The URL can be used to link to this page

Home My WebLink About040-1158-70-185 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 589742 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j Permit Holder's Name: City Village Township Parcel Tax No: Ryan & Christina Tietz TOWN OF TROY 040-1158-70-185 CST BM Elev: 1 -1 Insp. BM Elev: BM Description: Section/Town/Range/Map No: 24.28.20.619C-40 TANK INFORMATION 45 ELEVATION DATA TYPE MAN ;f ~N APACITY STATION BS HI FS ELEV. Septic Benchmark 5 I 2.2 102.2- Ibo, Dosing ~'VLTM" of O jar Alt. BM Aeration Bldg. Sewer 2 / 7 Hold t/ Inlet 13 3S- gg 53 TANK SETBACK INFORMATION St/ Outlet 13•!0 08'(p TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet or Septic 51' t Dt Bottom S2, Dosing Bader an. / y 0 '9-Z Aeration Dist. Pipe , Holding Bot. Syste q .w q z . PUMP/SIPHON INFORMATION Final Grade Manufacturer ~ / l~f'~ GPM Demand St Cover • J , Model Number ~ -bo TDH Friction Los System Head T I (6Ft Forcemain Lengt'(01011t r-z K Dist. to Well A , SOIL ABSORPTION SYSTEM 'v jyV il 'Z-7 Z- to BEDITRENCH Width ~f 11- No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De > DIMENSIONS f~ 10 -Z-- I~~ 11110, SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: n I INFORMATION T pe Of System: ' 'Zjj CHAMBER OR Z I UNIT Model / D IBUTION SYSTEM r~Vl C. ea /M ifold Distribution x Hole Size Ix Hole Spacing Wyel?d-) ak/~/ Pipes Length Dia Leng th Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx De t xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges opsoil Yes No Yes COMMENTS: (Include code discrepencies, per onrs/preseynt, e.) `Inspection #1: Inspection #2: / Location: 332 LINDSAY RD 1.) Alt BM Description L ►LV l.~vti1L~ 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes No ~j Use other side for additional information. 1 SBD-6710 R.3/97 D66 ` Insepctor's Signature Cert. No. C o2S Safety and Buildings Division G~ ' q 24 201 W. Washington Ave., P.Q. EIox,7162 Sanitary Permit Number (to be Slled in b3 x~ fr AU~ J Madison, V1(I 5370 ST. CROIX COUN 1 q c 9NOVV w P GQ VV action Number sanitary Permit Application N R- in accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than the Department of Safety and Professional Servies. Personal information you provide may be used for secondary l ' Z L d Purposes in accordance with the Priv Law s. 15.04 i m Stats. ~w. 15 d - I. A liestion Information - Please Print All Information Parcel # Property Owner's Name /1 711111111 1 Z " (1) d. NN l~ Property Owner's Mailing Address Property Location 1 Govt~ Lipp - 7-1 city , State Vv Zip Code Phone Number 6V y., ~_'A, Section j ~(cu~cle one M G-(.J E 5 ~ O T N; R 00 ,..Type of Building (check all that apply) - Lot # _ [_IJ Subdivision Name L) ~ or 2 Fancily Dwelling - Number of Bedroo N~~' ❑ public/Commercial -Describe Us Blocl:# pry oK e _ ❑ City of CSM Number ❑ Village of ❑ State Owned -Describe Use LStA CIO` b ,Town of T ! r w r P ~ III. ype of Permit: (Check only on a on line A. Complete line B if appii ) A" ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Isst B. ❑ Permit Renewal Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before-ExpMaion Owner IV. T e ofPOWTS S tem/Co- nent/Device: Check all that apply) Fll~ IX_Non-Pressurizedb-Gtound ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil 0 Mound <24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) ~n/~l UIIr V. Dispersal/Treatment Area Information: L Design Flow (gpd) Design Soil Applic io ate{gpdsf} Dispersal Area Required (so Dispersal Ar posed (s) System Elevati So V -7 -1 /071 1 r/ VL Tank Info Capacity in Total # of Manufacturer „ v Gallons Gallons Unitsp tj ?3 cis ~ New Tanks Existing Tanks WI / I. f t_ J w V An Septic or Holding Tanis TJ- i 1SD VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS sh the attached plans. Plumber's Name (Print) Plumber's tore umber `~t~ rDess Phone Num 3 F'F Fe X.~3Z IZ?5~ - a Plumber's Address (Street, City, State, Zip Codo) W1 VUL Corn rtment Use Only Date red Is t ved Permit Fee Ap 1215 20l o en R,-2 I DL Con provaURessons for Disapproval SYSTEM 41NNER'. 1. Septic, Lark. (IFivent filet r and dispersal r;eA mu.,'_!,~a ma~nt^ nod as pear Pit,v~d~ rj r~r ~er. 2 All setback rclqusre(nerts I~lUSii be Ilia"11auied g F+e r 3l) r) - to comp ate pions for the system and submit to the County only on paper not less than 8 M z 11 inches in sire SBD-5398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Rlko 4 Owner's Name: Owner's Address: Ll 1-I T'r-\sS ouo,%p W1 54 01_(o Legal Description: s z l T L e N (~_ZD Township: County: S j CRr~ Subdivision Name: Lot Number: Parcel ID Number: 158 70 -1 & Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: EU Y, License Number: M PR5 Z Z3 2 `I Date: (Z_ Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.C SBD-10705-P (N.01/01). Page 1 Soil Absoration §3 fflj n Cross Section Final Grade Y' Schedule 40 PVC Vent Pipe Qt/ With Vent Cap -U- ft Leaching _ ® ~sY1 ft Chamber System Elevation f ft Soil Abson talon Svstern Plan ~ltew lib ft ft Leaching Trench 1 -ft Vent Or Observation Pipe Ch~nbets 4' Die. Trench Header tLeching Chamber SR"Ifications L Manufacturer And Model 37FSOL 1 R~N- (Wke EISA Rating _a_ sq ft per chamber Soil Application Rate a gpd/sq ft gpd Design Flow = ~7 Soil Application Rate = ~y EISA Chambers 2 rows of 2 chambers each. Page of rTl T, G Tlj } G 14- l~ y tih Q o i / (,TIN i Page Of COMBINATION SEPTIC TANK/LUMP CHAMBER (No Scals) 4" CI Vent Pipe with 'Approved Locking Manhole Cover Approved Cap, +Z5' -a Bu a ~ a9 eggs With Warning L4bel Attached Fr weaeirpwpof Apprroved Warning Labe` Jnwtioil Bob Vent Cap 1211 Minimum r... ! r r,,, ! 4' Wi ini 1i um Final Grade---.,, 61, Minimum r 6" Maximum ~I4 ► Quick Disconnect DI Um q Insp. PI Pe 114" Weep n 14` Weep s - mole ~ Baffles g : d Joint Pipe a s A g i d S' o i 11 A¢ arm B I- Approved Jeri nt t On wli. I. ?pipe C Extending S' ° Onto Solid Soil Y Off i D ` Conc _ Block p of Bedding Udder Tank-J' ~-Une an. Z A-va On .4 w ~e Number of. Bases. 5 Per Day Gallons Per D}ayI 5: Doses . /S Gal ; o1is Volume of Backfl ow:... _ M-piiw& s p4 t anu ac :ua~e~': wl _ an Total Dose Volume:.:.. Size-sep tic IL':' p. O _ 31.131 - FItt Manufacturer: U el Number-. Capacities: A Z6 inches or o0 Gal-Tons + B- =i nc6es or tch TYPe : OT A U .rW 17 dais .p ;~anufac vurer: - ' + C ~jnches or. i~. - Ons- el plumber - ~j LS + D inches air . vGWfUfis iimum Discharge Rate: r~ CPR Total _ Y inches or~GaI ons tical difference Befiieen Pump Off and Distribution Pipe: ~ Feet. - n7mum Required Supply Press re 47 - Feet ~ 5Feet of Farce Main x s Friction Eactcr/100 Feet: +=eet 2--inch Diameter Force Main L i!J Total Dynamic Head: Feet- ~ ,6R ternal Tank Dimensions: Length_ ja; Width Liquid Depth,39,r Signature License Humber Date it jrJAjjQd3sjulw MAW ~T : 50 PAS, 951 ?3, 18787 " GO~Ai{Y PoZ WWJTE UOUELS 3 MODEL 151 752 j AL uwm *A. lam rAd 77 2n lz 4s 70 2b* W n 39 t~ 3MD 35 7A 2 2 :53 in 151 25 a ILA 3 Iif~ 1t e2 San it o at dD a 09 --1 S ' 37A - ' i a swat - 3 TjU 1 t a i a2 1/e at qAi ' s lie Z kz a~ t a JUN i fts s son t tow AW' ° POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner Rkif*J -4 C&O ikjZ Septic Tank Ca aci I 5 (~5 gal D NA Permit # tic Tank Manufisctmer e-s-E2 D NA DESIGN PARAM TF.RS Effluent Filter Manufacturer L 1 R~Tj L, X - D NA Number of Bedrooms 104 0 NA Effluent Filter Model D NA Number of Cormnercial Units A Pump Tank Capacity q5c) PI DNA Estimated flow (average)* dp Uda E~M Tank Manubetum 1F.SEy{ D NA Design flood (Peak), estimated x 1.5* -76 0 gal/day P Manufacturer `Z LLJ C/L D NA Pump Model Soil Application Rate , 7 Uda D NA RduentlEflluent Quality (NAD) Monthly Average" Pretreatmeat Unit DNA D Sand/Gravel Filter D Peat Filter Fats. Oil & Grease (FOG) 30 mg/L D Mechanical Aeration a Wedand Biochemical Oxygen Demand (DODS) < 220 mg/L 0 Disinfection D Other. Total Suspended Solids (TSS) Manufacturer. Model: 5 250 mjoL Dispersal Pretreated Effluent Quality D Monthly Average- jg_!n-ground Call(s) avity) D In-grotitud Or ) Biochemical Oxygen Demand (BODs) 5 30 ing/L 10-At-grade D Mound Total Suspended Solids (TSS) C 30 mg1L ® RKiltYRS Other: Fecal Colifarm (geometric mean) <10 efu/ I OOmI D Leaching Chamber Manufacturer T~ Maxiruum Eff laent Particle size 118 inch diameter Model_ c c Laying Lengtlt/Gluamber *Wastewater Flow Verification and Calculations: Soil Application Rate Area Req. z o fl (Other than bedroom based) Infiltrative Surfice/Chamber-FSIA Minimmn Number of (umbers D Aggregate De ' Flow Rate= mitt Values typical for domestic (non-commercial wastewater Materials: all materials must comply with WI Adm. Cade and septic tank efflruent. COMM84 and be installed per numheturas motions ***Values typical for preo-eated wastewater, and apprW letters. DESIGN CRITERIA 0 "Wisconsin At-grade Soil Absorption System, Siting, Design & Construction Manual" (Converse 041,1990) D "Wisconsin Mound Soil Absorption System: Siting, Design 8t Construction Manual" Converse,l.C. and EJ. Tyler. Publication 15.22 D "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publications 9.6 D "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Manual - Onsite Wastewater Treatment and Disposal Systems". EPA 62511-80-012 October 1980 D SBD -10570-P (R.6t99) "At-Gradc Component Manual Using Pressure Distribution" D SBD -10567-P (8.6199) -In Ground Absorption Component Manual" V$BD -10705-P (N.O VOl) "In Ground Soil Absorption component Manual" Version 2.0 D SBD -10628-P (N.6199) "Recirculating Sand Filter System Component Mannar' Q SBD -10656-P (N_6199) -Split Bed Recirculating Sand Filter System Component Manual" D SBD -10572 P (8.6/99) "Mound Component Manuar' D SBD -10691-P (N.01101) "Mound Component Manual" Version 2.0 D SBD -10595-P (8.6/99) "Single Pass Sand Filter Component Manual" 0 SBD -10657-x' (8.6199) "Drip-lint Effluent Disposal Component MaanuaP' D SBD -10573-P (R 6/99) "Pressure Distribution Component Maine' D SBD -10706 P (N.0 I MI) `•Pmasure Distribution Cbmpon= Manuel- Version 2.0 D Drip -line Effluent Dispersal Component Manual for Multi flo Onsite Wastewater Treatment Units MAINTENANCE AND MANAGEMENT MAINTENANCE MONITORING SCHEDULE sa-vice Evart Service FmItteocy 3 (Maxim= ym.) hiq?gct condition of s At least once every 0 months s Pump out contends of s When combined sludge sudscuin equals one-dVrd 113 of tank volume inspect oiqw-w s At least once every months s 3 YM) Clean effluent filter At least once ev D months s controls & alarm At least once ev 0 mo>stbs s DNA Ins Flush laterals and pressure test At least once everY D months s NA r . . _ _ A t lP-at nnrM rvprv ri months 0 vear(s) 0 NA System start up shall not Dorm whin, soil conditions are frozen at the i nfiltmfive surface. 0PARATTON The property owner is responsIle for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volunme. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed W handle do znesfic st =VM wastewater, however the disposal of food based greases and oils, vegetablef kWt peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minim. Toilet tissue is the only paper that should be discharged into the system Other non-biodegradable items such as baby wipes, tampons, sanitary napkins .condoms, cmatema butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petrohemm products, paint, disimfe•.miuits, Pis, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contswAmde your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system eompoumb. Compaction of snow over the dispersal unit may cause it to freeze up. D Valves Valves shall be operated in the following manner. D Akttrmas Alarms should be tested on a regular basis by the home: owner. If an alarm sounds, contact an individual licensed to sazvice POWTS, There is normally a l day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. INP_- z Inspection shall be made by an individual carrying one of the following licenses or certifications: Mtaste:r Plug, Master Phmiw Restricted Sewer, POWTS Mtaintamer or Septage Servicing Operator (per the attached Maintenance Schedule). D Septic Tanks Component Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks oar links, mossum the volume of Mined sludge and scum and to cberk for any bwkV or pandnng of effiazemt to the ground surface. Access openings used for service or assessment shall be sealed and/or locked upon completion ofservice - Any defects shall be promptly corrected Exposed, openings greater than 8 inches in dianmetet' shell be sewed with an effective hocking device td prevent accidental or unauthorized entry into the tank. When the combination of sludge and scum in any tank exceeds one-third (113) or more of the tank volume, the cadre contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code- The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manuafacnarer's specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. D Pmp Chamber/Treatment Taroks Component The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check mast be nude for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any &lkm Any service needs or repass shall be promptly taken care of. Cl M-Ground Gravity Component Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation: robes and a visual inspeetiaat far any evidence of surface seepage or discharge. Any discharge to flu ground mwhc c must be prompdy sport tv thus rogtnlatory authority. Ponding at depths gnu Haan 75% of the height of the component may indicate overloading our hung hydraulic faiJure necessitating mme fieque:nt monitoring. Pagt of D Mound, At-Grade, In-Grouutd Pressure The inspection shall inchude recording the levels of ponding, if any in the observation tubes and a visual imspection for any evidence of surface seepage or discharge. Any discharge to the ground surface moist be promptly reported to the regulatmy authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. The pressure distribution system is provided with an opening at the end of each lateral to be used for Rushing. The laterals should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to ensure that equal distribution of effluent is occurring to promote the longevity of the system REPQRTS Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative Code. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the fallowing steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Adztinistmtive 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 Se ptage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the vdid space filled with soil, gravel or other 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: C3 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption syst m. The replacemerit 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 from existing and proposed structure, lot lines and wells. Fail= 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. Q A suitable replacement area is not available due to setback andlor soil limitations. Barring advances in POWTS trxd~bw a holding tank may be installed as a last resort to replace the failed POWTS. 0 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. C3 Mound and at grade soil absorption systemic may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<wARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE 114TERIOR OF A TANK MAY BE DIFFICULT OR 14POSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAIlVER Namt ~ eTV k Name Phone Phone LOCAL R 'i ATORY AUTHORITY SI:FTAGE SERVICING OPERATOR O?MMF Name A l 0 Phorte Phone 15 r A82 --I 38le - y(o ~ RECEIVED Wis.Dept. of Safety and Professional Services SC69G3N19N0WGQW ORT Page of Division of Safety anAMile L j n in accordance with SPS 385, Wis. Adm. Code County Attach compleiSI OUN han 8 1/2 x 11 inches in size. Plan must include, t~ onzzoontal reference point (BM), direction and Parcel I.D. percent s ope, scale or dimensions, north arrow, and location and distance to nearest road Please print all information. Revi ed Date / Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ALL Y, Property Owner Property Location Govt. Lot 114-/:--1/4 T N R ~n, E (or Prope y Owner's Mailing Address Lot # Block # Subd. Name or CSM# /&V~ A,-,<' j , _ < City State Zip Code Phone Number El City ❑ Village ®Town arest Road sS New Construction Use: Q Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments and recommendations: 'o~z5jr~c,c.* / F] Boring Boring # Pit Ground surface elev. ft. Depth to limiting factor ?/Z,~, in. " Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 Al A" 7 • CA ❑ 4 Boring # Boring V ` ® ® Pit Ground surface lev. ~ ft. Depth to limiting factor > in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 h~ Q v 3 - q, UA r*) i pi A' Y)li j \ f\ I / P 1'/-~ ' * Effl t #1 = BOD e > 30 < 220 mg/L n >30 < 150 g/L * ffluent 5 < 30 mg/L and TSS < 30 mg/L CST Na lease rin CST Number Address Date Evaluation Conducted Telephone Number 1'~7 16 7C SBD-8330 (R11/1 1) Property Owner Parcel ID # ` / Page of Boring M Boring # t~I ft. Depth to limiting factor in. L~1 Pit Ground surface elev. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff41 ` ff#2 cf 7 i 1 /t - Y U / ❑ Boring ❑ Boring # ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ` ff#2 Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L e The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (R 11, 11) - t r • -J i - Property Owner Parcel ID # J - 1J 7Z) 1~Ps Page s--,~Iof. ❑ Boring # Boring Pit Ground surface elev. ^llk~ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 0f#2 f 3 17- - / 4' F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 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 onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff41 * ff#2 Effluent #1 = BOD s > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (RI I/1 I) r i do v la, - i I I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Z Mailing Address qy W~I t-~~CC( Zs /1~t&Q(1 WT 6q Property Addre 332. Lin on !5tJ01(p U'04'~ (Verification required from Planning & Zoning Department for new construction.) City/State NV(,&0in, ~iy1 Parcel Identification Number 040- 11597--70 - ~ 95 LEGAL DESCRIPTION Property Location S W '/4 , SE '/4 , Sec. T 2 _2(N RZ6 W, Town of )_O (d Subdivision Plat: -'row Twne Lot # Certified Survey Map # Volume Page # Warranty Deed # (before 2007)Volume Page # Spec house Elyes9!~ o Lot lines identifiablexyes❑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 ASPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on fl' 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 w ranty deed recorded in Register of Deeds Office. Number of bedrooms G T RE O LICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) L .,...v.., Ti s NV W11M z}aid 3 pue uefi~ !x nde~s~o -,~oeino~~~H~ 3~s .IC7~J U~19a~ P!(2 POGO' ~OJc t 0 o$ l \ N~ n Nil:. K I I~ I r ~I I v I ap e t ?91i~q ,s 'I - Iw - N a f ti G ®4 C a _ _ A E IF R 4~ III r ~ 999 o all- 4~i1 Imo, W1