HomeMy WebLinkAbout040-1292-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No 589716
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. /f//
Permit Holder's Name: City Village Township Parcel Tax No
Craig & Cathy Gray TOWN OF TROY 040-1292-10-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
g1111E 91-C 75" GQA'i>E &12/AJ6 g, gM 46,L _ 24.28.20.1668
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic + ig 5 /P Benchmark
Dosing (✓1 FE71',W~ Alt. BM
Aeration Bldg. Sewer
Sts 0Q 89z. S
Holding St/Ht Inlet ( Z d 8~~, y
TANK SETBACK INFORMATION St/Ht Outlet /
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Zg, ✓ Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade S S~Z Z
AV vrPSGojg~S e✓
Manufacturer Ge and St Cover / / 2.2q p93 ~f '
d.2 fy
'11 /11,
odel Number ` I)m TDH Li F ion Loss System Head TDH Ft
Forcemain Length ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1 / D I O r
SETBACK SYSTEM TO D P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR wF o- Pip-
Type Of System:
~A~ ` t ► y/~ ,l UNIT Model Number:
~'1 ` G lL 5 mot! .
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
✓ / 11 Pipe(s)
Length 4 Dia_ Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over r xx Depth of Seeded/Sodded lched
Bed/Trench Center Bed/Trench Edges xx soil xx E-1 P Yes ❑ No ruEl Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: $ el Inspection #2:
9
Location: 311 LINDSAY RD !N~/~ Acc# 1 /-1
1
1.) Alt BM Description = W,-rll 5'Y/4 V//p G04 J7_MV/ ~Ly
n ! D Kfj /vGc7~ , dvT 1~ Td ,e~11
/'1' ~3
2.) Bldg sewer length
- amount of cover = / jt4"f5 f(/bg 196141 /ill of A) IQ_" W4L KejefZaA~
s Ysr~ 94-01,417714J 6ELaC✓ 7-1415 4t,,Y AJ Prr~sE.v,,
Plan revision Required? 0 Yes ❑ No LSL9_11~j ~
Use other side for additional information. L f J F7/
Date I~epctor's Signature Cert. No.
SBD-6710 (R.3/97)
~QEp►atarT~ 1 Comity
Safety and 11 ngs Division T C (wj
201 W. Wa (7162
Sanitary Permit Number (to be filled in by Co.)
P ' Ma
z
o ^t 5 T 777
Sanity Permit A Il State Transaction Number
rY PP : 31x cou►vrYx~j
In accordance with SPS 383.21(2), Wis. Adm. Code, submission oMdf~~ulgGptal unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owne itted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 3j 1 Lj \W Hy
u oses in accordance with the Privacy Law, s. 15.04(1)(m), Stats.
1. Application Information - Please Print All Infor I
Property Owner's Name Parcel # atas_
`
0,2 WU + CATWI C--,RAy biro / ?-/Z /6- Coo
Property Owner's Mailing Address , Property Location / l/~e
3 11 L-) P,, Ru ~ Govt.. Lot / • ) ` eo
City, State Zip Code Phone Number ~tJ
Section L_
~j W1 tt61 to (circle one)
II. Type of Building (check all that apply) j. Lot # T Za N, R ZC-) E or
WZ-or 2 Family Dwelling - Number of Bedroo Subd'.ivision Name
nis
~U~I l~f L1.pGE ~1 ~i At'~~
❑ Public/Commercial - Describe Use 6k
r o~ti ❑ City of
❑ State Owned- Describe Use CSM Number ❑ Village of
Town of I R_Q `at
2 s ZZf- r
III. Type of Permit: (Check onl one box on line A. Complete line B if applicable)
Zi Ad-
A, )<ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
g- ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New
Before Expiration V Owner
IV. Type of POWTS System/Component/Device: (Check all that apply)
XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat nt Area Information: Q C K 'i -C,14 P, PA
Design Flow (gpd) Design Soil placation Rate( f) Dispersal Area 11,%~__ Dispersal Area Propo (sf) System Elevation
-7 ~ 8s7 ~$`o moo. 3 _
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units U
New Tanks Existing Tanks
I r a U ii1 ~ C?
Septic or Holding Tank
I jt" x
Dosing Chamber IZ60
1
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POVVTS sbown on the attached plans.
Plumber's Name (Print) Plumber's S' ature RS N ber Business Phone Number
- 'F-~ +C) 232~ 715-i4cil -J~ S8
Plumber's Address (Street, City, State. Zip Code)
oun epartment Use Only
Approved El ) PernitQFee Date Issued Issti wZ gnature
^ S L1/ en Reason for Denial 70 5' co to Z3 t Ir
IX. Condigg#(Reasons for Disapproval
i `5 piin tank, eMuentfilter and ~e. P ~~Gr✓
disperxs i cell must all be setot o lI ; lnt'r k
as per management plan provided by plumber,
2 'ACll.ee11beick requirements mustbe,inain ired ~f, ~l D I'1 Le, I/a(% A, NcrL.
as per applicable code / aMinances.
inches in size
Attach to complete plans for the system and submit to th VC!9.7'on paper not less than 8 to i V
r "~e AwH or it
SBD-6398 (R. 11/11)
GAIL 4 CATHY n key
Ld i NO I'KC~
s e ►1c s e'4 Z`i i 2Z~ O) i;~26 v1
I iZo,~ iDW ~441~'
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Brt Vet l~ i~ S Z: y
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PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
i- ILTC 2 SPrC:5 POWTS Application for Review
ST CRp ' (1"1R1KJ-TEk)A 6- Soil Evaluation Report & Site Map
v,,1A(ZRCk ` j l~)~'o
Project Name / Description
Owner Name(s): CRkIV 4 I'NAkAy G 1Z A:"-/ Phone: - -
Owner Address: Sill Li tj():5 p ,-J Re) A0 0 o®scl:, Zip: '~`1 (o
Project Address: S,AN\E
Govt. Lot: 5 114 of 1/4, Section z _ T 2-0 N-R ZO E ❑ or W ❑~C
Township: 'T Ol County: S-1 C L\i=
Project Parcel ID L40 JQ to()
Designer Information
Designer Name: Phone: '7( S -S'16 Designer Address: px ~ SSG. yy( _ Zip: `JU
E-mail: 'hj spare res rred Co" approval stamp.
License Number: z y
Remarks:
Signatur
Date:
i 4O4
6~~40411)Kgnature required on each submitted copy. '
'AIL CATHY G2E`l
L6i 110 TKo~ 11ILLp6 S~tJ OOfI1o1~
S ie= 1 4 SE 14 S Z I T ZR 04<26 Klj
Teo ( i tom. vltJs 441R' S-7 C 2c~ 1 x owjq"/ ?
I
Rf1S 225'2'-12
Vi
8 ~1- t VY1l~ iC S yZ; -I
5b /L i3d IZr N L S
Soil Absorption System Cross Section
ft
Final Grade
4' Schedule 40
PVC Vent Pipe
With Vent Cap
Leaching ft
Chamber
System Elevation
ft 5 _ 6 ft
Soil Absoro#lon System Plan View
88 ft
ft
ft Leaching Trench 1
Vent Or Observation Pipe Chambers
4' Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Models] ,WILA*~?I1A-V11t--,, d~jii<
EISA Rating sq ft per chamber Soil Application Rate 7_ gpdisq ft
gpd Design Flow : , 7 Soil Application Rate = ZO EISA = Chambers
2 rows of 22--* Z3 chambers each.
Page of
POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FELE INFORMATION SYSTEM SPECIFICATIONS
Owner 4 C S tic Tank Capacity ❑ NA
Permit # Septic Tank Manufacturer 2 ❑ NA _LJ DESIGN PARAMETFRS Effluent Filter Manufacturer V\.% 4z ❑ NA
Number of Bedrooms 100 oom ❑ NA Effluent Filter Model lit E3 NA r
Pump Number of Commercial Units NA Tank C act ❑ NA
Estimated flow (average)* Ueia Pump Tank Manufacturer 0 NA
NA
Manufacturer O
Design floc (peak), estimated x 1.5 Uda Pump Model ❑ NA
Soil Application Rate UdS Pretreatment Unit NA
InfluentlEftluent Quality (NAP) Monthly Average" p Sand/Gravel Filter CI Peat Filter
Fats. Oil & Grease (FOG) < 30 mg1L, ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (DODS) < 220 mg/L ❑ Disinfection ❑ Other
Total Suspended Solids (TSS) Manufacturer. Model:
5 250 mg/L Dispersal Cell(s)
Pretreated Effluent Quality ❑ Monthly Average:gin-ground (gravity) ❑ i Vmnd Orcw urized)
Biochemical Oxygen Demand (BODS) < 30 mg/L ❑ At grade ❑ Mound
Total Suspended Solids (TSS) < 30 mg/L ❑ Drip-line ❑ Other.
Fecal Coliform (geometric mean) X10 cfu/ IOOml -Leaching Chamber Manufacturer tJ LT R-A-W R
Maximum Effluent Particle Size 118 inch diameter Model C`,' IS K y Laying Lengthh~hamber
*Wastewater Flow Verification and Calculations. Soil Application Rate gpolfe Area Req.. `
(Other than bedroom based) Infiltrative Sunface/Gfiamber-ESIA Rath ' ;2 fe
Minimum Number of Chambers
❑ Aggregate Des` Flow Rate= min
Values typical for domestic (non-commercial wastewater Materials: all materials must comply with W1 Adm. Cook
and septic tank effluent. COMM84 and be installed per marnifixturm spycations
***Values typical for pretreated wastewater. and val letters.
DESIGN CRITERIA
❑ "Wisconsin At-grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.aL 1990)
❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Mannar Converse, ].C_ and EJ. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publications 9.6
❑ "Design of Conventional Soil Absorption Trenches and Beds". RJ. Otis - ASAE Publications 5-77 and "Design Manual -
Onsite Wastewater Treatment and Disposal Systems". EPA 62511-80-012 October 1980
❑ SBD -10570P (8.6/99) "At Grade Component Manual Using Pressure Distnbution"
C3 SBD -10567-P (8.6199) "In Ground Absorption Component Manual"
A,SBD - 10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0
❑ SBD -10628-P (N.6/99) "Recirculating Sand Filter System Component Manual"
❑ SBD -10656-P (N.6199) "Split Bed Recirculating Sand Filter System Component Manual"
❑ SBD -10572 P (8.6/99) "Mound Component Manual"
C3 SBD -10691-P (N.01101) "Mound Component Manual" Version 2.0
❑ SBD - 10595-P (8.5/99) "Single pass Sand Filter Component Mannar
❑ SBD -10657 P (8.6/99) `Drip-lion Effluent Disposal Component Mame'
❑ SBD - 10573-P (R 6199) 'Tressure Distnbutian Component Manual"
p SBD -10706 -p (N 0 f (01) -'pressure distribution Componcrrt Mau ml- Version 2.0
❑ Drip-line Effluent Dispersal Component Manual for Multi-flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORING SCHEDULE
3
Service Event Service Frequax7 condition of tanlqs) At least once eve Ci months ❑ year(s)
Purm out cotrtents of s When combined slut a and scum uals one-third 1/3 of tank volu>nc
Inspect dispq~g cells At least once eve ❑ months s 3
Clean effluent filter At least once every ❑ months s
controls & alarm At least once Sy!EL ❑ months ❑ s C3 NA
1, y=
Fhesh laterals and test At least once every ❑ months ❑ s ❑ NA
. _ _ At 1part nnrp Pverv r-i months ❑ vear(s) 0 NA
❑ Mound, At-Grade, In-Ground Pressure
The inspection shall include recording the levels of ponding, if any in the observation; tubes and a visual kapection for any
evidence of surface seepage or discharge. Any discharge to the ground surface mud be promptly repot to the regulatory
authority. Ponding greater than 75% of the height of the component may indicate overloading or inWending hydraulic faihtre
necessitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing, Thu laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
Reppoorts t for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is
properly and safely abandoned in compliance with Ch. COMM 53.33, Wisconsin Administrative Code.
All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator-
After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or other inert solid material.
CONTINGENCY PLATY
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system
The replacement area should be protected from disturbance and compaction and should not be infringed upon by n9u'cd
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 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 mod
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a
holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed
as a last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES
AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT
TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE
INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name ~ t:' F f-- b l~ Name
Phone 7 7 c3 L161 Phone
SEPTAGE SERVICING OPERATOR (I?umpa) LOCAL REGULATORY AUTHORITY
Name A enc
phone Phone
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
0PERiTION
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity
and quality of the wastewater stream will affect the performance and longevity of'your POWTS. The installation of water-saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
771is system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetableMruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should he minimized. Toilet tissue is the only
paper that should be discharged into the system Other non-biodegradable items such as baby wipes, tampons, sanitary napkins
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system Chemicals such as petroleum products, paint,
disinfectants„ pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
0 Valves
Valves shall be operated in the following manner.
0 Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a l day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
INPECTIIQNS
Inspection shall be trade by an individual carrying one of the following licenses or certifications: Master Phunber, Master
Plumber Restriewd Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
0 Septic Tanks Component
Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks
or teaks, nn more the volume ofcombined sludge and scum and to check for any backup or pondnng of effiuent to the ground
surface. Access openings used for service or assessment shall be seated and/or locked upon completion of service. Any
defeats shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an efliective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire contents
of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin.
Administrative Code-
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's
specifications. Provisions are to be mace to retain solids in the tank. Filter cleaning may be necessary at more
frequent intervals than staged in the maintenance schedule to keep the system operating -
E3 Pump Chmnbaareatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any filters.
Any service needs or repairs shall be promptly taken care of.
M In-Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be pronTfly reported to the regulatory
authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or in4mad ing
hydraulic failure necessitating more frequent monitoring.
rs,~ or
. v INSTALLATION INSTRUCTIONS
FILTER
-Ipm: =1114
i2,51PL-625 FEATU S B ED'S Mra, - -
Features & Benue-
f" IN -
a Rated for 10,000 GPD
- - PL-525 = 525 Linear Feet of 1f98" FFtllraftn
PL--625 = 625 Linear Feet of I /32° Filtration
PL-625 PL-625 *Accepts 4A and 6° SOM. 40 pipe
PL-6251M Efi rt FHW should operate effidently $ Built in Gas Reflector
;everal years under normal conditions before a Automafic Shut-Off Bag when Fier Is Removed
firing cleaning. It is rinmended that the filter be
ied every dme the flank is pumped or at least every a Alarm AccessibEtty
years. If the installed filter contains an optional At~Cepls PVC Extension Handle
n, the owner vAH be notified by an alarm when the O
needs servlc1119. SetvlGing should be done by a
fled septic tank pumper or Installer.
10MMENDED PRODUCTS _ -
oWWk PVC FSbt3r
Q
w
won Hanclie
Y' - n.~tty~I at i1--ta .ta¢~~K ~
V3 - _ r ass -
r.3
9
IF V!?-t
- ¢at and
=181C ISO Mffipmn~
P.~CbE+ild E,Ok;a saw scream FilftrAbrnn
s Riser Covers sututKiflar- GOrM
ng y lu POtytok safety amem
~ cover grade pobfiak _ Y 11D USS prevent tragIc acdd t~ aarm panels
be tank wW s~On tt~ can extend from hspWft by dIN&M aM swll o p v4d a via W
eawm s sing Yom Stier easier t~8 fire met or cam pipe wo and Pab %%g WD OW and ae.rdibla nadram ii of
by e6nd- make lifter andfor baffie septic to* a*wcm int 9 t and tank
bg digger to ttrid tame ~ 3 a
rance. pipe.
Fora WH ii$t of PoMok products pte~ our webMft at y r p*Wok C6M
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
.Owner/Buyer C RAt + C AT W01 6-t-Zi2d
Mailing Address S1 A L.l NDSPY 1 IN$o u " V 1 S-116/6
Property Address +'r x/, (3 • 0,,
(Verification required from P ing & Zoning Departm for new construction.)
City/State ~ \JQ$O Qf '6_W/Parcel Identification Number(
LEGAL DESCRIPTION
Property Location S9 '/4 , '/4 , Sec. Z'q , T ZS NR 20 W, Town of 'T Ro '-l
Subdivision Plat: . T ROB/ V(466 ' p1 ~>fll1"Ip ,,j Lot # ~f.~.
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume Page #
Spec house ❑yes[3no Lot lines identifiable ❑yes❑no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
0 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must. be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this for 1 are true to the best of my/our knowledge. I/we ain/are the owner(s) of the
property described above, by virtue of a warran deed recorded in Register of Deeds Office.
Number of bedrooms
NA U OF APPLICANT(S) DATE
****Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
DK451on of Safety land Bullclings
In accordance with Comm 86, Wis. Adm. Code County -
Si, C)2o\
Attach complete slte plan on paper not less than 6 112 x 11 Inches in size. Plan must
Include, but not lirnIted to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road 01V n _ r ZC( Z /D - 00 C)
Please print Oil Information. R awed b Date
~f
Personal Infomlebon you provlds may be used for secondary purposes (Privacy Law. s. 15.04 (1) lm)). i~ UU
property Owner Property Location
Cp/~ 1 fJtil ~ t^ (OFM>✓N~ Di`' P, , 51✓ 114 a 1/4 S 24 T 2!~' N R 2-p r W
Property Owner's Mailing Address Lot a Block d ;qu bd. Name or CSW
1$b0 A'RF" R.D ~ 1•DD 1ya JZ O VILLAC'T--T1~1N ADD
State Zip Code Phone Number ❑ City ❑ VtNage Town Nearest Road
ti r\1
nf~ (-7b3 75'- 7S"0 ~ M.. _C . ~ New Construdbn Use Residential 1 Number of bedrve~g~ Code delveow rate GPO
Replacement E] Public or commercial - Descri
Parent material Ol t'C y 5 f gn elevation it appllca'i 19
General cortynents O
am rocommendstlons: OIJVFJ~1~1~1JA<~ TIC NCtI~S GROG)
-7-0
N
❑ vn9 0
Bong Ground surface elev. Depth to limiting factor
Pit Soil lication Rata
Horizon Depth Dominant Color Redox peacription Texture Structure Consistence Boundary Roots EGPDltfE
In. Munseit Qu. Sz. Cont. Color Gr. Sz. Sh.
ION
2- Lo -1'5 ID Y Z 0,75
3 V5- Zlo 75Yp' re
3 S S r p, 7 1. Z.
rtl
Pic Ground surtece elev. Death to limiting factor 2-1n. Soil ICation Rate
❑
Horizon Depth Dominant Odor Redox Description Texture Structure Consistence Boundary Roots •E GPD1tPERd2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
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Effluent fl1 = BOD > 30 t 220 rrg1L end >30 _ 150 mg1L ' Effluent #2 = SOD < 30 mglL and TSS < 30 mgrl.
S♦ azure ~ CS7 Number
CST Name (:lase Print) 22- 4 8
AJAR~ Zo H t-L S-~i~ '
Date Evaluation Conducted Telephone Number
Address
W9%75 6`40+KAVE411VE FALLS WI 5902- 2 G-03-D2 CIS LA 2b-I~~S
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LaiandDepartment
gel Industry, SOIL AND SITE EVALUATION REPORT Page I of 3
Labor and Human Relations tions
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST ' CVO l~
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. L,u r
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY _ DATE
PROPERTY OWNER: PROPERTY LOCATION
GQV;. 6GT j ~ 1/4 SE 1/4,SZ~ T N,R Z 0 E (o w
PROPERTY OWNER':S MAILING ADDRESS. BLOCK # SUED. NAME OR CSM #
;MBER CITY, STATE ZIPCODE ( HON, ti ❑ ITY ❑VILLAGE [MOWN NEAREST ROAD
etn->k- , fv 44 Tt~oY t_trj,N-~) s r~
(X] New Construction Use [aQ Residential / Number of bedrooms [ ] Addition to existing building
j) Replacement [ ] Public or commercial describe
Code derived daily flow b~0 gpd Recommended design loading rate - bed,
Absorption area required S S~ bed, ft2 "ISO trench2 gI~/ft2 ' trench, gpolft2
, ft Maximum design loading rate 1 bed, gpd/ft2 • %
trench, gpd/ft2
Recommended infiltration surface elevation(s) 880.(3 GsO~ -Rzi~vO_Wts) ft (as referred to site plan benchmark)
Additional design / site considerations Se1EE- l~l'T t; '_~o L/i ST71(z az aj 3
Parent material Lp ~S3 0v1ZFN-t G l..~LfrL &j -N W'R-3 N Flood plain elevation, if applicable N f~ ft
s 7 =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitablefors stem Z ❑U I ZS ❑U 2S 11U I ®S ❑U I ®S ❑LI( ❑S f~U
SOIL DESCRIPTION REPORT
Borin # Horizon Depth Dominant Color Mottles Structure GPD/ft
Texture Consistence Bourrbry Roots
z_ in. Munsell Qu. Sz. Gont Color I I Gr. Sz. Sh. I I I Bed Trer~
1 0-l0 ~~~<Z3fZ - sil 1 ~~,k s1~ ~S I z 3
0- L
Ground 3 Z6 -~32 1•S ti~ 31 SG-( G~ U Sg y.L )i
elev.
g4.b ft
Depth to
limiting
factor
Remarks:
B ring #
' t 1 l n~ ~-b cQ s l~ ~S Z. 3
-L 1t-a(6 ~.5`ie Sly - S & C-) - 4~
Ground
elev.
RM, O ft.
Depth to
limiting
factor ,
~ l z
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425-0165
egerer Soil, Testing & Design Service-P.O. Box 74 River.Falls,WI 54022 '
Signature
C4ZA,41L, ;f. 14`~ °14 - Z 9 7 - 12 Date: ` _ 3 Q b CST Number: .
I 7 2 2025E