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Home My WebLink About026-1294-21-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 589739 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Permit Holder's Name: City Village Township Parcel Tax No: Oevering Homes TOWN OF RICHMOND 026-1294-21-000 CST BM Elev: Insp. BM Elev: Description: Section/Town/Range/Map No: /D(2N BM 0 (A t t)1 \ -i k,% 28.30.18.1503 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER • CAPACITY STATION BS HI FS ELEV. Septic J ~v Sig Benchmark ,Z 163. ~ r l Alt. BM Aeration Bldg. Sewer 21 C~v Holding St/Ht Inlet b• "1.7 C7- (6 • CI SETBACK INFORMATION St/Ht Outlet t0. 3 I 15 TANK TO P/L iR CkvaAo Air Intake ROAD Dt Inlet Septic 7Z • / Dt Bottom ~ Dosing Header/Man. G J ~p Aer ' n Dist. Pipe . 't 6 • t0 Holding Bot. System J, s cl - '7. to q -S Final Grade PUMP/SIPHON INFORMATION L Manufacturer Demand St Cover Model Num TDH Friction Loss System TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 Z_ / re~I', ^ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type f System: n i J CHAMBER OR ti • O/~J~,~/bttpl~'-' UNIT ModelNum3 tlly` 1 DISTRIBUTION SYSTEM Ala It' erg. Header/ManifgId I Distribution x Hole Size x Hole Spacing- Vent tgAir Intake 4 J Pipe(s) \ Length Dia Length Dia Spacin® SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center C Bed/Trench Edges Topsoil es No~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection 42: Location: 1148134THAVE~, / p Y-. 1.) Alt BM Description = ' ( C..O J (J 2.) Bldg sewer length = 33,k. / Q.~.$ S 1 n n - amount of cover = -7 AIL ~Z ~ I o r~ ,x,)L.~ Use other revision No side for additional information. Qf I t~ SBD-6710 (R.3/97) Date f InsepctorCert. No. i 1 county F1 - ; ~ r~ ass Safety and Buildings Division J t '1 / 8 201 W. Washington Ave,, P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) p AOG Madison, Wl 53707-7162 ST. 73 ' Application State Transaction Number In accordance with SPS 383 .2l(2), Wis. Adm. Code, submission of this form to the a Nn is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different thaw mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.0 1) m), Stats. 111IL-1.45 1. I. A lication Information - Please Print All Information Property Owner's Name Parcel # Property Owners Mailing Address Property Location ' ,1:563 , ~ Z ? r, f Govt Lot j City, State Zip Code Phone Number ~ 1. yy Section r 11 ype of Building (check all th apply) 1 Lot T - V N; R _ E W Subdivision N 1 or 2 Family Dwelling-Number of Bedrooms z J~ , Ok ~ Block ❑ Public/Commercial - Describe Use t ❑ City of Ao K- ❑ State Owned - Describe Use CSM Number ❑ Village of 2. IJ ~S~ Cetk l,J iz3 r_~."ers XTown - IIL Type of Permit: (Check only one b on line A. Complete line B if applicable) A' ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other modification to Existing System (explain) B• El Permit Renewal ❑ Permit Revision ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Dat*Issuel Before Expiration Owner - Type of POWTS System/Component/Device: Check all that apply) DIV. Jd~I1oa-Pressurized ]n-Crround ❑ Pressurized ln-Ground ❑ At-Crrade ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of suitable soil rs Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaUTreat nt Area Information: Des' Flow (gpd) Design Soil Application Rate dst) Dispersal Area Required (sf) Dispersal Area Proposed S can Elev u ' 2 J T? g- VL Tank Info Capacity in Total # of Manufacturer ,i.. Gallons Gallons Units CJ I ° New Tanks Existing Tanks I z m L m ILA t*~! V\ n U v n C7 t Septic or Holding Tank X ~~3 r Dosing Chamber - VII. Responsibility Staten - I the undersigned, ae responsibility for installation of the PORTS shown on the attached plans. Pl~+ 's Name (Print) Plumb /Signature MP/MPRS Number Business Phone N=ber c' ° _-c;At - -IJ Plumb 's Address (Street, City, State, Zip Col ountv!De artment Use Only Approved ~ Permit Fee Date sued Issuing t Sign P qb . oa g t g I ~o Own en Reason for Den al DL Conditi o or Dis pproval t hk, ertlt~ern` sr artd` 3 d t~ a ~Q a• 6s0eMI cell must all be s- ttcas. ! mgj n n2S t as per management plan provided by plumber, 4J1 4 2. A111000 ants must,•Jre FnWntz[lned I as per app*mble code / ordiunm. J.-~ L•: S Attach to complete places for the system and submit to County only on paper not less than 8 12 z 71 inches in size SBD-6398 (R. 11/11) Soil Test and System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 28 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION 97.34-.9 5' below q de 8/10/16 3 ~10~ f vv DATE BEDROOM CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK 1000 gallons LIFT TANK SIZE DOSE TANK SIZE MOUND SEPTIC TANK SIZE HOLDING TANK SIZE LOA r TE •5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. top of er box ASSUME ELEVATION loo' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 177' Property Line Scale = 1/4" = 10' 5o CQ: c; e. 9 c~ pc~c~ ar` c4s e r~•ej_~ 90' 102' Vents 2-3' X 94' Cells with >3' spacing 50' B-2 101' 30' B-3 0'. _1W V_L_j B-1 70' 5°Io Slope 1 5' 5' 60' 0) Vent B.M.* Pro 3 >6" Quick4 Standard Bedroom ~ of Cover Leaching Chamber use with 20.0 ft2 of Area 7~5.6ftA2/pair of end caps 12" 4' Long 34" Grade at System Elevation All piping shall be ASTM SDR 30/34, within Property Line 10' of tank, piping shall be ASTM F891 134th Ave Csrt-~~~~ l~5 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code C g County J i . ~ • Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. g / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. V' l Please print all information. Revi by Dat Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). $ t Property Owner Property Location 0 I: I 1 Govt. Lot 1 /4 5L~1 /4 S 9 T N R E( W kt~'J--Q L3 Property Owners Mang dress Lot # Block # Subd. Na or M# IL24 111 City ~ State Zip Code Phone Number ❑ Q.Village f4wn Nearest Road? 4411 New Construction Use: (Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement g ❑ Public or commercial - Describe: Parent material f l-✓ GA• Flood Plain elevation if applicable Iji) ft. General comments L~ and recommendations: _ System Type *1m,&a~ ' System Elevation ❑ Boring F ng # [ Pit Ground surface elev. 4~ eft. Depth to limiting factor= in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 y ~ !J 7 tJ y e~.~ v r J~~ e I/ La. Fs ho ob 11 6 Boring # t( 11 Boring Pit Ground surface elev. G 4-ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 G - r 1~ lY1 J Z A), t dU7 Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD. < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 54017 715-246-4516 Property Owner _ Parcel ID # Page of "a ❑ Boring Boring # 01 1 Pit Ground surface elev. ~ 6. Depth to limiting factor - in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F-1 ❑ Pit Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.6/00) Property Owner Parcel ID # Page of Boring # Boring pit Ground surface elev. Depth to limiting factor i I in. Soil liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 AEC, Boring # ® Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 E] Boring F-1 Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ pit Soil Application Rate Horizon 'Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD4330 (8.6/00) CSC ►`~s Soil Test and System PLOT PLAN PROJECT,Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 28 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION 97.3/ 9 5' below q de 8/10/16 3 j DATE BEDROOM CONVENTIONAL X00C #;4b/ CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. top of power box ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 177' Property Line Scale = 1/4" = 10' l ~ P 90' 102' Vents 2-3' X 94' Cells with >3' spacing 50' B-2 101' 30' B-3 B-1 0' 5% Slope 5' S 30' 5' 60' 0' Vent B.M.* Pro 3 >6„ Quick4 Standard Bedroom of Cover Leaching Chamber House with 20.0 ft2 of Area 5.6ft^2/pair of end caps Long 12 Grade at System Elevation 34" All piping shall be ASTM SDR 30/34, within Property Line 10' of tank, piping shall be ASTM F891 134th Ave Safety and Buildings Division County' 41 "EIVED < p 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, W1 53707 J7J62 a 2010, Fti 5$ 9 743? OOMMUNITY DEVERSP-4W Permit Application O~A fate Transacti n ' ber In accordance with SPS 383.21(2), Wis. Aram. Code, submission of this form to the appropriate goF is required prior to obtaining a sanitary permit Note: Application fortes for state-owned POWTS are st. lest Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for seco,. , purposes in accordance with the Privacy Law, s. 15. 1) m), Stats. j L Application Information - Please Print All Information t Property Owner's Name Parcel # Property Owner's Mailing Address - Property Location 30. i S d -1 k, tav, f ~S a Govt Lot ,City, state Zip code Phone Number Section (circle e} H. Type of Building (check all that apply) y rc;~ T J® N; R r W Family Dwelling-Number of Bedroo Subdivisio Name El Public/Commercial-Describe Use ,OP-- I`// ❑ City of ❑ State Owned Describe Use CSM Number ❑ Village of own of - III. T e of Permit: (Check only one x on line A. Complete line B if applicable) A- Iew System ❑ Replacement System catment/Holding Tank Repiacern ly CJ Other Modification to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ C ge of P]%ab Transfer to New List Previous Permit Number and Date Issued Before Expiration IV. Type ofPOWTS System/Component/Device: lick Vj~.Mtpply) on-Pressurized In-Ground ❑ Pressurized In-Ground t-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < LofsTui?tate 5 7(4 ❑ Holding Tank El Other Dispersal Component (explain) Pretreatment Device (explaina V. Dispersal/ Treateut Area Information: Design Flow (*pd) Design Soil Application Rat f) Dispersal Area Required (sfl Dispersal Area Propose sf} Syst m Elevatio VL Tank Info Capacity in Total # of Manufacturer j Gallons Gallons Units 6 F, a a` Yn New Tanks Existing Tanks P/4 ;JZ4-" 0~,L Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, 444e responsibility for installation of the POWTS shown on the attached plans. s ignature MPIMPRS Number Business Phone N ber P s Name (Print) Pi n s Ad ess (Street, City; " te, S P 2-- - f~ S r VIII. Countv/De a1 tment Use Only ssuins ent Signature L proved Disapprove Permit Fee g5 4!~O~ il/W/ Cc Lap* ❑ _Ze-r Giv Reason enial IX Conditi I ogsfpr~D pproval 2` Q J,`n L ro J~ , §Al s §l~ t ~7 J p ~f f a, ~'p disor al co MUO 411 as per management pli6 ~►ua~000 &rtk4f . as par gVic bia bold / ordlRlMIlft Attach to complete plans for the system and submit to the County only a paper not less than trz z 11 inches inlsift w SBD-6398 (R I1/11) System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 28 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION 93.5/93.2/92.9 4.5' below grade 7/6/16 BEDROOM 3 DATE CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1157 # of chambers 57 BENCHMARK V.R.P. top of 1/4" steel pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 177' Property Line P"AL Scale = 1/4" = 10' 100' Vent >6" Quick4 Standard B.M.* of Cover Leaching Chamber with 20.0 ft2 of Area 12" 5.6ft^2/pair of end caps 4' Long 3 4" Grade at S stem Elevation 54' -9-91 Vents B-1 4 % slope 60' Further testing will be S r. done to find a more suitable area and a B-3 60' proper boring depth 3-3' X 78' cells with >3' spacing 60' 30' B-2 20' All piping shall be ASTM SDR 30/34, within Pro 3 209' 10' of tank, piping shall be ASTM F891 Bedroom House 134th ave Ir LECOPY Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 7/6/16 Owner:Oevering Homes Location: NE1/4 SW1/4 S28 T30 N,R18W 1148 134th Ave Richmond Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Se tion 4-6. Maintanance and ontingency Plan 7.Filter Cross Secti Signature License num #226900 System PLOT PLAN PROJECT Oeverino Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4s 28 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION 93.5/93.2/92.9 4.5' below grade 7/6/16 BEDROOM 3 DATE CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 157 # of chambers 57 BENCHMARK V.R.P. top of 1/4" steel pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 177' Property Line Scale = 1/4 " = 10 100' Vent >6" Quick4 Standard B.M.* of Cover Leaching Chamber , 2 with 20.0 ft2 of Area Long .6ft^2/pair of end caps 4' 1 34" Grade at System Elevation 54' 99' 98' Vents B-1 4 % slope 0, Further testing will be done to find a more suitable area and a B-3 60' 12 F proper boring depth 3-3' X 78' cells with >3' spacing 0' 30' B-2 20' All piping shall be ASTM SDR 30/34, within Pro 3 209' 10' of tank, piping shall be ASTM F891 Bedroom House 134th ave L Cross Section of Quick 4 Standard Leaching Chamber Typical cross section for 2 of 3 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typicallnstallation Len K Grade Vent 34 Septic Tank ' 4' L5 4' Log Grade at System Elevation 34Grade at System Elevation 34" Spacing 5' 3-3' X 78' Cells Observation tube/Vent Same on other end To be located on end of Cells %A B System elevations: ;*c A 95--§' 61-7-3 B"ts-Q' C_ 19 chambers per cell ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 62eyg 1 Mailing Address ~t9 C~LO ~9 7for Proper ty Address 3 `4 (Venheanon required from Planning Zoning Departmw eonstntction.) City/State _ Parcel Identification Number LEGAL DESCRIPTION Property Location , y r4 , seg. T SO N R w, Town or_` i Subdivision Lot # c~ Certified Survey Map # Volume page # Warranty Deed # Volume , Page Spec house yes no Lot lines identfiabl D S no SY T TE M MAINTENANCE AND OWNEg CERTIFIGATION Improper Use and maintenance of your septic system could result in its premature failure to handle wastes. Prop r e maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Ownerr main nanceou put into responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County P owner and by a master plumber, journeyman plumber, restricted plumber o a licensed uimp artment eria certification form, signed by the fyin wastewater disposal system is in proper operating condition and/or (2) after inspection and p g that the on-site less than 1 /3 full of sludge. Pimping (if necessary), the septic tank is 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 Commerce 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. nntng ~ I/we certify that all statements on s fora are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a ?tranty deed recorded in Register of Deeds Office. Number of bedrooms IGNAT 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. 08/05) POINTS OWNER'S MANUAL & MANAGEMENT PLAN Page tit ILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity D NA Permit # Septic Tank Manufacturer D NA IGN PARAMETERS Effluent Filter Manufacturer ~ ❑ NA Number of Bedrooms D NA Effluenrt Fitter Model p NA Number of Public Facility Units ANA Pump Tank Capacity l D NA Estimated flow (average) to Vday Pump Tank Manufacturer NA i Design flow x 1. ~ (Estimated 5) f aliday Pump Manufacturer t::~=tNA galldayt Soil Application Ratez Pump Model i Standard Influent/Effluent Qual' rtY Monthly average Pretreatment Unit Fats. Oct & Grease (FOG) 53p mg/L D Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (SODS) 420 mg/L D NA O Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) s150 mg/L a Disinfection D Other: !Pretreated Effluent Quality Monthly average Dispersal Cell(s) D NA Biochernicai Oxygen Demand (BOD5) 530 mg/L Arq-Ground (gravity) D In-Ground (pressurized) Total Suspended Solids (TSS) <_30 mg/L : "f ` D At-Grade ❑ Mound Fecal Coflform (geometric mean) 5104 cfu/100ml D Drip-Line D Other iMaximum Effluent Particle Size 36 in dia. D NA Other. D NA Other. Other D NA '`VWues typical for domestic wastroater and septic tank ettluent Other D NA NTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: D month(s) ( urn 3 ire) D NA (Pump out cxxnterrts of tank(s) When combined sludge and scum equals one-third ('Yj) of tank volume D NA inspect dispersal cell(s) At least once every: g month(s) (Maximum 3 years) D NA dean effluent filter At least once every: ❑Lyearthjs) D NA I nspect pump, pump controls & alarm At least once every: .11 s(s) 4NA i7lush laterals and pressure test At least once every: 13 O month(s) year{s) At least once every: D month(s) r. ❑ year(s) MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be madeby an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer, Septage Servicing Operator. Tank inspections must inc*tde a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of toomtaned sludge and scum end to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shag 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 notifi *on of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (X) or more of the flank volume, the entire contents of ffie tank shay be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Cale. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, *A any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page of , START UP AND OPERATION pro ducts or other chemicais thO For new construction, prior to use of the POWTS check beatment tank(s) for t h pmence of painting concentrations are detected have the contents of tht may impede the treatment process and/or damage the dispersal cell(s). if h9 tank(s) removed by a septage servicing operator prior System start up shall not occur when soil conditions are frozen at the infiltrative surface. restored the excess wastewater will ble During power outages pump tanks may fill above normal highwater levels. When power in is the backup th surface discharge wastewater l~ discharged to the dispersal cell(s) in one large dose, overloading the oell(s) and may result u • Operator prior to restoring power to tnL To avoid this situation have the contents of the pump tank removed by a Septage Servicing normal levels effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore within the pump tank. disturb or compact, the area within Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise 15 feet down slope of any mound or at-grade soil absorption area. the We of the POW: Reduction or elimination of the following from the wastewater stream may improvq the performance and prolong disu polo n the fat; foundation T$: . antibiotics; baby wipes; cigarette butts; -condoms; cotton swabs; degreasers; dental floss; rp ; drakn fruit and vegetable peelings; gasoline; gee; herbicides; meat scraps; medications; oil; Painting Products (sump pump) water, pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT shall be taken to inure that the system is prcutly When the POWTS fails and/or is permanently taken out of service the following steps and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Coda: • Ail piping to tanks and pits shall be disconnected and the abandoned pipe openings scaled. • 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 fined with soil, gravel or another inert solid material. CONTINGENCY PLAN a code corrtplint If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide 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 re4uhled setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the ruleO in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologK 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 sal and site evalua*on 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 infiltrajive surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNiNG>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE 0 A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER 43 Name Lt E E C Name Phone ~J 7 c l/~ Phone , 1 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTH Name Z12'21 h1~ Name 22 Phone Phone This doo mmit was drafted in compliance with chapter SPS 383.22(2)(b)(1 kd)&(f) and 383.54(1), (2) & (3), Wisconsin AdminWastive Code. I -W h ;171, t ~ a t ' - I A fi ~ I 1 Lj P P J I ~l i t C > Q v v y i 54.28 Benchmark - Top of Iron Rebar 12' Utility Easement along road R= Recorded as UNPLA TTED LANDS -ter Corner of UNPL A 8-30-18 Found County Monument) -N89'56'03"E 5225.30'-- East-West Quarter J/4 Line N89'56'03 "E 200.00' 200.00' 177.00' 177.00' 177.00' 1458.08' .._..s--.- 19.4 6, 50' Easement for Prairie Crass 1 it 21' Prosvrwtion o ~N79'1 t'0 va z xc' DRAINAGE as z °o o° a r3~ EA ENT °o 0 a o o a a~ rn m o N o r m N -P o ni m ? a° 220.0 m' tkz t 4 V iiiw 38578 pg~ 24 1.98 acres 1.85 acres 1. 94 acres zs IA 6i z 8C~ 699 sq. ft. 84,451 sq. ft. 86, 344 sq, ft. a 1.67 a v N U 2.41 acres 72, 898 43 acres g 104, 04,560 sq. ft. S N 032 sq. ft. 1,1 L. B. 0. 964.0 0."` 964.0 t-N JO 54 55 _ 29- ¢ tt.35 ° • --fit 4 ' tgp 26' N NOOT01 3Q~ 00 77' 3t 8.68 $N^~7~9y/72 07"yy 440 _ 21.00 n 18'a3^W C17 200.00 S77~ . - LA S7 2' G7 3 4 S89-49'16"W` 283.02' C15 4+ _ ~ a ®3•E 3t8 45~ 58 3 / ~ 07"E 2"--~12 ' --°---~r ) - ~c"+ N77 t , aa4 c3g`° 173,13 - N89'49'16"E e_ Cl B 283.tt' C16 . $d~g• _ ` 83.11 11 '7 1.68 AC V to SP 72,979 o , ACI ACO 0'_ { CO M o z 2.26 acres Q 1, 97 acres o 2.14 acres PAJ 2.25 acres Z 98, 419 sq. ft. m 85,736 sq. ft. 93, 348 sq. ft, 40 acres Q 98,168 sq. ft. Q CO 517 sq. ft. cn . "S 1 964.6 _ for Prairie awls 968.7 4 966.9 .r Prosexwt,~r ~ i S89'53'36"W 170.00' Q ?r _ 963 ® Za3.35' M~171'ot "w 964.5 J 3.3~ 50^~' _ - - - - 236.92' o / F 7°= V-. C) Pit =11 U - Pit Y 6~a~5 - J g~f W a n 3 z mnTy$ g OI v 5 Ni NIA -0 z i8 O' w.a J,= W,! 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Reviewe Date Personal information you provide may be used for secondary purpols (Privacy Law, s. 15.04 (1) (m)). S!G) %~L Property Owner ZON vocation J lV/~~ Govt. Lot 1/4 W 1 /4 S a T N R E (or Property Owner's Mailing Addre Lot # Block # Subd. Name or CSM# )//too 9n Ave. N w I at o f sc m-o c CC City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road ~1k R MN 30 ( ) 1- 8 K;c.ti mn rj New Construction Use: T~ Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or mmercial - Describe: Parent material t^^ W e, Flood Plain e,evation if applicable ft General comments fj. S t:S J e S - 3 -T rc c and recommendations: -r, ! (95, 54,'~ 4( (S y, to j 3F t'1~Kr~vwrV ~T Boring # E] Boring Pit Ground surface elev. _94° y a ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 5 Y i49 .-I-. t L..i_ _ r.~ _ y i I J Boring # Boring t Pit Ground surface elev. ft. Depth to limiting factor /0 d in. Soil Application- lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff° in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -J t ! t.., 44 ica Effluent #1 = BOD > 30:< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L -LaT Name (Please P ' Signature CST Number a.t~- 4 J i 7 q Addr ss N bate Evaluation Conducted Telephone Number a~L ao 7-co9-b `715 dy8 35s8 ~~'oa~ Property Owner GerQ l~ ~L Parcel ID # Page _i;;p_ of _ r Boring # Boring - F-31 g Pit Ground surface elev. 79.-33 ft. Depth to limiting factor y in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •Eff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 ~ A ! C" Y1 1. AD w JYa ! ri f ® E Boring # Boring ft. Depth to limiting factor in. ❑ Pit Ground surface elev. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD(fg In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 Eff#2 ❑ Boring El Boring # Ground surface elev. ft. Depth to limiting factor - in. ❑ Pit W*Eff#ll ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 2 - - Effluent #1 = BODS > 30 < 2 20 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg(L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6/00) Property Owner Gera' 4 Parcel ID # _ Page CQ_ of _ 7 Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 . r4 AD M ►I Boring # ❑ Boring In e6 ❑ Pit Ground surface elev. ft. Depth to limiting facto,1+ _ in. Soil Appli tion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff#1 Eff#2 i Boring # ❑ Boring - F-1 - ❑ pit Ground surface elev. _ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 -Eff#2 I Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent 92 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6/00)