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HomeMy WebLinkAbout016-1004-20-300 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 589758 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 2723604 Permit Holder's Name: City Village Township Parcel Tax No: Mark Smith TOWN OF GLENWOOD 016-1004-20-100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 03.30.15.378-10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head 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 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution Ix Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing 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 Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 3075 180TH AVE 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. RECEIVED 2 11 c..fIN-3,1 ,.V: RT!yr1 JUN 17 2016 Industry Services Division o c x 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P$ i< ST. CROIX COUNTY P.O. Box 7162 'f MUNITY DEVELOPME Madison, W1 53707-7162 5'91 75Q Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit 2 7 -2- is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Pro'ect Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary + I A purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. j~ ~5 K„~..~ I. Application Information - PjeW Print All Information 76 Property Owner's Name Parcel # 11 &rK :Y$Awk / Q 1404- za - 300 Property Owner's Mailing Address Property Location 30 7-5 l0 ~ t~• 4-P, Govt. Lot City, State Zip Code Phone Number VAJ V. , ~S c~/ercc~oos , ul / section .3 & S/' 2 - 8'2 - gcircl ne II. Type of Building (check all that apply) Lot # T ~U N; R 7 I or 2 Family Dwelling - Number of Bedrooms CZ) CZ-3 Subdivision Name Z* cab PAIA- Block # Public/Commercial -Describe Use r of City of 1 Village of State Owned - Describe Usy CSM Number O 7, 7,1 " ! Town of III. Type of Permit: (Check only one box on line A. Complete line B i ap licable) A. New S stem t to Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) B• Permit Renewal Permit Revision Change of PlumbeTollp, ermit Transfer to New List Previous Permit Number and Date Issued ' Before Expiration er IV. Type of POWTS System/Component/Device: (Check all that apply) Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound > 24 in. of suitable soil X Mound < 24 in. of suitabl4soil~l Holding Tank Other Dispersal Component (explain) Pretreatment Device (explain) V. Dis rsaVfreatm t Area Information: Design Flow (gpd) sign Soil Application Rate(gp Dispersal Area Required (sf) Dispersal Area Propos ( System Elevation 415 U r I 1 ? 5'a r -7 5 G 1. 98'• 3 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units a E U $ New Tanks Existing Tanks [ / / v o v p U 'v', y in w C7 a. Septic or Holding Tank Dosing Chamber CO VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum 's Signat MP/MPRS Number Business Phone Number c6"d/ *Y,0-5 24,79~'S Plumber's Address (Street, City, State, Zip Code) Z? i/3 /3o 7'X I'4,e , 3 VIII. Coun epartment Use Only Approved i Permit Fee Date Issued Issuin ent Signatu 7W 7Al X r anon for Denial $ lY • 0 A., IX. Condi eases four Disapproval miptio e r f dWoemw 0011 ust 811 5 V jAij;~ilg&tlt► sr:per, ts~rageretertt plan prodded by plumber. ~ ,[i_ 2. ~-la it A. ss pwtr gggc" awk / ofdi wxm. a,. Attach to complete plans for the system and submit to a oun o yon paper not less fhan 8 112 x 11 inches in size SBD-6398 (R0313) r i= CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE. SOIL EVALUATION Scale: V _ 7 SYSTEM PAGE 2 OF SITE MAP 0 O PLOT PLAN PROJECT NAME: 5' DESIGN FLOW: 450 GPD Mark Smith Attach design flow calculations for commercial plans. PROJECT ADDRESS: 3075 180th Ave, Glenwood City, WI 54013 Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5) Sanitary Sewer. PVC ASTM D3034 BM Symbol: $ BM Elevation: 100.0 FT N Force Main: PVC ASTM D2665 SM Description: -ai•-e, dt~l twc,,r Indicate north by IMPORTANT: Slope Gradient 3 Well Symbol (If applicable): drawing an arrow Show ground elevation contours at suitable intervals. of Tested Area: on the approprite line. p®~L ~1fG F ~oW« IO~G I ~K ~r.p•sad 3 ad rvk i a3 ~ ~ ~ 71 I I 6C x DIVISION OF INDUSTRY SERVICES 10541 N RANCH RD HAYWARD WI 54843-6462 i U a1 Contact Through Relay http://dsps.wi.gov/programs/industry-services www.wisconsin.gov Scott Walker, Governor Dave Ross, Secretary June 10, 2016 OUST ID No. 267985 ATTN POWTS Inspector MICHAEL J MYERS ZONING OFFICE NORTHLAND PLUMBING INC ST CROIX COUNTY SPIA 2943 130TH AVE 1101 CAR-MICHAEL R-D GLENWOOD CITY WI 54013 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/10/2018 Identification Numbers Transaction ID No. 2723604 SITE: Site ID No. 825122 Mark Smith Please refer to both identification numbers, 3075 180TH Ave above, in all correspondence with the agency. Town of Glenwood St Croix County NW1/4, NE1/4, S3, T30N, R15W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1606715 Maintenance required; 450 GPD Flow rate; 18 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/O1, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced abov c The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Please see corrections made to the plan in red. Thanks. • The building sewer and distribution network piping shall be of material listed in Table 84.30-3 and 84.30-5, Wis. Adm. Code. Reminders • Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the septic tank outlet filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. MICHAEL. J MYERS Page 2 6/10/2016 Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Carl J Lippert Wastewater Specialist , Division of Industry Services WiSMART code: 7633 (715)6-)4-5035, M-f 7AM - 12PM cart.lippert@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484 , Monday - Friday 8:00 am To 4:30 pm Northland Plumbing Inc MICHAEL J MYERS Page 2 6/10/2016 Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Carl J Lippert Wastewater Specialist, Division of Industry Services WiSMART code: 7633 (715)6-)4-5035, M-f 7AM - 12PM carl.lippert'~`wisconsin.L o\ cc: Edwin A Taylor, Wastewater Specialist, 15) 634-3484, Monday - Friday 8:00 am To 4:30 pm Northland Plumbing Inc f ' PAGE 1 OF 6 Mound Plan Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10691-P (N.01/01, R. 10/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12) Pg 1 of 6 Index & Cover Page Pg 2 of 6 Plot Plan ~C Pg 3 of 6 Mound Cross-Section & Plan Vijn" © Pg 4 of 6 Distribution Network Specificationpo 6', O Pg 5 of 6 Pump Tank Specifications k <'6' Pg 6 of 6 Management Plan R,70, S Attachments: Enclosures: Pump Curve POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Owner Name(s): Mark Smith Phone: 651 _253 _4827 Owner Address: 3073 180th Ave, Glenwood City, WI Zip: 54013 Project Address: 3075 180th Ave, Glenwood City, WI 54013 Govt. Lot: NW 1/4 of NE 1/4, Section 3 , T 30 N-R 15 E F-1 or WW Township: Glenwood County: St. Croix Project Parcel ID Designer Information Designer Name: Michael Myers ,-4115 Designer Address: 2943 130th Ave, Glenwood City, WI A R 13 E-mail: mcmyers@centurytel.net ES DEPT OF SAFf°TY AFDND ~ TRY Si~RVT~CES License Number: 267985 DIVISION Remarks: SEE RESpoi,4f ALE Signature: / Date: 116 Original signature required on each submitted copy. Y , CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE. SOIL EVALUATION Scale: 1" _ FZ SYSTEM PAGE 2 OF 0 40 SITE MAP - Ae PLOT PLAN PROJECT NAME: 02-A = DESIGN FLOW: 450 GPD 5` Mark Smith Attach design flow calculations for commercial plans. PROJECT ADDRESS: 3075 180th Ave, Glenwood City, WI 54013 Pipe Material / ASTM Standard (Tables 384.30-3 $ 384.30-5) PVC ASTM D3034 100,0 N Sanitary Sewer: / BM Symbol: BM Elevation: FT Force Main: PVC / ASTM D2665 BM Description:6~RdEa1l L"Ir II ( a Eas4eFdr,~wac~ Gradient Indicate north by IMPORTANT: Slope ( 13 Well Symbol (if applicable): on the drawing appro roprite arrow line of Tested Area: Show ground elevation contours at suitable intervals. . wK j ~-7 ~r• r • 3 al rW. Vvl.e ~i, 1-~ vt-.e ~ I i i 06/1.0/2016 08:23 FAX a 002 i PAGE 3 OF 6 > M Z rn F c>? r N W NO ° fi 11 Il 11 O U) ? ru+ u I I I Y i0 cn \ Z O A O 4 I a? Cl i! I l I- 1 E U I 1 ! , -j -J I r W Cl) 1! J a a , z 0 b Q U W w I ~I O ° i i ° I I 1 i ~o b 10 ff, I I , ► .2 ~ LID - ~ I co ` I I ! I lo Q I I a, { { o I { L ` I I L_J rn l_ o~ ; a s 13 l m b i I I P Q n Lu w 11 1 z o _ cv I m o \ \ , ! o I a p L~.rJ ~ \ E I ` I I v II C) z PAGE 4OF6 0- a 00 - 0, W H cY N °p Q W Q Lo z ~C~~°" rn M MZ OZ o)l ~G L- 4=m Q LL E-2 O P U Q C p 'Q II II II II II p Z O Z o` v m m cn m W U ° ° a ii _ m m m co H W C\l CD 4- a v - m Z W m a o ~ Q) (3 ^ o U M a U o v a I- O J N a s a~ v N a x - T Z U U a Z am co o" _ U X W 0.0 m y E2 C/) U 0 c Cf) O J Q 1 o F FT Q ~ E p U U^ o_ N Q Z Oa Xa co 'c-X U m w O 211 _ a co i N 11 N a ? ° ~ c L.fr ° o X a U , 0 x 2 O 0 .2 (D N C6 LLJ p Q O r Y 'Q v M p m It N X 7 U U n O U_ Xa rn d I~, .v c I I Q- co U cA co Cl) Cl. O U) 0 o Lij J II _ ~ ~ ~ a L V J V= = a U O y = cm a m U V a Z L N co > z J O N o 1 N > O N _ 0 / C A N06 O~ O O 1 J X NL QE 75~ Q m O ` J H" c >a, oc W _ > > ° o w cu W > > E a 00 ry (n 0- Q U r: Cl) _ I Q II Z U) z U) O z J I ~ Q N LL \ U > o N Id 2 75- J W a> °G0) w ° m co / m m H m a cn r a>i O H--> a o m a) .Q m U U o m p UL -O O = Q a) a m o W y O XCL 0) w f- N' CU O m m o o L (n - a a> c 0 0 0 0 m N a p n w c Z 61 _n O NOO) O C O a 0 O O I O) O O Q c _ N a) LLI U or~I❑I > m v U > y,- N ¢ O U L m a 3 PAGE 5OF6 SEPTIC / PUMP TANK SPECIFICATIONS 4"0 Vent Pipe (No Scale) >10 ft from Building Electrical must comply with 12" Min. or 2.0 ft above SPS 316 and NEC 300 Established Flood Elevation Weatherproof Extend manhole riser as necessary. (typical) Junction Box Approved Approved Locking Manhole IMPORTANT: Vent ICap with Warning Label Attached Anchor tank(s) as necessary ` (typical) --Conduit pursuant to SPS 383.43(8)(8) 4" Min. or 2.0 ft above Established Flood Elevation (typical) Airtight Seal Finished Grade Quick Disconnect gal/in < a' (typical) CAPACITIES @ 17 ~ = e tylical Depth (in) Volume I a ! A 20.9 355.3 * Weep \-Approved Joints with B 2.0 34 Hole Approved Pipe 3 ft onto A Solid Ground (typical) [C] 5..0 85 Alarm D 10 175.7 B -On I [f] PUMP-OFF = Pump Tank Liquid Level = 38 In ~ Pump ELEVATION 88.8 ft Force Main Diameter = 2in ° Concrete INSIDE BOTTOM Block ELEVATION - 88 ft ° Force Main Length = 80 ft 3" Approved Bedding Material Beneath Tank Force Main Void Volume = 15.6 gal Vertical Head = 5, ~G ft + Min. Supply Head = 6.5 ft [C] Total Dose Volume TDV = 78.2 gal/dose + FM Friction Loss = 2.59 ft L (5X total lateral void volume < TDV < 0.2X design flow) + (force main drainback volume) + Fitting Loss* = ft % MIN. PUMP DISCHARGE RATE = 39.5 *(min, supply head x 0.3) 9pm = TOTAL DYNAMIC HEAD = ft PUMP TANK: SEPTIC TANK(S): Volume = 650 gal Total Volume = 1000 gal Manufacturer: Wieser Conctrete Manufacturer(s): Wieser Concrete Pump Manufacturer: Goulds Install approved effluent filter at the septic tank outlet Pump Model: PE44P1 M (See attached pump curve.) immediately upstream of the pumptank inlet. Controls/Alarm Manufacturer: SJE Rhombus Filter Manufacturer: Polylok Controls/Alarm Model: S1019300 Filter Model: 525 Float switches containing mercury are prohibited PAGE 6 OF In-ground Gravity Management Plan 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 POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow= 450 gpd; BODS 220 mgL"'; TSS 150 mgL"; FOG 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 / drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell 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 (1/3) 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 filter(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 months. 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: Northland Plumbing Inc Phone: 715-265-41 15 Local government unit: St. Croix County Phone: 715-386-4680 Local government unit address: 1101 Carmichael Road, Hudson, WI Zlp; 54016 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. Contingency 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. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. I ITT GOULDS PUMPS Residential Water Systems APPLICATIONS MOTOR Specially designed for the following uses: General: • Mound Systems • Single phase • Effluent/Dosing Systems • 60 Hertz • Low Pressure Pipe Systems • 115 and 230 volts • Basement Draining • Built-in thermal overload protection with automatic reset. • Heavy Duty Sump/ • Class B insulation. Dewatering • Oil-filled design. • High strength carbon steel shaft. SPECIFICATIONS PE31 Motor: Pump - General: • .33 HP 3000 RPM • Discharge: 1'/z' NPT • 115 volts • Temperature: 1041F (40(1C) maximum, continuous when • Shaded pole design fully submerged. PE41 Motor: • Solids handling: 112" maximum sphere. • .40 HP 3400 RPM • Automatic models include a float switch. • 115 and 230 volts • Manual models available. • PSC design • Pumping range: see performance chart or curve. PE51 Motor: PE31 Pump: • .50 HP 3400 RPM • Maximum capacity: 53 GPM • 115 and 230 volts • Maximum head: 25' TDH • PSC design PE41 Pump: • Maximum capacity: 61 GPM AGENCY LISTINGS • Maximum head: 29' TDH PE51 Pump: • Maximum capacity: 70 GPM CCO • Maximum head: 37' TDH us Tested to UL 778 and CSA 22.2 108 Standards By Canadian Standards Association METERS rEE file #LR38549 40 PE51 '00DELS PE31, PE41, PE51 35 HP 33, 40, 50 10 2 GPM Goulds Pumps is ISO 9001 Registered. 30 PE41 - 1 F°r w 25 PE31 U_ 2 a 2 Z 0 15 0 r- 10 5 0 00 10 20 30 50 60 70 GPM 80 0 5 10 15 m-Vh CAPACITY ST. CROIX COUN'T'Y SEPTIC TANK iti9AINTENANCE AGREEMENT AND O«'NLIZSHIP CERTIFICATION FORM Ownet;BUyel Mailing Address Property Address X' ]?e75 s moo' Gv/ a/~' (Verification required from Planning & Zoning Department for new construction.) City/State gleovx; odd Ael / Parcel Identification Number LEGAL DESCRIPTION Property Location IV J V4, A146 '/4, Sec. T 1o N R (5 W, Town of G f~+ v~ Subdivision Plat: Lot # 3 Certified Survey Map # 20 l (p- 6Y ! Volume 27 Page # ee Warrantv Deed # - (before 2007)Volume Page # Spec house yes~-elo 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 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 Comm. 83.52(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 ( I ) the on-site w istewater disposal system is in proper operating condition an&or (2) after inspection and pumping (if neccssarv). the septic tanl< is less than 13 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 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. Uwe certify that all statements on th' form 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 wa -anty deed recorded in Register of Deeds Office. Number of bedrooms lee~ SIGNATURE 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 decd. (REV. 08/05) GL Ca O~ `V ! ct vJ ~ ~ a Z00[] XV3 LZ:OT 9TOZ/6T/LO iii 31 c ST --,;)r ) 6 -019 N, ~oil -O3 tRlGl SOIL EVA4.~ ~ T i 1. # P$ Department of Safety and Professional Services Page 1 of 3 Division of S#et Northland Plumbing, Inc. in accordance with Comm 85, "A66Ciode County Attach complete site plan on paper not less than 8Yz x 11 inches in size . P - St. Croix include, but not limited to: vertical and horizontal reference point (BM , ir~tY~U i ' percent slope, scale or dimensions, north arrow, and location ang0to0& "elWfiW 1. D. Please print all information. Red By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). / Property Owner Property Location Mark Smith Govt. Lot NW1 NE1/4, S3, T30N, 15W Pro ertOwner's Mailin Address p Y 9 Lot # I Block # Subd. N e or CSM# 3073 180th Ave 2 City State Zip Code Phone Number City Village Town Nearest Road Glenwood City WI 154013 651-253-4827 Glenwood 180Th Ave , New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Glacial till Flood plain elevation, if applicable ft. General comments and recommendations: Boring 1 Boring # Pit Ground surface elev. 96.84 ft. Depth to limiting factor 21 in. ISoil Application Rate Horizon Depth l; Dominant Color Redox Description 1 Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 1 0-11 10YR3/2 sli 3sbk mvfr - cs if .6 T .8 2 11-17 10YR5/4 sil 3sbk mvfr cs 1f 6 8 3 17-21 10YR5/6 scl 2abk mfi cs .4 .6 4 21-37 10YR6/8 - 7.5YR6/8 fld spots s Osg ~ --I - mfi cs I .7 1 1.6 5 37-49 10YR5/8 7.5YR6/8 fld spots sc Om mvfl cs 0.0 0.0 I F-I Boring 2 Boring # Pit Ground surface elev. 94.35 ft. Depth to limiting factor 18 in. Soil Application Rate Depth Dominant Color Redox b escription Texture Structure Consistency Boundary Roots GPD/ft2 Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2 1 0-10 i 10YR3/2 sii 3sbk mvfr i cs if .6 .8 2 10-18 10YR5/4 sil 3sbk mvfr cs if .6 .8 3 18-23 10YR5/6.5YR6/8 f1d spots scl Om mfi cs 0.0 .0 0 i - - _ 4 23-28 10YR5/8 7.5YR6/8 f1d spots sc 2sbk mfi cs .2 .3 5 1 28-32 10YR4/6 s Osg mfi cs 7 1.6 6 32-48 10YR5/8 7.5YR6/8 f1d spots' sc 1sbk mvfi cs 0.0 0.0 1 1 Effluent #1 = BOD? 30 < 220 mg/L nd TSS >30 < 150 mg/L Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST me (Please Print) Sign ure: CST Number - - - -L-~ Z 7 ~S Address Northland Plumbing, Inc. Date al tion Conducted Telephone Number 2943 130th Ave Glenwood City, WI 54013 C Z Z~~lp 715-265-4115 SBD-8330 (R. 11/11) urllujivw 64 ~ r o ~ v o~ ~ I ~J P -J W vd t7cl ~ ~ W ~ ° O 7V N