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HomeMy WebLinkAbout026-1161-19-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 582042 GENERAL INFORMATION 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: Felicity Homes LLC TOWN OF RICHMOND 026-1161-19-000 CST BM Elev: Insp. BM Elev: BM Description: n Section/Town/Range/Map No: I5z) ilk I l a j o•~ 15.30.18.1242 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER . ~+a CAPACITY STATION BS HI FS ELEV. Septic !.n /,o Benchmark ZvD b aolwio- All. BM 4,- /b /aa Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet X4.35 7.&5 TANK TO P/L~ WELL BLDG. ant Air Iptake ROAD Dt Inlet \ Septic ` l t' I / D Dt Bottom cJ N Dosing Header/Man. 9 i Aeration Dist. Pipe C1• Holding Bot. System C17, !!5; •3 a~ 7 PUMP/SIPHON INFORMATION Final Grade 2- 99 . $ Manufacturer Demand St Cover l t GPM Q ✓til. / 6 / • 8 Model Number TDH Lift Friction Loss System Head TD Ft Force Length Pa. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 QO 7- f e.~ t J~ SETBACK SYSTEM TO J P/L BLDG CWE•` LLLLAKE/STREAM LEACHING Manufacturer- INFORMATION INFORMATION Type Of System: CHAMBER OR 7z I UNIT i n/ ~ J Model Numb r: CC, 1LJ4-_A,40,4 4/ Oka DISTRIBUTION SYSTEM Sa,! ZZ Z Z 4, Header/Manifyld , Distribution x Hole Size x Hole Spacing Vent to Air Intake /I Pipe(s) EQr,~cLl Length 7 Dia Length Dia_ Spacing` SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil N l(es No Yes ® No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1544 126TH ST 1.) Alt BM Description = ( 2.) Bldg sewer length - amount of cover = L Plan revision Required? ® Yes No L se other side for additional information. U41 Date Insepctor's ' nature Cert. No. SBD-6710 (R.3/97) o~eAnrE V County row Industry Services Division Coun 610 ~d$ 1400 E Washington Ave ry S N V 3 Z016 P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-71 C r' ° SSrot4 ST CROI.N, Coo TY z4q Z ani ary ermit pplication to ransaction Number 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 the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) u oses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. _ I. Application Information - Please Print All Information / 3 / Z- to 47 .Sf ° Property Owner's Name Parcel # ~slr! rr "Ilk el 02-& / / 1. / g - d coo Property Owner's Mailing Address Property Location City, State Govt. Lot Zip Code Phone Number /Vw f /o, Section /J' rh"n do- d :~Yfj 7 (circle on T.3p N Rib Eor1 II. Type of Building (check all that apply) Lot 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name -7 ❑ Public/Commercial - Describe Use 014 Block # ,t-or1S ~~cl 0 t'+ ~ ti• M.t, El State Owned - Describe Use El City of CSM Number ❑ Village of 2 11'7e- ZL S Town of h,•y1j p c( III. Ty a of Permit: (Check onl one box on line A. Complete line B if applicable) Z&AA, K" A. [Iew System ❑ Replacement System 1:1 Treatment/Holding Iolding Tank Replacement only ❑ Other Modification to Existing System (explain) V t Renewal ermit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued piration Plumber Owner OWTS S stem/Com onent/Device: (Check all that apply) zed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil k ❑ Mound < 24 in. of suitable soil Other Dispersal Component (explain) ❑ Pretreatment Device (ex lain) V. Dispersal/Treat men Area Information: 4;? - DY -k' C1 esign Flow (gpd) Design Soil Application Dispersal Area Required (sf) . ersal Area Propo d (sf) System Elevation © Rate(gpdsf] 1 7 8J 7 V 886 VI. Tank Info Capacity in Gallons Total # of Manufacturer ` o V ti New Tanks Existing Tanks Gallons Units / 1 o F 2 U iia v v C7 GY Sept, r Holding Tank ~ IZ .fO ( ZYA~ ❑ ❑ ❑ ❑ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. P er's Name (Pri ) mber's Signature MP/f 7P Number Business e 14 Phone Number 4 f ~Q w k~ n K ! 7- ZZ8?2. 11,5- yg1 -J-3ef Pl ber's Address (Street, City, State, Zip Code) U V of h-GClI VIII. oun /Department Use Only Approved lsapp Permit Fee Date sued c Issuin ent Signatur O iven Reason for Denial $ .615.00 /J IX. CondifiX Reasons for Disapproval (16 of 1.' Septic ank, effluent finer and Owl, dispersal cell must all be services /'maintained w as per management plan provided by plumber. 2. 'Ap'tga,4fidck requifemeM;~ mush ~titawtteiffl'~+d \ A n PK q*kable code / ordinances Art4., 4-, Attach to complete plans for the system and submit to he County only on paper not less than 8 1/2 x 11 chesffi size SBD-6398 (R03/14) ^J V` w ~ ~ o 3 i o 3 } J J CCC ~ t m 0 h ~ ~ N ~ 'yam ti k LI Nll ,p t s s a ~ 4 O v ~ 3 h I M h ~ ~ N xj M L 4 r ~ oft E 00 Wisconsin Department of Safety and ssional Services - Division of Industry Services ST. COUNTY ~OMg~UN3T°t DsvELoPtv5ffFL EVALUATION REPORT Page of 3 in accordance with Comm 85, Wis. Adm. Code County C.. A( o x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. •D a O Please print all information. Revie d by ~l Z Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(l) (m)). ItA5 Property Owner Property Location OOOF F;- -0 , -f- 141n„ , l Govt. Lot Nv-' 1/4 Sr 1/4 S /,f T N R .e E (or) W Property Owner's Maili g Address Lot # Block # Subd. Name or CSM# ! _r rej 19 eAexf- f%~c!ls crdd City State Zip Code Phone Number ity Village Town Nearest Roams bort 4 _ f5 ; C h✓m 0 ti L- I / L to NNew Construction Use Residential / Number of bedrooms Code derived design flow rate 6• o O GPD n Replacement Public or commercial - Describe: Flood Plain elevation if applicable ft Parent material General comments 3 and recommendations:/ S.~£, ~~G Boring # Q Depth to limiting factor > h3 in. 11 171 ffn Boring Pit Ground surface elev. 9~' 7 o~' 4 ft. Soil A lication Rate vj- pp Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *EGPD/fFEff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. tY D 3/~- ~i f>» v as l v / z L~.51/ yiy o l' 47ja -W1 40 7z Y/(, `b 120 Boring Pt v p F-/1 Boring # 7f 8 ft. Depth to limiting factor > 8 in. pit Ground surface elev. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E GPD/fFEff#2 Gr. Sz. Sh. T in. Munsell Qu. Sz. Cont. Color O 4 ~~y~ 3jZ S~ 1nngbk !aS 7 1. 16--/ 1471,S1.3 i JY 15, 01Y .-7 CP ti * Effluent #1 = BOD > 30 < 220 mg/L and TSS >3 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST e (Please Print) Signature CST Number y a4G Z Z2 87Z k f 1'j V-0 ~ S Addres Date Evaluation Conducted Telephone Number o; k(, CA' '4" 3Y~S /-Lo 7/5-49/_.S'388 SBD-8330 (R07/13) Property Owner Parcel ID # Page of 3 Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor' in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil AGPD/ft2 n Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Y1q Jr -k I V-/' _ Sa x1.5I/- Y/q _ 4,S' q S 7 , . Z-- 9.,5 '1 ,e %S. 0,5 t ❑ Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application n Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil A lic /fF Rate in. Munsell Qu. Sz. Cont. Color ry GPD Gr. Sz. Sh. *Eff#1 ' Eff#2 * Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L SBD-8330 (R07/13) i t N b N ~ V vi s v ~ M ,a r RECEIVED County fee . Safety and Buildings D ion s county S r K 201 W. Washington Ave., P.O. Box 7162 Madison Sanitary Permit Number (to be filled in by Co.) P `~J , WI 537 7 - 7162 Ay ST. CROIX COUNTY $ Z O Z -I0 and ary efmit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate gove Q unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitte Project Address (if different tth~tan mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary `~,~SJ. purposes in accordance with the Privacy Law, s. 15.04(1 (m , Stats. I / A 7 I. Application Information - Please Print All Information Property Owner's Name Parcel # Vol X- L 0 U - i Property Owner's Mailing Address Property Location 15. 3e. I. a ya Y~3 Govt. Lot /City, State Zip Code Phone Number /I!w Section /Jr- "~~~~~rryt xQl7 circle one) T0 N; R E or R. Type of Building (check all that apply) L, Lot ❑ 1 or 2 Family Dwelling -Number of Bedrooms r / Subdivision Name r 6~ ~o Blo C kr,, /~N a /l3 4 ~C/ • ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of / Z I:J:b Ceti Imo.) ZZ 1' ZZ Town of chrrn cz 1\- C1 e III. Type of Permit: (Check only on box on line A. Complete line B if applicable) A. ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) --1 B• El Permit Renewal El Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply) Non-Pres .G¢o ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ atment Device (explain) V. Dis ersal/Treat ent Area Information: e2 - CC l s 3 c ~ ge ° ! c 1< Ys Design Flow (gpd) Design Soil Application Rate dsf) Dispersal Area Required (sf) rspersal Area Propose (st) System Elevation 86- 7 0 v4- VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° c New Tanks Existing Tanks 1 2 p~ i 7 T!; !Y» c' . ~fG~ a U rn y v1 w C7 w Septic r Holding Tank 1k ! Z' u ` w K Dosing Chamber VI Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. tier's Name ) Plumber's Signature Number Business Phone Number tC ~~~C"- -,A.S ~ ~z2.e 7- 11.5-Y9/-53e Pl b 's Address (Street, City, State, Zip Code) / I C>e- X- c /C°. Gam,' ~S A VIII. Coun epartment Use Only ued Issuing nt Signatur pproved ❑ DiRsWraynd Permit Fee Date Isr, V C6, ~ rven Reason for Den $ IX. Conditions of Approval/Reasons for Dis pproval n dylO~Y>< GO trl, W 5.J 1o.c., yt. `a 6e.laLj belo r.-) 77~i, Attach to com" (e item and submit to the County only on paper not less than 8 m t 11 inches in size 1's{<-Septic tank, effluent filter and dispersal cell must a!I be services t maintgjned. SBD-6398 (R 11/11) as par management plan provided by plumber. ~~t~`tt ge'maartain'ad a ~ +IPt wct~ I o►d~anoa. v W , 'h h`~ \ J cp '1- 1 h Ilk, is v e ~ s 1 ~ CONVENTIONAL IN-GROUND POWTS DESIGN With DOSE CHAMBER Residential Application Index and Title page Owner's name: Owner's address: / YU 3 Site Address: i✓egal Description: Town: County: Subdivision Name: 61 C~L~ • Lot No. ~ ? Block No. Parcel Identification Number: C~ - 1 ~o 1 - 6 0 tl Paee Index Page 1 Index and Title Page 2 Plot Plan Page 3, Distribution Cell(s) Cross Section Page 4 Dose Chamber Cross Section (with ST & filter specs Pa°e Pump Curve and Specs Page 6 Maintenance. Management and Contingence Plans Plumber Name: Q e (4 £ plcv k' s Credential No. Z ZZS?~-' Plumber Address: P • oZ u G j< -5- Si gnature: ' Date: l (--1 -2 2-- Phone No. ~/J ~cO// X38$ :J" sIL'n00 Pursuant t0 in.-: -!ZrO UnG JC;! ACSDL'DL10): V)a❑ua:Or ?~I CFTC '~`'510~: ..J CF^_ - . \ Jjw~'wjP cUD;izanor. ,'.o:)CSiL^ O.' °SSUre DISM0111IOn :\C ~Oi :J P~aP O. o Nei ~ d a ~ h N ,11 u y v b o ~ a ~ W A-C b V v s o ~ M V' k Soil Absorption System Cross Section IL 4" Schedule 40 Final Grade PVC Vent Pipe fta IINith Vent Cap Leaching Chamber - System Eievaticn J `L Soil Absorption system Plan View g~ ft f< -VIII I I i I Ilillllllll I~illlll! Leaching Trench 1 I Vent Or Observation Pipe Chambers .,IIIil►111 .III III ~ Illlliiill i II i II II!I~i VIII 4" Dia. =ich Header Leaching Chamber Specifications 7EISAR22ttingg rer And (Model _ ~ i cK s sq u per chamber Soil Applicatio n Rate epd/so f rt v _ 7 Soil Application Rate _ Z 6 0 EIS" Chambers i 2 rows of 7- chambers each. Page of 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 for the 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: mike@lifetimefilterllc.com Phone: 502-724-2231 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ✓ S Septic Tank Capacity gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model NA Number of Public Facility Units --ETVA Pump Tank Capacity ~Q gal -ENA Estimated flow (average) 1060 gal/day Pump Tank Manufacturer N ❑ NA Design flow (peak), (Estimated x 1.5) ?C 0 gal/day Pump Manufacturer ujdj- ~I NA Soil Application Rate -7 gal/day/fts Pump Model OO _2 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) :_220 mg/L .219A_ ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) 530 mg/L ,8'In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ANA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :_104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve El month(s) every: 2-Tear(s) (Maximum 3 years) ❑ NA 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 ears) ❑ NA • -$year(s) y Clean effluent filter At least once every: ❑ month(s) ❑ NA •$'year(s) Inspect pump, pump controls & alarm At least once every: J C ❑ month(s) ❑ NA $"ar(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ year(s) Other: ❑ month(s) At least once every: ❑ year(s)A 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) 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 repla ement 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 NO 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 INSTALL FR POWTS MAINTAINER Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY ENa Name " A' K e - S .c Y. / ~,f ~'`1`~'88 Phon This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(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 repla ement 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 INSTALL PR POWTS MAINTAINER Name y E Name ~ ~"ol a S ~E ~'%C Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~c Name CA-o.` c~ f 'Q" Phone J 4lei"8 Phone ! 5- q .C ' b ? 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. Elb ~h - h a ~01 108,30"'W 299.45' 0 1 y O ~,r I l ry i ri ~ b 4 0LSb r v ~.AF fli r i to* r lip ni Z ' 1r r k C3 SO. 4f ~..~o cli a h~ m p to 1C 16 b ~ ~l J ci °i .Iry w N r4i x 04 JN~ +Fi ,ter a°fo a Sri 9W 060d '669 a+u110r1 ;W4000 PVV7 JO O(M )Sam z ,9Z'60£ .06'90£ ,00'99 ,LL •Z9£ 75, 511~7 f *j Meg Al. P9, ZLt10N- S, ~.t31d111S 33S SaNb'~ OfLDTI Ni V ' y 0 91L q tf Oaoo5 c 0: 3 ! 0 c Q ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ~»'►L°s Owner/Buyerlrc. t .10, Mailing Address yd.j 6 el lea h 1'i o &d g Iti, y yorz 4- 1 5 ~~y M Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number o / / 1 / 1 GQ 0 LEGAL DESCRIPTION p Property Location Nom' 1/4 , s£ 1/4 , Sec. /J- , T 3" N R W, Town of Subdivision Plat: es'1 rcNo Lot # g . Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑ yes Vno Lot lines identifiable (=yes ❑ 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 §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this fo 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 warra deed recorded in Register of Deeds Office. Number of bedrooms 4ei~' i_z~ 0 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) F, 11) Wsconsin Department of Com roe OIL . EVALUATION REPORT Page 1 of 3 Divisiors;of Safety and Buildings 2ul 11 R Ap In accordance with Com 85, Wis. Adm. Code UNCounty St. Croix Attach complete site plan on r ncCoa i Inches n size. Plan must include, but not limited to: verb I and M), direction and Parcel I.D. /~~~l percent slope, scale or dimensi crow, and location and distance to nearest road. T , l V Please print all information. Re ' by Date p Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Steve Derrick Govt. Lot -d$11/4 SE 1/4 S 15 T 30 N R 18 EE((or)W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1438 County Rd G 19 - Cherry Knolls 1st Addition City State Zip Code Phone Number 00ity EE3 Village ■ own Nearest Road New Richmond WI 54017 ( ) County Rd G El New Constriction Use Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD Replacement Public or commercial - Describe: Parent material loess over glacial outwash Flood Plain elevation if applicable ETA ft. General comments This site is suitable for a conventional below e s stem and recommendations: grad y Fl Boring # 0 Boring Pit Ground surface elev. 100.40 ft. Depth to limiting factor >90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-16 10yr3/2 sit tmpt mfr as 2f .4 .6 2 16-30 1 3/3 - sit lmsbk mfr cw if .4 .6 3 30-36 10yr4/3 sit 2msbk mfr cw if .6 •8 4 36-46 7.5yr4/4 f ifs Osg mvfr - cw .5 1.0 5 4690 7yr5/6 s Osg ml - - .7 1.6 F 2 Boring # Boring 101.40 >90 El Pit Ground surface elev. ft. Depth to limiting factor in. Soil ADolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/lt? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *01102 1 0-9 10yr3/2 - sit imsbk mfr as 2f .4 .6 2 9-18 1 3/3 sit Imsbk mfr cw if •4 .8 3 18-27 7.5yr4/4 - is Osg mvfr cw _ .7 1.6 4 27-90 7.5 5/6 Yr s Osg ml .7 1.6 * Effluent #1 = BOD > 30 < 220 mg& and TSS >30 < 150 mg& • E1Buent #2 :M:< 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Thomas C Nelson 227387 Address Data Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, WI 4/1/04 715-246-2454 Property Owner Derrick Parcel ID # Pending Page 2 of 3 171 Boring # ® Boring 100.20 90 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. *Efr#1 *Eff#2 1 0-15 10yr3/2 - sil lmpl mfr as 2f .4 .6 2 15-33 1 3/3 - sit Imsbk mfr cW if .4 .6 3 33-43 7.5yr4/4 - Os mvfr cW - .7 1.6 4 43-53 7.5yr4/4 - sl Om mfr cW - .2 .6 5 53-90 7.5yr5/6 - s Osg ml - - .7 1.6 F-1- I ❑ Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Ram 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 F Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/1F in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ef#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg1L and TSS >30:5 150 mg/L * Effluent #2 = BOD, < 30 mgA- 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 608-2648777. SBD-83307rom (R07/00) I~ w Cherry Knolls 1st Addition Lot 19 f NW lot corner BM 20' 24' 36' ~ - i B1 B 2 94' 159' 107' B2 2% Slope Scale 1" _ BM1 Top of ' n pipe 100.00' BM2 Top of c duit pipe 100.40' B1 100.45' 36' B2 IOI.40' B3 B3 100.20' 102' 100' Thomas Nelson 227387