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HomeMy WebLinkAbout020-1395-52-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ,f ~i~v-f ~ S ,= ~ (~ INSPECTION REPORT GENERAL INFORMATION (ATTACH•TO HERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Alleva, Anthon Hudson Townshi ~ST BM Elev: ~ Insp. BM Elev: SM Description: ,~ TANK INFORMATION ELEVATION DATA /-/: TYPE MANUFACTURER CAPACITY Septic L~Oa Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ r ~` S~- ~ 3L Dosing Aeration Holding PUMP/SYPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Fri Loss System Head TD Ft Force in Length Dia. is . SOIL~S.pRPTION SYSTEMf 2.3~~~Ct.-~,L,~c J-~¢wtQ,_ county: St. Croix Sanitary Permit No: 453212 0 State Plan ID No: Parcel Tax No: 020-1395-52-000 Section/Town/Range/Map No: 25.29.19.2446 STATION BS HI FS ELEV. Benchmark ~.t/~ ~S. ~~ p Alt. BM /.2 G ~ l `f !oo Bldg. Sewer . 9/ ~ z. qs St/Ht Inlet . 3 Dg'. SZ ~ SUHt Outlet . ~~ ~'. 29 Dt Inlet Dt Bottom Header/Man. w. ~. Dist. Pipe ~{'1 ts.~o i oe •~S Bot. System ~ ~~. ~ I ~9• Final Grade ~,~ ~ --.. 12 . a o t St Cover TRENC DIM NS Width ~~ L~gth ~, ~ No. Trenches 2 `J PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufac r r( c •~i Ty e Of System: . ~ ` ~ ! ~ ! ~ 9 t "' ~~ UNIT Model mbe~r IL, DISTRIBUTIOy~f&~M Header/Mani Id ~ Distribution x Hole Size x Hole Spacing Vent to Air Intake ~ Pipe(s) Length Dia Length Dia aang ~ $~ SOIL COVER ~ x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes ~ No I` -~`es Lj No COM~ TS: (~iclude,Gpc~ discrepencies, persons present, etc.) Inspection #1:J`~)"i~~ ~ ~ Inspection ~2 Q,~61~ J~,~A(a Loc ti 753 Regal Ridge R Unkn wn SE 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 52 Parcel No: 25.29.19.2446 1.) Alt BM Description = ~~ ~ 4 •`Cl 2.) Bldg sewer length = ~p • 3 -amount of cover ~~~~ °`~` (~ yvo~ ~° ~~„/ „_ ~, ~~.Q. A"`ro° 'tom 11 ~f ~o'`"~`' ~ ~ ---- Plan revision Required? Yes iNo o ~4- Use other side for additional informatfon. ~__ f f _!; _ _ _ _ _ _ ,_ ~ ~/_ 2 ~_ ~I SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. SatBty and Buildings Division County , 201 W. Washinlnon Ave., P.O. Box 7162 iseonsin Madison, wl `53707 - 7162 Sanitary Permit Num er (o be filled in by Co ) Department of Commerce (608)266-3151 3 Z/Z- Sanitary Permit Application State Plan LD Number personal information you provide Code Wis Adm !n accord with Comm 83 21 , . . , . may be used for secondary purposes Privacy Law, s15.04(I xm) Project Address (if different than mailing address) I. Application Information -Please Print All Information-~'""`" '~~?~ ~"` , ~ ~ ~ _ (/2/ ((// //_ ~ .~ t `~ l.~ ~ Y `I ~ Property Owner's Name ~ ;i /1 ~® /~ Block # Parcel # of # s . ,° 1 3 200 020- - SZ- avo . z Property 's a ing Address Property Location / ~' ~ ~~'/+,~%, Section ~ City, to Zip C e -~;, IierrtrtJE°r' _ (circle e) N; R~E or~ (check all that a l ) ildin f B II T ~ 5 t pp y g u . ype o ubdivision Name CSAQ_,Alutnlaer 1 or 2 Family Dwelling -Number of Bedroomg S i i ^ ~ ~ al -Descr Public/Commerc be Use ' 1 p ^ State Owned -Describe Use t t ~~Z ~ 3 t X l Z t S ^City_^ i age,~Township of e of Permit:.(Check only one box on line A. Complete line B if applicable) III. Ty p A' ,~ ,/ ,kJ New System ^ Replacement System ^ TreatmendHolding Tar,k Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Chan ge of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a I und < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ o Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ M !!~ ! Constmcted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ PC~at Filter ^ Aerobic Treaunent Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) _ V. Dis ersaUTreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requi~d (sf) Dispersal Area Proposed (st) System Elevati n L a qq VL "Tank Info __ Capacity iri ' ~ Total"" "Nuin)ier ~ ' Manufactiirer -` ` Pmfab " "" Site "Sleet rltx~r Gl Plastic Gallons Gallons of Units Concrete Constructed ass New Existing Tanks Tanks Septic or Holding-~hnk ~ ~ Aerobic Treatment Unit Dosing Chamber _ .. VII. Responsibility Statement- I, the undersigned, assum sponsibility for installation or the POWTS shown on therttached plans. Plumber's a rirtl) i ;; ,, , Plumbet's gnat ~ MP/MPRS Number Business Phone Number 3 s= ~ Plu ber's Address (Street, City, State, Zip Co e) ~~ 't ~ , ~~~ ~ ~ S ~~ T- VIII. Coun /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued F sui Agent Signa a (No Stamps) ^ Owner Given Reason for Denial ee) 2 ~ - Surcharge ~ IX. Conditions of Approval/Reasons for Disapproval ~> No t~ t~~~~ ~~~ 1 ~ SYSTEM OWNER: " .-~ 1 Septic tank, effluent filter and .,e.,,~ cQ~tir~a~Q .Q~.~«-~ et~4a S d dispersal cell must all be serviced /maintaine as per management plan provided by plumber. ~ ~ ~ ,) tback'requitements'must be maintained l se 2. Al as per applicable code/ordinances. Attach complete. plane (to the Gounry Doty) ror me sysrem on paper our toss u•a.• a.~. ,......~••~., ••• SBD-63,98 (R. Ol/03) -~~i ~~~ ___ _ _ 0 b \, W {7 \ ~ R' ~° 6 /(rte`' ~' ~ ~ / ~ a ~ U : ~ (Q a f ~l ' ~~ ~~~ ~~ ~ ~_~ ~ ~ ~ ~, ~1 L" ~ ~~ ~ y ~ ~ 1 ~~ ~ ~ ~~ ~~ ~ \~ ~ ~, ~ ~ o ~~ ~: ®~;~ ,0 v ~; ~~ ~~~ ~~~ G Z cc~11 ~V ,~ 1 ~ 1~ o d b~ ~ X WAS \ ~ \ CJ V s D a ~, ti ~~ ~~~ ~ ~ . ~ .~ ~\ ~ ~ ~ ~, ~ ~ ~ ~ \ ~~ ~. ~~ 0 ~ ~ \\ 1 ~ ~ 11~ ~ \ ~. ~` ~ ~`~ ~v ~ \~ ~ ~~ ~ \ o ~~ ~: © ~k S u Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of Division of Safety and Buildings Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. P ust County ~` include, but not limited to: vertical and horizontal reference point (BM), di ction Parcel I.D. percent slope, scale or dimensions, north arrow, and location and dista ~~~are t road. r Please print all information. ~ Date Re iewed by ~~ ~~ Personal information you provide may be used for secondary purposes (Privacy Law, s. .04 (1) (m)). ~~ / '~•8 .,~~~Sax!'0..~ Property Owner €` ~'~'""~~\/~!" Property Location Govt. Lot 1/4 1/4 S ~ T C N R ~or Property wngr's M fling Address - ~~~ 1 3 2004 ~ Lot # Bloc Subd. Name or 6rsNt# ~ / . ; , ~ City Sat ip ode , ; Rh~~.(~(u~bef City ^ Village Town ear t Road New Construction User Residential /Number of bedrooms Code derived design flow rate ~~~ GPD ^ Replacement ^ Public or commercial -Describe: Parent material Flood Plain elevation if appli ble ft. General comments (~ -- (--~ and recommendations: ,~~•s~i•, ~ 7~~ ~~ rZ r~ ^ Boring # ^ Boring ~ , , Pit Ground surface elev. ~ ft. Depth to limiting factors/. ~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ' c _ , 6 T' ~ --- 9 9 - s ~ ~ mot- 99• c~ ^ Boring - ~ ~ ` ~ v Boring # Pit Ground surface elev. - ft. Depth to limiting factor S/_ s'D in. . Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. S .Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 c ~J C_~/ J t . ~ 4 9 " Effl nt #1 = BODS > 30 < 220 mg/L and TSS >30 _< 150 mg/L * E uent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Nam P ase P in ~ J Signature ` CST Number ~/ ~ ~ Addres ate valuation Conducted Telephone Number ~rsu-a»v ticuiiuu~ Property Owner ~ S~ Parcel LR # Page ~ of _~ u Boring Boring # Pit Ground surface elev. ~ ft. ' ~epth to limiting factor ~~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 s c / ~ ~ .~ 3 s R Q ~ ~ yq 4 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Deparmment of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) ~~.~/ ~~ v sTSb;/ v _~ ,.~ ~\ A 1 \L t ~ `: -~-~--_ .,~~ -~~ ~ ~~~~~ ~ ~ ~a ~ Zi „~ ((nn ,~~, ~ ~ \ ~ ~ -~ ~ ~ J (jr`~,` 1 ~ ~ ~_ G~ ~~ ' V ~ ~ ~~ I POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION Owner ~ ~~ ~ i Permit # `^'532/Z DESIt3N PARAMETERS Number of Bedrooms 0 NA Number of Public Facility Units (i~NA Estimated flow (average) al/da Design flow Ipeakl, (Estimated x 1.51 al/da Soil Application Rate 7 al/d /ft~ Standard Influent/Effluent Quality Monthly average' ' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD,) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ,~NA Fecal Coliform (geometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Yo in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. nneuureueur•e er•ucni n c SYSTEM SPECIFICATIONS Page ~ of Septic Tank Capacity al O NA Septic Tank Manufacturer - O NA Effluent Filter Manufacturer 0 NA Effluent Filter Model O NA Pump Tank Capacity al ®-NA Pump Tank Manufacturer ANA Pump Manufacturer ~ NA Pump Model f~NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~"NA Dis~ersal Cell(s1 )~ In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound O Other. O.thar: ^ NA Other: O NA Other: ^ NA Service Event Service Frequency Inspect condition of tanklsi At least once every: ^ month(s) (Maximum 3 years) ~ earls- O NA Pump out contents of tankls) When combined sludge and scum equals one-third IY,1 of tank volume ^ NA -- ,..,~.;-=- ._-~:~ :-_.-, _x:.......;,,.-:- ...tea,,-~~--_.:2_ Inspect dispersal cellls( ,..~..._: __,.~.,_.. _, ..... At least once every. ~ . _ ~-•_..,.,.:-_^monthlsl~:-_•__.. ~. _ .._ ~ year(s) iMaximum 3 years) _.- ^ NA Clean effluent filter ~ ~ ~ ~~ `a At least once every: _ ^monthls) ~' yearlsl O NA Inspect pump, pump controls & alarm ,., , ,-... Y At least once .every: ;,. ^monthls) ^ earls) - JJ- NA Flush laterals and pressure.iesi ----- -. At least once every: - ,. ^ monthls( ^ yearlsi ANA Other.... At least-once•every: ^ eanl IIsJ 1~-NA Other _ O 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 visualinspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume`of combMed sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground_sur#ece. The ponding of effluent o~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 1Y3) or more of the tank volume, the entire contents of .the tank,_shall ;t>a removed; by a Septage Servicing. Operator and disposed of in accordance with chapter NR 113, 'Wisconsin Administrative, Go~~l.~ All other services, lnoludinp but riot Ilmited tp the servicl~g 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 provi~ed_ to .the local regulatory authority within 10 days of completion of any service event. OMW 14/011 Pape ~ of START UP AND OPERATION For new construction, prior to use of the POWYS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tanklsl 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 tho dispersal collie) In one large dose, overloading the c•Illsl and may result In the backup or surfao• discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to rostoring power to the effluent pump or contact a Plumber or POWYS 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 POWYS: antibiotics; baby wipes; cigarette butts; eondoms• cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable p~rjlipgs; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWYS 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 Saptage 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 POWYS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: J$( 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. D A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWYS _- ... ~,:--technal5~gy,:~:h5>).d..lfag-tarfk~:t1!18~~lnstall~ ~a s_Iaai Gesort to..replaca the failed .POWYS.......... O The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWYS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank installed as a last resort to replace the failed POWYS. may be o ... .. - ~ D Mound: and: at-grade:-~sa~~labsorprion`: systems: may :be reconstructed in place following removal of the biomat at the infiltrative surfacq.._ Recogstructions pf such systems must comply with the rules in effect at that time. «WARNUIIG» .... , e r , . . SEPTIC, PUMP AND OTHER TREATMENT .TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP d ' OTHER TREATMENT TANK UNDER 'ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM'THE INTERI~R"OF:a TANK fiAAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS ~ - , = ~ = - ~-- ./ f:'! ., POWYS INSTAL ER ~ ' "' "' " - ~ POWYS MAINTAINER .Name ;.. _ _ , _ .. ....... ~~. :.... Phone 1,. ~ s .~- "tl' Name { Phone SEPTAGE SERVICING OPERATOR {PUMPER). LOCAL REGULATOR AUTHORITY Name _ ~ _ Phone ~ ~ ~r,-. ~ l~ 4 u ,. .. - Name ' Phone _ J ~ This document wee drafted in compiiaroce-with chaptN: r,-I 83.22(2)Ib1(1)Id1&(f) and 83.64(1), 121 & (3), Wisconsin Administrative Code. •tlYlscoonsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page ~ of In aoooraanoe wrm c:omm ~, rns. yam. was t i i Pl u 11 i h e ~~ - ~ ~• C r0 t, an m s z nc es n s . Attach complete site plan on paper not less than 81/2 x inducts, but not limited to: vertical and horizontal fraction and Paloel I.D. 5 2 - U Uv 9 ~- U Z U - percent slope, scale or dimensions, north arrow, a - nearest road. ~3 . Please print all i n. „~ ,~ , y Date Personal inrortnation you provide may be used for Pu . s. 1 ~(1) (m))• ., G~~Z'~"" ~ / off- o~-~o Q P~~y Owner _ - ~ ! f f~~ Location P ... _.. ~. 2 ~? GoJt:~. ~E 1/4,f/Lv1/4 S Z5'TZ ~J N R 19 E(or)t~ Property Owner's Mailing Address ~ CRp~x Lot "' Bock # Subd. Name or CSMIf City Stale Z~ Code umber ~. \®. ^ Yrllage (,~ Town Nearest Road ~S~ i' I l w«.•I-cr -M ~.. ~"So ~Z ( b?I~i.' ~3.. _,~~ ; ~ _v . s ~' ~•~ -~ ®New Construction Use: ® Residential / Number of bedrooms 3 _ `/~ Cade derived design fkriv rate ~Sd ~(o O Q GPD ^ Replacement ^ PubNc or commercial - Descnbe: Parent material OU f i.,Ja.s (.~ Flood Plain elevation if appfuxible ~! _ ft Generalcamments S S~~ e.leJ0.f.b/~ - ~P 9S-$~ Lo`"~<r- q•s °C'" 3~lev. juwet~- ~n and recommendations: ~ (~~• 2 ~ •e. J a {.-, d ,,~ _ ' ~~ (~ 3,~ ~ rf-- 3 . S ' ~~~ swr~- a Bpi Pit Ground surface elev. O/ Z d ft. Depth to limiting factor 1 ~ ~ in. ~~#°i ~g Sal ication Rate Haizon De th Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GP D/fF . p in. Munsep Qu. Sz. Coat Cobr Gr. Sz Sh. •Eif#1 •EfflV:2 l p-IZ 3~3 -- .I Z c 2y.~ •5 •~ 2 I2' 3b Ip 1 1 Si~~ Z c mfr' C.5 - ~ o • a 3 -Ilb ICS r`ilco -" m ml `- ~ _ ,~ l • 2 ~ ~ ~ ,,. Z Boring # ^ Being ®Pit Ground surface elev. 4 7 Z o ft. pepth to limiting factor I ZD in. soy ~~ Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GP DIf~ in. Munsell Qu. Sz. Cont t:;obr Gr. Sz. Sh. _ 'Eff#t `Eff#2 ~ 3`1- Ipyr~~fllo T,r, os ml - - ~ 1.2 3. ~~ Z `' ,, ~ ~' `7 ~ 3.7' * FfH~ ~ ~t1 = R(1n ~ ~r1 c ~0 mnA anti TSR >~0 < 150 me/L ' Effluent #2 = BOD _ < 30 moll and TSS < 30 mcll_ CST nNa'me (Please Print) ~~ature ~ ~ CST Nurnber HUG VV~ ~~ ~,J Wt-ac-i~. 2 f'~ /i ---~ ~ 2.5 3~G Addmss Date Evaluation Conduced Telephone Number 211,3 86T'' S~ S~-,cr~c-{,, car 5~{d 2~ ~'~--C~/ 7IS-2y7-`fig Property Owner A.rk~ l~ ParcellD# -- Page z of_~. Bonng # ~ ~~ Ground surface elev: ~ft. Depth to limiting factor ~11~._ in. ® Pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfP in. Mansell Qu. Sz. l;ont Color Gr. Sz. Sh: `Eff#1 `Eff#2 1 ~,- ~p - Si I e k ,,~.~ c5 ~ v ~` . 5,~~ . $ 2- !a - 21 I v r ~'-I ~ 511 2mob mfr c5 _ ' S $ ~ 21-113- to ~-tIC, _.' mS ps m 1 _ - .'-l l . Z ~~ ~ 3 ,, ti ~~ # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~~ ication ~~ ri on H th De Dominant Cobr Redox Description Texture Structrire Consistence Boundary Roots GP D/if o z p in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. `Eff#1 `EffiJ!2 Boring # ^ Bonng ^ Pit Ground surface elev. eft. .Depth fo limiting factor in. Soil lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GPD/(f in. Mansell Qu. Sz. Coat Cobr Gr. Sz. Sh. 'Eff#1 `Eff#2 " Effluent #1 =-BODE > 30 < 220 mgA. and TSS >30 < 150 mglL ` Effluent #2 = BODs < 30 mglt. and. TSS < 30 mgll. The Department of Commerce is an equal opportunity service provider and employer. If you need as§istance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. ssn.saao (itmroo~ PAGE ~ OF NAME -~. Y` K -e- I I LOT# ~ Z LEGAL DESCRIPTIONS ~ '/<N~'/4 S 2 ~T za N R ~ 4 E (or) SCALE: 1"= yd , i BM 1 ELEVATION lOo • U ~- - BM 1 DESCRIPTION {a ~ o ~ Z " Svc. ~•'OT_ BM 2 ELEVATION q g• g z ~ o, ~ BM 2 DESCRIPTION ~p p y ~' Z" ,~.~,~_D c SYSTEM ELEVATION ~ p 9 $' 8 o G~w < r 9~° o ALTERNATE ELEVATION •{o p 4 y. ao Go.y-~ rrl3 8 d CONTOUR ELEVATION Q 7• v o, 99, a o, /~y. v ~S0' --- - ~ i ~~~~. Sz, v~ 6~-~ lad ~,,-~e., ~' J ~ ~ _._ _ -._.. . 0 o S z~ ` 0 `~ ~ 6 0 ~C~CC+_.~1b~ ~ 0 I z S' ~-rnr, , a (j ~ ~- (~dL . .~Z SIGNATURE G- ~- ~-. 3 A ~c ~~7, ,~,,~ ,o 3~ 1. 3~,A X ~ 971. ot.s x .7 AC ~C1,0.~) 9 5.9 ,, __ . 156.2 /~l X7,,~~ -~, o~-~ 1054.2 ~ X ~/ ~~ / /~. sT, cROrx covlvz~ SEP'T`IC TANK MAIlVTAIRA~NCE AGREEMENT AND OWNERSHII' ~RTIFICATE FORM Owner/6uyer ~ r\ L ~ 1 ~'e-~/~ Mailing Rddrezs ciiY t'1'~ ~ ~ f'~fit~ 6 Property address _ _ 75~J 1'1 (VaiEcatim roquvad fr~Ptamaig for aew Vim) City/State ~ ~• Parcel Identification Number ) LEGAt:, DESCR~ION Property Lacation~'/.,~'/. Sec.~T~N-R~(Vjr, Towa of-~~tI1/~ Subdivision~/~, ~ !T i ~ l ~ ' Lot# Jr~ Certified Survey Map# , Volume__ ____ _ Page Vb`arranty Deed# ~'~ 2 7 ~ ~ .Volume Page Sptc house yes ~no L""ot lines identifiable yes no /,~/ SYSTEA7~ MA~NTENr~1tiCE rC'r_e.-d~a.o(~ ~ C+K ~- t>w ~~e~bKs.. v+~ sl ~T/~~. lraproper use and maintenance of your septic system could cesult"its premature failure to handle wastes. Proper maintenance consists ofptmtpiag out the septic tank every three years or sooner, ifaeeded by a licc~rsed pemrper. What yotr put into the system carry sffat the function of the septic task as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterp lumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on- sitewastewater disposal systerrr is in Proper operati:rg corrditioa aml/er (2) after irrspectioe apd pumping (if necessary), the septic tank is less than 1/3 firll 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 th Department of Commerce and use the Department of Natural Resources, State of Wiseonsirr Certification stating that year septic system has been mairttaiaed must be completed and returned to the St. Croix/,C, ounty Zoning Office within 10 days of the three year expiration date. ~/ l (~ _.._.__ ~ l5 poi SJ ~ URE OF APP ANT DATE OWNER CERT[FICATtON [ (we) certify that a[I statements on this form are true to the best of my (our) knowledge [ (we) atn (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. / {U /~~A L ~?„'"\ " tadude wph this applicatim a sramped wsrnsay deed from the Register of Deeds affioe a WPY of the astif ed sorvry taoQ if refamae affisde m rha wtrrrsoty deed SIGNATURE OF LICANT DA "'*" Any mfotmstioo that is mi~apressated may restalt iD the s+abay permG being revdradhy the Zmimg Departmmt""* Z'd 86E~b-GfrZ(SILI ~{oeeW ja~ud e9T ~60 ~0 9T .add , - .. ~ V ." ~7y~p W~1~6~~I~6t~ p®~~7[MNe1~.1C~KV1~A1W~ i71`fJ~i N+ 11 ~YlWiri~Y `~ti~V ~~ ~~~~~C ~r~w f , ~ .. }~ ' W 9 ~r ~00'Ll rn 1~ ~1 M 1euri1->uroy ~ ai'sct ~~ ~ ~~ ~ $ ~ ~ ~ ~mvao~ asp x I~ ~~ ~ H last ~noq . ~'•~`_ ~ J ~\\ ~~ `~~ `;`; \` ~'I ~ ~ 0 •` ` i I w '~ ~` r h .~ ~~ `,` ~ ` ` ~, ~ ~ ~ ~/ ~`~~ ~ ~ ~ ~ t r ~<` ~` i - - - - ~ - - - _ - .~ -. _. - lN:~ ~ ~-- - s} - _ ~ . 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