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HomeMy WebLinkAbout026-1051-70-000 rosin Department of Commerce ry and Building Division PRIVATE SEWAGE SYSTEM county St. Croix INSPECTION REPORT Sanitary Permit No: 58265 7 4 GENERAL INFORMATION (ATTACH TO PERM(T) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. P it Holder's Name, p City Vi ge X Township Parcel Tax No: Paw,(P k' "`�e,fG e i e r K i�w f e k o- oat. -- /66/- '76- 065 CST BM Elev. insp.BM Elev: ( ABM Description: —� Section/Town/Range/Map No: /� Q 1 66 j /5.30 . !8 ; Z(07 6 1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ren.111111111111 Benchmark 14/ Z. 7a <da •76 /o • ffiNEMZIMIII 5tO A. Alt. BM -3. 8 y1 , S 1 k_ ' Bldg.Sewer _ IG exl 41-1`A -3 Holding 1 St/Ht inlet , St/Ht Outlet ��`/� ,E, C�S TANK SETBACK INFORMATION TANK TO P/ WELL BLDG. ent to ,r Intake ROAD Cr-brief I 440-4_— S Septic 3 r_ in I —/' Dt Bottom /I'S g $S Dosing Y,I / der/Man. O O+ g 3l`I I Lb z4 3o .. # *, 16 - 3 Aeration Dist.Pipe .l 454 9y. 3 Holding Bot. System 1.35l aft69-I/6 93. 3 Final Grade PUMP/SIPHON INFORMATION yon erg ` c4,S 'Manufacturer / � n Demand St Cover 1 / p� l7a�ld� S GPM �N. Caat..L. 3 g 1 `7 Model Number -‘-f V6 0 r-_____ TDH f Lift 4c,Friction Los f System TDH 1 �Ft Forcemain Length , Dia. a I Dist to Well I i ,$0 z - SOIL ABSORPTION SYSTEM • BED/TRENCH Width Length i No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia.,iiquid eQ pth DIMENSIONS ' gto 3 —ifeALLAA ..... -, SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: / 1 i INFORMATION / CHAMBER OR Il (� �L irZexy-� Type Of System: 18 (71/ PO JAM—/ — UNIT Model Numt r. ;U j. q 6 DISTRIBUTION SYSTEM S•J z)-3 -- (0 3 P" Header/Manifoldu I' Distribution x Hole Size x Hole Spacing Vent®Air intake ,. Pipets) ` ...` \ b Length lQ Dia Length Dia Spacing `\ te,IN R..,...1oee • SOIL COVER / x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Miliktk Bed/Trench Cent .3 Bed/Trench Edges Topsoil Yes E No es E No Ge. COMMENTS: (Include code discrepencies,persons present,etc.) inspection#1: / / Inspection#2: / / Location: = /1 /bv�� i3 j`1" r�.�,n 1�-p Parcel No: 1.)Alt BM Description= Nr-I♦I t�y-(, a 6 aw Q/p� 2.)Bldg sewer length= �!1 34i _ amount of cover= i t 4- rOLe p I /- Plan revision Required? rI Yes )iNo i 3''7 Use other side for additional information. (0 16! IWAINKAANO I Date Insepctor t/-ignature/ Cert.No. SBD-6710(R.3/97) I x W l A_ ��" o� RECEIVED County Safety and Buildings Division 57`. � � 8 .- DEC K 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) ° p EC 1 4 ZOIS Madison,WI 53707-7162 Tom° '' �` ST.CROIX COUNTY 2 oS 7 ■� ' a K-`-cX�UN r(DEVELOPMENT Sanitary Permit Application State Transaction Number pp . cordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit NT�]7 I •uired prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) Department of Safety and Professional Servies. Personal information you provide may be used for secondary ; noses in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / �p c ' pplication Information-Please Print All Inform. 'i n < S/6 ?< J -. .e 'Owner's N.g ; ,,. 0 Parcel# �' , 0 Z —1 OS-7 —?O --0000 . Property Owner's Mailing Address, • Property Location Z,C 7 [Z /7't 0 ?LC—T C 57 �� 6 Govt.Lot / [� City,State . fi Zip Code Phone Number / �1-2/<, A-)444%, Section ! Z5 AZ∎LA f W... 1 77 7/, _9 ,716_ 3/��,� lrcle one H.Type of Building(check all that apply) 7--- Lot 4 T R 1 E o W 0.1 or 2 Family Dwelling-Number of Bedroo Subdivision Name '�� Block# ❑Public/Commercial-Describe Use (((•••er `/ l ❑ City of ❑State Owned-Describe Use CSM Number PYO 2.16- ,q ❑Village of 3 n /' ( r. r _ Q_ �iJ 0;64- Ce2 NJ z( �l/��• er`j ett.L3 35-5 a^ / RI Town of III.Type of Permit: (Check onl one box on line A. Complete line B if applicable) ZO At/ A ❑New System �Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner G3 , eitl. IV.Type of POWTS System/Component/Device: (Check all that apply) / ,4KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil .P.( % ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treat ent Area Information: Design Flow(gpd) Design Soil Application Rate( f) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation 75-6) 9 40 D/DZ /, 6 0 ✓ 3,3,5– VI.Tank Info Capacity in Total 4 of Manufacturer Gallons Gallons Units ///��� ° o "c New Tanks Existing Tanks I / _ w a /l Z a � � 1 • wi a Septic or Holding Tank Dosing Chamber /e_)00 J<)©Q VII.Responsibility Statement- I,the undersigned,ass ,1 e responsibility for installation of the POWTS shown on the attached plans. Plumbe';z4),V rint) Pluml Si. . e 'Ti I•RS Number Business Phone Number /b ei / %� t�3 -� 7/-5----7‘o—.Oft Plum s Address( et City,State,Zip Code) 9/3 14 i l� �' O© VIII. unty/Department Use Only Approved Permit Fee Date issue Issuing ent Signature / ven Reason o al $ 475.0‘) / / /`�' 7 Ilk IX.Condittlsli> agEgroggfiReasons for Disapproval 3, L I S Vi r �-o O 0. 3� 1. Septic tank,effluent filter and J ,J disper'-1 cell must all be services/_maint;aifl.E: /1 _ ��� ,S �� as per management plan provided by plumber, V [hi q Cete.2. 'AU ,,r a qr itt.intt itl d rJ L J u as per ' acods/ordinances. �ac.1 a 15(4 1[o re �;RaD Qc.a. Attach to complete plans for the system and submit to the Co ty on n paper not 1 8 1/2 z 11 inches ii4ize f�� 5 be.�1lc�oaslN., tz.� 61&.6.6 /� Su l e • dec- SBD-6398 11/11) Gs �� ) — / -7- / e)0 f 1 / -G 3 77 /oex) ,. ,__O / '(.- vo • /4)„(2w- .57,6--00 ?, ,.....0 5 Vile", / 01,0 53 #(\re . Li- to-Ai-4- ,frc ,e ov• < AA.4.3.7- riQ K---- 4-J' 0 6-700,■/ , ) 4._ Ar 0 , sip V a 0 ' 1? A )3- - 131 0 00M-Ds 1 1 14 7 dki9 °3-c . . 9 --"----7-4 of r 111 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE �Project Name: (J�7 -� Owner's Name: Ax_u_zej c - Owner's Address: /,j qQ 5 iV. r 5 4/b/ 7 Legal Description: _ W A104 —5/p – 730 f/a '-'- Township: County: 4 Subdivision Name: Lot Number: Parcel ID Number: cD -/c3 / 7 '- CEO©O 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: ge �6 / 641 2cense Number: 0R.-7 Date: /o7 "` /—/5 Phone Number 775--7 6 d ,7 /- Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 /3/14 � 7- 4,160 r • s --vim ?„-_,--40 du ,, Jo/c. /ocn °s et -? ,=__ /0/135 S P/c /19, 6 / x 5-- / :: 9o, r 5V 93, 3S` x 0 - ICS/10 r )( 5 -3 z_ ,q,,caRi io _ j,,.±- 42,;,,. _ 4 4`09 t>?)11 Ill i\C ‘\: e L{- ev-e, Had-42- 3y, / tiau,- `0 D K o 1.�� al °0/A , , ET P � s '9, -1 01°' Of 001"-a 1 1147 °3-C -7 r .i 1 1 6I, ,Atell Absorption System Cross Section 0454 4 T 79 4'Schedule 40 PVC Vent Pipe WIth Vent Cap 9 4/3,fft- I Final Grade Leaching _..0. Chamber r 3/3i `._ 1--3 / System Elevation / pr Lion System Plan View 8a{ f 3 ft 1111111111111117 ;111111111111 11111111#1111111 1111111111111111f11I1111:.:111ff11 .___ft 4: Ding I Trench 1 Crtbers i 1. 1111111111I1111I1111 IIIIIIIIIIII111f111I11111I11 111f1I1111111111ii1111■ 11111IC 4°Dia. I Trench 2 Header (--'' Vent Or Observation Pipe 111111; 1111111111IIII11111f 1111111N11111111111f111f IIIf111111111f 11 ITrench 3 Leaching Chamber S ifications Manufacturer And Model L/ EISA Ratin /�, Rating V sq ft per chamber Soil Application Rate ® �gpd/sq ft 7 C 6 gpd Design Flow+ ✓ 4/ Soil Application Rate ; go EISA= 4,5-,—Chambers 3 rows of ,,/ chambers each. Page of ..%_•;__ ' _____ , ___ __ __,I ''''_,_,,,,,,, --- --------- — - - - - = -- - - -- --, --- - _?4,.. el i Ii i-1 li i t 1 ___ -- WI 1. ill" U 7 to 1"."Mit illWo i I 0 MI I I MI , 1 1 0 ' 0 1 CNJ C). I LC) ----------*1 -., ■:1" -1.-4 C,) i N.- -et 1 C=, C,") Ch CV ., — _________CO' i co cri ...- t - 1 -1------ 7..... I iiir a. .. r/ -__ lit 17-------,a,\,1 1 1 . n bi , // 1 -.4 , t , \ . ... ... ,,,., ,..jo, , , , 1 , ,‘,\ ,, . , , ., , \ _ 1 _...zi . . , i , , , r 1 , \ \ Pr , „,....... i.......4"....■%.•••••., -- A;: — — I-71' -s4 I 1,- LO • - •••■••■•■ - l' ' lik )". 1 / \ \ i , \ \ \ \ s 1 / \ ,-, , I i 1 , I C:1 C fl CD / ... 411111::............0.1AMV ...b Ci) >< "*. ,--—..-,1 4 e si 4 1,1 IP I ,, ,jow 1 ma 1.,./.11 0 a ___■tie a, M t.0 LU 111 = W (...) .....W.: ,e'l ) 4,1 A r A V/ C9 01 A./ / / 1_ LU = Illr !hit ,,, C...) X ......i = <4.1 / /.... ..■ IIMIII AIM, MEW/ C L > LU LU — CO 06 --,17/ ------''' 0 CL L.L. —I 11.i = (9 Lu c...) 03 ca -44■ 0 M cp 1 -C--4 -„, kr 0 •-•,..„ Z 1 Up I i Cr) 0 c:13 I I yi. assissmsnimmi■ 0 . CNI F- = , , ZS I ..E..N■ ce o 1-0 i i LU co = 0 ai i 0 ._/ u.... ..,....44. .r) Z EE , CNI )-- Lli -'- '' / , , /, ---I N I-9 114 1j- .. /...toi.■.4............ , k, \ , 1 1 1 1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2• FILE INFORMATION SYSTEM SPECIFICATIONS Owner 4 �� Septic Tank Capacity /000 3-(:),C) gal ❑ NA Permit # Septic Tank Manufacturer ( ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer /Q ❑ NA Number of Bedrooms 5 ❑ NA Effluent Filter Model AZ -5-a_5- ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity ld® ® gal ❑ NA Estimated flow (average) 540 gal/day Pump Tank Manufacturer j £ .. v , ❑ NA Design flow (peak), (Estimated x 1.5) 75-0 gal/day Pump Manufacturer ❑ NA A Soil Application Rate .' gal/day/ft2 Pump Model F�Q /,/ ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit IAVA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (B0D5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) 5530 mg/L /k In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510" cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y8 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 every: 3 Y month(s)lC (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume3rit,c1 NA Inspect dispersal cell(s) At least once every: 3 ❑ month(s) Al year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: }3 month(s) ❑ NA / ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA 3 oa year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: 0 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 (1/3) 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. I r Page Z 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. A� T - i'v� - aluat.. •• .. — 17;� - (I o • ngank be 'r • -- _ . • r.�r iiFT�3+.e al e. -• . ?1 D4d1 'FDA-N/€v✓ cof JSfl ❑ 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 (,l'�'6j-fvep Name Phone 745", 740 - C'S'YG Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name sue', C-e-b(X CO U OTY 20A1/4 C- Phone Phone —VS-- 41(pg'D This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page ' of 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. J T - -•- - - _ - ,{� • -• . . -. ' • - �//sr"� aluati.. •• � - .. -. .. .. - a o sing ank •- be .• • -- _ . • tomfaaT �.e ale. ••„ . TRD“1' Foie- A/> eb"sflWC I.0 ❑ 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 jt j_,Aep Name Phone 7/5-,- 74d - 05./ f6 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name Name �9- ( �( Cc u Ji 2o,J1�c1Cr Phone Phone -VS--— 3 MCP. / ,,s27 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. 11B 00S-0001:11% :3114 9518-5Z2-008 af10d-1SOd 31VO 00/00/00 31V0 OSLi' IM ')IOON N3OIVW 01 AMH S(1 9LL£M w \O� - 'A 321 717p��o� �b'f1Nb'W �Ild3S w af10d Sad «0 ,1-«4/l 31VOS dOM l8 NMVaO _ 0 ' \ 1313111 ,a� 005,000 ldlM W a' W w W 0: v) z J o H Q U > J Q N M Ce w co O a' O O 0 fnv Q M CCm V (n < .. w ix IT Li. O W j V O Z Z Z mJ Z Z Ce m Q w O a w 0 Q J< z F OJ O H O c c z U ° 0 w QQ Z a z2 U 3 LL o a C O a D ui m J c90 ° w z -v� v, Q > 1() e s m J Li 00 r s v)0 Y a ce c U -NO acv W Q O_ t0 O < Uo- Z 0 ¢ a w O W Q �1 .*.- O H.J O t- I H Vh N.- 00 W a\ z Z N~ Q a O CL the NM�s LL-1 WQ W J SNP v)- ZO i[,r'tb > Q Z win a O UI s 1nW I4zW— H F U' \a °W M2 ..off 30= oa 0 0 Q w mPo x° ov co vi -Oa z OQOOawz0_132 a, a w U z a <n0 �- -o Q 23mU�= *mJ3 ° rWWY OL_ I— O Q Z Z N J J O O a n 3 z z J F. U1- U J U W I a I 1- a 1- v z �� "0* a w 0 a > a I- z �. I� w ,1 % I I 1 w 'I L . N s I ° \ a w w " w O� O — w Q 1L 1 wmrn o I- 1 Q I, „s „isti „S w 0 . l: M 't (<1' 1 I 0 fie. ) II 1J ° — cc P IIII a : - 003d J�Z_ Q „9L SV „f cg Y Z a I- ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: .5 `n (Street address) / located at: N 1/4 A 1/4, Se on / 6 , Town 3 ® N, Range / S Town of fj �� , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes " No)( (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /0-0 0 Construction: Prefab Concrete X Steel Other Manufacturer (if known): t .1� Age of Tank (if known): w/ Permit number (if known) w/p 5/f/f1) 1// (Lice id Plumbe/ ignature) (Print Name) ei;73,5-7 (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CER'IIhICATION FORM )J��''c^-' Owner/Buyer (' n Mailing Address 5 Q ,s �(,t! d J 5 /617 Property Address /S-'/0 95 (Verification required from Planning&Zoning Department for new construction.) City/State / Q 1.J /Q- Parcel Identification Number d a 6 - / )5 / ,-?O 606,0 LEGAL DESCRIPTION Property Y Location 1/4 N uC / Sec. 1 � , T 3O N R 8W, Town of 16--a1444,11LIS . Subdivision Nat: ,Lot# Certified Survey Map# j ,Volume / , Pg # �T Warranty Deed# 3 1 (before 2007)Volume 7 6 ,Page# s— Spec house 0 yes kno Lot lines identifiable eyes 0 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. llwe,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. Uwe certify that all statements on this rm are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a w ty deed recorded in Register of Deeds Office. Num r of bedrooms D 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 referenee is made in the warranty deed: (IOW. 04/10 74 GOULDS PUMPS Submersible 1 ow Effluent Pump MEIIIIIIIIIOSIMIIIIIIIIIIII EPO4 & EpO5 Series APPLICATIONS �`� r •EPOS Impeller: p Specifically designed for the •9 in nrpeiier:Thermo las ■Bearings:Upper and iowrer • lubrication and efficient enclosed design for heavy duty ball beannr! following uses: improved performance. • Effluent systems heat transfer, construction •Casing a • Homes n9 nd Base:Rugged • farms Aval ab for thermoplastic design provides AGENCY LISTING • Heavy duty sump superior strength ___- manual operation.A�eD> gth and corrosion ma*models resistance. el.Canadian Standards Acsooabon • Water transfer S ■Motor #1838549 • i�ewatering Housing:Cast iron assembled tJ and preset for efficient heat transfer, Pumps n ISO 9001 Recpstered SPECIFICATIONS � � strength,and durability. __.T._ ■Motor Cover:Thermoplastic. .Solids handling capability: FEATURES cover with integral handle arts! 3/4"max;mum. •£PO4 impeller: Thenrop float switch attachment points •Capacities up to 60 GPM. tiC semi-open design with (as- is Power Cable:Severe duty • total heads: up to 31 feet. pump out vanes for mechanical rated oil and water resistant. •Discharge size: 1'/2"NPT. -Mechanical seal:carbon- Seal protection. rotary/ceramic-stationary, RUNA N elastomers. • temperature: 104 r(40'C)continuous 1 40 ,, f 60 C}intermittent. METERS FEET :_. •r Is eiders= 300 series 10 „ainit,ss steel. t •Capable of running 9 30'----- --- i without damage to t 1 AN C1-• ti .«, ortip«nPnts 8 25} Motor: i r tPO4 Single phase:0.4 HP, u 6 20` { 115 or 230 V, 60 Hz, 1550 i...._ . RPM,built in overload with r 5 l ' rutomatic reset. o is --- -- 3 P •EPOS Single phase: 0.5 HP, ti 4 115 V of 230V, 60 Hz, 1550 3 I U- .,. ...._ ... EPOS N. RPM built in overload with !V . autornatit reset. '~�- --�`• •Power Cord: 10 font EPU4 standard length, 1613 5'" SJTW with three prong r grounding plug. Optional 20 (IL oo ; foot length, 16/3 51 rW with 10 zo three prong grounding plug GPM (standard on E.PO`)) 9 6 l__ I u i.' In'Jir CAPACITY GOt IEcis Pumps .Y 400 t(,;,,,,,,,,,,,,; l l ltif`tec iiiS; t l COMBINATION SEPTIC/DOSE CHAMBER TANK&PUMP ECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening,not top of covet Access Opening,not top of cover, ' must extend to a point no greater must extend at least than 6"Below Finished Grade 4"Above Fished Cover with ada ,n,1 _ . Y �� f U�'f it Locking Device 84i IN P":".b-D" '�YL'l�l (typical) iti- Finished Grade lZ M DUI GI3Nl�6C' /e? N// V SEW EP-- �30 1► Min. 23" 0 NI f� Access Opening PI 4E Min. Z3"Access Opening " MP" Ouht Effluent Filter el Z p/W�G mo6/h!/N� ► Gv/TJY 1/1PVG SL.Ea3'E Inlet baffle APPROYEA P/Pc ,3 Pr ' oAha soda . .01 G.-al ilitil # 5V0e,y) _.,1 ,. /60 0"":5,--Q t wow ,y Tmro Compag ent Sep it Pump Tank w/ 61/44 7 2 1!714"1'u,2�;tern'5117o sh i dee dl gce s j.Cs) SPECIFICATIONS TANK MFR: (.uk--1-‘14-Q--L DOSES PER DAY: 6--- TANK SIZE: SSEEP TIC 0_2_ _GAL. .DOSE VOLUME: f , (p4. GAL. �— — (INCLUDES FLOWBACK& <20% OF DWF) ALARM MFR: A CAPACITIES: A= 3�s;Q�1� MODEL# / / 8NVCHES =_ 0 ,a.GAL. Switch type: . B = 2_INCHES = 3 PUMP MFR: G' ,.5._ C = g, OINCHES = I O , AL.MODEL#: F } SWITCH TYPE: - REQUIRED DISCHARGE RATE 35- D �' INCHES ==,QCGAL. GPM PUMP&ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF& DISTRIBUTION PIPE(LIFT) = MINIMUM NETWORK SUPPLY PRESSURE (DISTAL& NETWORK PRESSURE) = + -© ` FT. -- 5 FT. OF FORCEMAIN x ,i FT./100 FT. FRICTION FACTOR . . . . . . INTERNAL TANK DIMENSIONS: LENGTT FT. TAL DYNAMIC HEAD (TDH) = 4 ___ . WIDTH ' ; LIQUID DEPTH NIl'/MPRS SIG1`tAT � v 1 1 RECEIVED 5. k gOV 17 l • ' 3 Wis.Dept.or =ty and rofessional Services �� A ° � 1 REPORT Page, of Division gistoo tt II IT1( r in accordance with SPS 385 vvis. Aim. Code :,OMMUNITY DE VELOr�',V3 N1' County Sk• C RC;I ?4 Attach complete site plan on paper not less than S 1/2 x 11 inches in size.Plan must include,but not limited to vertical and horizontal reference point(BM),direction and Parcel I . percent slope, scale or dimensions, north arrow.and location and distance to nearest road. oat 1a5 _ 70.. boob Please print all information, Rev ed by . D//ate Personal information you provide may be iced for secondary poi es r i,-...�,Law s 15 04(1)(m). I //Vtte - Property Owner I Property Location 2 Govt.Lot 1/4 , 01/4 /cg T30 N R /2 E(o W MOW-% � Soh e�a r -- --------� - N� Property Owner's Mailing Address i Lot#— Block,# Subd.Name or CSM# s o _95fi"► _ _--— City State Zip Code Phone Number t ❑City ❑Village 5flTown Nearest Road ,`_ i �%I&V) ft '. ! 5 I7 s, W5 )-)+f 6',31.2j1..--_ P.-.e...1..vri a vN.S),. 1 9s S±. ❑ New Construction Use: Residential/Number of bedrooms ___9 ____ Code derived design flow rate 6 b0 GPD E Replacement ❑ Public,or commercial-Describe- I ><•I vfe .,I__V.",A' 1 ? ---- Flood f Plain e!e es.ion If apoticable __ __ --ft. gRepl General comments C Q t + 3 r �5 L h • 1)844105 G I{,t `SrA�'/, and recommendations: a'... J V J J s `�� GhG . OF"CQ'� ,qG k D �1r1 I ma•� b 5 Q..-I- �.�- 53, 15 J.; F+ w� 1 L Boring H Boring# p O Pit Ground surface elev. i 35 Depth to limiting factor I Q in. --- ISoil Application Rate j Horizon Depth Dominant Color Pedcx Description xc,re i Stl rcture onsistence Boundary Roots r GPD/ft 2 in Munsell i CuSs. `_o.1t Cot's' 1 _j` .Sz.Sh " ff#1 -* :f#2 - 1 �x_ 10-2_I I D y�a L_ la fs - rn Fr- a4) a r' . L_ .-S?--1 _-_`�11_4-1y 1!C'�$/`/at I --" -° i t2F5tt ry f- C v-' I Pn . I�_,S__1 3 • i p.,4 1 - ! 2 Fs bit. I rvi ft C.4v )v f . l� _.,_`?.. - '- - 1.39_1 7,5YRy ' - - ; -`--L-' w%5b1 - vy,�f r Cw !v - l . a s 1 %-07,5' 8 l4 5 -� 10 **/ 1 1 a 5 I si 1 c Boring# Boring i) id� a pit C sa'face ellev I DL•D(o ,". Depth to limiting factor--_ (..3c? in. �^ I �" I coil Application Rate_ Horizon Depth Dominant Color Redor,Description ure Structure onsistence Boundary Roots GPD/ft 2 in. Munsell nu.Sz. Cont.Color I Or.Sz Ph. o w 7_I )o I R�Jal _ �-- , - — ,,y). - _.c)�Sb14-mfr 4W _ a m . to ,_ _ 3 i°�13 i YR,Y ' 5 E-- _4451 tote.. w r^ c�J 1 vF . b I:CJ _-' — _1 s / __ / -� jjr_►�_ 17 1. i--r---- 435- - fit ._-r Q--- — Li_ r _y F`fue, ff =SOD =2 o L and T S� o: / # _ fuen OD <30 mg/L and I SS <30 mg/L. r CS! Name(Ptn ese Print) 'urns'ru e CST Number I ,p471 p9 a Ua tr' 5'1'. .to Evaluation Conducted Telephone Number r 61'a.� ra',r: e WT S4D b J!• ' D1 s a ---- . S a S lot- 3g-ye iS ST-ID-8330(Rl t/1 l) ■ .. a ..„ , ,.• ' . .. Property Owner SC,VN ec9e Y Parcel ID#_ Page a of a Ei Boring 3 Boring# ,____, NI! pit Ground surface elev. CO6'D, 71 Depth to limiting factor 1 20 in, ' Soil Application Rate Horizon Depth Dominant Color Redox Description 1-7Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Cu Sz. Cont.Color j .4_,:Gr.Sz.Sh "Iff#1 Iff#2 I 0- 9 ( oi a 4/2, . _______, 4 1.-- IA F5ble. rt■fr.- a ' c9r4 • 11-,,51 /D'i a31,2 , — , r--- _1 1-- c9 F5104 mcf- C u...? 1V\ # Co , g _ , 3 !Is.icl ID Y a Lily „„....., ! 1.... ,c9 F6.6 fre ir. r e to, i m . • (.0 . -- V - . 5%leY19 ....00101.0..MON., t 5 L 0 01664 OF r C v., 1.2? i (47 i I r) , 5 •MI 7 mo ...................... i Sr_!. 6615 to k. re/f ir C IA? --a a ii_l ,. tg, _ 6 65-1;oLs-,125/3 ..........................- .. ...$13, a _To L. 1 L:5 . 1 i I ----; ,_ 1 1 1 rrn o. i I __Jo. , ._____-")_/,,,,___-. 0 ir) 3 1,4,(0er-it 7 (.14)) I 1 i 1-----1 D Bodn Boring it 116.014 I I g# r._.1 U Pit Grounc -104e':.e ) ft Depth to liming factor in. L Soil Application Rate Horizon Depth Dominant Color Redox Description 1 Texture 1 Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Cu.Sz. Cont Color 1 Gr.Sz.Sh. "Eff#1 *Eff#2 ; 1 I i I .tl I / I 1 . 1----i---- i I I . , i i , 1------ __I 1 !.._____________Jr.____ l I . .. Li.— I ; 1 _ 1 Boring ri Boring# F-_-_,. U Pit Ground surface elev._ fl Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description — LFe.xture 1 Structure 5onsistence Boundary Roots GPD/ft 2 in. Munsell Otl Sz. Coot.Color : 1 Gr.Sz.Sh. _ _ *Eff#1 Iff#2 1 1 I I 1 ! ---i- lin -I , 1 ____. _ II , , L_ ______ I, ___,_ _,.._ _____ 'Effluent#1 =BOD ,>30<220 mg/t_and TSS>30 ----1^T.f.0 mg/l_ -Effluent#2=BOD ,<30 mg/L and TSS <30 mg/L The Dept. or Surely and Professional Services is an equal opporhinity service provider and employer. If you need assistance to access services or need material in an a liern;;;.c format.contact the department at 603-266-315) or TTY through Relay. 5Tii)-R.1.1,,(R11/1 ii Property Owner S G eS)0 r Parcel ID# Page of 1 3 Boring# ❑ Boring n Pit Ground surface elev. 9q,5 ft. Depth to limiting factor 1 at) in. Soil Application Rate Horizon Depth !Dominant Color l Redox Description I Texture j Structure Consistence Boundary Roots GPD/ft in. i Munsell Qu.Sz. Cont.Color _ i Gr.Sz.Sh. _ *Cff#1 Eff#2 I o_9 i 1 ei a.%. _________ I I- ;a F564 m j,r- GOA, a M ► Io , % i9-:_151 1 t)q R3la r L- 'c9 F564 m.Ft- c l A.2 ;r ■ 6 , e 3 ':15--)D I D /a41 .`"--- 1- a F5 b g el rr• c vo 1 rYv cg V �u�3 T'7. s`�Qyj�t� --�--`� 1 5 L ;off rnSbIG t r C v' ) ) , (3 i i Q `^' A-to I '54 IC A/ °�•sw. `. e_t.9 616 1 k V e � tAi� v / r I (. •I;Dis4 a'5il3 I _�-�----! . L 5 10 . rrt I -- e -7 ! ,R. 1 - ' �/� 1�`t ate- (• (tp X33 I Boring# ❑ Boring i 116 II I ❑ Pit Grouni fib , ed. V ft. Depth to limiting factor in. �,�r Soil Application Rate Horizon 1 Depth Dominant Color Redox Description j Texture I Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu.S._. Cont. Color 1 _i Gr.Sz.Sh. "Eff#1 "Eff#2 I l I ! I i 1 I i I Boring# 0 Boring (_—I ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate_ Horizon I Depth Dominant Color Redox Description { Texture i Structure Consistence Boundary Roots GPDlft 2 in. Munsell Qu.Sz. Cont.Color _ 1 Gr.Sz.Sh. 1 —. *Eff#1 "r2 1 . 1 ! _ ,_ _ _________, _ ___ • , 1 . 1 a I , , . Effluent#1 =BOD .>30<220 mg/L and TSS=30 <1;=.0 Ma/i_ "Effluent#2=BOD ,<30 mg/L and TSS <30 mg/L T'lje Dept. of Safety and Professional Services is an ecua.i opportunity se juice provider and employer. 1f you need assistance to access services or need mate°ia.l in an aii:crnai,c format,contact the department at 605-266-3151 or TTY through Relay. seD-233ofRun1) ( 5eak: 1 'Ir. `io ' ' f fa°` _ , vire\ --,.....i> , L _ 5 E 5,; e o fCs a,, • Nw . s. ; e , S 4 �� k • , X!_..! v� JJ/f i La! ` { ■ ar w I I _ I ! i 1 ._ Sb. i .rte; i i_____,______T . Ili. 1 , • i i . , . . . , i i Sr ' 1 0 i ,__ i , , 1 at•, ,4. - -7 :. �5,�70 s« I $ t" i ►.6i1 5 i , ' i X1%5 t. •• • f �