HomeMy WebLinkAbout032-1025-90-025
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division ~
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 582034
State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, S.15.04 (1)(m)].
Permit Holder's Name: City Village Township Parcel Tax No:
Bronson & Ann Austreng T TOWN OF SOMERSET 032-1025-90-025
CST BM Elev: Insp. SM Elev: BM Description: Sectionlfown/Range/Map No:
• 81 Q ' z GS ( 09.31.19.127A-25
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
QJ ~•6 Benchmark
-7.
S to • 3 9 $
D Alt. BM
F.l 0 `a /Z' SZS Walls *A-- +F b 7.3 `7?
Aeration / Bldg. Sewer 9g •
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet SS • ,7
TANK TO P/ WELL BLDG. en to Air Intake ROAD Dt Inlet
Septic 7 66 i 2.4 1513 Dt Bottom
- ~
Dosing Header/Man.
Aeration 9 4
Dist. Pipe /0,0 17(0-3
Holding Bot. System /1,5 f7-4-
5 0)3. g ht,
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover` / S 3
GPM i fw !a j
Model Number
TDH Lift Friction Loss System He Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches l ~ PIT DIMENSIONS N(: Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 Z ~~r{G}
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: E Z /~Q
INFORMATION CHAMBER OR h
Type f System:
6 / UNIT Model Number:
AL/-elL,i a / 7'l7 A i~ J ff~t.n, ~i /
DISTRIBUTION SYSTEM e6 4)
[Herder/Manifoy / Distribution Ix Hole Size Ix Hole Spacing Vent to Air Intake
gth Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over -Topsoil
of xx Seeded/Sodded r ulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes No Yes Q No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 2218 50TH ST OR 49 222ND AVE Ckwar A16 Coe-,sc `S _ a
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
7 !'S ar< <ti 1"
Plan revision Required? ❑ Yes Xf1o
Use other side for additional information.
SBD-6710 (R.3/97) Date Ins ctor's Si ure Cert. No.
~£QARTII Count7Peit A V
=s? Industry Services Div'
1400 E Washington itNumber (to be filled in by Co.)
$
t ' Q 2
P OCT 8 0 1 5 P.O. Box 7164- S Madison, WI 53707-
IOSi-. ST. CROIX COUNTY O
Sanitary Permit Application 3taeTransactionNumber
in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit N
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 purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats.
1. Application Information - Please Print All Information
Property Owner's Name ~ n r Parcel #
Property Owner's Mailing Address L Property Location Oq S I, 101 . Id-74 - 95
J .;k / S J-0 Govt. Lot
Cily. tate Zip Code Phone Number 5'46 '/4, cS.C '/4, Section /
(circle o
d ✓YYI CMG Z T3 N R E or
II. Type of Building (check all that apply) Lot # /
[1~ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
❑ Public/Commercial - Describe Use Block #
S ❑
❑ State Owned -Describe Use City of
v ❑ Village of
CSM Number ft-
,\46W,6 2Ao%c., 2g
Z N 1 :JT ' C46k:5 two O;u rj Za} Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 1%A,0_
A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS S stem/Component/Device: (Check all that apply)
9LNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
Holding T--~ther Dispersal Component (explain) ❑ Pretreatment Device (explain
V. Dispersal/Treat me race Information: - C CI S ".1t $8 ' Y -r6 1 14 , y s
Design Flow (gpd) Design Soil Application Dispersal Area Required (sl) / Dispers ea reposed (s System Elevation
Rate(gpdsf) (goo 7 b ?,-f -7
✓ ~8D 9d `
VI. Tank Info Capacity in
ai o d v
Gallons Total # of Manufacturer
Gallons Units
New Tanks Existing Tanks
~4"r p U v u C7 0.
EE t' r Holding Tank x Z fd S/1 A W~/ ❑ ❑ ❑ ❑
Dosing Chamber ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
lber's Name (Print) l Plumber's Signature MP Number Business Phone Number
e V-1K.k'S ZZ87l- 7/J V9/-Si
er' Address (Street, City, State, Zip Code)
~v• oZ wcX 5~8~3
VIII. Count /De artment Use Onl
Approved rPer-mit Fee Date Is ued Issuing ht Signal e
even Reason for Denla q 7! 3a
IX. Condi T ea ens for Disapproval
3,
epttcak, efficient er and
dispersal cell must all be seryPces 1'mainfairled
a3 per management plan provided by plumber.
2k>luaae►+: 4 aiid
n PW code / ordinances.
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 (R03/14)
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: N50 X.-I Q L4
Owner's Address: Z 8 J-t
Legal Description: - 9 _7-3 j A, Le I9 w
Township:
d~-~.,
County: CiL 10
Subdivision Name:
Lot Number:
Parcel ID Number: D 3 Z - 90
, oL•~
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: qc t( License Number: z? LS72--
Date: /0 ? Phone Number yJ1 -S396
Signature
Designed pursu nt o the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
.W
1, ~ A
`e-3
Cf ~ ~ I
Z rto
r6 _
c
C]
a
&s
a
Z
~ C
Soi! Absorption System Cross Section
F gYd~9l. o
C
4" Schedule 40 Final Grade
PVC Vent Pipe O/ kf 6
With Vent Cap ft
Leaching
~8~' o
Chamber 01
- /
System E:evaticn
3 ft
Soil Absorption System Plan View
ft IIII I I I I II111111I
0llll ~
Leaching Trench 1 1
Vent Or Observation Pipe ,
Chambers
.,Iilllllll I it I C ELL
l I I I Ii !t1 11 II
-
4" Dia.
Trench 2 Heider
- Leaching Ci~amber Soecications
Nlanufacturer And Model CL e-J; 4 ,
EISA Rating ~ aq per chamber
Soil Application Rate 7 gpd/sq ft •
gpd Design Flow _ -77 yy I
Soil Application Rate
EISA =
Chambers ~
2 rows or? chambers each.
Page or
ti
I 31-V
I
_
Installation and Maintenance Instructions
Installation
Step 1 Dry fit the filter case onto the outlet pipe going to the drain field. Ensure it is centered directly under the
access opening. (if outlet pipe is already in a fixed position, additional pipe may need to be added)
Step 2 If utilizing the additional single side support and the two bottom supports: While the case
is still dry fit to the outlet pipe, measure and cut 1"schedule 40 pvc pipe to the length needed to extend from the
hubs that are pre-molded into the case to the side wall and the inside floor of tank. solvent weld pipe into the
hubs that are pre-molded onto the case.
Step 3 Solvent weld the case to the outlet pipe. Insert the filter cartridge into the case pressing down on the
cartridge until it locks into place at the bottom of case.
Step 4 if utilizing a vertical read switch: Insert switch into the hole pre-molded into the top of the filter. Press
straight down until it locks into place
Maintenance
1) Remove the access lid of the tank. Note: To ensure undesirable solids do not exit the tank and into the
drain field, the tank should be pumped out until the level of effluent is below the outlet level of the tank.
2) To remove the filter cartridge from the filter case, pull up firmly on the handle of the cartridge dislodging
it from the case. (if utilizing a vertical read switch, removal of switch is optional)
3) Using an ordinary garden hose, rinse the filter cartridge ensuring all visible septage material is removed.
4) Place the filter cartridge back into the filter case pressing down on the cartridge until it locks into place.
5) Place the access lid back onto the tank ensuring it is secure.
Lifetime filter has a lifetime limited warranty:
Lifetime filter LLC warrants the-filter will be free of manufacturing and workmanship defects during normal use forthe period of
time the original purchaser owns the product. Lifetime filter will provide a replacement filter in the event that the original filter was
not damaged during the installation or maintenance process. Damage to this product caused by accident, misuse or abuse will not
be covered under this warranty. Improper care or malfunctions resulting from product not being installed, operated or maintained
properly will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal charges, installation or other
incidental or consequential costs.
Contact: mikePlifetimefilterlic.com Phone: 502-724-2231
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS '
Owner . f Septic Tank Capacity 11000 gal ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms 3 ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units _-P-MA Pump Tank Capacity 600 gal ❑ NA
Estimated flow (average) S Pump Tank Manufacturer 1 j w ❑ NA
b gal/day
Design flow (peak), (Estimated x 1.5) b 7j gal/day Pump Manufacturer NA
Soil Application Rate . v gal/day/ft2 Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease (FOG) _<30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) :5220 mg/L _EMA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :_150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD5) :_30 mg/L n-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) S30 mg/L 4;1-ftA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) :510` cfu/100ml ❑ Drip-Line ❑ Other:
Other: ❑ NA
Maximum Effluent Particle Size Y. in dia. D-NA
Other: ❑ NA Other: ❑ NA
Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑ month(s) (Maximum 3 years) ❑ NA
Inspect condition of tank(s) At least once every: Z- E year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Byear(s)
❑ monthlsl ❑ NA
Clean effluent filter At least once every: . / -B-year(s)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: , l $year(s)
~
❑ month(s) LI-M
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) ~A
At least once every: ❑ 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 (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 chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Uh_') 1--o' - s f,~ Septic Tank Capacity i d gal ❑ NA
Permit # Septic Tank Manufacturer
J'A e. ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer e ❑ NA
Number of Bedrooms A,1 ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units .VIVA Pump Tank Capacity gal -L"
Estimated flow (average)D gal/day Pump Tank Manufacturer -I-Nq
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer A
Soil Application Rate -7 ti
L gal/day/ftZ Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit :J-NA
Fats, Oil & Grease (FOG) :_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODS) 5220 mg/L ,.E?A ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :_150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODS) 530 mg/L n-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L .1211~A ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) :5104 cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Ys in dia. 49YNA 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 least once every: ❑ month(s) (Maximum 3 ears) ❑ NA
3 -6-year(s) y
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once eve ❑ month(s)
every: ` 'ear(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: r ❑ month(s) ❑ NA
-B-year(s)
Inspect pump, pump controls & alarm At least once every' ❑ month(s)
❑ year(s) 8-IdA
Flush laterals and pressure test At least once every: ❑ month(s) 4=- A
❑ year(s)
Other: At least once every: ❑ month(s) El 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 (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 chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
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) 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.
❑ 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
at th at time,the biomat at the
may be installed as a last resort to replace the failed POWTS. removal ❑ Mound and at-gdReco1n tbuctiotns of such systems must comply with place
following in effect
infiltrative surface.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
DEATH MAY RESULT. RESCUE OF A
ENTER A SEPTIC, PUMP OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
PERSON FROM THE INTERIOR
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name
Earn e i►~s Na
e Phone L:=j
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
~ ~ N• ~
Mme K 5 /<e_ u ;~7 Name ~f
I -f 6,i Phone 71j- - 3f3b V WO
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 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.
❑ 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> >
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 -5-- Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY -7
Name Name e'4_01'A u ~..r"t pn.:
Phone (~%:j j 3 QV yt Phone 3,6- ~ .-V ~ eo
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.
1
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 1~-o ti~a 10 u 5-
to-Mailing Address 74
Property Address ~ •
c (Verification required from Planning & Zoning Department or new construction.)
City/State ~ti~ t f Parcel Identification Number
LEGAL DESCRIPTION
Property Location -Tf '/4 ~t %4 , Sec. / T 31 N R ! W, Town of yd r2 ~'r
Subdivision Plat: , Lot #
Certified Survey Map # , Volume Zy , Page # S!v SS .
Warranty Deed # (before 2007)Volume Page #
Spec house ' ] yes JF no Lot lines identifiable Xyes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
1/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 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 t 's 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 w ranty deed recorded in Register of Deeds Office.
Number of bedrooms
n
SIGNATURE OF AP ICANT(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. 08/05)
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Wisconsin Department of Commerce JUN 3 0 2090IL EVALUATION REPORT Page of
Division of Safety and Buildings
irmakem lblfl~ 85, Wis. Adm. Code
PLANNING & ZONING O County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D J
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. tJ 3Z 7,410
Please print all information. Re view Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). a -"t I v4'
Property Owner Property Location
Govt. Lot 1/ 1/4 S T, N R (or)(0
Property Owner's Mailing Address Lot # BI AA#
Uty 1 d.~d /j'tl
Sta a Zip Code Phone Number ❑ city ❑ illage FXIlVwn arest Road
h New Construction Use: f Z Residential / Number of bedrooms < Code derived design flow rate GPD
❑ Replacement / ❑ Public or commercial - Describe:
Parent material /~r✓1,y w ~-t,~ Flood Plain elevation if applicable 41 ft.
General comments /
and recommendations:
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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
- 4 Q
_ 4 4
/ ~ trr
Boring # ❑ Boring
pit Ground surface elev., ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf
in. Munsell Qu. Sz nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2
•7
3 _ Q a
q 4
E #1 = OD > 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD 5 30 _
CST Name - - _ rnglL and TSS < 30 mg/L
/ Signature CST umber
Addiess Date Evaluation Conducted Telephone Number
Property Owner Parcel ID # Page of
F&I Boring #❑r~t Boring
ldl Pit Ground surface elev._ eft. Depth to limiting fade S1i' in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
i
G 4
4 ~
f
11
a Boring # ° Boring
❑ Pit Ground surface elev. ft. Depth to limiting fades in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Mu nseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
E Boring # ° Boring
❑ Pit Ground surface elev. ff. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fi?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
• Effluent #1 = BCC a > 30 1220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 30 mglL and TSS < 30 mg1L
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.
SOD4330 (RAW)
Property Owner ' ~xjll~ Parcel ID # Page c of
Boring # ❑ Boring
® ~I J
loll Pit Ground surface elev. 52 ft. Depth to limiting factor S f, in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. ont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
4L& z/
F-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/lf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •042
❑ Boring # E] 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 a 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 608-2648777.
SBD-8330 (FL60) .
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Parcel 032-1025-90-025 11/30/2010 11:06 AM
PAGE 1 OF 1
Alt. Parcel 09.31.19.127A-25 032 - TOWN OF SOMERSET
Current DX ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
09/22/2009 00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
EDWARD & THERESE SCHACHTNER. 0 - SCHACHTNER, EDWARD & THERESE
2210 50TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): • = Primary
Type Dist # Description " 2218 50TH ST OR 493 222ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 10.336 Plat: 5655-CSM 24-5655 032-09
SEC 9 T31 N R19W PT SE SE CSM 24-5655 LOT Block/Condo Bldg: LOT 01
1 (10.336 AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
09-31N-19W SE SE
Notes: Parcel History:
Date Doc # Vol/Page Type
09/22/2009 904190 24/5655 CSM
06/21/1996 545692 1185/483 QC
02/27/1996 540076 1163/486 TI
402/429
2010 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/12/2010
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 9.336 800 0 800 NO 05
UNDEVELOPED G5 1.000 100 0 100 NO 05
Totals for 2010:
General Property 10.336 900 0 900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00
0.00