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HomeMy WebLinkAbout030-1021-20-151 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 589754 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: Aaron & Nicole Voeltz TOWN OF SAINT JOSEPH 030-1021-20-151 CST BM Elev: Insp. BM Elev: BM Description: n I ~ 1V~ \ Section/Town/Range/Map No: TANK INFORMATION 06.29.19.900-51 ELEVATION DATA TYPE TUR CAPACITY STATION B,, HI FS ELEV. Septic _ Y a l OD, Benchmark De4iffr l / U U L LJ - Alt. BM Aeffltiafi G G- Bldg. Sewer Heldtng i Ht Inlet TANK SETBACK INFORMATION jTANK TO P/WELL BLDG Dt . Vent to Air Intake ROAD Inlet Septic "7 G / Dt Bottom D L..~ / -1 p c~ 0 1~' b I t Head an. ~O l U 9. IS 'Aerations Dist. Pipe Ho 'ng Bot. System h PUMP/SIPHON INFORMATION Final Grade ov, •aV r / a~-• 7 Manufacturer ~1r / Dnd er I~ Model N Zr T Lift Friction Loss System Head TDH Ft / Fhrcemain Length Dia. Dist. to Well _ SOIL ABSORPTION SYSTEM t BED/TRENCH Width , Leng , No. Of Trenches PIT DIMENSIONS No. Of Pi Inside Di a. Liquid Depth DIMENSIONS ~s SETBACK SYSTEM TO INFORMATION P/L BLDG WELL LAKE/STREAM LEACHING Manufactu Type Of System: CHAMBER OR NIT Mo N / Vl D BUTION SYSTEM G eade anifold Distribution x Hole Size x Hole Spacing VQr}~ t l,7r 1 t Pipe(s) ,~n e ength Dia Length J ,(~J Spacing ly SOIL C VER x Pr sure Systems Only xx Mound Or At-Grade Systems Only Depth Over Dep Over xx Depth() f Bed/Trench Center 1 ~1 _ 1 i e /Trench Edges I t To Seeded/Sodded xx No V V L pso l No ' 'Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: n ,rye Ins ection #2: Location: 1164 TROUT BROOK RD l'~`d Ids ~1°~ ~ ~n 5 3 V(•~~ 1.) Alt BM Description = -h 111 c Gov 2.) Bldg sewer length =1WLr\ I CST` all~~ f ~61(1~ ~JfCJ. J -amount of cover = J on 06". Plan revision Required? Yes 1~4 No ~ Use other side for additional informatidn. k SBD 6710 (R.3/97) Date ql Actors Signature Cert, o. oBraar TOE C~ Arai --o ,16 ~ IECEIVED ( * Safety and Buildings Division Sj/ . C/ O r K 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, Wl 5?"-7162 S JUL 1 tl ?016 °FESStoNPti JF19 COMMUiVt &rmit Application F4Q2X9 State Transacf umber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govet,... K'go c is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submnw_ to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondarw urposes in accordance with the Privacy Law, s. 15.04(1) m), Stats. 1. Application Informatio -Please Print Aglqformation 1 CJ (OKC ~/r},g~~~ Property Owner's Name t G , Parcel # Property Owner's Mailing Address Property Location Q + b Govt. Lot / City ~S/tate Zip Code Phone Number t/, Section C i 5 ©7/,S' 7K0.0J 9 (circle one T~N; R 0 r Vor Vb II. Type of Building (check all that apply) Lot # ®1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name `If, QI Block # ❑ Public/Commercial -Describe Use ❑ City of ❑ State Owned - Describe Use Q G' CSM Number ❑ Village of 2:1 P Town of It, III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner d IV. Type of POWTS System/Component/Device: Check all that apply) -_7 A Non-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 Flint Area Information: Design Flo (gpd) Design Soil Application Rate(g f) Dispersal Area Recuired (sf) Dispersal Area Proposed s0 System Elevation, 6 , S- Z .'r VI. Tank Info Ca aci 12 00 1 Z 00 2 89' ~/0 p ty in Total # of Manufacturer _ Gallons Gallons Units a o a New Tanks Existing Tanks CJ y v a, ~ ~ .N Septic or Holding Tank l S O Z S~ I W C f C/ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number T/s- 2 y7-3z 03 Plumber's Address (Street, City, State, Zi Code) 3 Pef' /~2 a.- e N /*17 VII ount /Department Use Only Approved El D' Permit Fee Date sued Issuing nt Signatur Ten Reason for Denta $ O J ' IX. Condi' y , ea for Disapproval 49* ciM'hw*a# be YIGIILit>S P'e r 10 tttwirillMk plait provided by . 2 `~f~"1li(~i~t+ltiNM1~.A~w1 bs mtinttl~d M PK X110" OOdf / a1diM1owns. ' Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size SBD-6398 (R. 11/11) tL OWNER Page 3 of 3 Name-..,4420- O -7 ~Oc~ fZ Brian Parnell Address /19/ '7;~m- 7' CST 231314 m ..r L-- .r Date / 7 / 6 A Benchmark 1~ /~6. D 'lb~ 2 "ru c ptpr- ® Benchmark 2 /°A 73 7'6f m& ❑ Soil Boring 17- I _ 1 Suitable Area 1" = 40' Scale fill T ? ? ? I I , i I ! 14 0 1~i1€~? ~ f ( ri c , r 2 0 0,l ? I ! { d , it- ! roe I I I ~ € I a i ? old ~ ~ . ` f~/ 2 ! j i + i ? I I i i ! FT7 ` i 1 ! I r F `4 I ! a 3 i N -bi b O'f' l C .mss i CONVENTIONAL COMPONENT DESIGN Residential Application IN,DE/X ANDLLTITLE PAGE Project Name: Q a V O e / i Owner's Name: 14 Ir yD e- ~Z Owner's Address: h'u- ~ f6 -r Legal Description: ~jl f G 2 9 ~j Lv Township: S~ . ✓®'e°jfIh County: Subdivision Name: Lot Number: Parcel ID Number: C' 1,57 Page 1 Index and title Page 2 Plot Plan Page 3 _ System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Designer/Plumber. a J F611A e License Number. 2731,71 c/ Date: 7- I Y- 16 Phone Number 7/ 1'- 2 7- 3 2 0,3 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 OWNER Page 3 of 3 Name 44.,,^ o 17 00cl fZ Brian Parnell Address-fl9/ %~m-t' CST 231314 Date ?--/6 A Benchmark 1 i5*Z /96• D I6- P 2"?u c pi~c O Benchmark 2 ~ /04 73 761 2 J,ee- _ Soil Boring Suitable Area 1 " = 40' Scale c I I ~ i 1 I L -!Y 47, I I i ! I 1.S,c rt Z o I i j ( { d < t le 00, ~ ~ 1 ! i ~ ~ I I i~- i i r I I I r' 1 10 I !I , I ~ v , I t ~ le J rv J f 3 at C' ~~t 2 1~ PO lr o f S-Z.s-- F eJ 2 Z /12 X s o 12001 ~~2-- /2 0 3 - ( - SOIL ABSORPTION SYSTEM DETAIL I GRAVELLESS LEACHING UNIT Page-of l ( f2 Project Name:(! •6 c:2.-~ 7c' / No. of Cells Per Cell tt Cell Width Total No of , Z ~ 2 -r~- it Cell Length '~C1 f ✓ sq ft EISA Per Cell ft Cell Spacing / O C' rq it Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ12031-1-10ft 10.0' ? 50.0 Graveliess Leaching Unit Manufacturer. Gravelless Leaching Unit Model: Z• 0? ~C ~j Typical Cross Section Finished Grade Observation Pipe with approved cap or vent --Soil Backfll ■ < : . Geotextile Fabric Infiltrative Surface 12 in O -4 /ft Limiting Factor in Slotted and Anchored Vent/ Observation Pipe with Cap e.■■seaer...■............■ Plumber/Designer Signature: License # 2 f~ j y Date: 7- % ` /G1 SOIL ABSORPTION SYSTEM DETAIL! GRAVELLESS LEACHING UNIT Page-of Project Name: ' ~"T re,, e No. of Cells Per Cell ft Coll Width Z- Y Total No of ' z 3 eU ft Cell Length L~ ©0 sq tt EISA Per Cell C/ ft Cell Spacing / -Zo u sq ftTotal EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-Sft SO 25.0 EZ1203H-10ft 10.0' ! 50.0 Gravelless Leaching Unit Manufacturer, Gravelless Leaching Unit Model: Typical Cross Section Finished Grade jk.4 Observation Pipe with approved cap or vent : ■ --Soil Backfill < Geotextile Fabric fix ft infiltrative Surface 12 in ft Limiting Factor in Slotted and Anchored Vent/ U_ 1_'_ Observation Pipe with Cap ■a■t■■■6■a■■ Plumber/Designer Signature: l yL, License # ' Date: / / - SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page of Project Name:-~o -Z D t! /7( Z 3 No. of Cells 9 Per Cell 3 ' ft Cell Width 2 Y • Total No of C z i2os - /0 So it Cell Length cb sq ft EISA Per Cell y e Cell Spacing 00 Sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ120314-5ft S.0' 25.0 EZ1203H-10ft 10-0' 50.0 Gravelless Leaching Unit Manufacturer, ~n 1 44 Graveiless Leaching Unit Model: ~Z / c/ Typical Cross Section Finished Grade Observation Pipe with approved cap or vent ::a>>>>:<_-:: Soil Backfill Geotextile Fabric ~9• ydit Infiltrative Surface 12 in O I 96.1 ft Limiting Facto: i V2 in Slotted and Anchored Vend Observation Pipe with Cap Plumber/Designer Signature: y License Z 3 /.3 /Y Date: AL E 1, OX- INSTALLATION INSTRUCTIONS PJ31 °`'w ^^°'9 PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS { Center filter with opening r 1 ti ~g f 7M Add~uona( pipe or Pol} lok Extend & Lok Glue = for c ntenng - Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS o.- _ F y~ i Y Step 4: Step 2: Step 3: Locate the outlet of the septic tank (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing making sure (B) Pull the filter out of the housing. the filter is properly aiighed (C) Hose off the filter over the septic tank. and completely inserted. USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover WHEN CLEANING,FILTER ; septic tank. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS V o G Z Septic Tank Capacity Owner a1- o it ~2 .S6 gal ❑ NA Permit # Septic Tank Manufacturer Co j PS'c ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer f 0I 1 o C. ❑ NA Number of Bedrooms IL/ ❑ NA Effluent Filter Model Z ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ® NA Estimated flow (average) /yd v gal/day Pump Tank Manufacturer 0 NA Design flow (peak), (Estimated x 1.5) 0 0 0 gal/day Pump Manufacturer id NA Soil Application Rate 0 s al/day/ft2 Pump Model 19 NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit 121 NA Fats, Oil & Grease (FOG) <30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) :530 mg/L El In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) <_30 mg/L IN NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <10° cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA ® ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 W year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA R1 year(s) ) ❑ NA aspect pump, pump controls & alarm At least once every: ❑ ❑ month( yeaarr((s) s) ❑ NA "aerals and pressure test At least once every: ❑ month(s) ❑ year(s) At least once every: ❑ month(s) ❑ NA ❑ year(s) O:her: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 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 For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, 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 another inert solid material. CONTINGENCY PLAN 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 required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at 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 CONTAIN 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 ~P~~ati Q~•e 112- Name Phone 715-- 2 y, -,TZD 2 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Gp Phone Phone . 3S This document was drat - 77iance with chapter Comm 83.22(2)(b)0)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT . When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, 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 another inert solid material 'ONTiNGENCY PLAN 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 required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setbabk 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 CONTAIN 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 'OWTS INSTALLER POWTS MAINTAINER Name re- Name Phone 7iS"- Z Y7 _T 203 Phone ;EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ` Phone Phone 1'6~ 3g~ his document was draL_t _='iance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROI(X COUNTY SEPTIC TANK ALARdTENANCE AGREEM7~ AND A OWNERSHIP CERTIFICATION FORM Ow~er/Buyer a / o Iv,, e o le (/De 174 z. failiugAddress xoper'iv Address j v (Verification QU from Plarming & Zoning Department for new construction-) City/State Parcel Identifcalion Number LEGAL DESCRIPTION Property Location. Y, /V i/4, Sec_ , T'-,? q NR If , Town of ff • J-oese~h ~'-r4?~ivIsion - Lot Certified Survey Map # , Volume _ Page # ,Warranty Deed-# Volume . Page # Spec house yes ao Lot lines identifiable & no SYSTEM MAYMTENANCE AND OWNER CE TII+`iCATION ~azntenanrr o er use o and maintenance of your segttc system could result in its preinature fame to banme wastes- Proper PAP out the septic tank every three the system years or soonq if needed, by a licensed pumper- Wbat you put into can affect the function of the septic tank as a treatment stage in the waste disposal system Owncr maintenance responsibilities are specified in §C,,. 83.52(1) and in Chapter 12 - St Croix County S amity Ordinance. The pzoperty o'vkMer agrees to submit to St Croix County Plauuing & ,7-0~g Department a certif ication forrq signed by the er wand by a master plumber, journeyman plumber, restricted plumber or a licensed pumper venting that (I) the on-site waste-w- ater disposal system ism proper operating condition and/or. (2) after inspection and pumping (¢necessa~), the septic tank is =ess than 1/3 fu11 of sludge- VI-e; the undersigned have read the above requirements and agree to maintain sewage the private set forth, herein. as set by th D alizueiit of Commerce and the disposal system with the Uep Cei*: caµon stating that Department of,,arzal Resourcesy State of Wisconsin. your septic system has been maintained must be completed and reftuned to the St: Croix County Planning & Zor C JA. fment vdthm 30 days of the diree year expiration date- I/1•e certify that all statements on this ma are true to the best of my/our knowl Property described above; by of a deed recorded R Ywe am/are the owner(s) of the egister of Deeds Office. Number of bedrooms SIGNATURE OF PLICANT(S) DATE Any information that is misrepresented may result in the san't ry Pezm't being revoked by the Planning & Zoning Department. -de I this application a recorded y deed from the Register of Deeds Office and a copy of the certified survey map If _ is trade in the warranty deed. RECEIVED rtment of !f- MAY` ~et and S®I,L EVALUATION REPORT #1780 P Y in accordance with Comm 85, Wis. Adm. Code Page 1 -of _7 S7 ~R I C9fq , ai Services Schmitt Soil Testing, Inc. ~OMMUNITY DEVELOPMENT County Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Part of: 030-1021-20-150 (EASfd Please print all information. - - Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). L 1~,4 11, AM Property Owner Property Location n Andrews, Joh_n_ Govt. Lot SE1/4, NE1/4, S6, T29N, R19W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 229 Sommers Landing City State Zip Code Phone Number City Village Town Nearest Road Hudson WI 54016 St.Joseph Trout Brook Rd North New Construction Use: I Residential/ Number of bedrooms 4 Code derived design flow rate 600 GPD - Replacement Public or commercial - Describe: Parent material O_utwash (Burkhardt Series) Flood plain elevation, if applicable 6kg General comments Area is suitable for a conventional system with a 0.5 gpd/sgft rate. Possible system elevation for area 1 is (step trenches) High and recommendations: 91,10% Low 89.40'. Slope is 14%. Boring ~ pfUP°5Eb Gol- I bF CIrM, as rR v 2sol v, ti, P.3703 Boring # Pit Ground surface elev. 94.10 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GPD _ fft' _ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •E1`f#1 'Eff#2 1 0-8 10yr3/3 none sl 2mgr mvfr as 2m,2f 0.6 1.0 2 8-19 _ 10yr4/4 none grsl 2msbk mfr gw 1m,2f 0.6 1.0 3 19-39 7.5yr5/6 none grs Osg ml gw 0.7 1.6 4 39-57 10yr5/6 no Ifs Osg ml Cs 0.5 1.0 5 57-96 10yr6/4 ,no s Osg ml .7 1.6 t Boring # ---I Boring L~li S~.y gZ Fil . Pit Ground surface elev. 94.1 - ft. Depth to limiting factor 97+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 1 0-10 10yr3/3 none sl 2mgr mvfr as 1vf 0.6 1.0 ` 2 10-23 7.5yr4/6 none grsl 2msbk mvfr gw 1vf 0.6 1.0 3 23-34 7.5yr4/6 none grs Osg ml gw 0.7 1.6 - - 4 34-97 10yr6/4 none s Osg ml 0.7 1.6 rw~ 17 Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L "Effluent #2 = BOD5 < 30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd St. New Richmond, WI 54017 4/24/2015 715-760-1978 SBD-8330 (R 07/00) Property Owner Andrews, John______ Parcel ID # Part of: 030-1021-20-150 Page 2 of 7 Boring # Boring 51 :L - 1 Pit Ground surface elev. --_98.85 ft. Depth to limiting factor _105+_ in. Soil Application Rate Horizon I Depth Dominant Color Redox Description Texture Structure iConsistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#t *E02 1 0-12 10yr3/3 none sil 2mgr mvfr X2f6 .8 2 12-25 10yr4/4 none sil 2fsbk mfr 8 3 25-38 7.5yr5/6 none grsl 2msbk mfr .0 - 4 38-51 10yr5/6 none gris Osg ml 6 5 51-105 10yr6/4 none grs Os g ml 6 Boring 4 Boring # ; pit Ground surface elev. 95.65 ft. Depth to limiting factor 103+ in. Soil Application Rate H izon Depth Dominant Color Redox Description Texture Structure Consistence Boundary i Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color I Gr. Sz. Sh. *Eff#1 *Eff#2 1_ 0-9 10yr3/3 none sl 2mgr mfr as 1vf 0.6 1.0 2 9-36 10yr4/4 none sicl 2msbk mfr gw ivf 0.4 0.6 3 36-47 10 r5/3 c2d 7.5yr6/6 y7.5yr6/2 sil imsbk mfr cs 0.4 0.6 4 47-103 10yr5/6 none grs Osg ml 0.7 1.6 -7 L4 Boring F5 Boring # pit Ground surface elev. _ ft. Depth to limiting factor 23 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#i *E02 L32 0-9 10yr3/3 none sl 2mgr mfr as 2vf 0.6 1.0 -23 10yr4/4 none sicl 2msbk mfr gw 1vf 0.4 0.6 - -54 5yr4/4 m2d 7.5yr6/6 sl Om mf 7.5yr6/1 0.2 0.6 * Effluent #1 = BOD5> 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 (R 07100) Schmitt Soil Testing, Inc. Property Owner Andrews, John Parcel ID # Part of: 030-1021-20-150 Page _ 3 of 7 Boring Boring # Pit Ground surface elev. - ft. Depth to limiting factor -15 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1- *Eff#2 1 0-9 10yr3/2 none sl 2mgr mfr as 2vf 0.6 1.0 2 9-15 10yr4/4 none sd 2msbk mfr gw ivf 0.4 0.6 m2d 7.5yr6/6 3 15-19 5yr4/4_ 7.5yr6/1 sl lmsbk mfr gw 0.4 0.7 4 19-51 5yr4/4 m2d 7.5yr6/8 sl Om mfi 7.5yr6/2 0.2 0.6 71 Boring# ! Boring Pit Ground surface elev. ft. Depth to limiting factor 19 - in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr3/3 none sil 2mgr mvfr as 2vf 0.6 0.8 2 7-19 10yr4/4 none sd 2msbk mfr gw lvf 0.4 0.6 d 7.5yr6/6 ~ t 3 19-61 5yr4/4 7.5yr6/1 sl Om mf 0.2 0.6 ~ I Boring Fs-1 1 1: Boring # F -j Pit Ground surface elev. ft. Depth to limiting factor 25 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * Eff#2 1 0-11 10yr3/3 none sl 2mgr mfr as 2vf 0.6 1.0 2 11-25 7.5yr4/6 none sid 2fsbk mfr gw 1vf 0.4 0.6 - 3 - 25-32 7.5 r4 -4 - c2d 7.5yr6/6 - - - _ _ Y 7.5yr6/1 sl lmsbk mfr gw ivf 0.4 0.7 4 32-55 5yr4/4 m2d 7.5yr6/6 sl Om mfi 0.2 0.6 7.5yr6/2 * 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. U 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. SOD-8330 (R.07/00) Schmitt Soil Testing, Inc. Property Owner Andrews, John Parcel ID # Part of: 030-1021-20-150 _ Page 4 of 7 Boring Boring # F-g] Pit Ground surface elev. _ ft. Depth to limiting factor 26 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence) Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#t 'Eff#z I 1 0-11 10yr3/3 Xnonesl mgr mvfr as 2vf 0.6 0.8 2 11-19 10yr5/4 sbk mvfr gw ivf 0.6 0.8 3 19-26 7.5yr4/4- sbk mfr gw lvf 0.4 0.7 4 26-31 5yr4/4m2d 7.5 m mfi cs 0.2 0.6 7 5 31-61 10 m2d yr/5 3 7 mfi 0.4 0.6 Fi-ol Boring # Boring Pit Ground surface elev. 87.2 ft. Depth to limiting factor 5 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#t -Eff#2_ 1 05 10yr3/3 none 4 sl 2mgr mfr as 4WO. 6 1.0 2 5-14 7.5 r4 6 c2 d 7.5yr6/t3 y / 7.5yr6/1 sl 2fsbk mfr gw .6 1.0 7.5 r4 6 c2d 7.5yr6/6 3 14-28 y / 7.5yr6/i sl lmsbk mfr gw .4 0.7 4 28-68 5yr4/4 m2d 7.5yr6/6 sl Om mfi 7.5yr6/2 0.2 0.6 5-11 Boring # i )Boring j Pit Ground surface elev. 83.55 ft. Depth to limiting factor _ 24- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2_ -1 0-10 10yr3/3 none sl 2mgr mfr as 2vf 0.6 1.0 2 10_24 10yr4/4_ none sic) 2msbk mfr gw 1vf 0.4 0.6 3 24-38 7.5Yr5/6 mZd 7.5yr6/6 _ 7.5yr6/1 sl lmsbk mfr gw ivf 0.4 0.7 m2d 7.'yr6/6 4 38-64 5yr4/4 7.5yr6/2 sl Om mf 0.2 0.6 Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BODS < 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. SHD-83;0 (R.07/00) Schmitt Soil Testing, Inc. Property Owner Andrews, John Parcel ID # Part of: 030-1021-20-150 _ Page 5 of 7 12 Boring F]Boring # Pit 90.38 ft. Depth to limiting Ground surface elev. g factor _ 34in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/3 none sl 2mgr mvfr as 2vf 0.6 1.0 2 10-17 10yr5/4 none scl 2fsbk mfr gw 1vf 0.4 0.6 3 17-34 10yr4/6 none sl imsbk mfr cs ivf 0.4 0.7 4 34-64 10 r5 3 m2d 7.5yr6/8 Y / sil lmsbk mfi 0.4 0.6 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/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *-E02 - Boring Boring # F-1iPit Ground surface elev. ft. Depth to limiting factor _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 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 = BODS - 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 ITY 608-264-8777. SBD-8330 (R.07/00) Schmitt Soil Testing, Inc. Page 6 of 7 Conducted by: Conducted For: - - - Schmitt & Sons Excavating, Inc.. Name: John Andrews ! Thomas J. Schmitt, CST 227429 Address: 229 Sommers Landing 586 Valley View Trail City, State, Zip: Hudson, W154016 Somerset,Wl54025 Phone: 71 -760-1978 Subdivision: Pending Signatur ~c G~72ea L' Lot No. Date Legal Description: SE1/4 NE1/4 S6 T29N R19W - ® Backhoe Pit Township, County: St Joseph Township, St. Croix County A Bench Mark 1 El. 100.00' Top of 2' PVC pipe. A Bench Mark 2 El. 101.73' Top of 2" PVC pipe. Slope= 14% Scale 1"= 40' s ~r /~i41 7 / /qL Z- Ile C C,6,4 7-1 v /V-S Utz r - - 36 X71,3 - - a fb' I Page H&7 Conducted by: Conducted For: - Schmitt & Sons Excavating, Inc.. Name: John Andrews - Thomas J. Schmitt, CST 227429 Address: 229 Sommers Landing 586 Valley View Trail City, State, Zip: Hudson, W154016 Somerset, Wl 54025 Phone: 715-760-1978 Subdivision: Pending Signature Lot No. - Date r Legal Description: SE1/4 NEl/4 S6 T29N R19W Backhoe Pit Township, County: St Joseph Township, St. Croix County Bench Mark 1 El. 100.00' Top of 2' PVC pipe. - - A Bench Mark 2 El. 101.73' Top of 2" PVC pipe. Slope= 14% Scale 1"= /S3 -1 is 12 8i f di. i i , ! j j