HomeMy WebLinkAbout020-1136-90-000
40i,sconsin Department of Commerce County. St. CrOIX
PRIVATE SEWAGE SYSTEM
Satety and Build -)g D osior' Sanitary Pe'r`tit N0:
INSPECTION REPORT 584761
GENERAL INFORMATION (ATTACH TO PERMIT) stele Pla, ID NO:
Personal Yorrrat on you provide may be usec fur secnnd._ry f:.,rposes [Privacy Law. s.15.04 0)j,')1
Permit Holrrr's Narnc Ciry Village Towrsh o Paracl Tax No.
Patrick Miller T TOWN OF HUDSON 020-1136-90-000
c_~- BM Elev Insp. Bre Flov Bfd Description Secti_0rJow vH;mge;flap NO:
A ~l~r` 20.29.19.679
s 94.3 `f I i S r ~4, X7
TANK INFORMATION ELEVATION DATA
TYPE MANJFACIURER CAPACITY STATION BS HI FS ELEV.
Septic KS Bench orr (j ~x ?K i~Jl . 7 !
EX ►y~D o C
All. BM
3352 6K 0157, 5r. c a ~ 117 7. 17.
F!C- TEjN~ -a
Aeration I ~I ~~ci~ SZ5 Bldg. Sewer
Holding SUHt Inlet
SUHt Outlet Q
TANK SETBACK INFORMATION CwN .9 .7q TANK TO PL %NELL BLDG. Vent :o Air Irta.(e ROAD ot'Inle:
Septic - - - - - CX/5, ti%:S7 71 • ~t
f r HeadeoMan. o ; CI
Aeration Dist. Pipe
Holding Bot. System 7. S '
Final Grade
--,PUMPISIPHON INFORMATION
`.4a1iUf~acLrer - Demand St Cover
GPM
Model NumUr{r
TDI'. Lift - Notion Loss System Head F H Ft
Ina if) length Dia :hst. to (Nell
SOIL ABSORPTION SYSTEM
BED)TRENCH ;^Jid:h I_urgl i No Of Trenches PIT DIMENSIONS No. 71 Pits Ins de D a. Liquid Depth
DIMENSIONS -75' 101 Z
SETBACK SYSTEM TO `IL BLDG 'ANFLL LAKFSTRFAM LEACHING Marifacturer ~z~~/ D~
INFORMATION CHAMBER OR
Type Of Sys:em I
(oc1G~.~l 1 ~L lz ' UNIT docel Number
3
W-' Y 7D A /()q /2-L
DISTRIBUTION SYSTEM
Heade,,Marlfrl,i Distribution x Hole Size x IiDie Spacirq Vert tD,Air In:aku
e r Pipes)
cjr Le-gP, L Dia Length Dia Spacirq
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth C.c c T pth Over o Deptn of xt Seeded Sodded xx M~Iched
Bed,7-ench Center 3+ ` WTrench Edges I Topsoil yes No Yes Nn
COMMENTS: ,Inc.uce code discrepenr.ies, persons p•esent. etc.) Inspection #1: y -z E7 -~~F Inspection uc.
Location: ggq RIDGE PASS
1.) Alt BM Description = of F!c-)AP_ 7AAV UP
2.) Bldg sewer lenyth - 0-101110
- arrcunl of cover - N'4 (j k Plan revision Required') Yes V No
Use other side for additional information, uG L / KKK000 4 JJ~~~1
Cale hs pctOr's Sigral_„e Cert. No
SRD -f,"lu tFc.3ig7i
CEIVF=D
it eat tj, County
o '4 Si, Croix
`1 F1 MAY 2 ~Q b Industry Services Divisi
S 1400 E Washington Ave anitary Permit Numl er (to he filled in by Co.)
s P S~ CROIX COUNTY P.O. Box 7162
Y, Madison, WI 53707-7162 S F / / 0 6
`C UNITY DEVELOPMENT "j
Sanitary Permit Application Sta Transaction Ntxttbcr
fn accordance with SPS 383,21i-' i• Wig. Adm. Code, subnissuri ortlik forni to the appropriate g(verninemal unit
is required prior to obtaining a sanitan perm. Note: Application Bono Con ,tote-owned POWTS arc submitted to
the Deparment of Sa'ety and Prolcssionsl Services Personal mlbrmation you provide nwN be used for secondan Project Address i if different than mailing address)
purposes in ac ordarcc with the Privacy Law. I;')-H 1(111. Same 4943.4 ^1. Application Inform M' n - Please Print All Information 4:404m,
Property l woer"s .Name Parcel a
Miller. Patrick / C20-1136-90-000
Property Owner's Mailing Address Property Location
N84 Ridge Pass Go%'t. Lot
City. State Zip Code Phone Number N NW Section 20
I Indson . Wl 5401 ri (circle one)
T29N R19ForW
H. Type of Building (check all that apply) r3 PIB31ock 71 Q I of Famil}
Dwellirw umber oi' Bedrooms Subdivision Vwne
1~'illow Ridge addition
I i'ublicrConunercial Describe Case ❑ City of
❑ State Owned - Describe Use ❑ Village of
CSNI'Number
3 n 1 1 t w 1 ' lot ^ " ®Tovsn of 1 Dodson
III. Tvpe of Permit: (Check onl of one box on line A. Complete line B if applicable)
❑ Nevc S}st:m Q Replacement System [ ll•eatinenui lolding l ank Replaccme.iv Only ❑ Other Modri,ation :o xisting System (explain i
R. ❑ Permit Renewal ❑ Permit Rcvis.on ❑ Change of ❑ Permit Transfer to Ncw List I'revijus Permit Number and Date Issued
Before Lspiration Number Uwner -5015 4il5i1986
IV. T-,-Pe of POWTS SN,stem'Component,,Device: (Check all that apply)
0 Von-Pressurized In-Ground ❑ Pressurized "r-(imund ❑ At-Grade ❑ Mound ? 24 in. of.suitable soil ❑ Mound 24 in of suitable soil
❑ Holding'fank ❑ Other Dispersal Compon,ent lexplainl ❑ Pretreatment Device (explain)
/ 2
V. Dia ersaliTr•eatnt nt Area Information: r
Design Flow (-pd) Design Soil Application Dispersal Area Requir i<I ispcrsal Area Proposed (st) System He,,
- 1 G 1
41 R tt !(gpds0 643 9800' /
r
NT Tank Info Capacit} in
Gallons
t J J
Total « of' Marutfaclurer r J -
Gallons knits n - = O -
New Taaks Esi::uar Lc,ks ro I _ ✓ r, f -
Septic or Holding Tank 320 1000 1320 ~l ieser Ak cek's _ ❑ ❑ ❑ ❑ _
Dosing Cha,r.hrr ❑ ❑ ❑ 0 ❑
VII. Responsibility Statement- I: the undersi(;ned. assume responsibility for installation of the POWTS shown un the attached plans.
I lunitc:n*s Name (Print) 'lu Si- route NIPAIPRS Number Busmcss Phone Number
, I tnh,~e f
John Schmitt y' fL n/z 223760 715-760.0486
'lumben's Address (Street, City. State. Zip Code)
1, 16 150;11 Ave.. Somzr~er. b4'1 54025
VII ounq,1 )e artment Use Only
Approved ❑ vc Permi~Fdee `Dat; Isssuue lssuin gent Signature
VV Ciut ~n Reason for Denial 5 { O J I /
1X. Condiibl~i~rRets Disapproval 21 f _ ~l
e uen i .~11 ! a sAA~- ~C t't °~t,'t !4~
pi"r::si cell crust all bg ~t:icess?int
as par management plan pro Aded by pk rnber.
2. AU sefbtick ragturet-tents rnu t. twtu wkiried
as per appN zWe cade / _rditt on,.
- kuach to cumplen• plan, Il,r the 1satcmt and submit to the Count, onh on paper nut less than N t : 11 inches in si1c
til3l) !u` S iR01 141
PLOT PLAN
Pro;ea Name ; Milier 3 Bedroom Replacement Septic System
-eaal Description: NW1;4. NWE1J4, S20. T29N, R19W P.I.D. 020-1136-90-000
5unliv siar Name. Willow Rid a 2nd Addition Lot # 70
SCALE: 1 "=40'
Tow sh:p: Hudson 'arcel Size: 1.75 Acres
Cn,ir y St. Croix
System. Elevatior:{ 96.3 Existing 18'x36' Bed _
Slope 3% iTI= 98.00' Proposed 45.00' EZ Flow Trench
A BM1 EI~vancn 99.39' ! Existing septic tank outlet T2= 98.00' Proposed 45.00' EZ Flow Trench
BMA Elevaf cr. I T3= 98.00' Proposed 45.00' EZ Flow Trench
■ Backhoe Pits.
Existi-9 TanKs (S11 Week's C. P. 1000 gallon
See Plat Map for complete view of parcel New Tank ;K) Wieser Concrete W320-MR
Fttlupn- Fr'ter Polylok 525
inch Sch 40 -AS-M D2GG5
I» Inc ASTM D3734
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Page 2
CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Miller 3 Bedroom Replacement Septic System
Owners Name: Patrick Miller
Owner's Address 884 Willow ridge Road
Hudson, WI 54016
Legal Description: NW1/4, NW1/4, S20, T29N, R19W
Township Hudson
County: St. Croix
Subdivision Name: Willow Ridge 2nd Addition
Lot Number: 70 Block Number
Parcel I.D. Number 020-1136-90-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 Valve Information
Page 6 System Sizing & Cross Section
Page 7 EZ Flow Information
Page 8 & 9 Management and contingency plan
Page 10 Existing Tank Certification
Page 11 Septic Tank Maintenance Agreement
Page 12 & 13 Warranty Deed
Page 14 CSM or Plat
Attachment 1 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 5/11/2016 Phone Number: 715-760-0486
Signature: ~71 ~A /L //L
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN N
Project Name: Miller 3 Bedroom Replacement Septic S stem
Legal Descriptior- NW1/4, NWE114, S20, T29N, R19W P.LD- 020-1136-90-000
Subdivision Name: Willow Ridge 2nd Addition Lot 70
Townshio Hudson Parcel Size' 1.75 Acres SCALE: 1"-0'
County: St. Croix -
System Elevation 96.3 Existing 18'x36' Bed
Slope: 3% T1= 98.00' Proposed 45.00' EZ Flow Trench
A BM1 E evatioi: 99.39' Existing septic tank outlet T2= 98.00' Proposed 45.00' EZ Flow Trench
BM2 E evatioi: T3= 98.00' Proposed 46.00' EZ Flow Trench
■ Backhoe Pits:
Existing Tanks (S1) Week's C. P. 1000 gallon
See Plat Map for complete view of parcel New Taik {S2) Wieser Concrete W320-MR
Effluent Filter Polylok 525
4 incn Sch 40 -ASTM D2665
4 i-Ich ASST~T~M D3034
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Page 2
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Page 3
P~L~~ INSTALLATION INSTRUCTIONS
Inc
aYd~~Sr ^r,~al,A IC~Ei P-w'uk1C. PL-525/PL-625 FILTER
b Vi'dstewater ~ro:.'..its
INSTALLATION INSTRUCTIONS
Center fi'ter
,i th opening
f~
D _ w z
J~
EL-C)
_ O
Additionai pipe or -
Polylok Extend & Lok Glue
for centering.
Step 1: Step 2: Step 3:
(A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
is positioned so the filter can be housing, making sure the filter
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS
IA.
~ r ,mot t",
p
I
I
Step 1: Step 2: Step 3:
Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back
if necessary. into the the housing making sure
' • •
_ ~ _ • ~ (B) Pull the filter out of the housing. the filter is properly alighed
(C) Hose off the filter over the septic tank. and completely inserted.
USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover
WHEN CLEANING FILTER septic tank. Page 4
American Manufacturing Company Bull Run Valve Page 1 of 3
xo •
Home About Site Map Order Info Training Videos Contact Drip Systems
Treatment controls Products Downloads Design Guidance
'THE BULL. RUN" VALVE
YW1TB~-TI4FIr
f f AOCESS CAP
r
RISER CAP
ADAPTER
RISER
TUBE
VALVE DIRE%`T10N
HANDLE
The Bull Run ValveT'^ is designed to split flows to septic
fields or systems. In addition to the advantages of f OUT PORT
longer life and easier installation it is the most public C OUT PORT
health safe alternating device available for wastewater
disposal applications. The use has absolutely no contact
with wastewater due to the valve's leak-proof and
external operating characteristics. The change over from Ar IN PORT
one drainage field to another can be accomplished in
less than a minute by simply turning the valve without
digging or contact with wastewater. The Bull Run Valve is available in 4" sch 40 pvc
and is suitable wherever septic disposal systems
are used - in commercial, industrial, and
residential applications.
OPERATING THE VALVE
The direction control handle should be rotated
Field Field V~. periodically to direct effluent to one or the other
No.1 No.] of two septic fields. After removing the screw
cap at the top of the riser tube, the valve handle
Valve can be turned with the valve key furnished.
Positioned BULL RUN VALVE
on No. 1 B Co
mplete Valve Kit
during during
Odd Years Septic Septic Even Years Contains
Tank Tank 1. Bull Run Valve body
2. 28" Valve Key
3. Riser Cap Adapter
ITEM DESCRIPTION 4. Watertight Access Cap
BRV4 BULL RUIN VALVc 4"
Page 5
Zile:.r%C:~'L'sersi.lohn?~:~?OSehmittr'Desktop:.iohnlr\merican°-o2llttat~tpacturin°~2O( ~~mhany"~;?(I--°-o?QF3ull°~?... x`11,'2(116
SOIL ABSORPTION SYSTEM DETAIL ! GRAVELLESS LEACHING UNIT
Project Name: Patrick Miller
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
EZ1203H-St. 5.7 25.0
1~=dtrator
EZ1203H 10h 10c ' S0 C
System Sizing
EISA Rating per Foot of EZ Flow 5 ft` Soil Application Rate 0.7 gpd!ft`
450.0 gpd Design Flow Soil Application Rate - F5 I EISA = 128.6 Feet of EZ Flow
F2 0 ]trenches 65 feet long each
3 No. of Cells 4.5 Per Cell
3 ft Cell Width 13.5 Total No of 1203H
45 ft Cell Length 225 sq ft EISA Per Cell
3 it Cell Spacing 675 sq ft Total EISA
Typical Cross Section
Finished Grade 1C2 Ft Observation Pipe with
approved cap or vent
Soil Backfill
s ~
36 inch c Geotextlle Fabric
12 inCl1 0 I O Slotted and Anchored Vent/Observation Pipe
with Cap
98.00 ft infiltrative Surface
F>36 inch
94.98ft
x-. .
Plumber/Designer Signature:
License MPRS 223760 Date: May 11, 2016
Page 6
Installation Instructions for EZ TM
E4#,w Systems in Wisconsin by INFILTRATOR
'A"sconsin Deoa-tmcnt of Ccmmerce. Safety and Buidings 5. The Absorptior area (SF) necessary for a giver site shall
Divis on, has reviewed the specficatons and / or plans for _h s be sized based on maxirrum daily sewage f'ow (GPD) and
product and determined i. to oe n compliance with chapters : the Pe,rreability fo, the site. If certain cl is met, the
Coma 82 through 84, Wisconsin Admin. Code, and Chapters ; EISA siz ng can be used in Wisconsin, resulting in a 409!)
145 and 160, Wiscorsin Statutes. All sites must meet the Site smaller drainfield,
& Sol Conditions & Locations & Isolaton distances as noted in
ocal regulations. G. Place EZflo~,v bund e(s) n the EZflow configuration ap-
proved by system design oermit specif ed for the particu-
Tl-e approved products are 1203l-- iS-12" ourdles .vi-h pice n lar site. The top or center-most bundies containing pipe
rteeter bundle in b' or 10' lengths) and ' 203HP 13 2" bund es are joirec enc to el with an internal pipe coupler. Any
N th pipe in each bundle in 5' or 10' lengths, additional aggregate only bundles :hat may be required,
• should be butted against the other aggregate-only bur-
s single pipe bundle contains a four inch perforated pipe sun- cles and do net require any type of connection,.
rounded by EPS aggregate and is held together with poly
ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cyl rider contains a filter fabric p,e-
cnly and is held together w th polyethylene netting. manu'actured in between the netting and aggregate. The
fab- c is irse ted to prevent soil intrusion. The installer
Materials and Equipment Needed : shall make sure the the GEO is positioned upward and is
• EZf o,.v R.r,cle~ : in contact with he fabric contained in .he adjacent cylin-
• EZf ow Gectextile Fabric : der before backfilling.
• EZtow 6nternal Pipe Ccu7lers
• Pipe for Header enc Irlet 8. The EZflow Drainfield Systems should be installed in a
• Backhce'Fxcavatn, level :rench in all directors (both across and along the
trench bottom) and sheulo follow the contgur of the ground
Installation Instructions surface elevation (uniform depth), with all continuous
1 he instruc.ions for i•rsrallation o- EZflow products are given adjoining 10-foot cylindrical bundles placed end to end,
rjclcw. I his p,oduc: must be installed in accordance with state with central bund e distributor p'pe interconnected,
rules defined in chapters Comm 82 through 84, Wisconsin Ad- : without any dams, stepdowns or other water stops,
rninistrative Code, and Chapters 145 and 160, Wisconsin Stat- :
utes, as well as the loca' health departrnert's current design 9. The tench top shall be graded such that wate• will not
manual. pond. Backfdl should be seeded or sodded immediately
aster comoletior to reduce erosion.
1. After the local health depa t rent nas determined siAry,
r_orfiguration, and layout for the EZflcw systems, sta-e 10. EZflow EPS bundles are flexible and can fit in curvet
or -nark with paint the location of trenches and lines. 3e trenches as may be necessary to avoid trees, boulders, or
ca eful to set correct tank, 'nvert pipe, header Inc or dis- other obstacles.
IriLutien oox and t,encn bot crr elevat ors hefcre nstai-
lat on of pipe bundles. 11 . EPS aggregate is lighter than water, therefore, it might
be expected that natural buoyancy forces would tend to
2, Remove plastic EZflcw snipping hags prior :c placing cause EZflow assemblies to float cut of ground when
bundles in the trench(es). Remove any plastic bags in the pending occurs. Field experience has shavn, however,
:rench before system is covered. that this is rot a prebtem when systems have a minimum
of G' of soil cover as recommended by manufacturer.
3. This product must have geotextile fabric that meets re-
quirements of s. Comm 84,30 (6) (g), Wis. Adm. Code,
installed direcay on top of the product and extending 1203H-GEO
down alcng the sides of the product to a point at least six
inches from the bottom of product. ~e tong io
• 3arrier Material
4. When nstalled in a trench, the trerch should be cug to ( j
a width of 36 riches. This not only saves laoo- in excava
tien, but also provides better load-oearil capacity ai'e
backfillirg is ccrnplete,
..............................................................................PaO67..... .
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner. Patnuk ^.hlle[ Tank Manifacturer Wieser Concrete L- NA
Pernit * ] Septic ❑ Dose ❑liolding Volume 1000 gal
DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete ❑ NA
Number of Bcdroorrs 3 NA Septic l,J Dose ---)folding Volume: 320 gal
Number of ?ublic I-acdity Units NA Vertical Distance Tank Bottom(s) to Service Pad ft
Estimated (average) Flow 300 gallday Horizontal Distance Tank(s) to Serivice Pad: ft
Design Flow = estimated x ' 5 450 gallday Spec`c seroiurg mecnanres must be provide i1 vodica s-1E `get of d
In Situ Soil Application hale: galidayM2 rarzanta s 150 fee:. 3peci c instnrctors to to proviclod an track
Standard Domestic InfluenUEffluent Monthly average Effluent Filter Manufacturer: POLYLOK ❑ NA
pats, oi,s & Grease (FOGY s3) ng~L F-Muent Filter Model 525
Biochemical Oxygen Deward ;BODsI :5220mglL ❑ NA imp anuacturer
Total Suspended Colids JSS, =150mg1 Pump Model:
High Strength Influent/Effluent Monthly average Peveatment Unit NA
Fats, Oils & Grease (-oG) S30 ,r92- Manufacturer:
Biochemical Oxyger Demand (90n=.'> t=Cwq,L 0 NP, L7 Mechancal Aerauon U Peat Fmw
Tots Sus perded Solids (TSSI 515Crrgi_ F Csir`ector ❑ "euanc
Petreated Effluent Monthly average C Sa,)do(3ravel F tar C ocher
Biochem cal Oxygen Demand (20C_1 530mg1 oI so tion System F_
Tctal Suspended Solids ( i SSj 533mg!L F NA LJ In-G-oun: mavity; In-Ground ;p-essu•e:
Fecal Coliforrr (geometric meat} 51)acful100ml ❑ :-race ❑ mcu,d
Maximum Effluent Particle Size. % in dia- LANA ❑ E,-p-_ 1E, ❑ Other
other: Other: NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
~Nhen combined with sludge ano Scum equals one-third of tank volume
Pump out contents of tank(s) When the high water alarm is activated
Inspect condition of tank(sl At least once every 3 mortFsy (Maximun 3 Years) ❑ NA
vearlsl
At least cnce every 1.5 morth;s) (Maximun 3 Years) C NA
Inspect dispersal cei(si = vearisl
At least once every: r F mortf;s) C NA
Clean effluent filter yearts
morth;s) Q NA
Inspect pump, ourcp ccntro's & alarm At least once every: IJ y ear's
mau7(s1 ] NA
Use new drainfieid for 5 years Once every 5 ar }
1 moral (s; -
Alternate between old & new Once every 1 NA
= • gar sl
drainfields annually or as indicated oy
inspection
MAINTENANCE INSTRUCTIONS
Inspecticis of tarks and dispersal cells shall be made by an indiv dual arryirg nne of the to 'owing licenses o, certifications Master
Plumbe•. Maste• =lumber Restricted Sewer. PON47S Insepector POV."I S Maintainer. Septage Servicing Cperator (pumpers. Tank
inspections must include a usual inspeciton of the tank(s) to identify any m ssing or broker hardware, identify any cracks or leaks.
measure the volume of combined sludge and scurr aid a check for any bacx up of pond ng of effluent on ground surface The
c spersa! cell(s) shall be visua y inspected to deck tie effluent evels in the obsevatior p pes and to check for any pording of effluent
on the ground surface. The bonding of effluent or the grcurd surface may ind cared a failing condition and reeuires the immediate
notAcation of the local regulatory authonty
When the combined acc irtualtior o° s .edge and scum in any treatment tank equals one-third ('/h; or more of the tank vo'ume, the entre
contents of the tank shall be rem, ved oy a Septage Servicing Cperator and disposed of it accordance v; th chapter NR 113. Wisconsin
Admir nistrative Code.
All other services. ;ndud ng but rot limited to the servicing of efuent'ilters, mechanical or pressurized components petreatment ur ts,
and any servicing at intervals of s 12 morths, shall be performed by a certified POW-S Maintainer.
A service report shall be proviced to the local regulatory authority within 3C days c° comp'etior e` any service event.
Page 8
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatmert tank{si for the presence of pa rt ng products, solvents or other
chemicals or sediment that may impede the treatment process and!or damage the soi dispersal cell(s). If high concentratiors are
detected have the contests of the tank(s) removed by a septage servicing operato• prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface
During extended power outages pump tanks may fill above normal highwater levels. When power is restored Me excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent
To avoid this situation have the contests of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pumo 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
Reauction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POVVTS
antibiotics: baby wipes; cigarette butts; condoms, cotton swabs, degreasers: dental floss diapers: disinfectants; fat; foundation dram
;sump pump) discharge; fruit and vegetable peelings; gasoline: grease: herbicides, meat scraps; medications, oil. painting products:
pesticides sanitary napkins; tampons, and water softener bane.
ABANDONMENT
When the POWTS fads and!or is permanently taken out of service the follow ng steps shal be to<e.n to insure that the system is croperly and safely
abandoned in compliance with chapter Comm 83.33. Wisconsin Administrative Code
• All piping to tanks, pits and other so !l aosorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly d'sposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and rerlcverd or their covers removed and the void scace filled with soil.
gravel or another inert solid materia'
CONTINGENCY PLAN
If the POWTS fails and cannot be repai•ed the `olle'w rg measures •iave been or must ce taker. tc provide tie oppohunity tc ootain a sanitary permit for
a code compliant replacement system
❑ A suitable replacement area has been evaluated and may be utilized for the ocation of a replacement soil absorpt,or, system
The replacement area should be protected from disturbance and compaction and snould not be infringed upon by required
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will resu.t in the need for a new soil
and site evaluation to establish a suitable replacement area Replacement systems must comply with the u es in effect at the lime of the r
permd issuance
❑ A suitable replacement area is not available due to setback ardror soil limitations If the soil absorption system carrot be
rehabilitated and barring advances in POWTS technology a holding tank may be installed as a last resort
[ The site has not been evaluated to 'dentify a suitable replacement area. Upon failure of the POWTS a soil and si,e evaluat on
must be performed to locate a s rt t;' r r.l~cer rt a•ea If r° r:.t-' rri
replace the failed POWTS.
❑ Mound and at-grade soil absorpti- a*
surface. Reconstructions of such sysisms rnst r.<~n;i;,y m-h trr, runs ITi arfec: at that erne
WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE DEATH MAY RESULT ESCAPE OR RESCUE r-ROM THE IN-ERIOR OF A TANK IS VFRY DIFFI, tit
ADDITIG',A_ i`•!-b R,P.'.~Tlr~h.
POWTS INSTALLER POWTS MAINTAINER
Name John Schrrtt Nare: John Schmitt
Phone 715-730-0488 Pnnra 71b-'60-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Owl Cnoice Name St Croix County ZorIng
Phone: Phrie 715-38111
i his document is intended tc rreet minimum requi•ements of Ch Comm 33.22(2)fbi(1) d)&ffi and 93-54!') '2i & i3} Wisconsin Administrative Code
Use of this document does not guarantee the performance of the POVd'S
Page mss;
ST. CROIX COUNTx
SEPTIC TANK MAINTENANCE AGREEMEh
AND
OWNERSHIP CERTIFICATION FORM
Owner%F3uver Patrick Miller
Mailing Address 884 Willow Ridge Road
Property Address Same
(Verification required from Planning & Zoning Department for new construction.)
City/state Hudson, WI 020-1136-90-000
Parcel Identification Number
LEGAL DESCRIPTION
Hudson
Property Location NW , NW Sec. 20 , T 29 N R 1 9 W. "Down of
Subdivision Plat. Willow Ridge 2nd Addition Lot # 70
Certified Survey Map # Volume Page #
Warranty Deed # (before 2007)Volume , Page #
Spec houseavsEltu Lot lines ir.'cntitiahlr E]~cs0ntl,
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its nrcmaLire iaiIurc tv handle «astc,. vror
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What
the system can atlect 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 j, the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set tbrth, herein, asset by the Department of Safety And Professional Services and the Department of atural 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 ys of the three year expiration date.
1/we 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 watra deed recorded in Register of Deeds Office.
er of b rooms
SIGNA GRh; 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 ofthe certified survey man is
reterence is made in the warranty decd.
(REV. 04/12)
Page 11
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Page 14
I
DEPARTMENT REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IP.D'DS JSTRY, t c DIVISION
-ABOR ~Uh ANA ELATIONS PERCOLATION TESTS (115) MADISON WI 3707
(1163 090) St Chapter 145.0451
LOC TION. 'I ON: - ITOWNSHIP~ PAI.~^11CIPAl tTY OT NO.: BLIi. `Jtl: 17 SUBDIVI ION NAMJE.
CUUNI y: OWNEH'Sr6 Y R/'S',NA ~J' 1A1L J R ss: l
USE DATES OBSERVAIRI S MADE
`a.~--,~++ NQ ES@ORMSC' CUMM H~j AL UESCRIPTIO ~s. PAb-_FII y nrgRIPTIONB• PPRf.O A /Z" J RAT-ING. S- Sit. suitable for system 11- Sitn/umuitable for system
1 Jv 11U M U~IN C C,UIFtE: _.EEM-IN-FIL OLDIN TANK: RFCOCr1 F! iln c7 l~f)/
IRS I If Prrcclat vn Tests are NOT reyu/y~~{~d,~ Ls LSIGN HAVE.
J/ It anv -i ..of the tested area n in the
,nder s,I lG3,U9{r~llb), indieateo-yr _ L 3 _ I Flcuo, lain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
SUHING -T0' pTH TO G R OUNDWATER-I NCLIES CHADACTCI I -UIBOIL WITH TH ICKNLSS, CO LOH. 1 LX I UH L, AND ULPIH
`J MPFR ;~P"ll IAt cLEV ATION QFISERV _U EST. IIlUTTI TJ BLIHOCK IF 118SER11ED (SEE A86HV. UN BACK.)
7, iv'
76 1
r
r - -
i
' B 5 7 III ~,y' y . c ! c7 i i . ii y y -
r i,
i
PERCOLATION TESTS
IL:iI DEPTH WATER IN HOLE TEST TIMF DROP N WA77RI EV L IN .HFS RA-'F MINtITFS
'vl!MRFR NCIIES AFIEHSV.LLLING INTERVAL-MIN. PE 1QD• _.-PE RIDD2 R PER INCH
PL J
F•.
Il
sr-
1 I
P le
r-
P j
- T
I d d I -
PLOT PLAN- Show locations of percolation tests, soil b,-,
rontal and vertical elevatiur mlerenea. points and show th,
rvl land slope, C.#}
SYSTEM ELEVATION
- y'
4.71
r I yc
I r
i. 9dersigned, hP.rehy certify that the soil netts reported on this forte were made by me in accord with the procedures and methods srvrcified in the W1 Sr 1-n
:elm-nistrative Code, and that the data recorded and the location of the tests are Correct to the best of my knowledge and belief.
NAMEFn inf F IESI~ YERC OMPLC TCU7N.
/rah
OUHLSS: !CERTIFICATION NUMBER: PHONE NUMBER{opuonali ~
1 ~
kf.~G<<.~ 33 /fi, Se, 51o'6 C5i a,3yr? - 3bL Gy 3 ~
'csI SIG f
i
DISTRIBUTION: Original and one cr:oy to 1 ncal Authnnty, Prope•ty Owner nrd Soi I
DILI In S1`111-6395 1R. 02/821 - OV t h -
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that ( have inspected the existing septic andlor dose lank
presently serving the following residence:
(Street address) 884 Ridge Pass located
at: NW `/a, NW '/4, Section 20 , Town 29 N, Range 19 W,
Town of Hudson . 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 SPS. 384.25, and it (they)
appear(s) to he functioning properly.
Most recent date of inspection or ser-,,,ice
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 1000
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): Week's Concrete Products
Age of Tank (if known): 30 years
Permit number (If known) 75015
le John Schmitt
(Lic lsed Plumber Signature) (Print Name)
MPRS 223760
(Title) (License Number) MP/MT`
5/11/2016 7- ~L
(Date)
Form to be completed by licensed plumber (Dept of SafE
Services Chapter 305 and s. 145.06, Wisconsin Statutes) disposer
(NR 1 13 Wisconsin Administrative Code)
Rev. 212012
Page 10
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Parcel 020-1136-90-000 06/29/2005 10:28 AM
PAGE 1 OF 1
Alt. Parcel 20.29.19.679 020 - TOWN OF HUDSON
Current XST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
PATRICK R MILLER * MILLER, PATRICK R
884 WILLOW RIDGE RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 884 RIDGE PASS
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.750 Plat: 2624-WILLOW RIDGE 2ND ADD
SEC 20 T29N R1 9W WILLOW RIDGE 2ND ADD Block/Condo Bldg: LOT 70
LOT 70 EX.04AC TO HWY
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/12/2003 746433 2455/01 WD
1094/234 WD
742/315
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.750 36,800 158,900 195,700 NO
Totals for 2005:
General Property 1.750 36,800 158,900 195,700
Woodland 0.000 0 0
Totals for 2004:
General Property 1.750 36,800 158,900 195,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 140
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Dorm - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER K"tli Ie TOWNSHIP U( SC)1`.1 SEC. Q16 _ T 9 N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
W' JW -D, I
SUBDIVISION (1 13 , f~ LOT LOT SIZE
PLAN VIEW
f Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3d~Jr7
L~J
a ~
INDICATE NORTH ARROW
r. t
3~1
BENCHMARK: Describe the vertical reference point used
€p,
Elevation of vertical reference point: ~Q(1 Proposed slope at site: u
SEPTIC TANK: Manufacturer: ~~-q k Liquid Capacity: A }
Number of rings used:_ Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side,O Rear, -7 ~ feet
From nearest property line Front, 0Side, 0Rear, 0 - l feet
Number of feet from: well building: IT (Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
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e
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:TTaM waa3 jaa3 3o aagwnN
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:IaTui 30 uoTqunaTH
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l~
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9 '•~g ~`aEag `aPTS U `~uoa,I :auTT 6laadoid isaasau woa3 laa3 3o aagwnN
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:uoTIunaTa xus3 3o wollog :19TUT 3o uoTIunaTa
:aaanjou3nuvN uogdTS/dwnd :TapoN dwna
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2 a, gKVHO dNfia
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
L4BOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
97dONVENTIONAL
' ❑ A LT E R NAT I V E Slate Plan LD. Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If as signed)
NAME OF PERMIT HOLDER: =R.R. HOLDER
DATE.
Arnold Bertelsen Willow Ride II2 Hudson-
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
EV.: JCST REF. P ELEV.-
NW NW, Section 20, T29N-R19W, Town of Hudson, ot#70 Willow RidgName of Plumber
TII
MP/MPRSW No
mit NumbeRichard Hopkins 1059 St. Croix 15
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL
LOCKING COVER
9~ EJ~ PROVIDED: PROVIDED'.
BEDD ING: VE'NT DIA.. VENT MATT HIGH WATER NO
f7 c/S ES ❑NO ❑YES
ALARM NUM ER OF ROAD. PROPERTY WELL. BUILDING: (VENT TO FRESH
❑YES ❑NO C" ` FEET FROM LINE AIR INLET
❑YES ❑ N O N_EA R E S T ~ 7j ly~j`~ G.- ~ 7
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODE L. p
UMP; SI PEION MANUF AC 7l1R Eft WARNING LABEL LOCKING COVER
❑YES ❑NO t PROVIDED. PROVIDED:
GALLONS PER CYCLE: PUMP AND C r PERATIONAL ❑YES ❑NO ❑YES ❑NO
(DIFFERENCE BETWEEN NUMBER OF PHOPFHTY WELL BUILDING I VENT NLET FRESH
4.11 LINE E
PUMP ON AND OFF) FEET FROM AIRINLET:
ES ❑NO NEAREST lop
SOIL ABSORPTION SYSTEM. Check the soil moisture a thedepth fplowing of nAMErEEi MATEHInEANDMARKwG
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTH PIPE SPACING COVER
/ ~ TH%NCHES NIATEHIAL INSIDE DIA PITS LIQUID
DIMENSIONS 0 3l PIT DEPTH
EI `~'FL DEF TI! FIL DEPTH DISTV H. PIPE DISTH PIPE DISTR"PIPE MATERIAL NO (7I ,.THE
BE LOW PIPES ABOVECOVEH EI . INLET 'IS ENE) NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
n / f PIPEFEET FROM LINE AIFV4)TT .
f NEAREST-i- 9 a s :1 wa >
MOUND SYSTEM: -
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES NO meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER TEXTURE
PEHMANE NI MAH KF HS OTION DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED ❑YES ❑NO YES ❑NO
CENTER DEP 7H OF T(1PSOIL SOOOE I)
EDGES SEE DED MULCHED
❑ ❑NO ❑ ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM: :]YES. NO ❑ YES Y ES
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES: FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATER N-0-T) ISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL -MARKING
ELEVATION AND ELEV. ELEV CIA ELEV PIPES DIA
DISTRIBUTION
INFORMATION HoLESIZE LE SPACING DRILLED CORRECT Lv I
COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: - -
Gi] NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST-
_70
-J - a
Sketch System on
` Retain in county file for audit.
Reverse Side.
SIGNATURE:
TITLE
DILHR SBD 6710 (R. 01/82) '
Mw wii;consin APPLICATION FOR SANITARY PERMIT
wisconsin APPLICATION FOR SANITARY PERMIT
ILHR
(PLB 67) OUNTY
MMMEM" T OF
inOUSTRV /j UNIFORM SANITARY PERMIT #
- nOUS,LR LFiBOR 6NUTFnRELFiT10n5
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPE TY OWNER MAILING ADDRESS
No k- 1 S0, 1 I
PROPERTY LOCATION CITY:
N01/4NW1/4,S To 9N, RI E (or
Vw
LOT NUMBER BLOCK NUMBER SUBDIVISION NAIE NEAR
ESI D, LA OR LANDMARK STATE PLAN I.D. NUMBER
i oW I rA 41
TYPE OF BUILDING OR USE SERVED _
K 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): C0 I ~
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ AlternaA System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Nd Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ^ ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Con ete Constructed Steel Fiberglass Plastic
Septic Tank Capacity U V
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total Of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPGO~SED (Square Feet): WATER SUPPLY:
1 U ii,r7/ / Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Na of Plumber (Prin Signa e: 11 /11/11 No.: Phone Number:
Plu er,'s Address: Nam f Designer:
e,
COUNTY/DEPARTMENT USE ZONLY
Sign at re of Issuing Agent: F e: Date:
J / ❑ Disapproved
a ' Q~~J / (Q Cl .?~j ❑ Owner Siven Initial
ved A
Reason for Disapproval:
dverse Determination
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
iNDUS
DEPARTMENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,
LABOR AND P.O. BOX 7969
PERCOLATION TESTS 115l DIVISION
HUMANRELATIONS
(H63.090) & Chapter 145.045) MADISON, WI 53707
LOCATION: SECTION.. TOWNSHIP/M NICIPALITY: LOT NO.: BLK. NO.: SUBDIV ION NAM :
%TN/R E (or S~
C UNY°°: OWN R'S/B Y R/S~NALL Al LIN ADDRESS: _ ~ 4
k )e lr1~l~~ ~Jt'~ T~SO ~ ..1 ~/l•
USE
NO. BEDRMS: COMM R IAL DESCRIPTION: DATES OBSERV TIO S MADE
esidenceew ❑Replace PROFIL DES RIPTIONS: 31 K5 -7V=
RATING: S= Site suitable for system U= Site unsuitable for system
C rTIONAL: MOUND IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDIN TANK: REC/OMMENDE SYSTEp~:(o tin ) ~c
If Percolation Tests are NOT requ" d DESIGN RATE:
under s.H63.09(5))(b), indicate: /0 If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation: /V
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I ~LEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 7~ We > 70d° J, S" ,5 f as
s av. sl~ r •N n
B-Z d1` 0~I/ O" >7,62
r
13-3 102 ,71 r7~ >
B- ),2 z DAL - 1,2L` 1A. sl J125 ` lief On 1 71os' a.-, s
B- 5 7 ~ % 99' PhG > ~.9a' r , L Y. 7~' &A, s16
r
B-
PERCOLATION TESTS
NUMBER INCHES AFTER SWELOLING INTERVAL-MIN' DROP IN WATER LEVEL-INCHES
PERIOD t RATE MINUTES
PERIOD2 PER] D PER INCH
P-
P- 309
S
P / e
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
E
l
,
E
;alit
t ,
i E
3
97
. 3 I r
t N
_
E
E
r
c5
6
. r
I
P
E 3
-"46
= ~ f
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME rin
~1 ~ TESTS ERE OMPLETED ON:
ADDRESS: 3 1
33 Sep, CER IFICA ION NUMBER: PHONE NUMBER (optional):
lJ C
CST SIG T
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LDILHR-SBD-6395 (R. 02/82) - OVER -
I ST UCTI I 'S.. , OMPL °TING FORM 115 - S - 5535
`Co be a complete and accurate soil test, -ur report mace il~CIUCle.
1, Complete legal clescriptio i;
2. The use section must clew` this is a r€ e or c
3. MAXIMUM number of «r, rcial use plar d;
4, Is this anew or r(-
5. Complete the IS SUITABLE FORA HOLDING TANK ONLY IF ALL
OTHER SYS E EIS ON SOI L CONE 1S,
s profiled' rpleting the plot plan;
6. PLEPcF o-e the
wCIF'_ t scale is preferred. A
7. M
`,owtl' at, re permanent;
i, pe tE st exemp-
as to ,
uch as flood plain, elev oes not
1C.
y
11. si(V _d place your current addrt t ~ ~ _LD ITH THE
12. Make _ and distribute as re, _ _L
LOCH VI`t"HIN 0 DAYS O.
,TION! F( --IFIFC SOIL TESTERS
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