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HomeMy WebLinkAbout034-1031-60-000 '610scens n Deoa tmert of :.orr-nerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT San tary Permit No GENERAL INFORMATION (ATTACH TO PERMIT) State ❑ an 0 1•,~ 582086 Personal iforrraton you plovide may be used for secc)dary purposes [Privacy Law, s 15 04 (11(1 Permit Holder's Name City Village Townsnip Parcel Tax No Theodore &Theresa Shackett TOWN OF SPRINGFIELD 034-1031-60-000 CST 2M Elev Insp BM S'ev BM CesnriptiDn actor Tovn,Range,'i No 14.29.15.220 TANK INFORMATION . ELEVATION DATA TYPE MANUu+C L• CAPACITY STATION 0S HI =S ELEV. Septic & ii "1 17,% Denchmar~ Dosing T Alt 3M Al' 71 y ~U Bldg. Sewer 1J~ / /v 6 J I1?.~it]t? 5 ' t Int uetlet q,52 i I TANK SETBACK IN MATION t1 t Outlet TANK TO P'l LL BLDG. vent to Au Intake ROAD Dt Inlet V Septic Dl Bottorn Dosing HcaderlMan. Aerator Dist Pipe I Io ding ot. systdrilif Fria Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover 10V- 3z o C) Mod umber TDH Lift =riction Loss S ead TDH Ft Forceil -erTgm DIa Dst to'A'ell SOIL ABSORPTION SYSTEM BEDITRENCH Width Length iNo Of "•enrhes PIT DIMENSIONS Na C)f Pits Inside Liqu d Depth DIMENSIONS SETBACK SYSTFfv1 T iL JiLLL [RE=AM LEACHING Manufacturer. INFORMATION CHAMBER OR .r pe Of $y3 UNIT Model ',umber: DISTRIBUTION SYSTEM Feacer,Van `clc Distr oution x rule Hole Spaang Vent to Air IntakP{i Da Le^atn Dia Spacin SOIL COVER x Pressur s Only xx Mound Or At-Grade Systems Only Depth Over II .er xx Depth of xx Seeded,'Scdced xx Mulched Bed'Trench Certe• Be:F renc-) Edges Yes No --'Yes No J - COMMENTS: iscrepencies, persons present, etc.) r~S Inspection #1 ~ I~p~ tr' n ~ C J 1,V~J I,~. Location: 3136 CTY RD E 11.1 Alt Btv1 Descnption = 1 L 1 G~ Cb V C V` tnA p rn 2.) Bldg sever length ' -amount of cover w•1oe,,~ a '4ig 'eAA DvC ) Lj22, drn V W ~\v be r ptivMl I,, Plan revis.on Requned7 ❑ Yes 10 'W w Use other s de for additional information. iZ NV/\ u I~ t 1 SBC-G; 1G (R.3+9; j Date I)- Cert. No. J ~ ~ rye L a -Ilk ~1 111 V v ~ 3 r ~1J i`,eeARTyfvr County \o RECEIVE Industry Services Division i s i 1400 E Washington Ave S utihtry permit Number (to he filled in by Co) PS P.O. Box 7162 i° S MAR 0 7 201 Madison, WI 53707-7162 State TransactionVumber C(DMM pyL 11@?* Application OF' " ccordancc with SPS 38;.2112), Wis .Adm Code, submission of this form to the appropriate governmental unit e, quired prior to obtaining a sanitary permit. Note: Application forms tor state-owned POW I'S are submitted to Project Address (if different than mailing act ess) ' KDepartment of Safety and Professional Services. Personal information you provide may be used for secondary L uses in accordance. with the Privacy Law, s. 15-p4{ I)(m), Slats. 1. Application Information - 'lease Print All I formati j operty0wricir amc eJj' l Parcel # ✓ 63`q - 1031- OCC) !~6~z Levy_ Property Owner's Mailing Address Property location f. ~ZZb 6vvt. Lot 1 L City, State Zip Code Phone Number ~ 'i:,51A) Section circle 4~~4 VlJ r S S_2S, `1 T29 N IL Type of Building (check all that apply) Lot # Xl or 2 Family Dwelling - Number of Bedrooms Subdivision Name ock 4 ❑ Public/Commercial - Describe I isc nl~ Ir City Of 0 ❑ Slate Owned - Describe Use E] Village of CSM Number ~JA_ O Town of 111. Type of Permit: (Check o rte box on line A. Complete line B if applicable) ID ^-4- 0 New System ❑ Replacement System TreatmcntlHalding'rank Replacement (fitly ❑ Other Modification to Existing System (explain) g ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Re for e Expiration Plumber Owner 7-5-0-el-111 Ty -z, e of POWTS S rsteniXorn onentiDevice: (Check all that apply) r~!'J'r Lo✓ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in of suitable soil ❑ Mound < 24 in. of suits Ic soil [I ing'lank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design low (gpd) Design Soil Application Dispersal Area Required (sY) Dispersal Area Proposed (sO System Elevation /,e 2d Ratc(gpdsi) 7 5,6 -7 V1. Tank Info Capacity in - - V Gallons Total N of ° _ Manufacturer Gallons Units = 2 b Neu "ranks Existing Tanks V5 1% a reACO l Septic oi.. k 1 ~ j~L(f ❑ ❑ ❑ ❑ i Dosine Chamber "OTC) ❑ ❑ ❑ ❑ V11. Responsibility Statement- 1, the undersigned, assum es nsi fo stallation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbc • Sign c MP/MPRS Number Business Phone Number Fodd L Sinr. MP139462 1115-235-2674 Plumber's Address (Street, City, State, Zip Code) j 1;5609 708`t' Ave Menomonie W'i 54151 l VIII. unlylDe artment Use Only d Issuin ail Signatt Approved Disappm~ . Permit Fee llwill0 _ iven Ke>son to I $ Z~0 ' IX. Condif ?K#NAReasons for Disapproval 31 R.) IS .e, q, enk, mu effluent filter and l C dlSper': ai cell fl must al as per management plan pro•Acled by plum!»r, 2. All c requ0*r v nts nwst, be rtaintit rAd r 6 J~ O as per applicable code / ordinaf1m. / )k -A Attach to complete plans for the system and su it to the anry• only paper no ass than 8 in z I nc in xiie P e~ a I1D s i SBD-6398 (R03!14) V 5 Private Onsite Wastewater Treatment System Index and Title Page Projec` Name: A ,ETT 4G~ Owner's Name: "rY Ovvner's Address: Lega'. Description: /,,j l2a Z'J o.~l~ g~ C -cf- i 4-0 Municipality: ston'l ccllmv~ Subdivision Name: Lot Number: Bloc:c'~lumbe:; Parcel I D. Num~er: _ P a ge I pA6w [21 4 T Page 2 /S?-;e pZO T f L j ~1l~f~. Page 3 7- , j Page 4 / ~~:YTJ1 `7/- } Page j/rLJ W l'✓f Page 6/ G UCH % ~~J'~ti page , Q~i~-tom S •~-liter dirl~ Page 8 Z ✓x- - Page i N~%f.~ ' ` - - A dame c,'Desi;ner: ~OD Ai Z - Licc:lse Number: ~P139 `Z Signature: Date: Designed Pur ant to tl OIAO '.r.g PO ,VTS Ccrr.nnnei- Manual > 3 $1- 30 a i !1 Nll ti ~VN IZS z~ 3 S ~ j V y t V Z ~ tUiv ~ - c.1 • r 9~ 22 90L1~ . s SNGiVCXM IIVCNM 1SVO.Wd MSMXISW V 14N0_Vh - r W'o,';;n~jjnyrrr ■ iifL Cc'.L (ML, XV, ao a~ewarr 91st t26 (008) ■ 9*tL CCZ (SiL) 3UI 313 tl 0 U 0 3 HNV i -Iiid is mn dHnd NTYWI) OSL/OSZ': ~ md a3LJuzfla _ bzttis w 'srroJ an3dHJ iRNAH 133diS PJCZ1 Kit 1133(O ld .Q i In N w¢ > J 0 ~ u a ~ U W N t N aa.. a7 I 0 = c7. J d1.7 Q, IW .S4 < w X L6 Rv z c ° >o C3 `N pQ U Q J Q W N 00 3~ u viu a CD W (Y .J W U N i rc 'M z W n W f1 Z ° W W Q U.] II ~I w> U y = ma Q U Z J U Q Id °0 m Q ° zid~FaU Q • v U Q J 0 0 n Z .'Wn .S'9 :r J Q nl 3° Y j t ; D z , ft- 0 ru N ` v W p n: i. rtl > ~f J O 4 ~ Q U I n u I ~ J m (7 re fu z 61 =a U Z L) W ` V> H Q D pq ~a 1 Y Z a F- o' , a cz 'r c D r- F- In m W ~ LL. llO uw z Li M > CV Z r O J [7W Q U Z U J > dJ = u~ -i iu a vi Q ® Y i W a v o - - a iu W O m H W L .OS Q Its; N H LJ J Y ~ Z O ~ i~ I WE~.~kkhPRcc:F r i.DClf~rvG GOv~+R -7uN c' ~c w,v~N Wa •a8r! . IN 14 }4 t. , r ~ ;~NalSiv~t3Eo ~ y ~ 24" Y.L.' i I I I ! M4k u 4LE irT srrS (~hFFLE Ii A~ o-r c t1EG.TIOIi.S ~ I w~ ~ ~ ~ ~ ~ Z ' QN ~ ` I I~ I i WWI r l 47 `~I Corrraet-r~ I . f c C- I r. I SfPTi E 1 ~~PGATI~ OOSF Tn~,;~ : f1,►,u;JF,►CYL,sgCR: tx' 1.11:~'^~~il OF p01CS: _ r~k rte Tbk.K S11r; IZS~ ~ 3 r4C_L0QS OOSC vOLUME 0^ ALA~6,^ P'4S,Y;,UFAL7uKLTt; S~ Y~,• 11iCLU01►JC> b1, ;,1CFl.GrJ: 17(0 ~OGCL llLlKbCR. 1 • c 1-t CAPACITIES: A= IR;CNCS Or• b. SWITCH T~IPL', i Moot -7 L lr:UMbt`<:1y ~-7 SwITCIi T~PC; ~ iJE: PUr1P AWD ALARM ARC TC DC Msk1lMUhl OiSCNJtift(yC RATC. 6445 pol iNSTALLEO O+J SCPNRATE C.KC- VLRTtCA'- DIFF[XlL;C,E 4CTW[[u PUMP OFf AJJD 0I6TRIGU710►4 PIPE,. FEC^r + r',i+ tr~Ux ►Jr-TWOstK SUPPLY PAC&&ustr . . / PLE- + rC E T OF •ORCC MAI tS X f p sEFKtCT:00,; FACT01K., r F E[ T TOTAL 051JAAIL y1{-,iaLAO FCET 1 1. i ~r iUTER►JA- DIMEUilobit OF TAQK: LEWCvTH ,LdlOrr{ ;t_tQ'tiilp DCPTI-~ •f PUMP PERFORMANCE-CURVE TOTAL DYNAMIC HEATF_CJV.r MODEL 15111,52'153 PER MINUTE So 14 4f EFFLUENT AND DEWATERING i -17 tz `0 MDDEL 151 152 153 10 36 152• :ee; Mete's' Gal. Uters Ga. Liters Got ;tors 5 1.5 10 189 es 261 7, 281 265 19 3.0 /S 170 6' 231 7 a 1!1 IS 4.6 36 144 201 11 2]1 2C 6.1 29 t 10 14 ;':161 !2 197 ! 7p `:a X25 "6 75 zt 129 159 3C s 1 - _ - 23 - 97 12S If ~ 36 I 10.1 - _ _ I 22 65 /C 12.2 1 a2 ° 5nuI4Y Heed: 3C . (9.irn) 35 f .1,1.5m) U 6, 03.1; p1aSJe8 s l I 0 10 29 39 0 SO 60 73 !3 9o too 0A...0" LITEAS sp a5 III 1 0 2 210 1& 32C FL0'.V pi MINUTE Model 151 Model,s:.152. 1153 CONSULT FACTORY FOR SPECIAL APPLICATIONS'. '7n1 v I L -4 1 3 27,32 1 • -'mod dosing panels avq table. - ~~t1 I • Electrleel alternators, for duplex svstems, are available and 27132 sm supp'ied with an alarm, ~ `l` ; P 4 • ,c e 1712 Variii level control switches ae available for cono ) single phase systems. • Double;plg9Ybaek valliab'e level float switches are aval for varleble evel tong and short cycle controls. I - ' Sesied OWik•13t3x available for outcoor Installations. See FM' 420. it Dver 131 ;S4 i spetial quota;!on required. 1S111S2l1S33erles - - I _T I r P, 1SIili2f1f3 M00EL! Control Selection 1 ' L Model Vall;•'h I Mode Arroa Slm be Du~lax - s a 1a N15' "S 1 Non rS.C 1 2cr3~ 1 lit "S i Ati 6.C Included 2 or 3 E1S1 23C 1 Non 3.2 1 2or3 BE151 230 1 ALI$` 3.2 Sneluded 2 cr 3 sr4au s~ce. N152 111 1 Non e.5 1 2C•3 aut52 t15 1': AQo* 8.5 Included 20.3 E152 30 1 No 4.3 2or3 Bc!. J A~ 4.3 - Included 2or 3 N'S 11 do 10.5 _2Y 3 1 11 1 Auto . 115- -Included 2 of 3 $ELE-T CN GUIDE E.53 230 1 h'on 5.3 1' 2 or 3 BE153 30 1 Auto 5.3 Included 2 or 3 1, Singe piggyback veriat a level float s l or double ]199yback variable level Scat n CAUTION switch. Refer to FM047T. All Instillation of controls, protect'an ceylets and w1i si be donl by a q.eClied 2 See 12 1c, correct rno:ol o` Electrical Allerrla.or E•aak. lensed deetr'clam. All alectrlal and safer/ codes should be lnllewed Inc'ud.ny thrrlost Variable level control switch 13.0225 used as a ~onlrol al , specty dwIl (3) recant Nations Elsetrle Code ±Nl and Vie Oecupatlonal Safety and Health Act (OSHA, J . o• i float system. RESERVE POWERED DESIGN< Fi i wil a 'eserv? Safe:y i?C:Oi 15 °Og rEEf°C If iC tic d°5ign of srv°^j ZCe'ler pump. i A l TO, P.O. 115341 lcu:av141. KY 40256.0347 vanufaclwers of . 1 SNIP TO, 3649 .Il K Come Run Fcad :cu'sv svCe,KY 4OZ?f•1541 u?~/~rrPU'co9,7/NCF ,g`1q1fY c (51,2, M-2721 • f ,'30C, 924-PUMP htip://4wW.Jaf!fer.from PUMP CLJ, FAX`507)17,(•.614 ~....,i.., r`,. all-rln H!a rwanrvAf:. a I -1 Fj' Dia. Biotube15-1 Effluent Fikers General Orenco BiotubEr Efflimnt Filters (U.S. Patents No. 4,439,373 and 5A92,635) are used to improva the quality of effluent Optional exiting a septic tank. The Biotube cartridge is remuvable fur Alarm Float Assembly maintenance; the handle assembly snaps into the notches in (Ordered Separatoly) the top of tiro vault, and the handle can be extended for easy removal of the cartridge. A "base inlet" model is available for Handle low-profile tanks. !assembly i _ Standard Models Standard Series: Fr0854.36, FT1254-36, Fr1554-36 Slide Rail Series: F171254-369, Frl5..W36R Biotubes® Base Inlet Series: FT0822-14B Optional Alarm Float Assembly. Standard: MF1A-Y-1IFTI,; Hasa Inlet MF1A-Y-5FTL Nomenclature ' 1, Pipe r Coupling Oyy~ions, RWnk - sttutdard sett y R - base inlet seticsy/ ! R = alldc rail woes (]2" and '5 " ouly)" £ i Cartridge heig~c (inc,ies): i Vault t 36 = standard ; r 14 - base inlet neodcl V / . E Housing height (inches!: I 22 - base in lei model V Inlet 48 = w4m minitntun liquid level is 37" - 46" (8" dia. ally)" 'y Holes 54 when rule iintnn liquid level is 46"- 63"°' 6il when llu iumnaliquidlevelill 4"-g4"` St} 1'sUppOrt 66 - when minitrmcn liquid level is 85• - 11:" Coupling l Filierdiatuc oA ° g"VU: s tSupport 12 _ l2" i Bracket 15 n l5" Blank - 118" filuation t 12' and 15" only, P = 1116` flttatioa IIiotube clltttGtt filler „c[i~ ' l: sc the slide rail when only one:. acccaa ie available (or ibc riltcr elwnbca °w Min rmmn ligwd level is m.wsurcd Gom the itlvett of &c aotkt to the tank floor (Select the using be4d tint oorrapm& b the tank's mmus rn kPW imel lu r1w&u fly [omit the inlet hole. between 65T. and 75% of the tadC,< nunumn iiq- vid level-) Materials of Construction V_au;t_ PVC Biotube Cartridge Polypropylene and polyethylene Pipe Coupling: PVC Handle Components: M. _ Support Coupling and Bracket PVC A W" amore sr oemo Inc- 16[YFT FT 1 sa f~ awl I'tlao 1 W2 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Tank Manufacturer: 1 ❑ NA Permit # ffSeptic O Dose ❑ Holding Volume:! -0 gal DESIGN PARAMETERS Tank Manufacturer: C] NA Number of Bedrooms: ❑ NA ❑ SepticA~'Dose ❑ Holding Volume: IL0 gal Number of Public Facility Units: NA Vertical Distance Tank Bottom(s) to Service Pad: ft Estimated (average) Flow : (~Q gal/day Horizontal Distance Tank(s) to Service Pad: fi Design (peak) Flow = estimated - 1.5: _ jjIL gallda Specific servicing mechanics must be provide if vertical is >15 feet or if y horizontal is > 150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate. gallday/ft Effluent Filter Manufacturer: Q~f~C`D Standard Domestic InfluentlEffluent Monthly average Effluent Filter Model: /'~Q f 2Z T El NA Fats, Oil & Grease (FOG) <_30 mglL Pump Manufacturer: Biochemical Oxygen Demand (BOD5) -220 mg1L ❑ NA ❑ NA Total Suspended Solids (TSS) 150 m /L Pump Model. High Strength Influent/Effluent Monthly average Pretreatment Unit Fats, Oil & Grease (FOG) >30 mg/L Manufacturer: Biochemical Oxygen Demand (BOD5) >220 mg1L ❑ NA ❑ Mechanical Aeration ❑ Peat Filter -9'~ Total Suspended Solids (TSS) >150 r L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Fitter ❑ Other: Biochemical Oxygen Demand (BOD5) s30 mg/L Soil Absorption System Total Suspended Solids (TSS) _30 mg/L ❑ NA Fecal Coliform (geometric mean) ! 1Wcfu1100ml fir?-Ground (gravity) ❑ In-Group pressure) ❑ NA ❑ At-Grade ❑ Mound Maximum Effluent Particle Size: in dia. ❑ NA ❑ Drip-Line ❑ Other. Other: ❑ NA Other ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) ❑ When combined sludge and scum equals one-third (fs) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: 3 El month(s) (Maximum 3 years) ❑ NA _ ear(s) Inspect dispersal cell(s) At least once every: month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once eve El month(s) Ngf El NA ry: • year(s) O Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA J;Zpar(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other. ❑ month(s) At least once every: NA Other. - ❑ year(s) A 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 (pumper). 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 a 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 treatment tank equals one-third (X) 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 <:12 months, shall be performed by a certified POWTS Maintainer. _1/1I A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.8! 14) 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, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil 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 extended 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 and may overload them resulting 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 vripes: cigarette butts; condoms; cotton swabs; degreasers: dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge: 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 SP S 383.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sual::d. • The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or thai• covers emcved and the void space filled v,Jtr' soil. gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired Tie Iollowiry -ieasur_~s have be_n, cr mint be taken, to prr,vidp the cpl:oitu, it,,, to ul.tair a sanitary permit for a code compliant replacement system ❑ A suitable replacement area has been evaluated acid may be utilized ~or tliu luca:ion o` 3 epiacement ~.:,il ahsorpticri 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be reh ilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. 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: 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 FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: L /I F Name: 7-1- Z L Phone: /11r_ 23S- Phone: 1S- 0-3T_- _ 7, SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name: fly L- Name: / / h Phone: Phone: ~S = This document is intended to meet minimum requirements of Ch. SIPS 383.22(2)(b)(1)(d)&(f) and 38354(1'), (2) & (3), Wisconsin AdmrrAtr five code. Use of this document does not guarantee the performance of the POWTS. Q / (Rev. 3113) Wisconsin Depwtment of Sa ft and Rofessbul Swam Dirisias of Industry Servfoes SOIL EVALUATION REPORT Page C of in accordance with SPS 383, Wis. Adm. Code County C cl. Attach complete site plan on paper not less than 812 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point MM. direction and Parcel LD percent slope. scale or dcnenmons, north arrow, and lorAor► and distance to nearest road. R J'~ V D Pd38Se Paw aff trfllfWM8>!>iNL Personal vftrn Wn you provide may be used forseoondray purposes (Privm Law. s. 15.0-9 (1) (m)). 3 / Y Property Owner Property Location C 0 G ~ Govt Lat 5 1l4 114 ( XT N R / E (or Property Owner's 3 /ifmg Acid f Lot Rb&.* Subd. Name t ci O State Zip Code Phone Number 131/Olage awn Nearest Road © New C minurfion User Residential / Nwiber of bedrooms Cade derived design flow take GPD © Replacement Q Public or corntnarcial - DesQibe Parent material Flood Plain elevation if applicable ft General comments. and recommendations: Boring # F 71 Wpit D Ground surface elev. 11L Depth to 6mifery factor in, 5cff Applicabon Rate Horizon Depth Dominant Coior Re*= Description Te)d" Structure Consistence Boundary Roots GPDIftt in_ Munsell Qu - Sz Cont Color Gr_ Sz- Sh. `Et€#1 •Ef1#2 Ord ' 3 ~ ~ 1►.,.5~~. ~ ~-s 3 P~- 3 G lU~j S S c.~f- e~c C- It G c ❑ Q Pd orotund surfa elev. R Depth to firm" factor O in. Sod Apprnation Rate Horizon Depth Danrina t Description Teinrue Structure Conzi~ Bouncy Rants GPDM in. Munselt Sz Cont Color Gr. Sz Sh. •Ef#1 'EM L.~ 5F g F c6L b G ( V41 Pq A K. • Effluent #1 = BOD > 30 < 720 mglL and TSS >3D < 150 MglL ` Etfluent82 = BOD5 30 mglL and TSS < 30 mglL / CST Number " Will Heldt Soil Testin Address O 7 Dale EvalcaefiOn Conducted Telephone Number Mondovi, WI 54755 SMD4330fR07l131 ST, CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIl' CER'IT&'ICATION FORM Owner/Buyer T~ieoc%r~ _F 5~r~~Ke__ - ?-~►eres 9 A. ,f ~i4 c.I~cI' I Mailing Address Cr ~st WZ ._S~ LC3 Properly Address 313 ~n LOcr,, RDa~l l~ G'~enwo ocC,r_1c _ G~ S ya~-3 (Verification require from Planning & Zoning Department for new constnictiAl ) City/State Cr k-vtwood C ; 4 Parcel Identification Number LEGAL DESCRIPTION Property Location S£ r, SW_ a ' , See. 1 T ~9 N It 5 W, Town o-,^-- Subdivision I4 , Lot # Certified Survey Map # Volume Page Warranty Deed # Volume , Page it Spec house yes no Lot limes identifiable yes no SYS'I EN4 MAifi''I'ENANCE 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 lire septic tan}: 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 rrraintenance 1 responsibilities are spccifled in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. j The property ovmer agrees to submit to St, Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumbar, journeyman plumber, restricted ph:niber or a licensed pumper verifying that (1) the on-site ; wastewater disposal system is in proper operating condition andlor (2) after inspection and pumping (if necessary), the septic tank is ess 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 tH Stdii2ards set forth, herein, as set by the Department of Commerce acd the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and rerrrned to the St. Croix County Planning Zoning Department within 34 dayspf the three year expiration date. Vwe certify that all statements on this form are tme to the best of my'our• know edge. I/we am/are the owner(s) of the ty deed recorded in Register of Deeds Office. properly described above, by virtue of a 7 Number of e oot s .3 dr n "e'~ 3 SIGNATURE OF APPLICANT(S) DATE **.A iy informatior 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 cf Deeds Office, and a nnpy of [lie certifi-.d survey map if re'erenre is made in the warranty deed. (IKE, V. 08105) dl i c d'7o I - - t' I n I q II ~ Y ~y II I ~ Y a FT ~ , II l i III I II I ~I - I I # III I II I 1 I II j J' I I i I I I II II I II II II y II I I I II I i I ~ 4 _7 I ill / I ~ I I~ I` ~ I II , I I I I i II % ~ I I oc I li j I t I `I I I I I P~ I I I I ' ~ I I f I ~I~ ih I I i I I I I i' ,yl I 'I 1~ I I I II~ I I I II i; a ~ 1 I I - J I I~ 11 I I I I I I ~ I II 1 ~ I I I i j 11 ~ I I M f~ f • J ~~'1 df l~r~rx , ` z I~°°`-II II Tr_- 77 i / II I ( I ~ ~ 1 I I I S I I I ~ I ~ II ~ , I I 'I ~I I I 117- 2 I I I I I ~ I I I I I~ I' i t I i I I I I ) I I ~ r I I I I I I I I it I I ~ a- r h' ~ I S V I t ;9 ;zl - n 91 j M l 1 W I Vr I 1 - yit~ z_ iu IA [J I _ I I I ~ 7 n M Q i •p ~Z f ~ I .e . M cQ I I YQ .2 N C ~ J t I 3 I ' 'o 1 ~ .o I m ..Q- Z E nw id e~ v PC -,a 'ur a 71 o I I 1 ~ 5 yom,~ c3 ~ ' z !i ~ ~ IT, a, d _ _ _ lip I I-I lip fj ~a i 2 ' j Q y I 1 M) ~ ~ ~ LI _I ~N SQ L' ,o •.7 i I I I U _ I St. Croix THEODORE FELIX 1£ THERESAANN Municipality: TOWN OF SPRINGFIELD 3i-l; RD E Permit Number. 16143 GLENWOOD CITY 1^il 54013 XMIlrAYMMber. ~ 4z ~~6ffo Site Address: 3134 CTY RD E Components C_ omponent Manufacturer Description Last Next Status Schedule rviCe Service Conventicnai Trench - Seepage Trench - Seepage 08124;2015 08;2412018 Current 36 Drainfield Septic Tank Septic Tank 08124,2015 08124!2018 Current 36 Maintenance History Service Date Maintenance Name Gallons Pumped 10i18=07 Not Available 0 09123,12008 Not Available 0 09116;2009 Not Available 0 09130;2010 Not Available 0 09113;2011 Not Available 0 Notes Date Text 7!4i1776 12:00:00 AM ADDITIONAL NOTES: as-built missing - see site plan for mobile home with 1000 gal. septic tank to 2 trenches 5'x 50'. 600' of effluent line between tank and trenches header. 10 days later permit approved to add a 3 BR house to the same dispersal area, so both dwellings on one system MIGRATED ON: 09104,12015 'No data found for Notices. Violation, G ~e. 2~ i ~ AS BUILT SANITARY SYSTEM REPORT OW`N EK~~/ ~/G U ~0 ti~S__-- TOWNSHIP SEC. Z~I-T~-l ADDRESS e cj iT-V ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 OW- EVEMTHING WITHIN ].00 FEET OF SYSTEM are 10Zth Arrow I di t f - - - - SCALE : J BENCHMARK: (Permanent reference Point) Describe: A," (.b`c( T re e- e sir Gr{ad~ ede` !~'c Elevation of vertical reference point: Slope at site: 1 6) SEPTIC TANK: Manufacturer: Liquid Capacity: joa D Number of rings on cover : Tank manhole cover elevation: Tank Inlet Elevation: Tank Out_1ec Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; tots parity-off-- distribution lines gallon: size o pump- head; gallon per minute horsepower brand name of Dump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Typpe of warning device SEEPAGE PIT SIZE: - Number o pits eet iameter feet liquid depth___ seepage pit in et pipe-elevation-- bottom of seepage pit e evation feet. SEEPAGE BED SIZE: number of lines width le:tgt-_h -tile depth - S ' SEEPAGE TRENCH: width length PERCOLATION RATE AREA REQUIREDt4ci AREA A INSPEC'" DATED PLUMBER ON JOB (c} ` LICENSE NUMBER - REPORT OF INS VIECTION INVIV IUUAt S1 WAGt 5VS I L M f • ti U rl ~1 f ~I fI r( I' r' rl Ifl c plloe I e .S _ tiec-t~unI Lot SubdA.vis4--On :r at'tUrle Numbelt u6 compaktmen-tb- Wv)Ie~ ~ bu~xcl~ny J 120 4Y.upe. - H.L' ghwa.te4 t1 ,1~.~(i(=R gaUona , Pump Manu6ac.tuhen Mudet Numbvll _ ` f ANK _ ya.Ezone Numbea n6 Cumpanxmerl.ta Axahrn Sye tc'.m 1l U1eft' - 6ut41 d4-ny-- 12''o 4 xuNe--- 1I irw ri ( r-q Ir 1'c~'n1'11 I. cu~jt~' -13u~~c1t►11~~~~_/- - 12~ e~',~r-'c-- If! if ilwrl I It UIM(NSIJNS h tnenc`h_ - 6t Recfu.4 lced an.ea each Z.,{.nk' 6-t Uepth r,6 hock below ti eo 1 ~ ~ r1r I ill;lfil u6 -Cne4 6" DeO!h i,6 -t<,Xe b VfOW yllilkit! i 6t ti t' U fJ V 04 l- h. e. n c h - - - (rl I , rr 100 11Yti,,r1 rlliva Cw' _.._-..6t frlpe u6 Coveh: Pape 11 nl+ 4 It if 141~ t - - t- Gllave-'-anound r< A"5 N 11,1` Imrtr v p t h b1 kuw cvie('! j1 ~~'r;flr~Y, t'rrrc TI TL L c J _ DATE 19 DATE ►`+r 1 .'r 1'1 1(('TlOIJ  i State and County State Permit PLB67 r~ Permit Application County Permi for Private Domestic Sewage Systems County "DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: - V i MC- ( L 4 0 A45 B. LOCATION: S ull '/,_c',i,, Section LX1, T,a N, R E (or) W Lot# City _ Subdivision Name, nearer est roa,; lake or landmark Blk# Village Township 5~R1d C. TYPE OF OCCUPAJVCY: Commercial 'Industrial "Other (specify) "Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder- YES NO # of Bathrooms--- Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks 'Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete 'Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2} 77 3) Total Absorb Area Sad sq. ft. New Addition Replacement _ _P"' `Fill System Seepage Trench: No. Lin. Feet__/_d d Width Depth 34~ -Tile Depth 0 No. of Trenches Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size - 11 Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I [lave sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME ! G /ti A r? d 1 e C.S.T. # S .5 and other information obtained from _ r (owner/builder). q/ Plumber's SignatureMPRSW# Phone #1a3Jr- Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). Do Not Write in Sp Below - FOR DEPARTMENT USE ONLY Date of Application C' Fees Paid: State// d'~ Co nt Date Permit Issued/R j cted (date) ? '_7b ~ Issuing Agent Nam 1-nortinn Vat y Nn Valid# Date Recd  I county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. stare (pink copy) 4. plumber (canary copy) Revised Date 6/1 /76