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HomeMy WebLinkAbout020-1166-40-300 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 582024 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village Township Parcel Tax No: James Berling TOWN OF HUDSON- 1 020-1166-40-300 CST BM Elev: Ins it t) Elev: BM Description: Section/Town/Range/Map No: ~t) , b boor S 10 1 I 17.29.19.P1027 TANK INFORMATION ELEVATION DATA TYPE MANUFACTU CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing / Alt. BM G Aeration Bldg. Sewer Holding SUHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD DLIaie~ Septic Dosing Header/Man. /a Q, x Aeration Dist. Pipe 12 J q,v3 f3.Z-7 Holding WG o,b7 Z, 2 PUMP/SI PHON INFORMATION q, d , 3 Manufacturer errand St Cover GPM Model Number Q t !I TDH Lift Friction s System Head TDH Ft 01 ?.7241 Forcemain Le Dia. Dist. to Well U 7 SOIL ABSORPTION SYSTEM BEDITRENCH DIMENSIONS Width Length f No. Of Trenches PIT DIMENSIONS No. Of Pith Inside Di~ Liquid Dept DIMENSIONS G(J~ / SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: L^ INFORMATION CHAMBER OR -j , Typ l{'ttf~+ D /1Ql NF7 UNIT Model R ! W [Nr(/l DISTRIBUTION SYSTEM W{$ f - Header/Mandold Distribution Hole Size Ix Hole Spacing Vent to Air lintakp (s) Ix _1 LPipe ~ Dia Spacing f U VM_ Length _ Dia SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Pth Over Depth Over xx Depth of xx Seeded/Sodded Mulched /Trench Center Bed/Trench Edges Topsoil Yes ® No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 451 BROOKWOOD DR h 6 ~ O Ia M ~ ,n pn, QS,.I J d) (m 1.) Alt BM Description = r I ~Y^" rl~~ L/t~[1 v rc t 1 2.) Bldg sewer length = Q ~Y'S J I S t J V i\ ` ` t l t -amount of cover -1/1,014 V v Plan revision Required? Yes I.V ~ 1/1_7~ ~ Use other side for additional informat n. Date I ctor's Signature - - Cert. No. SBD-6710 (R.3/97) RECEIVED Conn Safety and Buildings Division J`f> rC9l"t DS, 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) P Madison, WI 53707-71i2) °*stox~t' ,aMMUNil`rnit Application Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to roject Address (if different than mail g 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 , Stars. 1. Application Information - Please Print All Information S~ + Property Owner's Name Parcel # Property Owner's Mailing Address Property Location I ~qp n u 7 / ( I1/ Govt. Lot 1 .or City, State Zip Code Phone Number ~J 1 , Section l circcone) v/ T N; R EorW II. Type of Building (check all that apply) Lot 1 or 2 Family Dwelling - Number of Bedrooms //T Subdivision Name 74 -4 -a ❑ Public/Commercial - Describe Use a ra; ❑ City of ❑ State Owned - Describe Use I CSM Number El Village of 44L ^ ~ uM d ~Z G1~ A" I W Town of _&z &AgeY) III. Type of ermit: (Check only one boa on line A. Complete line B if applicable) A' ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) _/1 74e) / B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 7/4, W. Type of POWTS System/Component/Device: Check all that apply) JR Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVrrea ent Area Information: Design Flow (gpd) Design Soil Application Rate( gp Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation - 300 ✓ Z. &I VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units c New Tanks Existing Tanks ri o i w 2 a U Q0 h ~ w C~ o, Septic or Holding Tank X Dosing Chamber of VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si e MP/MPRS Number Business Phone Number 10012&S -41,'dZ# A W, 3 71Z ~Z ;2 - Plumber's Address (Street, City, State, Zip Code) 14 oVIH,County/Department Use Only pproved Permit Fee Date Issued Issuin gent Sift re ,KA en Reason for enial I $ / 1 175 0o io z3 /s IX. ConditMT4ftA.0Rensons for Disapproval t / ^ 1 ' Septia'tank, effluent filter and ti~+t G G ..dispersal cell must all bebeservlces / maintained as per Management plan provided by plumber. ~ Allk.%eg4iir+et~errts.tntlsl; be maintained p PK cods / o~nsncea. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 z 11 inches in size SBD-6398 (R 11/11) Pg of Private On-Site Wastewater Treatment System (POWTS) PLOTPLAN FILE INFORMATION PROPERTY LOCATION Owner r~ %4, '/d , Section T_42~_N, R_Z,~7 E or W PIN # OCity, OVillage, MTown of roa two l E ~ c N 1 W Wall rQ far J~ ~ ± B0H0*1 of S G~ t ~t~ C3/~7 i vJ i~ Sir -7~p aPra,~r r? )f 9~q JoaO ~e~,c ~ v~L-Full run Valle,. J44 Cvaai.(°t' f`fer 0obel 81 12 a d~a C/i a roo \ C7 _ 1 62, ? s f ~ i + E i F t Pg of Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner's Name: ~~t C.YJ~ic e!/rG~ d t~% Site address: Location: Lot , Block , Subdivision/CSM 1 d A d V-0 4/0- AS being part of the 1/a of the,~]~ '/a, Section _/Z, Town N, Range~W, Town of oll~So-n , Pierce County, WI. - Parcel Identification # C&Q 6_ - 11466 Design: In accordance with Department of Safety & Professional Services (SPS) Wisconsin Administrative Code ch. SPS 381 through 387 and 391. Design manual (choose one): ❑ Holding Tank Component Manual [VER 2.0, SBD-10855-P (N. 03/07, R. 1/12)] ❑ In-ground Soil Absorption Component Manual [SBD-10705-P (N.01101)] Contents: Page 1: t7PX 16 Page 2: Pis-1 -J cen Page 3: C r6sg 1d~ Page 4: 1~er 6ex1s-j $7 Gl! Z`/ -I Page 5: 2 t°.~ rd r~ ~ Q2 Page 6:r nl~iP ~~°7 Page 7: &2U Page 8: Page 9: C ~~aT Attachments: Plumber/Designer: Deni1 rs 77P1r~~ Signed: Vu4z" Credential Number: ~V-11 Date: Pg of Private On-Site Wastewater Treatment System (POWYS) PLOTPLAN FILE INFORMATION PROPERTY LOCATION Owner r/ ~ / f '/a, `S~ `/d , Section James T_42?f _N, R_a_E or W PIN # / OCity,, O/Village, MTown of 41a -,-Fa r'PO WO t ✓ O N S f ~~i~'-~rh5 ~ar~Q r l~ gM 90f/W of S,d/nor Qm~~~ i w~2ser Tap o~ rna., de u 9&q IOdQ .,C \v/~clll run v4/Y- a?lvl gal.( /her Cex"niz;,fe,r za~e~ ~1~~r" ao sr axis-l~►oJ ~ax3~ O NY \ \ \y.~ 1 \ \ prU~Ctii~~U 7 Q a1Z Oh 0 QW17-11 dr \ raw o 1P aohes ~QO~) 0 8.3 1,4-61 1- or 2- Family Dwelling In-ground Soil Absorption System (1-cell Conventional) Daily Wastewater Flow (DWF) of bedrooms x 150 gal/day/bedroom = 60 _gal/day Design Loading Rate (DLR) or Soil Application Rate = - e gpd/ftZ (per SPS Table 383.44-1, 2, or 3) Required Distribution cell area = DWF - gal/day + DLR gpd/ftZ = ft2 # Chambers = Required Distribution cell area ft2 + ft2/ unit PISA Chambers Chamber Manufacturer and Model: ~rl 9 1-MI 140- 01AC -4 Actual Distribution cell area = Required cell area ftZ + ~ ft2/ unit EISA End Cap Pair= ft2 Cross-Section In-ground Soil Absorption System (1-cell): 4" Schedule 40 PVC vent pipe with vent cap 12 inches minimum _ ft Final Grade Elevation 76 inches Soil Cover inch Chamber Height ~ft System Elevation Leaching Chamber Width ft to limiting factor Plan View In-ground Soil Absorption System (1-cell): Leaching Chambers m ft f, URI 4 inch Header Sch..~J/- ~ft with end camps Draw O for a Vent and for Observation Pipe above. They will be located ehCl ft from the end of the cell. Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade. Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC. ` Page -&-of -2- VOWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of _Z_ FILE INFORMATION SYSTEM SPECIFICATIONS Owner er. Psi Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer N,4 Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Commercial" Units i4 NA Pump Tank Capacity gal JU NA Estimated flow (average) gal/day. Pump Tank Manufacturer W NA Design flow (peak), (?Estimated x 1.5) gal /day Pump Manufacturer W NA Soil Application Rate 'gal/day/ft2 Pump Model IV NA Influent/Effluent Quality Monthly average" Pretreatment Unit 8a NA Fats, Oil &,G rease (FOG) <30 mg/L D Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BADS) <220 mg/L ❑ Mechanical Aeration D Wet)and Total Suspended Solids (TSS) _<l50 mg/L ❑ Disinfection O Other. Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD5) 530 mg/L ❑ In-ground (gravity) 0 In-ground (pressurized) . Total Suspended Solids (TSS) 530 mg/L ❑ At-grade ❑ Mound Fecal Coliform (geometric mean) c10' cfu/100ml 0 Drip-line ❑ Other: Maximum Effluent Particle Size Y8 inch diameter * Values.typical for clomestic (non-commercial)-wastewater and septic tank effluent. * * Values typical for pretreated `wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months 9 year(s) (Maximum '3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one=third (Y3) of tank volume inspect dispersal cell(s). At least once every 1, ❑ months ayear(s) (Maximum 3 yrs:) Clean effluent filter At least once every ❑ months :4 year(s)., " Inspect pump,.pump controls & alarm At least once every ❑ months ❑ year(s) NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) Br NA Other: At least once every ❑ months ❑ year(s) l~ NA Other: At least once every ❑ months ❑ year(s) JV 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 (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a"Septage Servicing Operator and disposed of in accordance with ch.:NR 113, Wisconsin Administrative Code, The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less 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. 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. Page °P of 8 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. ABANDONEMENT: 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 ch. 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. ❑ . The site has not been evaluated to.identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performedto 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> > 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 Name Phone Phone SEPTAGE SERVdCING QPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name E.Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.' Use of this document does not Page ,R of 8 During :power:outages_pump tanks may fill above normalhighwater 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 effluentpurrip 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 'ceTls. 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 ovelimination 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. ABANDONEMENT: 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 ch. 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 e, code compliant replacement system: 0 A suitable replacement-area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replac•#mPnt-area should be protected from disturbance-and compaction and .should not be infringed upon by required setbacks from existing and proposed structure,Jot 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. D A suitable replacement-area is not available due to setback and/or soil .limitations. Barring advances in PO.WTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated torldentify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must tie 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. 0 Mound and at-grade soil absorption systems may be. reconstructed it 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 Name Phone:. Phone SEPTAGE SERVJCING.OPERATOR..(PUMPER) LOCAL REGULATORY AUTHORITY Name Agency' Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Vl/au a otonsnnddm n st atttCr3de etlse of this document tdoes tnot the minimum requirements of ch. Comm 83.2212)(b)(.1)(d)&.(f) af?d-S3.54(°1L l2f . (11 s ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer __gmnes Ber4nC4 Mailing Address Property Address S®,~ (Venfication required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number - - LEGAL DESCRIPTION Property Location," 1/4 , '/4 , Sec. N R_Z,~ W, Town ofl~lKS'BY7 Subdivision Po r V, 12J C) T S - ~ AnYI>1101~ Lot # Certified Survey Map # , Volume , Page # Warrailty Deed # , Volume , Page # Spec house . yes no Lot lines identifiable yes no SYS-1EM 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 alicensed 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the 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 form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warr ty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APP ~ICANT(S) DATE ***Any information that is misrepresented may result in the sanitarypermit 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. 08/05) Wisconsin Department of Commerce County. $t. C~OIX Safety and Building Division Sanitary Permit No: 430180 0 (ATTACH TO PERMIT) State Plan ID No. Personal Information you provide may ba u4ed for secondary purposes [Privacy Law, x.15.04 (1)(m)). Permit Holder's Name: City Village Township Parcel Tax No: Henry, James Hudson Township 020-1166-40-300 CST BM Elev: InsAp. BM Bev: BM 0 do : Sectior✓rown/Range/Map No. "1 ! V`I ~ td 2- 17.29.19.P1027 TYPE MANUFACTURER CAPACITY STATION BS FS ELEV. 2- 1 Septic ` Benchmark go Of V Alt BM AV o, r ! Aeration BI . & er •$2 ~ S Holding t Inlet 1764-K q-0-7 gSHt Outlet 27 ~3• `I TANK TO/SL~ E+ BLDG Vent to Air Intake ROAD Dt Inlet Septic I ( Dt Bottom er 4- Header/Man. i ~ • 761 q-3• (f -7 Aeration Dist. Pipe 0 0~ V79 C3 TI ~ Holding Bot. System 0 Final Grade ,!X ~ G/• ~y~ Manufacturer Demand St Covu 'G I 0 Model Numb "tot e(.J-~A... S YlY TDH Lift Loss System Head TDH F 740 Length Dia. IS. L4 Width + Length I No. Of Trenches / No. Of Pits Inside Dia. Liquid Depth SYSTEM TO PJL BLDG WEL LAKE/ST EAM Manufa 1 - Typfi Of System: C~ L~r L F „7 el Number. "MM 'I dlGl~ 31~ He anifold Dx Hole Size x Hole Spacing Vent to Air Intake I JPipstribution i e (s) I ~Lg- i Length_~ Dia_ Length Dia ypacin Depth Over r Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center L> Sed/Trench Edges Topsoil I Yes No Fgj Yes EN] No (Include code discrepencies, persons present, etc.) Inspection #1: / Inspection #2: 451 Brookwoooodd~Dr udson, ~Y WI 54 16 (NW 1/4 SE 1l4Y17T29N R19W) Park View iEses ddn. VI Lot 110 ) 17.29_.19-.P,1.0277 1.) Alt BM Description = f V f 6 W st / „Q~(~(/GcC,~l.. Ct it~~'Q1JL/ 2.) Bldg sewer length - amount of cover Plan revision Required? ( Yes - No - ..~jbt~ lP Use other side for additional information. SBD-6710 (R.3107) Date Insepato Signature Cert. No. ' Safety & Buildings Division Sanitary Permit Application aD~ 201 W. Washington Ave. NVIsconsin In accord with Comm 83.2 1, Wis. Adm. Code PO Box 7302 Madison, Wl 33707-7302 Department of commerce. Persona6infotmation you provide may be used for secondary purposes Submit completed form to county if not [Privacy Law, s. 15.04(lxm)] state owned. Attach com fete lane to the count co only) for the system, on paper not less than 8-1/2 x 11 inches in size. County Slate Sanitary P ormit Number D Chec evision to previous application State Plan 1. D. Number 43 p 1. Application Information - Please Print all Information Location: Property Owner Name a Property Location r1 1Q m I M W I MS 1 /4 S 1 Tot 1 N R or W Property Owner's Mailin Addrc OQ Lot Number Block Number V1, -0 City." S to Zip Code Phone 2" Subdivision Name or CSM Number r~uso , O / " l-w ~sfia es t II Type of Building: (check one) ❑ City I or 2 Family Dwelling - No. of Bedrooms:- O Village Public/Commercial (describe use): R1'o1XwQ.5o State-owned III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest R d t oO A) I- O New System 2. J Replacement 3. ❑ Replacement of 4. O Addition to Parcel Tax Number(s) S tem Tank Only Existing System - / Qa Y(S B) Permit Number Date ailed O A Sani Permit was previously issued IV. Type of POWT System: (Check all that apply) iMislon-pressurized In-ground O Mound O Sand Filter O Constructed Wetland O Pressurized In-ground ❑ Holding Tank O Single Pass O Drip Line ❑ At-grade 2 t t Aerobic Treatment it ❑ Re irculating Ot r. S V Dis ersaUTrea ment Area Information:' - 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application S. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals./day/sq. ft.) (Min./inch) EI a 'on GO .0 85 ri V , ~ 93.00 78,0c) VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed T ks Tanks l+~bbK----' • ❑ ❑ a ❑ ee- (2, 0) - o a o 0 0 VII Responsibility Statement. t the undersigned, assume res nsibilit for installation of the POWTS shown on the attached plans. Plumber's Nam ) mber's Siirj (n - MP/MPRS No. Business Phone Number ~ZD go a M ee.~ te; Plu Plumbers Addddress (Street, City, State, Zip Code /Y 61" nnrly / 141 VIII County/Depart nt Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 1 uin gent,Sipature o stamps) Approved O Owner Given Initial Adverse Surchiirge Fee) Determination 2'"-"_ 23 IX. Conditions of Approval Ateasons for DisapprovalV . ~,49 "~~4 1,04 IC~ - 6e a 11 - - ~ ~.ef~3 lm.-.e~a.r. /l4/l" _ :'n ~_.uu.m~.e3 lea': . AMP 3x87.sa So' Caul 1 ~uN lloluc pdd,~y ~i ~ 4 -ICD ,-S IWOy~) AI fi Q t'►pwX 'T p o~ 9 t 93 ~Z~ DlL3S~ ~ ' Cl~ed= IUO~o Wisconsin Department d Commerce SOIL EVALUATION REPORT Page I of (D Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Eval s Attach complete site plan on paper not less than 81A x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), drection and St Croix percent slope, scale or dimensions, north arrow, and location and dstance to nearest road. Parcel I. D. 020-1166-40-300 Please print all information. R By Date Personal reformation you pvAcla i W be useilfOlfSe=WWY. PWP I~^r~Y Law, s 15.04 (1) (m)). 3 I0 Property Owner Property Location Jim & Barb Henry Govt. Lot NW 19 SE 19 S 17 T 29 N R 19 W Property Owner's Mailing Address ? r . ; Lot # Block # Subd. Name or CSM# 451 Brookwood Drive 110 Parkview Estates 4Th Addition city )State `Zip Code 'priors Number ' _j City _j Village~1 Town Nearest Road Hudson 170t'°-14016 215.-3W- 1 20 Hudson Brookwoood Drive New Construction Use: 0 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD N` Replacement Public or cammerc ial - Describe: Parent material Glacial outvvash Flood plain elevation, if applicable na General comments and recommendations: Install 2 trenches at elev. = 93.00' using 28 leaching chambers. Each trench to be Tx 87.50' using 14 chambers per trench. a Boring # Boring Pit Ground Surface elev. 98.27 R. Depth to limiting factor >121" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Etr#1 *EflW2 1 0-12 10y2/1 noone sit 2fcr mvfr as 2f 0.5 0.8 2 12-22 10yr414 none sl 2msbk mvfr ce - 0.5 0.9 3 22-27 7.5yr4/6 none gr Is 0 sg ml gs - 0.7 1.2 4 27-53 10yr5/6 none gr s 0 sg ml aw - 0.7 1.2 5 53-121 10yr6/4 none sjqj. it 0 sg ml - - 0.7 1.2 93.0 / q ~ ro3 •L5/ H #3 contains • approx. 15% gr., #4 contains approx. 10% gr. • 2 ~ ❑ Boring # -J Boring Am Pit Ground Surface elev. 97.88 ft. Depth to limiting factor >118" 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 •012 1 0-19 10y2/1 noone sit 2fcr mvfr as 2f 0.5 0.8 2 19-33 10yr4/4 none sl 2msbk mvfr cs - 0.5 0.9 3 33-40 7.5yr4/6 none gr Is 0 sg ml gs - 0.7 1.2 4 40-58 10yr5/6 none gr s 0 sg rn aw - 0.7 5 58-118 10yr6/4 none s 0 MILli - - 0.7 1.2 H . 10% gr.M a 10% gr. • Effluent #1 = SOD 30 < 220 mg/L and T >30 < 150 mg4 02 = BOD < 30 mg/L and TSS <-W mg/L CST Name (Please Print) S re: CST Number James K Thompson Z- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane Osceola WI 54020 6252003 715-248-7767 scale: A N R~s CO weig, ss u.~ed a tad: lao.QD' Exi~fi~~qq ~ Ib. l3 M 1 o S.T '~bQ°^ Gana eS~lsncG ho/? CaK+'• ¢rJ! = 98.5+x' ~.wi i d tc~' eX;,b•~g ~ c~~o a . pat elect: a-6 owtls,E 9s~ 9l = Crag a 6 01 i -w .4)0 , ~ 0. p , Sy s4xm W e~+ J ■ s 8z no ae pMCc Qf le Slope arm Area. J 83 f 1 v N PO.3 of'3 Property Owner Jim & Barb Henry Parcel ID # 020-116630-300 Page 2 of 3 Boring El id # A Boring pit , Ground Surface elev. 97.63 ft. Depth to limiting factor ->I 19" In. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Bourxtary Roots QPDfiF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 1 0-16 10yt2/1 noone sil 2fcr mvfr as 2f 0.5 0.8 2 16-27 10yr4/4 none sl 2msbk mvfr cs - 0.5 0.9 3 27-34 7.5yr4/6 none gr Is 0 sg ml 98 - 0.7 1.2 4 34-80 10yr5/6 none gr s 0 sg ml aw - 0.7 1.2 5 80-119 10yr6/4 none s 0 sg ml - - 0.7 1.2 cc~' Q3.a~ H #3 contains approx. 15% gr., 14 contains approx. 10% gr. /q i • S(o ❑ Bceng # ,J Boring f Pit Ground Surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots iGPDMF n. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •E111111 "Eff#2 E Baft # Boring _f pit Ground Surface elev. ft. Depth to limiting factor in. Sod A tion Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots in. Munsell Qu. Sz. Cant. Color Gr. Sz. Sh. "Eff#1 GPD/fF •Eff#2 Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD5 <i.30 mg/L and TSS <_0 mg/L The DePwIment 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. nomlanooe ""x°"51" APPLICATION FOR SANITARY PERMIT DILHR PL COUNTY °0USrR E"T°F ( 6 67) / UNIFORM SANITARY PERMIT # -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS if 4e--e BOA- Z__ PROPERTY LOCATION ti~~0h 4VI,5 W1145F-4A S , T.29, N, R a(or) TGlA{p1.BF: 'S yo/ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ? Bia TYPE OF BUILDING OR USE SERVED I P, 1 or 2 Family Number of Bedrooms: 3- Public (Specify): THIS PERMIT IS FOR A: 56 New System ❑ Tank Replacement 11 Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued - ED An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity pO Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer j&j'&,w, IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure A/A Total *of Prefab. Site Steel Fiberglass Plastic Gallons, Tanks Concrete Constructed Septic ank Capacity Lift ump/Siphon Chamber Ma facturer: LRCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: tes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): "3 & % Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number: D,(44 I z (z y-r 3 z 3 Plumba Address: Nameof Designer: e# COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved WaA,~& I j ~i, ❑ Owner Given Initial O a y IXApproved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHRSBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING: l,,ABOR SO 8i HUMAN RELATIONS P P.O. . BO?f~ 7969 ` PRIVATE SEWAGE SYSTEMS DIVISIOP MADISOAr, WI 53707 BUREAU OF PLUMBIN( A a CONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound if aser9ned) NAME OF PERMIT HOLDER; ADDRESS OF PERMIT HOLDER: INSPECT: N DATE: If F( Sam Miller Trout Brook Road, Hudson, WI S J'oo BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: ACST REF. PT. ELEV.: NW SE, Sec.17,T29N-R19W,Town of Hudson,Lot#110,ParkView Est. IV Name of Plumber: MP/MPRSW No.'. County: Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 54966 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET PEE V.: WARNING LABEL LOCKING COVER r~ p a w e a / ~y P OV OED: PROVIDED: BEDDING: YES ❑NO ❑YES ❑NO VENT DIA.: VENT MAT HIGHR WA NUMBE R OF ROAD: ROPERT WELL: UILDING VENT TO FRES F { ~ ALAM E 51 T F ROM LI E:.a AIR INLET: YES ❑NO I e. ❑YES ❑NO EAREST o/\ D S G CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: IPUMPAND CONTROLSOPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. V NTTOF SF (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEA ST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH uIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) TMF0RCE AIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH' LENGTH: TOF IND OF DISTR. PIPE SPACING: COV R JINSIDE OIA : *PITS: LIQUID DIMENSIONS M L. PIT DEPTH: AVEL DEPTH FILL OE H DIST IPF DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTR. LIMBER Of ROPERTY WELL: BUILDING: V NT TO FRE51 BELOW PIPES BOVE VER: ELEV. INLET ELEV. EN PIPE LINE : AIR INLET: 9! / i J FEET FROM (0 D NEAREST---- r Z71. 5-1 UR MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO OIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS, ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TREN H/BED DEPTH OF TOPSOIL: SODDED-. SEEDED: MULCHED: CENTER EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BEDlTi1Q111G}f WIDTH: LENGTH: ENF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: ILL DEPTH ABOVE COVER: DIMENSIONS. ' MANIFOLD PUM DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DIS R, I DISTRIBUTION PIPE MATERIAL d MARKING ELEVATJpN AN : ELEV.: ELEV.: ELEV.: PIPES: DIA.; DISTR1gU.IDN 1NFOBMATIDI!(. HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYE ❑NO ❑YES ❑NO COMMENTS: PERMAN NT MARKE S: OBSERVATION WELLS: ;WISER OF PROPERTY WELL: BUILDING: fT F110M LINE: ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SI NA U E: ITL . DILHR SBD 6710 (R. 01/82) Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ,s o v~ r ~I p TOWNSHIP _t(001 p h SEC. 1 7 T I N-R I W ADDRESS rl rO k Z S ST. CROIX COUNTY, WISCONSIN Jul k ~l s i n w r 5 G on (fl S ror ~ SUBDIVISION p,~,~ n V P/w LOT (r b LOT SIZE. P-5 ~a f cti PLAN VIEW Distances and dimensions to meet.requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF.SYSTEM r rwro C) try Al ."74 L-. IL L r n r► 40 pc Q c7 p 5 ~ A 13 Al Al 12- it- -we// v G 0~n1' ~-a v /I f c.lr7 1 i, v 4 z t U Noksr , T 40 3-Z ' Iki l-F2~ INDICATE NORTH ARROW 0 LA - tj. opt a 1 P , I I I IN ~ ~ r Cl I , LA r (,I - t t t , U r a p TTI C Q P 8 5.. ~ '?o p 4 Go 9 - w 9 n ril rr, N Air°'' - t.A ~ o A tl P o s s- J -~j 0 o 70 Olt o f v 04 i . I 0 IF { ~f ~ a k r O~ V! ~ I w ~ N F I i - i izv I u, t ~ rti u i JLT- f ~t DEPARTEhi 40 PORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,' DIVISION ''4- t/61, LABOR AN P.O. BOX 7969 HUMAN FIB IONS ERCOLATION TESTS (115) MADISON, WI 53707 /ps 9 , r (H63.09(1) & Chapter 145.045) LO AT 0 E TOWNSHIP/My0-9-IPgMTY: OT NO.:BLK. NO.: SU DIVISION NAME: JAW w l~' pry COUNTY: AME: MAI Lt A DR SS: , ` w ~ el, o WES• s K401~ USE DATES OBSERVATIONS MADE 7-5B DBMS: ~~7.4 SC PTIO PROFILE DESCRIPTION OLATION TEST11 Residence ii ❑Replace 7-grS/ / RATING: S= Site suitable for system U= Site unsuitable for system ONVEN 1 NAL: MOUND: IN-G N ESSURE: S STEM-I -FILL OLDING TANK: RECOMMENDE SYSTEM:(optional QS ❑U &S ❑U S CDU ❑ S IRU ❑ S [MU If Percolation Tests are NOT required DESIGN RATE- If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Ftoodplain, indicate Floodplain elevation: ~ P FI E DESCRIPTIONS BORING -IOTA-L#,- P H T R UND ATER-IMeMCS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH +W ELEVATION OBSERVED EST.MgH TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7P ?7 la61-f .7 AM s/, .S~5.,/1~3•(0,finCS4-wkJ • V 6A B-.Z ,f' 7 f, /•,t 8/s/, . 6vIIs/~ .7,ls,,S6nCS~•rJ /I 01L 0A gg A. . o A c r ,I- r{ cb B- :7-J r, • r d a 7 /i A 3 an-r 6 I ~ An /S/ Ah CS•t~r. css~Y~r. ,O/-J/, , Ewa 1 o 4f,% 7 rB---T PERCOLATION TESTS EST DEPTHI WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATE MINUTES NUMBER MWjdgS- AFTERSWELLING INTERVAL-MIN. p t ql PER INCH P- o z P- P- /P 62 C2 -3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION r s s t I TN f r r ems.