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HomeMy WebLinkAbout020-1085-00-200 • 'Alisconsin Cepartmen: of Cuminerr:" PRIVATE SEWAGE SYSTEM County St. Croix Safebj and Build rig C vsior INSPECTION REPORT Sanitary Permit No. GENERAL INFORMATION ;ATTACH TO PERMIT) 584799 State Plar ID No: Perseial information you prcvide may oe used `c- secondary purprsrs IP,vacy Lay: s 15.04 -ermrt -16der's Name Gity 'v' age Township Parcel Tax No Song Xiong TOWN OF HUDSON- 1 020-1085-00-200 CST BM E ev, 1 4/0 Ins:) SM Flev E!vt Description Section:Tewn Range;Map No: • 2. N, ',t sIA, / 6 06 0 ( -LOA-, 29.29.19.3400 TANK INFORMATION ELEVA ION DATA TYPF MANUFACTURER CAPACITY STATION. BS HI FS ELEV. Septic T Benchmark W 0"tring- _j Y 1• 7 r r zY 1 Alt. BM "v l J^'~ Y 1~ tom. \ AZ~ Bldg Sewer Holding Stil It Inlet i _7 TANK SETBACK INFORMATION SVHt Outlet 7 /Ob, Z TANK TO PI_ WELL BLC Jeryto ntake RnAO P~_ ~ 5 4e, rv` Septic 3 D> 8eR rn d "7, 3 m , b? Dosinc :5,4 / 7z z L9 1 HeaderiMan. 7 _55 ~Q Aeration Dist. Pipe A q(0 . qlo --7q Holding Bot. Systern PUMP/SIPHON INFORMATION Final Grade (5 b O Manufacturer DPanc St Cover t+ Ju ~7 /A . V Model Number TDH _'ft Friction Lass System He TCI t Ft I 5 • FOrCemain 1 e P1 a_ Cyst to'Afell ~ h ~ 7 5.75 SOIL ABSORPTION SYSTEM BED?RENCH '4idth T i gth No ~A I renches PIT DIMENSIONS No Of Pits Inside -)ia JLiquid Deptn DIMENSIONS -3 r _ 1 :5 Q ' -g atu-,,}u s 1- ~jJ U/ SETBACK SYSTEM Tn P;L BLDG WELL LAKL!STREAM LEACHING Ltarufact xrer J ~ INFORMATION CHAMBER OR rY~ tl[rp"L Type Of System 71 Jt, d QitUr?✓1 i d Jl7 Zy ~u ~J~ UNIT Nuclel Number_ -4 116S__ 1? QJi Q il, DISTRIBUTION SYSTEM (,AjQ~~- - 33 04-~ rr dHrrMan Disb oution x -isle S ze x Hole Spac ig Vent to. Air,1Intake y L~. Pipeisi__. I 7Te,- -engthg D a ( Lergth Dia Spac rig - - _ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over r tf3)eJ,'-reici r:th C nr xx Depth cf x SeededrScdced Mulched HedrTrer::f Corte =dges TCDsoll Yes No Yes No '4 !La, 1 COMMENTS: (Include code discrepencies, persons n went etc) Inspection #1 Inspection #2: Location: 71E COUNTRY VIEW CIR ~Xl I S~'t I,. eyt ~OJ Fem. ~ w ~ ~c' ~i, 1.) Alt BM Descri t on CtvY.Y , ,Ya~ Je J` ~f 2.) Bldg sewef length = ~~/I S-~-I^ v ` amount of cover = it /~l1 J ~t Plan revision Requires? Yes ; No 61, '3 r r- ~7J Use other side for add tional infcrmation v 56D-F 710 iR ?r'97' Cate Insep is Sr ure Cel No r County o Safety and Buildings Divi 4f Alf d~ a $ A R E C E I'VE C 201 W. Washington Ave., P.O. 71 Sanitary Permit Number (to be filled to by Cu) P$ ` Madison, W) 53707-7162 -2i' JUN 0 20' 1 ''1 l ~MsT. ( it Application Transacti/o~n~ mber In accordance wit(i'SP5 my is A m. o -Submission of this form to the appropriate governmental unit / " is required prior to obtaining a sanitary permit. Note Application forms for state-owned POWTS are submitted to Project Address (i different than mailing address) the Department of Safety and Professional Servtes. Personal information you pmvide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 l m Stats 1. Application Information - Please Print All Information {J Pro erty Owner' Parcel # pp Property (honer s Mailing Afidress f Property Location 5 `7 .j~ f 7l f I J' 1(rL Govt. Lot ° City, State Zi Code Phone Number P a Sectiun~ N; R /4circle one), II. Type of Building (check all that apply) Loth / I or 2 Family Dwelling - Number of Bedrooms Subdivision Name `(I N ~r ❑ Pubiic.'Commercial - Describe Use Block ~l ❑ City of CSM Number dC•# f991g0 ❑ Village of !7 SL'lp) State Owned - Describe Use / ❑ I O ❑ Town of ![l. Type of Permit: (Check o o%-0n+Re`A. Complete line B if applic bte) New System Replacement Sysu Treat,nent/Hulding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued ❑ Before Expiration Owner IV. Type of POW'TS S stem/Co >ff tcc: Check all that apply) ❑ Non-Pressurized In-Gmun Pressurimd❑ At-Grade E Mound a 24 im of suitable soil ❑ Mound < 24 in. of suitable soil ,a ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Desigr. Flow (gpd Design Soil Application Rate(gpds DispersalAreaa Required (st) Dis rsal Aura Pr /sheds0 System Elevation r J, / / / <y - VI. Tank Info Capacity in Total p of Manufacturer Gallons Gallons Units 2s o New Tanks Existing Tanks v u i 9 W a` v ~n n rs V O. Septic or Holding Tank Dosing Chamber , t a VII. Responsibility Statement- 1, the undersigned, assume res sibitity for installation of the PORTS show on the attached pin us. Plumber's Name (Print) Plu VS Signature Ml' Number Business Phone Number Plumber's Address (Street, City, State, " ip Codc) 1 v ~J r /6A 5 ~,Y VIIL CountylDepartment Use Only .Approved ❑ Disapproved„ Permit Fee Date Issue Issuing Agent Sig b ~Ul ❑ Owner GivoKkcason for Denial IX, ConditifiW% easons for Disapproval 1. SepCc tank, efflL,ent filter and J A 1 I (,L{ J1 Gt /I I I J dispersal cell must be, s°tviGf'd maintained 0` r'` a11 ,f ~ I f~ net d1, o 1 J T 'J as par management plan p,ovided by plumber. 91 2. All setback requiremcr-ts must he maintained n I~ I I as per apnlicahle code/ordinances. `7• !v Attach to complete plans for the system and submit io the County 101y on paper not less than 8 in x I I inches in size SBD-6198(R. IlitI) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: ~~l1 r t Owner's Address Legal Description: Sif c 779~ /V f~ 1 k) Township: -~~E U r County: Subdivision Name: Lot Number: Parcel lD Number. OD - zoo 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: a (3~Z l License Number: Date Phone Number Signature Designed pursuant to the in-Ground Soil Abs tion Component Manual for POWTS Version 2 0 SBD-10705-P (N.01/01). Page 1 ui ~ r f>i A ~jr ~ 11 l v { X_ 1 1. 1 21 11 I ` r 1 { . 111 i 1 , 1 1 t 1 l 1 ` 1 p.3 = PAGE 3 OF 4 ~ o ww -:3 z ~gz ~ 1 1 S C Q. ~ ~ g 1c E ~ ~ ~ ~ sQ ~ c E m $ _ is p C; m~ o E e t= W . _ Z Z m . o .l v P W l~ v n If m U) E v CO ? f- -f a ci 17 a t1~ ago f,' : a N- A U a. .l o J aEa v ~ f 1 ~ O CL Ix S~ f Cl) @ + I W U) rn [ ~ o [ 1A <:n-- ~~.N 7= --1Q -d v f t It a 11 n x l co -a > it 3 _ a E v [ + 9 O ~ a~ ~-1 f I a C cu- to CO b c " [ f ® W r Z QI E f, [ Z N lop CL Q g~ F- 3! 'S Q = V~ Z, US cc 12 ;t a f • sf J set > C3 t co ["mil Q a i LU CO . z 10- c + 1 9LOb51.,%, uoSpny peod au pbe15 EOtr uaoo'sue'o's/yduospnH 1099 6£9'96L :j 00991cS,9LL a aolnuas lelsod 'SYl aul em inolaq ssaippe 9141 le sn 01 a6essaw Jeu161Jo a141 wnlaJ pue auoudalal aul dq dlalelpawwi sn flpou aseald 'jojaa u uo!ssiwsueJl s1141 pan aOai ar,e14 noA 11 ~papgigojd dllouls si ,uaidioaJ papualui aql of .ka llap hanp sly ldaoxa 'ainsolosip due leul paililou ngajau ;aae no' ':uaidioaa papualm aul lou aJe no! ,;l -a.Aoge poweu lua diow aul to asn a141 aol dluo pepualul uoUewaolui lelluapyuoo inleluoo .4ew uoissiwsuejl ajmuisoej siyl 6ul.4uedwoooe sluaiunaop aul '33UON lollJVIiN3013NOo molaq palsq ja4wnu euogd eqi x Aialelpawwl sn d1Rou aseald 'sa6ed a41 1o Ile aAlaDal lou op nod 11 V", S1N3WWODiS310N 3101.0321 3SV371d A-Id38 3SV31d ❑ 1N30JW00 3St13121,~ AA=-II1 ]H HOd ❑ 1NFiow E] 11 3?~ :~J38Wf1N 3NOHd , 'a3n0:D JNIafIIONI S3Jdd ]d101 \ a1 ien 1N XHd 31VO :NOI1N311N ~JaddnH aullslJgD AOW :O1 133HS -1V111WSNda1 3lIWISOVA 6 -4£5-56[ :X-A 9989-6ES-S6L :4d aupipaw Ieuoijednoap SUPIOISJU4duosp 1H wi~ In-ground Gravity Management Plan PAGE 4 OF 4 IMPORTANT: The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POW/TS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow . 450 gpd; 1300115 =1 nigL"; TSS S 150 rngL"; FOGS 30 mgL" Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution i drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution eel prior to dosing o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.) o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filert's) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 j_, ~ months. Po j~ I~ l System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: Thomas Wang Phone: 715-425-9958 Local government unit ~:,jLro'.>~C;OUNTY ZONING OFFICE phi: 715- ~,.-7l7DCi Local government unit address: ~ lk, - %ckA WI ZIP: S U b Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Continaiencv Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils. Svstem Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. RF PORr OF M[_DICAI FY,AMINATION Neighs linCt CS) _ 22. YJoI((IttVhr ;ln;l,) 23. Statement of Ihenrm..tralrrl A )lily (SUI)n) 24. SODA StnJ,f Nurnbcr NO ?u4:c:1 tJ>t~~ii YES CI ECK EACH ITEM IN APPROPRIA I L COLUMN Nurnt.,l Ir bn~nnal CHECK EACH I IEM IN APPROPRmAl E COLUMN - I Nurina11 AbriL;.mt - - 25I Irac, face, neck, and scarp 1 - 3r va J,CUI J( Sys !U R (I'ulsc nlj iU, i t. 1 hr ai if atmS, IBgS, UJtetS) - f 26 Nose 33. r+bdcmen and dlscrra rlnrlrTnc r nIa) SInIISC3 t 39. Anus (-I it rdir-j d1.11 rx mlrwinn) 28. Mouth and throat _ t0. kin 29, .ar5, gerlera ;Ir.lomat atxl oxtornal canals; Iraar•rg under ilem 491 41. System WC: ireuding r+el.•c examiriali0r) 32~. Ear Drums 42. Jppe` and IOY.er extrelnitieS (S(rergth and mate of mnion) - 3 1 . Eyes, (loneral ~v,son under non's 50 10 54) 43. Splno, olryur iusculoskeleta! ' 32. Ophthaimoscopic 44. Identifying body marks, scars, MR008 (Siz(, R Icration) 33. Pupils (cc.taiity and reaction) 45. Lymphatics - i•Ass=Xaf panlloi movor~ r• ny~ stag,licsl 46. Nourolo9 (Ir.r 1rn r,~llnx n, .psi'. txium, Son ;o,, cratimi nerves, 34. Ocular mutlity -34. - ~ - a x m on, ©t~.) - 35. LUng-, and chest Nni Inr.1w1or. ):tans: rxnr iatiuri 47. Psychld:rlc auance, hrJhavinr, mood, _ rrmunl^nyan, ano memory) 3^. I-learl fr'•ec0rr9a acrv'•y, rhythm, -itic- cvt mi.%ri¢a) 4U. Genora[ systemic NOTFS: Describe every i!-.nnrma ity i J rirtal .Inter applicahle item number before each comment. Use ad(fitional shoots if necessary and attach to this form. i 49. Hearing J„co f .',u9iun air c spear, Right Ear Loft Ear _ _ Diacrn:Nan•.'an Score 6olu.v _ Conversatlona' Audiometer 500 1000 2000 i 3000 4000 5O0 1000 2000 3000 4L'00 Voice Test at 6 Feet - L-- - _ Throsllc :f in Pass ❑ Fail doclbe!. 80. Distant Vision Y- 51.a. Near Vision 51.b. httormudlato Vision - 32 Inchos 52. Color Vision Right 20, Corrected to 201 Hight 20! Corrected tl\ 20i l iuh! 207 Gorrocted to 20i ❑ Pass left 20! Corrected to 201 Left 20! Corrected to ` 20i Lelt 20/ Gorrected to 20/ Roth 201 CorrCGIod to 20i Both 20! Corrected to ~i 13c1h 207 Gorrocted to 2ni ❑ [_all - 53. Ffold of Vision 54. Hato ropharia 20' On pr ,n c• pars; Esopho Exophoria Right Hyperphorfa Left H erJhorla ❑ Normal ❑ Abnormal 55. Blood Pressure 56. Pulse 57. Urine Tout (if abnormal, give resu s) 59. ECG pato) T Sysloli:; Diastolic (ResGnr3) Albumin _ 5u, ar M M D U j Y Y Y Y (3i;t;n0, 1 ❑ Normal (J Abnormal - - - mrn 0f Morcury•) 59. Other Tosts Givers - 60. Commonts on History and Findings: AME shall comment on all 'YES" answers in tho Mcd, al History section and for FOR FAA USE at;rormal findirns 0 iho oxan ination. (Allarh all consultation reports, FCGs, X-rays, etc. to this r art before rnailinu.) Pathology Co In •5 r„ao~i By - % ~ CLsric-rl Rr.jeri Significant Medical History YFS NO Abnormal Physical Findings ( ] YES -1 No 61. Applicant's Name - 62. Has Been Issued - I_] Mod cal Certificate ❑ Medical $ Student Pilot Ceriifiea!e [ 1 No Certificate Issued - Deterred for Furthor Evalualion %r I Has Been Denied I-otter of Uunial Issued iGopy Attached) 63. Disqualifying Defeo (List by itrxn nurnbor) - - 64. Medical Examine ?is Declaration - I hereby certify that I have personally reviryrer! the medical history and personally exam ned tho applicant named on Ibis r-Jed:;al exrirli i:!iun report This [(:port w Hl any attaehlncnl embodius my findings cunt:;!utely and correctly. Date of Exatmnal cn Aviallun Mvdicai Examiner's Narno Aviation Modical Examiner's Signature M M D U Y Y- Y S(reet Address AME Serial Number - - City _ State Zip Cudo AME i elephone i ) FAA Form 850(" (006} Supersoft,, Mov-)us LAO )n - NSN: 0 52-00-670.600: P.5 ' Filters PL-525 EFFLUENT RLTER Polylok, Inc is pleased to add its new c ornmercief filter to its existing line of quality effluent fiiters.The PL-525 is rated for over 10,000 GPD Alwm (gallons per day) making it one of ~a PVC the largest commercial fitters in its «eamfon f~anefa! class. It has 525 linear feet of 1/16' filtration slots. Like the Polyfok PL-122, the new Polylok PL-625 has an automatic shut off ball installed szs f infest with every filter. When the fitter is d tns- rernoved for cleaning, the ball will filtrat w sk is ROW ikw rar float up and temporarily shut off 10AN GM the system so the effluent wont leave the tank. No othw tliubor on the rt>m omit cart ate" that al~fiynl J coots V & 6- StM 40 Pipe ~r" . PL 525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years k; under normal conditions before C requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. tf the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. Aatamrlcshuto beg wimt ffhsr 1. Locate the outlet of the U.S. Pat"I tNa GMSAM is nrmoasd septic tank. BA71AMO Z Remove tank cover and pump tank If necessary. PL-525 Installation: 1- Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2- Remove the tank cover and 4. Pull PL-525 out of the housing. mer+cial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank- Make sure all solids fall 4' or 6' outlet pipe. If the back into septic tank. fitter is not centered under the 6. Insert the filter cartridge back access opening use a Polytok into the housiin Extend & Lok or piece of pipe 9 making sum to center filter. the filter is properly aligned and 4~ Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover- t pr-od 2uga6e}ti COtt"OD sueiols/ft{duospnH 1i1g9 lf'4 l l aoiwaS elsod s n aw ein molaq ssa.ppe agl le sn cJ 06essaw lewEuo agl u;rwi pue auogda aJ agJ Aq Alale paWuii sn AJgou asea d 01M w uassiwsueJJ S1141 panlaoaJ aneg non JI paJlglgad Apouls si Jtiaidloaj papualui agl c} AJa,nllap Joajip sp Jdeoxa 'ainso osip Aue JegJ poiJilou Agajag aje non 'lua dioaj papualul ay} lou aye noA JI an.oge paweu Juoidioai ag: ;o asn agl jol Aluo paoualul uogeuuoJul elluapl;uoo u,eluoo Few uo sslwsucil al uilsoe; snJl EulAuedwoooe sluawnoop agl 3:DIlON Ail1VI1N30HN07 nsolaq pals,l jaqunu auogd agl le Alalelpaiui.ii sn A}rou asea,d sa6ed aql Jc p,e anlaoaJ Jou op no! J', / i / S1N3wwOO/SillON 7l~)J.Z)38 3SV31d O Ald3d 3S`d31d ❑ '-LN3NJPJOO ASV3ld ❑ AA31/132! 803 ❑ 1N3!D8n ❑ :3y b38wnN3NOHd :~I~IAOD JNIQf1l:DNI S3Jbd W101 :~138wnN Xbd 31b4 NOIiN3ilV V,gddnH GUIISIJgO WONT :01 133HS I`d111WSNV> J1 311WISOV-4 089-M-S~L :X=l 9989-~£S-S~L :ud eui:DipeW leuoilednoop su-2101s4duospnH Ti N1)US-t°='•: REPORT ON SOIL BORINGS AND ' """`O4• IA^IJSTRY~ UI`JISIItiICI'd L"e ''J° PERCOLATION TESTS (115) °x 3707 1111(vIAN Rr!.AI I{?pl.`; ':':'~:115JM '•':I 53707 N63.09(1'1 $ (hapw, 145 04511' - - - T7 1F~:1.. r I_I`r. r :.•aE C. f-•r'• 1 S~J'/ NAMF IISE DATES OBSERVATIONS MAUI- _ Ir. ,.l if th:: ~ )'.'P:r4::'. a~ Ir~~.-I~ -u_rrJ I ~,pr Pal r I t;?P'"rn 1 '1'-•c I 1111 .16$115 SO r' / M/) /1 ~A U R ATING S- S to mm.b a sor vw, 11 $ile 11I •ntr•m t '•'-I I] A. •rJ ,.IW1 I1 ..F-:~ , C ~S-1 -U_ I IJU A, $ . U XU $ '~'C~ ~:.CONJYrac{[7rea/ ~F~ /d'/~r36 J J cif TS.•~. I~.Ina. s.1167.03 i! m >I r _i~p, . -.a•e FF oodu am s •.etro:, ~1 ry fy^t~~c 7FSCRIPTIONS CORINCj IU14_/ PTI-Tr I.!1111{•"u ly.-+-!!~ 1'. I1•!I .:II 4I'>ITI1; E C L 'I IIH:I F;:..-~-r: i,SEf.. C❑ 1 .-LI Vi: M_ It L.b5Ir •F -I, F. _1_• .,4u 1 r td - w3' l %t~e{ c' 7 Q < < 3 Y Brl S t Cr - I . I 'i • d' C3/s B„ . 3 G., / s, / BUJ' c s~ l6- ~ !~,C7 _ ~4/.Q--~ ~'-+1~'. _ ? :~!•C ~~h .5-11 r~ •r C~_ 1 3`81 S/ 6+J / S 8~ fs S Bi! cs L 77 - B. r 7 C ' • ~ ~ 8/f/,-~__~i, S 7' (ri, s r go~~i•3' i~1~,~~ g.~~ I3~fB'~<v•83,~0, 21, fob 1i\~ r ERfOL111UNTESTS L l TE,.I Ir '+1F-t HJ IK f-~I I'AF I C.c ID.. , iF,F. 'J., 1--- - - PATE h111UTCS M r .t~-4-~.•-- 1 ~ F- •.F I ff 1•JI _.i -~tlr F--- I _ _ _r ~in~ ~ G n[R IP.CIi Aic V:-OT PLA% M-, 1.]af 01 .,'.a[ on 1 :;,-;E ,r ; r' - d °•:•u - ..n . t I. .:a :r ccs. li„s~ , s.' ..t.it .ire the Yon ...~ntal a~. '.en to +Loi.,r. r .r•: ~~r f.- n•s a .I stn:: •r,n . r :1111 It J., ;111.-f, 11 r s, tt.-• -1r :a.1 d• I 1111. rn 111. •r I •rre:.On and pert-, f Ian ,r:,_:~ SYSTEM ELEVATION ___2~'• - ~~-G - g' A B. M : t s rye 4'rP f• + . 1 f'11 a F /'o„~ t J~~ */,z. 1 ~r T ~ 0 3 PC" ~t I p s. /,-:.r; ' f Co rtt c, o,u tdP 1- 6 ~ ~r LL C 1 ~ S~y-ti O el ~ TPS t 60 _ ~ _ t SK:tfl6~c. ltrc/~ W~~7~ 9010~~ 119 37 SMfjI/ Cw f /3n~',u ! Ta ~~A-~a I/A,r.+ r. r•. r. f . el••I~r . ,.r 1,.,.. ,I ~..1 ....r -.t•i ~ ~il ~ it I' .t I::~ I I,.. I:.-. I.,.. rl~- ,ir tl., . r. ,.r n~ ~ 1 S7 t/h I ~~s•lu. $ L-~~J'iS T6~/tCP SQN I~.' ~ ,l~r~( I H ~ ~ v ( _ ' ` CLI IIf .~I J '.1'.I^-h F4 }'vE NUYt 11=1 )Jt.o~ailr, I.• 1 //E: ~liYry-~_f f./c ~~i~/s~~.; ~t`S• l~~c 1 S_ Y `j ~ =t !-s'f8/ :01ST" IJ T 101. - :•~•tw`•a:~:]::nr, f A I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT ..AND OWNERSHIP CERTIFICATION FORM C01V uyer 1 { xj'i~ Mailing Address CGLI II ~jlr~Te Property Address (Verncation required from Planning &Zoning rtment for new construction.) City/State" i~ Cam! , Parcel Identification Number LEGAL DESCRIPTION Property Location AJ 'A, Sec. Q T ,2-~ N R, Town of _/~Ad l c Subdivision cobt4r el) Lot 4 Certified Survey Map # , Volume , Page # Warranty Deed Volume Page # Spec house yeso Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic lank every three years or sooner, if needed, by a licensed pumper. What you put it 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 §Comm. $3.52(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 t 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 less than 1/3 full ofsludge_ Uwe, 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 Comrneice and the Department of Natural Resouitces, State of Wisconsin. Certification stating that your septic system has been maintained mast be completed and returned to the St. Croix County Planning Zoning Department within 30 days of the three year expiration date. I/we certify that all statyrnentsgn this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by of a #~a deed recorded in Register of Deeds Office. V73 /I Number of bedrooms I 3 NA . OF APPLICANT(S) DATE 40W MWORM 1NM1 If NdI"liik Md 1N# HHO 10 N 160NW OtM1tt1 b WOW 4 k 111MON4 A 0010#0 H100"10: w dude Mth ibis aow1ic4,jii a icc0l-~jed'A'dTF4111V dCr a 7r0i1I 1111; Reeisler of Fkt%is Glftice af-ld a rn,v ,,t, ihr w", rifir-ri v-, ,i-" CENTER 5EC'1'IOl1 29 2" IRON PIPE: N89006' 51 "E. I ' ►2~ ,J-WITY- - 522. 00' - -t- - - SOUTH LINE NW1/4 - - - N89006' 51-"E - 133,732 sq.ft. 12'~ s 3.07 acres r9 LOT 3 _ ,.w tI~ l v LOT , LOT 4 0 Hj n 90,930 sq.ft. - - -4 o of 132,481 sq.ft. o mj x 2.09 acres 0 3,04 acres 1 V) b 5 -X38.51' - -1,4 587°46' 58"W w i H N ~--'~0 `t "1 o o t56~ t u, 3 6 U7 f FOR ELECTRIClT ~I o LOT 1 0 ; ~lO~ EASEMEIV WI w r 661 ~,a 4ROUND ROAD. 88,832 sq.ft. 0 2.04 acres _ ° of o o N 2 !v 1C 661 ROAD DEDICATED T4 S87046_t5811W ~ THE PUBLIC. o - f_^ 23.00' J _y_platter L 8 unplatted_lands ^owned_b ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR l1TILIZATION 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: (Street address) 3) located at: 7,~J ''/a, .3,,~7 '/4, Section , Town ''N, Range r~ W, Town of '~V;<° ' S"n t~' , St. Croix County Wisconsin. Upon inspection, 1 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 be functioning properly. Most recent date of inspection or service 1)id flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: 11Z~0 gallons minutes Tank Capacity: C;') Construction: Prefab Concrete Steel Other Manufacturer (if known): f,(J j G' Age of Tank (if known): Pern"t-Llpmber (if known) (Licensed Plumber Signature) (Print Name) r (Title) (License Number) M"P (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2 /2012 n e°» W ^i C rl 1 i' C' C 3 T LL J r, v a$i _T ~ C Y ;t z to N N cn C C7 O Z V c U Z O J fn H r ~ 1 z C ~ a - N ~ 2 a L L w` O N Q r r Q z m z N C o r E o' lV Ur O ~.1 a o H d ~ _ L A < o co (1) Q, o zN' yin 0 0 0 •ti ; oaaIL a a N o in r, v y t~ ~ V N co C-- V v ~I ~y ~ - ° 2) C °O O U H C O N U C Lam, C ° CO C :n N C O N R C r~ O y N p N U go O N 2 C'pD O Z r= n :C t > C # r E v 3 # L a CL d c u m E 4! C E E- 3 D vat ~inci ~ Form- S T C - 104 i AS BUILT SANITARY SYSTEM REPORT l OWNER' x-};11 TOWNSHIP SEC. ~ cr T N-R ADDRESS E'/ _YST. CROIX COUNTY, WISCONSIN SUBDIVISION(c, ,d, ,Q LOT LOT SIZE L- c c r'' j PLAN VIEW Distances and dimensions to meet requirements of TLEER 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~v ; Y/' • to C v N r i 1l~ - r Ve c,><~-f6t 07 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point uGed Elevation of vertic=al reference point: r` = Proposed slope at site: < '7 L SEPTIC TANK: Manufacturer: l,7cZ`, -Liquid Capacity: (Cc-% c Number of rings used: -z- Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: /r Number of feet from nearest Road: Front ,Q~j Side10Rear, O feet From nearest property line Front,OSide,i~Rear,O feet  Number of feet from: well building: /j , , r HC c Lr. w ~A (include this information of the above plot plan)( 2 reference dimensions to septic tSEE REVERSE SIDE PUMP CHAMBER ~'I rt Manufacturer: Liquid Capacity: Pump Model: !J _ _ Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed:,` Trench:-- Width: 4-; Length: r_. Number of Lines: Area Built:' Fill depth to top of pipe. Number of feet from nearest property line: Front, O Side, Rear,0 Pt. 3 y Number of feet from well: s Number of feet from building: (Include distances on plot plan). SEEPAGE PIT ! .t Size: ' G Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: 0 Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). J HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, n Rear, n Ft. Number of feet from well: / ~J Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: (c 1 L, 1 J F Dated: - - Plumber on job: License Number:  LL 3/84:mj A DEPARTMENT OF, REPORT ON SOIL BORINGS AND SAFFTY & BUILDINGS INDUSTRY DIVISION LABOR A~UD P.O. BOX 7969 HUMAN RF,LATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (1163.090} & Chapter 145.04511 SUBDIVISION NAME LOCATION: SECTION p TOkAjNSHI7-1 _ LOT CIO. 11K. N0IF"-Ai-or S 1/4 -65 1~ a2 /U / M/11/ Q to ( .2- B rs ~'y 'Ilk COUNTY: OWNER'S;BUYER•S NAME: MAILIN'; AuIiHFSS: USE DATES OBSE RVA IONS MADE NO. BEDRNIS. COMMERCIAL DESCRIPTION _ 7DESCRIPTIONS- FI_EPERCOLATION TESTTS Residence ikNew ~ Replace so, A P $X v Z RATING: S= Site suitable for system U= Site unsuitable for system On / 10 I:ORVF.NTIONAL: IMOI)ND: IN-GROUND-PRESSURE: SYSTE'.- N-FILL HOLDING TANK: RFCOMMEND-D SYSTEM:(optiona l $ 56S ❑US ❑U ❑ S ®U . 0 S XU Corr r~,d/ Be ~~36' Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5l(b), indicate: oodplain,!ndicate Floodpiain cluvatiorv ~l ry- ~ E DESCRIPTIONS PR IF BORING TOTALS DEPTH TO R UNDW.ATER-I1a"-f-E-S CHAHACTFR OF SOIL WITH TIIICKNESS, COLOR, TEXTURE, AND DEPT H NUMBER DEPTHAK.. ELEVATION OBSERVED EST. HIGH6i1 TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.i _ - - - /.Y8ti/s4,-Bi1cs o,>e{ z 7 ~D s tgr rv d -3. y B- to, ol. ' e.t(~ ,pr 'd'Q /s/~ ~n+~~ B~7/s~ r /$07 CS, IS-13ts1z A" Not ` B- _3 1,10, 0j'•3' A4we- 7' , o' - Bannc s B a.ue 7r Q' f 6151, 'A 6 AA e S / ~7i7 S t 07 B 3 t ~lo.tl e- 7. 3~ p rS ~j may Bi S B- PERCOLATION TESTS TEST DEPTH/ '.'DATER IN HOLE TES] I IMF DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER "f+d9+•FEi-9 AF IERSINF1 LING INIERVAL-MIN. P NI D1 PERiOD9 PERT _ PER. INCH P- P- P- _ P- 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 aontal and vertical elevation reference points and show their location on the plot plan. Show the su-face elevation at all borings and the direction and percent of land saooe. SYSTEM ELEVATION C'.' 0.3 Q 18.,07r tr r.4~a 1fr.--I• ]F A4,.;a. T r 0- { 1 0 P y P 1 I- f Po,;zc t rte y-~ gig, 4 J, ZL 6~ T N o Cs t gopp< I~qr 39 SMA// C•v~ Q / ra 1~A6r`t+ ned, hereby certify that the soil tests reported un this form were made by me in accord with the proce ores an^ methods sP' xified in the Wisconsin I, the uncle Administrative Code, and that the data rerorded and the location of the tests are correct to the best of my kno:rledge and belie'. print TESTS WERE COMPLETED ON: NAME (print): 7 TDDNESS \~"_v CERTIFICATION NUMBEH PHONE NUMBER;option- a-If r f i . v ~ ! CST TORE: ~q_  DISTRIBUTION: Original and one copy to Local Authority, Property nd Soil Teal CIL'itR-SBD-6395 (H. U2182) - am accurate soil ;est, your repo I t ntust.inr;ludU: mLrcir: legal desea iption; 1 use semi on must dew ly,iridicate4vhetlrer thi: is a ruddenee or commercial project: ww; X IbIUM number o, hedroorns or cominex.i rl use pl.lnnec!: ,hi; ~ nc'.^a or re_ hla~'erirent systerYr -rifii(Je tote luitahihty wtirtrt boxes. A SITE IS W TABLE FOR A HOLDING TANK ONLY IF AI-L HER SYSTC?OS ARE RULED OUT BASED ON'-4)1:L CONDITIONS; =ASE ust: tirr'a~br ev;atic}.ns st>ovan hers: fo, twfritind profila r;escriptinns and completing the plot plan; lKF A L_EGIRL.F rl anram accurately Wadng ya,u; te_t loc<itiuny. Diav;ing to sca!e is preferred. A ~araic~sheer may tx:~rsei3 itr~c•;Irect; ke swo yo.,r buncltrrimk and +ertica, efcvation tetcrence point are cloarly shown, and art permanent; mhlFae ali apprnpi iale hoxes a to dates, names, addrenes, flcod plan t3afa, parc:olarion tes; exemp- 'hc i u"rawn & _eh tluni =;Erin, ::IcvafiM dew ii-)t pli:,o N-A. i-, the appropiiate twx; lh- ' foi m aird play=e vo'il current addvuss arld your Certifieal-on number; egihlropes <i-l a sUAara ns regMerl. AI L SOIL_ TESTS MUST BE FILLD tVI FH T1IF 1' r+ ace 3 i7. !LL i:L i I <i i BR - Rolrork SS - Sac0slof++'. 4nue; "1 LS - I imestn,-. ?dm y: C'la , t l u w: C. C. aC' t Air. {;'r :~'UBrIT,pt rar711 -1-I n R i,;. {,n il t;nrr ?(r ihir lt,^r".•;.,+a. a ` o f i{ t" h w1 p ~ 1 rCk r ~~V : V I f\ T, 1 fyi N ~ ~ ter, ~ _ 1 ,o! 1` se-