMBER X,-SECTION 3 ofr 7 (DRAWING NOT TO SCALE) FINAL GRADE MANHOLE RISER L COVER - - fperSPS 3 84,25 (7) & (8)} 4-0 Vent Pit) imP0R i AN T : {slope ground surfaLa menhofe(s) for pro---- 'io Builnding ng Anchor tank(s) as necessarl pursuant to SPS 383.4`3(8 ViT~i 1. Q~~ .1 above i2I {..a) ~ta68shed Flood i evalron ttYitital) :A,r.pmved Extend manhole riseras necessarv- BUILDING SEWER , VentCaap (per $ PS! 8230 (11^ Approved Ladcino rvranhole ELECTRICAL JUNCTION SOX mitts wenvno t aosl ktlached t=ice) Electrical must =ngly vlh SPS 316 and NEC Sao x 4° iiin. or 2g It above Gon 7 Established Flood Elelre f r qty Plcal) MANY.OLE h"NOLE ` I MANHOLE 18" min. BOMM OF INLET (int2tt elevation) ( pwperiy X48 When no, Und 1 - Mftivasoavater~+tel)--- fWET G F-/o cis re& ALARM FLOAT e ON FLOAT 9°R&ET PIPE FILTERED $ 71 ° OFF FLOAT r flee orttaRft) APPROVED EFFLUENT FILTER EFFLUENT REQUIRED ON OUTLET A elav = ' - S MINIMUM OF Y OF SUITABLE BEDDING BENEATH TANK PUMP PAD EFFLUENT FILTER OR EQUIVALENT COMPONENT Tank Manufacturer - I-11cs&t Lo.yG a•,~rE DWF (daily wastewater flow) y3-0 GPD Septic/Pump tank model _/ooo /d oa Number of daily doses (DWF / actual dose volume) Alarm manufacturer ,s -T /Wo/yBy S Alarm model number _ ~A.t1K RLER r• / Forcemain volume 9. 8 (1/0 !g . /G 3) Type of float switch /"Y--trYg.V" zo Actual dose volume (gallons) S.?, y (total dose volume - volume of torsemain) 917• 1? - 9.8 s 8 i,1/ Effluent pump manufacturer _ ZoA-zie/t Effluent pump model number PUMP TANK CAPACITIES Reserve above alarm a/ inches = 2.5' ?gallons Minimum pump discharge rate (GPM) ?,6. 0 Alarm float above on float ~ inches = 33. S gallons (C) On/Off float measurment -•f inches = 9.7.2 gal(ons (B) Vertical lift (pump off to distribution lateral) q, 9 Off float above tank bottom 7 S Inches = /aS. 7 gallons (A) system head (distal pressure n 1.3 feet) - TANK DIMENSIONS tz PUMP CHAMBER SPECIFICATIONS Friction loss in the forcemain Go o. 6 L Total dynamic head (TDH) ~a..s Length /S•o Width 8'Y Liquid depth 31, " Gallons per inch /G. 74 N TOTAL DYNAMIC HEAD/FLOW w PUMP PERFORMANCE CURVE PER MINUTE 50 - MODEL 1511152/153 EFFLUENT AND DEWATERING 14 45 153 12- 40 MODEL 151 152 153 Feet Meters Gal. Liters Gal. Liters Gal. Liters 0 35 t0 152 5 1.5 189 69 261 77 291 v 10 3.0 45 170 61 231 70 265 15 4.6 144 53 201 61 231 ro 8 25121-2 20 6.1 29 110 44 167 52 197 25 7.6 16 61 34 129 42 159 ~ 6- 20- 30 - 23 87 33 125 35 22 85 75 - - 4 40 12.2 - - - - 11 42 1o Shutoff Head: 30 fL (9.1m) 38 ft (11.6m) 44 fl. (13.4m) 2 0145088 5- 0 Model 151 Models 1521153 10 20 30 40 50 60 70 80 90 100 GALLONS _ 6 7132 6 7732 - LITERS 0 40 80 120 160 200 240 280 320 360 37/8 I F-45'6 3718 45/8 FLOW PER MINUTE 0145MA T_--- I ` a 3'~ CONSULT FACTORY FOR ( T-. SPECIAL APPLICATIONS o i 3718 • Timed dosing panels available. a e • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. j • Double piggyback variable level float switches are available j for variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See 1111,16 i 121/8 FM1420. • Over 130°F (54°C) special quotation required. 415116 5318 15111521153 Series SK2444 SK2064 15111521153 MODELS Control Selection Model Volts-Ph Mode Amps Simplex Duplex N151 115 1 Non 6.0 1 2 or 3 6N151 115 1 Auto 6.0 Included 2 or3 E151 230 1 Non 3.2 1 -2 -or 3 BE151 230 1 Auto 3.2 Included 2 or 3 N152 115 1 Non 8.5 1 2 or 3 "Easy assembly" BN152 115 1 Auto 8.5 Included 2 or 3 (Pump & discharge pipe E152 230 1 Non 4.3 1 2 or 3 not included.) BE152 230 1 Auto 4.3 Included 2 or 3 N153 115 1 Non 10.5 1 2 or 3 BN153 115 1 Auto 10.5 Included 2or3 E153 230 1 Non 5.3 1 2 or 3 BE153 230 1 Auto 5.3 Induded 2 or 3 SELECTION GUIDE 1. Single piggyback variable level float switch or double piggyback variable level OPTIONAL PUMP STAND P/N 10-2213 float switch. Refer to FMO477. Reduces potential dogging by debris. 2. See FM0712 for correct model of Electrical Alternator E-Pak. Replaces rocks or bricks under the pump. 3. Variable level control switch 10-0743 used as a control activator, s Made of durable, noncorrosive ABS. pacify duplex Raises pump 2" off bottom of basin. (3) or (4) float system. Provides the ability to raise intake by adding sections of 1'/2" A CAUTION or 2" PVC piping. Ail installation of controls, protection devices and wiring should be done by a qualified ' Attaches securely to pump. licensed electrician. All electrical and safety codes should be followed including the ' Accommodates sump, dewatering and effluent applications. most recent National Electrical Code (NEC) and the Occupational Safety and Health NOTE: Make sure float is free from obstruction. Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. - © Copyright 2008 Zoeller Co. All rights reserved. P'AW'S OWNER'S MANUAL cot MANAGEMENT PLAN Page 5 -of 7 FILE INFORMATION SYSTEM SPECIFICATIONS Owner )7-0 IV C f E T a.) Tank Manufacturer. A l'r-f-.x p NA Perrri)t (fSeptic p Dose p Holding Volume: loco (gal) DESIGN PARAMETERS Tank Manufacturer: ~fjESE,t ~c.~c, ❑ NA Number of Bedrooms: 3 p NA p Septic Dr Dose ❑ Holding Volume. `po (gal) Number of Public Facility Units: ® NA Vertical Distance Tank Bottom(s) to Service Pad: Estimated (average) Flow : po (gallday) Horizontal Distance Tank(s) to Service Pad: moo (ft) Design {peak) Flow = (estimated x 1.5): y (gal/day) Specific servicing mechanics must be provided it vertical is >15 feet or so ay if horizontal is >150 fleet. Spec instructions to be provided on back. In Situ Soil Application Rate: .7 (gaudaylf?) Effluent Filter Manufacturer. EST p NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) s30 mg1L Pump Manufacturer 2 oELLE/L Biochemical Oxygen Demand (BODs) x220 mg/L ❑ NA - ❑ NA Total Suspended Solids (TSS) "s150 mg/L Pump Model: /,S'/ High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer (BODs) >220 mg/L p NA 9 NA (TSS) >150 mg/L p Mechanical Aeration p Peat Filter O Pretreated Effluent Monthly average Sande/Grravav n Wetland ~ Sand/Gravel Filter 0 Other. (BODs) s3o mg/L Soil Absorption System (TSS) !530 mg/L ❑ NA Fecal Coli€orm (geometric mean) 510` - Ad In-Ground (gravity) p In-Ground (pressure) F-] NA Maximum Effluent Particle Size '/s in dia. ❑ NA fl At-Grade p Mound ❑ Drip-Line p Other. Other: - 0 NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) 5'When combined sludge and scum equals one-third (3S) of tank volume 13 When the high water alarm is activated Inspect condition of tank(s) ` At least once every: p month(s) (Maximum 3 years) ❑ NA 3 0 year(s) Inspect dispersal cell(s) At least once every: 3 0 month(s) (Maximum 3 years) ❑ NA Clean effluent niter At least once every: 1.3 1K month(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm 1 At least once'every: Q month(s) p NA -3 0 year(s) Flush laterals and pressure test I' At least once every:. ❑ month(s) NA p rear(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other fl 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-thins (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 Page 4 of 7 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 'andlor 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, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. - ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shalt be taken to insure that the system is properly and safely abandoned in compliance with s. SPS383.33, Wisconsin Administrative Code- * All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator (pumper). e After pumping, all tanks and pits shalt be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. 'Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems •may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING c--. TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK U-N 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 .,/oN~✓ cd'L/GE %YP-.~313f~4 Name :py,J ELxGF ELKS 0,4iV Phone ~S G 72 -S'.764 Phone 715- 67•?- 5$ ?LG SEPTAGE SERVICING OPERATOR (PUMPER) ~i~wlK.~owtd LOCAL REGULATORY AUTHORITY {lame E715- <r-. 4wx moo. Zodiac OfFio~ Phone 84 - yG8a NJ a; ii O m m> c O vE O v a a V 5 c C > i.+ c m v Y O m v N 0~4 E iig V V > V/ D a v E ul v+°• 3 oYY .o ~°°j G c+ "C v w c E ~ _ N2 red J N m y' i- f a a LU uw.. C O ~ ~ o>o~v• ~ ~ i - CD's_ _ m mlmk LLJ o v \ t4~ _0 V D 3 G 4. y r ai { ti a^o ~I m n ff7 m o "3 Q} r ~ U o 0 x c Z y 4- c CL 3 i M a A Oyu ai E Z Q tiJ N c E Y y Z ✓ q-_ v1 6 7E LN C yqm a C ! p' Y 5 E 3 iv o 3 c 3 av ° a a a a T ~ r > cn s c sn iv a ~ $~1 F - (r' vTTi.. _ O Z5 B? m .c N O i0 N a ~ H O d C a s~~ a, n c 3 A c Z214 Z~w ci Y a it a C c o i 3 L v CT CL C O a vN n C vdi 3 0 cc 1_ 'e g -cw ti !~4 s, _ ate.. ~3 C y3 N 0! ~p f: O y 7. C C O O H O 3 y = O ti p afl.. qQn C G YL d r N V v 2 t. O ~4 J = N t'J E E 1 V 'O Y , w A vs %A 0 fI 2 O V y a .fl ~ ~ 81 • yy ~ v Y Q 0 'L' ~ as S' ~ t i a C C gyn. L= C pip ci ru Y ~ is, m 2 -a 7E -E Pn 3 y.ei a 10 a~ ! C O i N 0 ~O X R y111 _ a~ LU ~ ~ vA C ~ 4-4 J }y /v i~I L L ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEM~NT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer--6t cA- C kP V- 5►D Mailing Address ZZ ' q f>-T- PiCkro"o nt+ Lt~7" S7-101-7 Property Address A V (Verification required from Planning & ning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRIPTION Property Location V4, Ste. T 3j I _N R t ! W, Town of 1-:vWX'Ce 5' Subdivision ;A~ i nn nC. 1 ~ t 4 Lot # 2-. Certgfied Survey Map # Volume - Page # Warranty Deed # Volume Page # Spec house yes Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER ER RTIFICATION 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 the system can affect the fiction of the tic tank ast a~ three ~ sooner, if needed, by a licensed puts, What you put into resPonsibilities are specified in §Comm. g~3.52{l) and inte nt stage in the waste disposal system Owner maintenance Chapter 12 - St. Croix County Sanitary ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Departalmd a certification form~ owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper v signed by the ff&An g (if g that wastewater disposal system is in proper operating condition and/or (2) afkw inspection and Pin necee arythe on-site less than 1/3 full of sludge. ssa), the septic tank is set , forth. by the undersigned standardI/we read the above requirements and agree to maintain the private sewage disposal system with the herein, as set have the Certification stating that yours Department of Commerce and the Departru nt of Natural Resources, State of Wisconsin. system has been maintained must be Zoning Department within 30 days of the three year expiration date completed and returned to the St Croix County Planning & Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/am the owner(s)of the ProPMtY descnW above, by virtue of a warranty deed recorded in Register of Deeds Office. Nu of bed , J SIGN TURF OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty dee (REV. 08/05) 0 ° oD (D LO N I GD 9 4 04 (5, r t-- z C.0 C~ M 0 T N a W t8 bib U- 36904 LL_ ° 1 W t C.C A U d v `D W tO ~ N 9} s4 7 T N C-1) ` O ry 595.00 G r O ~ r N _ T 4 CY) 0 ~a r- Cl) s- CY) N , c z nF 21(a 1 - tV, C~ T N 0 0~ . , tT: c o,3 N r~ C V ~ 5 1i y C N MS- `c OP 4 ° T h 14D Y _ w 0 T t 04 r g w.{Q C ~y Cl CV T • _ 5047 C15 C4 0 c o z}35 d C14 I Q .4 04 I ao ®oo~® I A® ~nBai®= ~ ~W/Y~dV9~96 " # ~ I ~ II i arm 1 t! J: Z 13 Orr, \VA 9 i i _ \ 4 All =4 r \ d LLB U. Jill I I ~ :1~ ppC ~ ii y e WAR \ d \ 1 qg a a6 3 00 0 b is D b $ gg E 9~ b g a a Dxawlxcs rROn°eD er: rfnlEC cescarYmx: McCormack Classic Tom & Char Peterson House F SMN ~ OPeo Construction ft ]mph, w1 5101f FOR THE Ex p /$NE V4 E OF NaORx ty~gtC mY,,~.u~e1A AYE wxfmuncex. usE yr, vI 57Z 1,y wI 54016 COxYAIRID Y" N f ~ wY AxD tOXCErff is Gwi 11' MxoxMACIC GAffX COxfTPUC1'[ORIf WMXIBREDAN MAY fXB]ERYW TO A Cll~lM AR DAMAGE& ODPYRIONY 0 J . i i f { i 1 I I~ r/ ~ f N~ M I ~ Po I' a~ uNNmsw+ uwBUNax t I la,~ N O DPAWDN33 P~VIDED DY: pRECT DE9CRDRW N: ORSCOFTION TE TNE9E DRAWIN" ASE l%E PRDPRMAW WORK PRODUCE AND McCormack Classic & Char Peterson House +RO►M CLASSIC CON6TRUCIIIIN DEVELDPEO FOR INEE M USE DP fCORIMCK CLASSIC 4 yy N Construction eL7MUph, W141016 WNSTRU"Ok LRE OFTNF9EDMWD768 ANO WMIFYYB N o W128thAve CONEAiNEDT"N4~aWD'NONTHEWRITTENPEMIRSIONDF IR NNdavn, WL 44018 MN.GRMAO( CLtS9IC CORSTRUCrM IS WNI6MO AND MAY TI MD-2211 • SUE1ECf YOU TOO A CAD/ FOR DAMAGES. COPWGW 0 I • i i 1 ii ii !I !I C I u ~ I I a s~ C I I~ I ~Y ! ! I 4 II d I g i! Y~ 2 S DMWINGS [RDVtptp BY: WW1ECf DESTAffiTIOM: X D tltM70X Y DA 71155E DRAWfN~ARETXt ?===AND McCormack ssic Char Peterson House WwAENT7DFN~uv~ Construction ft u6e N7~ACK CLAASSICLD7eD w M 57a Uft A" 3~1 ~ 51516 c TXE [XpUYU CW t6, DRA, AND N XUff-M W7 5 M ATTMAINED cDro1Aa h . CSA551C }*.XeDVf THE wX1T7EX PEN4NN6DF 715 75:2411 - W TOLCItON Et 7NOX1GtfED AND NAY SUNEp YDD TD A RM DAMAGES. CD7YRiGXT p a I 'i `j 1 j I :i ii +Q~ I f 4 e $ sad ~ w ~ ~ ~ o ►nomoex xr: rwo~aoes": McCormack C3asslc Tom & Char Peterson House ° '"FORA"~"wueetxevaomeraxrwoaKVxouuer vau - Construction vaovemrw ,Z, All t Ol .oye s'"~`wn, va ssoic roxmeexausrvs~n ~K * Smx, ucvnoveo x a is Zeo-71u MxSinULR7ox. uxe rrae auwu~as ~xu merry ~n~aTxeraar rrmry,~ n~wmrnm ~xxssfox or soaucrrou~ayp,~"s ~ s:w w~®o"~r Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings 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 S1 ro jr include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. l I- percent slope, scale or dimensions, north arrow, and location and distance to nearest road. V 3 d- - I l,-7 -3)1-60- Please print all information. R iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 3 O Prope Owner L I E- Y a u Pro erty Locations / d2 C TT ~C~ fi/r -S Gov . Lot S.G 1/4 IVIZI114 S :2 6 T3/ N R ! (or)N Prope Owner's Mailing Address A Lot: f Block # Subdd. Name or CSM# KCU, c)~. 7.?/ ~ 3 / /tee Ckff ~li.aL ~o~o~ City State Zip Code P one!~yer ❑ity 1:1 Village RLTown Nearest Road k ~sr,~ 1.~~ S'-f~d/~ { ~~j:~~`~/c t"C ,SC'~r►1e~sY~ (j Z -S~ New Construction Use: Residential / Number of bedrooms Code derived design flow rate tS 6 O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Yy~ e) w r b V a Js 1 5 /d1i' Flood Plain elevation if applicable lyi~ ft General comments l ~M ~L ~Z Z and recommendations: r 1-1 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/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 i3 3/ ~U .S G 2 mJ~k ~1 Z C}~ S O , 2 J3-2/ /Dy/~~ SL 2~,86k ~o~ ce 40,5- aI-3f 7Tir,~!y /U,~ SL 2rts~~ h, G~ t D S Y 171-40 7~y4C AA GSyob ~sl4- O• 7 ~ S 166-16 7 S)X 6 l . -li I4 lu 6-S r, - 0,-7 1.2- T F-1 Z Boring # ❑ Boring © pit Ground surface elev. q(~ 7i '!~ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/112 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I D-18 /©~'/1 3 L S •/rte ~d~ rt~.~ Cc~. Z 7/. Z Z ^,g e c G- z C~, s q 12?- L4 7j~- C c- 0,-7 0 J6' _ ~ C~ r ~ ~ , 2 ~ 96 7<sr LA'S S b , - s O, q .4 :1 ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L Effl ent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print Signature CST Number Address Date Evaluation Conducted Telephone Number SBD-8330 (R07/00) ti AV G®~- ?Z Property Owner 6p -Ii el. Parcel ID # Page Z of 3 ❑ Boring Boring # 1-31 ®pit Ground surface elev. 7 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 Z _ 16 0 R 9~ Ct 2rL O,S O, 9 3 1` 3 rre y LS c-6 n•shi Ike. C C., 1 d l p~ 3y-6y ~,sy,~ ~ ms/ob os- rn~ as o, ~ , z y-96 7,17;f% /VA- 6.9 ❑ng Boring # -32-Y bS-• a ❑ 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] 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 I I ' 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. SBD-8330 (R.07/00) , Property Owner & C parcel ID Page ~ of Bor•rig M ® Boring ® pit Ground surface elev. 7 1. R Depth to limiUng fact in. Salt Applic2tion Rate Horizon Depth Dominant Color Redox DescApton Texture Structure Consistence Boundary Roots GM W In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •6!EFFP 0- --F ov /1✓/~ r~.f A- C gyp? Cd-16 out Y SL r~.sa~ ~,~,s 2r~ Orr O, Y ~l 3 7 sre LS 1-A S c 41,C-7 L Ics s F-1 Boring j~ . B.~firg k pit Ground surface elev. ft. Depth to ;uniting factor s:[3ii Application Rate Honzon Depth Corninant Color Redox Description Texture Structure CC~SiSlence Boundary Pcoi_c GPDrft2 in. Munsei[ Qu. Sz. Cont. Cvior Gr. Sz. Sh. 'Effttl •Etfi+:' I i ! ra u F3Cring U 3 7» pit Ground surface elev. ` Depth to iimitir;c !ac+aa tn. ! Snit ApGi.czGonRa'.e ; Horizon ! ::>ep3 Domrraet Color Redox Description Texture Stmciure Consistence BCarrtda Rcx.l~- GP?l#ft2 I M ~nsett Qu. Sz. Cont. Color ,r. S: Sh, 'E f# 1 E i i E i E t r e Effluent k1 = BOO, > 30 < 220 mgR and TSS >30 < 150 mgt Effluent a2 = 800, 30 mg•'L and TSS < 20 mg'l T21e 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 608-266-31 5 t or TTY 608-264-8777, sao.43so ix mAai Y Ctr`NER PaQ `tame [1 .2 e C I(` f=F Brian Parnell Address /,4 CST 231314 Date Zr4,e 20-02 Benchmark 1 TO l fee~ Benchmark 2 b Soil Boring - -i Suitable Area 1" = 40' Scale * i - i ~ I i I i i I I I I i- --~---~----r------;--- i -1 - - r-t-- - i 71-1 - - ` -r - - -t - r----'-j-- 1 i f i 1 I ( 1 i -r- T-~-..-T - --r-- - - - - - i ' i I i ;