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HomeMy WebLinkAbout032-2114-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 582031 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)]. Parcel Tax No: Permit Holder's Name: City village Township 032-2114-80-000 Todd & Karmen Rushton TOWN OF SOMERSET Section/Town/Range/Map No: CST BM Elev: InsppBM Eledv: BM Description: ^ r 03.31.19.1056 I L-- /Gr O ~Vl TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 31 *3 , Z3 ~O Alt. BM 11+. 3.4 3 Cj (v• Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. V nt Air INt',. ROAD Dt Inlet Septic A~. Dt Bottom o6f q3 27 I Dosing Header/Man. 93-06 Aeration Dist. Pipe G X75 93.4 4 Holding Bot. System 7-5Z &12 7 Final Grade 4,7 cl4 PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM cg 1 Go Model Number TDH Lift Friction Loss System He TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth BED/TRENCH Width Length No. Of Trenches DIMENSIONS 1 & 5 2 rc-&J' ° LEACHING SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBER OR Manufacturer: EZ r7a :.I INFORMATION Type of System: 57 IZO J UNIT Model Number: DISTRIBUTION SYSTEM Vent to Air Intake Header/Manifold ;:jDistribbution x Hole Size x Hole Spacing S) i i Dia Spacings Length Dia Length SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ,a Mulched Depth Over Depth Over xx Depth of xx Seeded/Sodded Bed/Trench Center Bed/Trench Edges e~ Topsoil _ s No Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 233953RD ST 1.) Alt BM Description = ( `^'JL~A- 2.) Bldg sewer length = - amount of cover = E Plan revision Required? FE Yes ' RStI No ,a Use other side for additional information. Date 411nnseepctore'ss Cert. No. SBD-6710 (R.3/97) County 5T Safety and Buildings Division C; DD ! X- 201 W. Washington Ave., P.O. Bo 62 Sanitary Permit Number (to be filled in by Co.) F7 ~p V ! Madison, WI 53707-7162 UNIT ? Y DE7VFJ-- RA W-1 tatter S TVA actionNumber A- Sanitary ermit Application In In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1 (m , Stats. 7,339 G L Application Information - Please Print All Information Property Owner's Name Parcel # ?o~~ ? ~~rzM~v 1~11s~6N d3Z•- Z1/~-SO oo?S Property Owner's Mailing Address Property Location 2339 530 5 Govt, K- Lot X6-5 City, State C Zip Code Phone Number Q / 2 /V 1/,, 'j tA~ 1/<, Section (S 50AW 3i5 / r V • J d-' S 715 (circle on _ T~ IL Type of Building (check all that apply) 2 Lot # T 3t N; R ~ E or ~1 or 2 Family Dwelling - Number of Bedroo 3 Subdivision Name Block # /ti( G14TDO 60 (A' O S Pep-1-4CAVV,.tV4-+- ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use / CSM Number ❑ Village of ER .SE ` s Town of S ©~~I~ III. Type of Permit: (Check only one ox on line A. Complete line B if applicable) A- ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ' ` ❑ List Previous Permit Number and Date Is B sued er L l ` D6~ r~ O O • El Permit Renewal 11 Permit Revision ❑ Change of Plumb Permit Transfer to New Before Expiration Owner 7LV 3 C IV. Type of POWTS System/Component/Device: Check all that apply) XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ er Dispersal Component (explain) ❑ Pretreatment Device (explain) Z- ~ot..> V. Dis ersal/Tre ent Area Information: A Design Flow (gpd Design Soil Application Rate( dsf) Dispersal Area Required (sf) Dispersal ~Dersal ro se (sf) System Elevation i 7 l/? , 6 !p z , .7 VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks E E GG a U r~ m w C~ p. Septic or Holding Tank Dosing Chamber ZAGS , MG VII. Responsibility Statement- I, the undersigned, assume responsibility for installation' of the POVVTS shown' on -the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number ,E-1A tf,4t;~i A) --S z'2403 7iS'- 23y- og>i> Plumber's Address (Street, City, State, Zip Code) io s &AS CGS tM ~ 01-- 57- Cr9-;~ o r i ~v~' s~ 7 Z VIII. Coun /De artment Use Only Issuing t Sim ire roved isapprove Perm~itt'Feeee Date Issued < rven Reason for D $ 1 ✓ ' U0 ~D z+g 5 1 --Z M Cond * e ns fo Disapproval 1 eptic k', 'et "t ands ,dispersal cell must all be services / M intained as per ynanagement plan provided by plurnbor, 2 III k:iequ eM . grinairtt inlea as per appkable code / ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size SBD-6348 (R. 11/11) u p c~ t, 3 n NO Vl c~-L ~ ~ o o I c~ o- 3 o o Q 0 f / If ~ - 2 3 If If / 11 ipa r~1 If Pei- ~ ~ ~ /l f 1/ /l ; 11 / • • ~ N t / 1~I p If If d Op If \ If / If If !-`3Z It l ° ! Ml 1. / ~'C 1 J ~ ~ ~ Per /o r r / 3 C-I o ~ /Qf Z qz~ ~ v CONVENTIONAL INGROUND POWTS DESIGN Public/Commercial INDEX TITLE PAGE Project Name kgRM EN T 0 D D R USA ~oAJ 5 ~ e-P 1(G .5y,5 T M Owner's Name ~ ~ M~~ rooD s G, f6 Owner's Address Site Address ~3 3 oaf 53 R~ ST. SoML= (Z$ r W!, 5~p Z, ~c Owner's Phone # 715- 3Pl-8963 Legal Description A) 6i sw S.ec.3, T33, I>. 19w Township 50MeR56"-r County 5-r. ciRbt X PIN p 3c;Z- 2//y-~a - oov Subdivision M~4,96 w W66493-- t PROJECT DESCRIPTION • -p/J4G~ME>uT SLFP+I G 5 yS`{ tTiq, 1 N ` p©(-)NL7 Cow Ulu T /off flL J P° P- A FAi (L-D S y5rt~M w 5fA-IIitD Nov..200 y. Cry. Z o mm& A 3 Raw To A cep 1-/-USE" 021(r1,4i a L SOIL ?""S 7- fir= ~l~ i~c~~?- s ysrEM r~ CZ afi Flb6-. zo, q06 % 1N S+R iloij Drr s Cr~a~~ p S; yN r 12>✓ Pl~rc~M ~T R RSA- , sySTLM 15 ApR~,~~p Tay NOAZT S To &5 51z~v R,5 to P • ~gC.... 14 Pg.1 Index Sheet (Reverse side, Flow Calculations) Raw* P4.2 Plot Plan Details 1kBRl j ' miss. Pg.3 System Sizing Details & Cross section Elevations C9G VAI Pg.4 Filter Specs a Pg.5 Tank Specs & Cross Sections Pg.6 Owners Maintence & Management Plans SIGH Pg.7 If applicable., Pump Tank Specs & Pump Details Plumber K1 SNIT License #'-2- 7 Date Plumber' s Phone # L "7 ?71 Signature `7 Page 1 Designed pursuant to the Inground Absorption Component Manual POWTS Version 2.0 SBD-10705-P (N.01/01). n N N c-~ o k Q N i1 • ` flL ►.s1 w 3 3 ? ~ . o o a Q i J gyp/ t - l J l/ l I Q -zr, / l l l / ,mil / Ir `r 1 1 ~ l M l l. J ~ x 10/ LL i t i ~t I ,s /o /oe W 2 o / Qd Oo yc° y°- a O o ~ v ~ -10R) 'U t 77 57 - 3. ~SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page of~l Project Name: 2. No. of Cells tD ~~I f5 Per Cell - E4 G 144Li f D~`L- bIl) (T- _ ft Cell Width 3 Total No of VA I f 5 5 ft Cell Length - SD sq ft PISA Per Cell (0 ft Cell Spacing (p 0 Q sq ft Total EISA O V'(' o tA3► un~ fs, Manufacturer Model Laying Length EISA Rating VT. Infiltrator EZ12031-1-5ft 5.0` 25.0 F11203H-10ft 10.0' 50.0 SA-fi 17/M7 0,~ Gravelless Leaching Unit Manufacturer: Gravelless Leaching Unit Model: Z. Flo to 5 INS Q~pTi0.0 q'•d Typical Cross Section o~yE Finished Grade ft 10 ~ Observation Pipe with oG~~ a approved cap or vent Coo W l ~<< y/ ~I Iii ~ G ~ •y h}+ • <;>:::.:':<:<'>;: ya Soil Backfill R I • :<.:>:< Geotextile Fabric 50 qA. 50 ft Infiltrative Surface .4 Y5 , 12 in ft Limiting Factor 11-in Slotted and Anchored Vent/ Observation Pipe with Cap ■•.■rrrr■■rrr■rrrr•■■■■■■■■■■■■■rr■■rrrrr■■rrrrrffrrrrrra0aMrrrrrrrrrrrrr■ F cTtR Plumber/Designer Signature: License Date: -pg o f ==M 10 00 0 ~2E ~ o o a o 0 68 I ! ~ ol u O lfi r CV O N O C, U U O O N L ~ u N O N U 07 co O ~ ~Y cD ~j E 1- U LO Ci CIA O U ~d cD 1- U L6 EMI ~ co c0 U ~ N ti C6 U W O u U of cn Y 2 U 0 m U \ Q N III il' ~ P LO cn N O ^ ~ x Zc O U in J U F- V) 3: 9! LL Lo Q to o Cn O t- 2 (n Q O F N C^C O U W Cn LQ M co w F- O U Q a- C/3 U a ¢ O O U w = - C;lo ~w~ W Q LL Y r d C. LL w co o z o L n U° w M - M J LCD CD j a ~w `O w U- a z Of r o ~ aU=J)~ w J m J J Q w U.. ui ~00 0 I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 6 of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ~j ? ODv 'RV5 h7 Oil} Septic Tank Capacity /0-0-0 gal ❑ NA Permit # Septic Tank Manufacturer W9( 5_1k'5 ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Z A f3 c L ❑ NA Number of Bedrooms ❑ NA Effluent ilter odel ❑ NA Number of Public Facility Units NA Pump Tank Capacity gal `KNA Estimated flow (average) 0-0 gal/day Pump Tank Manufacturer )KNA Design flow (peak), (Estimated x 1.5) 0 gal/day Pump Manufacturer XNA Soil Application Rate al/da t2 Pump Model XNA Standard Influent/Effluent Quality nthly average* Pretreatment Unit l ❑ NA Fats, Oil & Grease (FO Gf' <_30 mg/L ❑ Sand/Gravel Fi feat Filter Biochemical Oxygen Demand (B D5) :5220 mg/L NA ❑ Mechanical Aeratio tland Total Suspended Solids ( < g/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) 530 m ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS _ 0 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometri ean) 510' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At le st once every: ❑ onth(s) (Maximum 3 ears) ❑ NA 5eyear(s) y Pump out contents of tank(s) When combined sludge and scum equals one-third (%3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: Z ❑ month(s) Ayear(5) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ monthh((s) ❑ NA year 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) XNA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. 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 to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 tank equals one-third (%3). or mote 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 NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical' orT 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 10 days of completion of any service event. i Page 7i of START 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. During power,outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large,dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. 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 POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit" and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 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 chapter Comm 83.33, Wisconsin Administrative Code: • All 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 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 that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T aluati ~iONank be ' e ai a 't~~.D;-li3 9'D2 ~NS`T?Z(J ❑ 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> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER'A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER ) POWTS MAINTAINER Name / LC Name S-7 U~~y fig//('~ (J~ti~ C Phone _ Z ?J 07 3 Phone / / 5, 3 6 06 RaZ "7 2 7/ -5 1 1 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~evE- VE'v/ ti Name ST. (S l UN Phone ,-Z7 Phone (p 9D This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 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 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.notlb'ccur when soil conditions are frozen at the infiltrative surface. During power,outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. 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 POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit. and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 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 chapter Comm 83.33, Wisconsin Administrative Code: • All 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 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 that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as "a last resort to replace the failed POWTS. T ;rte aluati a o ding ank (v ll~ be i e ale ~~D+-{1t31'3>✓~ ~2 N~ C~~rS7-7ecl~a'~.o~ ❑ 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> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER P ) POWTS MAINTAINER Name k/ Name Phone 7/5-::23-5-01-35 one 7/ 5' Ro;. 7 7 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name VL~' C Name ST, 1`() l 0L// J Z01AIJ Phone 396, e~77 Phone -7(S- 3E'(" f08(D This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 2 Owner er TO Dl> 7 kAR M EN P 03A46 /V 71jf 391 h05~/ Mailing Address Z 33 1 5~ RD S SO tif~S~ T Property Address (Verification required from Planning & Zoning Department for new construction.) City/State ~M ns W1. Parcel Identification Number D 3 2 - ?,-//7 f© 0 0 0 LEGAL DESCRIPTION Property Location N6 1/4 , 5W 1/4 , Sec. 3 , T33 N R W, Town of Subdivision Plat: /~1 i4 ~OI,tI W b0 I? S , Lot # v Certified Survey Map # , Volume , Page # Warranty Deed # ( (before 2007)Volume 2.g16 , Page # Y12- Spec house ❑ yes/, no Lot lines identifiablel yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION ,,11 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 §SPS. 383.52(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 system with the standards set forth, herein, as set by the Department of Safety And Professional Services 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 this edeed are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtu'e~jof a warr recorded in Register of Deeds Office. Number of bedrooms IGNATURE 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 deed. (REV. 04/12) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) o~v kiieltfgN T06A46A) ~14 _,~9_ - This is to certify that I have inspected the existing septic /or dos: igi,, presently serving the following residence: (Street address) 2-3 3 f 53 RD 5/ S~~l /2S 7 located at: ,L 1/4, 6A) 1/4, Section 3 , Town__3,~_N, Range_L~_W, Town of 50 tilipSE7'`~ , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly., Most recent date of inspection or service ~UA-) Did flow back occur from absorption system? Yes No (if no, skip next line.) 2 Approximate volume or length of time: g gallons ° minutes Tank Capacity: / O" Construction: Prefab Concrete Steel Other Manufacturer (if known): (,o~~~ 5 Age of Tank (if known): l y/2 S Permit number (if know _ b (Licensed Plumber Signature) (Print Name) /V 7 (Title) (License Number) 11"PRS b~f . z~- X015 (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) f ' D ~L.~,e U~ UUI G Rev. 9/2008 - X_ S }/57 /A) T/77 iu'g 3 9, NY- oppa ~~M~ A6 50LV 44 - Z~k, 04~J 139- RE ~96a69 U 2 8 1 6 P y 1 2 KATHLEEN H. WALSH State Bar of Wisconsin Form 2-2003 REGISTER OF DEEDS ST. CROIX CO., WI WARRANTY DEED RECEIVED FOR RECORD Document Number Document Name 06/ 07 / 2005 10 : 30AN WARRANTY DEED EXEMPT # THIS DEED, made between Scott C. Thell REC FEE: 11.00 ("Grantor," whether one or mor , TRANS FEE: 785.70 and Francis T Rushton and Karmen K. Rushton, husband and wife COPY FEE: CC FEE: PAGES: 1 ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys and warrants to Grantee the following Recording Area described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space Name and Return Address is needed, please attach addendum); Estreen & Ogland Lot 8, Plat of Meadowoods in the Town of Somerset. St. Croix County, Wisconsin. 304 Locust Street Hudson, W1 54o16 032-2114-80-000 Parcel Identification Number (PIN) This !soot homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated ^0 6 ~r / SEAL) (SEAL) ~ ( * *Scott C. Thell (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Scott C. Thell STATE OF ) authentic tedpn ) ss. COUNTY } *Kristina 45ila Personally came before me on TITLE: MEMBER STATE BAR OF WISCONSIN the above-named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Ogland Notary Public, State of Hudson, W154016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 • Type name below signatures. INFO-PRO' Legal Forms 800-655-2021 www.infoprotorms.com t - Wisconsin Department ofCommeme SOIL EVALUATION APO ~ Page-Lof I Division of Safety and Buildings' in accordance with Comm 85, We. AcJwa county Attach complete site plan on paper not less than 81/2 x 11 inches in ,PI~ , include, but not limited to: vertical and horizontal reference point (BM), irec Lion and I.D. percent slope, scale or dimensions, north arrow, and location and diets to neares ` f F \ Date Please print al information. Personal infonna5on you provide may be used for secondary purposes (Privacy Law, 15.04 K(i N .J~'' ZZ ~F Property Owner P arty L n _ of 1/4 1/4 S T N R (or Property Owner's Mailing rase Lot # # Subd. Nam City Zip Code Phone Number ❑ City village Town Nearest Road ( ) (g( New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial Describe: Parent material ®jJr~s.Y Flood Plain elevation if applicable ft- General comments and recommendations: qp, F Bodng # inl Boring Pit Ground surface elev. ft. Depth to tirrriting factor > in. ~ Application Rata Horizon Depth Dominant Colo Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E1f#1 1002 Q Z 0-7 A0 keWlj 1/1 d~ y 4 4 .5 ® Boring # Boring pit Ground surface elev. ft. Depth to limiting factor ,;iz-- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EfF#1 'Eff#2 e 6-9 .4 q Q 4 P R2 • ~ ' E #1 = BOD > 3(:5 220 mg/L and TSS 4:5 150 mg/L #2 = BOD < 30 mg/L and TSS 30 mglL CST lease Signature CST Number ZY- ~oe Add valuation Conducted Telephone Number 52Z ~p Z U~ I,TT 1,1•~/,TMM,N Property Owner Parcel ID # Page Z:~2 of Boring # ❑ Bonrg Pit Ground surface elev. ~ft. Depth to limiting factor }5~ in. Soil AgmUcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDJff in. Munsell Qu. Sz. nri. Color Gr. Sz. Sh. *Efr#1 *Efr#r2 e 025 Z a q 4 C; q ❑ 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 GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etr#t1 *Eif#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to Urniting factor in. Soli k adon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary' Roots GPDIff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EW1 *01102 * Eft at #1 = BODE > 30:5 220 mg1L and TSS >30:5 150 nV& • Effluent 41= BOD6 < 30 mgA_ and TSS 5 30 mglL 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 608-2648777. SBD-8330 OL07100) I i4 Oo oC,,~ Mt 1 -z.zzz~3 9 i~ r N 1-- F- N 4. w N ~ W ~N A NU OV t0 ~z NV W NQ N Q O> N (000 0 r 0O 00 ri N M M U M co M co U co YC' N O 04G ul z I~ 1 I ~ M M ~ f W ,S L' l£~ ,5l' lS L 00 00 moo' 3.99.0 LOON z 00 OD 60R6 Z \Y \ _ O b N na Fl H \ c .....:A l X31 N`~ M6S H,U1.00S ~iv~~s6~ 8pf• \ ~t ~ rn W ~ o~ •ti N CR C3 L M OM `\6 ' a Z ; o Z 3 v. 0 %0 I- wNPOI M //~CQ sl W f^T ~r r Safety and Buildings Div' County ar 201 W. Washington Ave., P ox 716`2, ' sconsin Madison, WI 53 S nary Permit um r (to filled in by Co.) lVi ` (608)2 Department of Commerce 2L/ Sanitary Permit Appli ~ to Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal ormation you)Rowlle > { may be used for secondary purposes Privacy Law, 15.04(1 x Project .Address if different 41( tharkmailingaddress) - 14, VIM 1. Application Information -Please Print All Information ✓ D Property Owner's Name Parcel # Lot # S Bloek7l-- Proper AOw.ne, 'sMai g A dress 032 2114- -060 0s' Property LocatioA '/y Section_ City, State 7,ip Code Phone Number ~,`shj (circle e) II. T e of Buildin T, N Rq YP g (check all that apply).: _P 1 or 2 Family Dwelling - Number of Bedrooms S SubdivisionName E9M3iat111 er• ❑ Public/Commercial - Describe Use ❑ State owned - Describe Use ❑City ❑vinage o ship, of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ,VJ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision El Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner i IV. Type of POWTS s stem: Check all that a 1 Non -Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter JK Leaching Chamber ❑ Drip Line ❑ Gravel-less Pipe ❑ Other (explain) V. Dis . Ysal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) D11 ispersal Area Proposed (sf) System Elevation ~ r VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks septic or Holding Tank Aerobic Treatment Unit Dosing Chamber 7-1 T VII. Reapo sibility Statement- I, the undersigned, a ume responsibility for installation of the POWYS shoved on the attached plans. Plum 's ame (Print) Plum 's Si MP/MPRS Number Business Phone Number f, Plumber's Address (Street, City, State, Zip ode) 2 ~Q VIII. Coun ' /De artment Use On Approved El Disapproved P5F~~ des Groundwater Date Issued IssA gent Signature (No Stamps) ❑ Owner Given Reason for Denial Z 2 2 ?a IX. Conditions ofAJ~►►pr~oval/Reasons for Disapproval p SYSTEM UwNER: ~,,p_'~-+ a. ~p i ¢lwu 1 Septic tank, effluent filter and 1 dispersal cell must all be serviced / maintained ~t f OL (1 & c~.~,ot r+~ i - as per management plan provided by plumber. ) 2. All setback requirements must be n sintained C0.4A, 4o ,Q.IciS~ as per applicable code/ordinances. Attach complete plans (to the County only) for the system oa paper not has than 81/2 : i 1 inches in size SBD-6398 (R. 01/03) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisiori INSPECTION REPORT Sanitary Permit No: 463064 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)(mii F Permit Holder's Name: City Village X Township Parcel Tax No: Thell, Scott Somerset Township 032-2114-80-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: Q d` G / !7 U v~/ 03.31.19.1056 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark / A-V r 3 n'3 . ( as 'b Dosing Alt. BM Aeration Bid er -30741 Holding St/H et St/Ht Outlet TANK SETBACK INFORMATIO 9 / 3- 9 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / Dt Bottom -6 rr~ /30 Dosing Header/Man. Aeration Dist. PipeC U 3 Holding Bot. System /p, S Z Final Grade -7.3 9'-- 9 PUMP/SIPHON INFORMATION Manufacturer Demand St Cover PM r~ (p, 3 / d' Model Nu TDH Lift Fncti s ys em TDH Ft Forcemaln Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Tren es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man r INFORMATION D CHA uBER Ty Of System: Model Number. &K &Z DISTRIBUTION SYSTEM Header/Manifofd Distribution Ole Size x Hole Spacing Vent to Air Intake PIpe(s) ' - - - - Length Dia LL_ Length ~•J' o Dia_ Spacing --!5 x H r- 10-0 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only l II Depth Over Depth Over xx Depth of eeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx S FBI Yes Fill No M Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / 16Y Inspection #2: / Location: 2339 53rd St Somerset, WI 54025 (NE 1/4 SW 1/4 3 T31N R19W) Meadowoods Lot 8 Parcel No: 03.31.1.9 1056 1.) Alt BM Description =WAMel - K4- 'f"`4,t 2.) Bldg sewer length = 2, / - amount of cover a Plan revision Required? §?,j Yes Y Use other side for additional information. ( V _ SBD-6710 (R.3/97) Date Insepctor's Signat re Cert. No. ;r o a, ~ °Q ok -0 ~ 13 a )h, i J~ -10 / Iti 0 w COPY