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Home My WebLink About032-2116-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix ;Safety and Building Division INSPECTION REPORT Sanitary Permit No: 584748 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)]. Permit Holder's Name: City Village Township Parcel Tax No: Chris Nelson TOWN OF SOMERSET 032-2116-40-000 CST BM Elev: Insp. BM Elev: IBM Description: Section/Town/Range/Map No: Of ~ /9d, v v 5/11L dAl 4,41A - ~ chte-Ah /7aa e 15.31.19.1064 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet / TANK SETBACK INFORMATION St/Ht Outlet 7,-/c/ 70 l0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic \ Dt Bottom Dosing j Header/Man. r7,k /J~/.ly j,/~' Aeration Dist. Pipe r7~9 Bot. System 6! PUMP/SIPHON INFORMATION Final Grade r t 99 IN Manufacturer Demand St Cover G M Model Numb )5r TDH Lift n Loss System Head DH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length 1 / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 9? -1 SETBACK SYSTEM TO / P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR AT- 1 T~~ %Z Type Of System: ' t UNIT Model Number: 6 011(16A , o vo L 11 Nh G7~~ lc t~ y GL:'~ vj- DISTRIBUTION SYSTEM Header/Manifold ID istribution Ix Hole Size rHole Spacing ent to Air Intake Pipe(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 bl"o Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~3-Q~~pll~p Inspection #2: Location: 587 217TH AVE /41(~ f~S 1.) Alt BM Description = J 2. Bldg sewer length = 0r m 6 ( lLr / r ^B',, Q 20LvY - amount of cover = nsP '0V✓~ plnC~dN` ~-~•p T LIxLW~ L~'~~ 4 ,1~ a 9 ((NN Plan revision Required? ❑ Yes `fJ No ! L Use other side for additional information. ~('0 I S: Date I sepctor's Signature Cert. No. SBD-6710 (R.3/97) County " r, Safety and Buildings Division ST. Croix 201 W. Waj P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) P P~t MaU A V 15 94 74 00 Sanitary Permit Appli t on State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission o~, AQ emmental unit NA- is required prior to obtaining a sanitary permit. Note: Application A5 ~itted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. ^ I 1. A lication Information - Please Print All Information / Property Owner's Nam Parcel # 15, 31. 141. lolly Chris Nel-gonC) 4)~4 2 wig-gilliAn-non Property Owner's Mailing Address Property Location 587 217 Ave Govt. Lot City, State _Zip Code Phone Number SE NE Section 15 Omerset W. (circle one) H. Type of Building (check all that apply) Lot # T -3_ 1_ N; R E or W 81 or 2 Family Dwelling Number of Bedroom -7 Subdivision Name look # ❑ Public/Commercial - Describe Use ❑ City El State Owned Describe Use CSM Number El Village of _ 2 pt- A1 ` ZZ_~ 1?_ ❑ Town of Somerset III. Type of Permit: (Check only ode 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 El Permit Revision El Change of Plumber List Previous Permit Number and D e Issue ❑ Permit Transfer to New Before Expiration Owner S C,~~ ` j t /J CJ IV. Type of POWTS S stem/Com onent/Device: Check all that apply) 91"N.-Pressurized In-Ground El Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of su ble soil ❑ Holding Tank Other Dispersal Component (explain) _ ❑ Pretreatment Device (explain) V. Dis ersaUTreatment Area Information: r 1 Design Flow (gpd) Design Soil Application 7(gpdsf) IG al Area Requi (sf) L Dispersal Area posed (s System Elevation AI ✓ I.1 00 7 880 'S VI. Tank Info Capacity in Total # of Manufacturer Gallons allons Units o a New Tanks Existing Tanks Lot P U , { JG 3 y Septic or Holding Tank 1200 Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assu a respon,§ibility i tallation of t r" n. shown on the attached plans. Plumber's Name (Print) Plum r' ignatut$`~ MP/MPRS Number Business Phone Number Keith Knudtson 648443 651-470-1737 Plumber's Address (Street, City, State, Zip Code) 927 150th St. Roberts Wi. 54023 VIII. C un /De artment Use Only pproved Permit Fee Date Issue Issuing t Signature men Reason for Denial ' y$5 . ob 5 /z Ico IX. Condit Etir to VN~Zeason for Disapproval 1. ~n r t~, ✓ 1. 5eptir. tank, effluent filter and dlspem.ni cell must all be brt~ic,as ! nial t@'re' as per management plan pro.iided~by plumber. 2. 'A,~*4WeM8nt,S'Ir1USt tie rtaintziriEd n per aWlicable cAdp / wdinancea. Attach to complete plans for the system and submit to the County only on paper not less than 8 tia x 11 inches in size SBD-6398 (R. 11/11) f O r 66 ~ ~ ! W~L~J eL7-J!~s3r J':v f h a 1 ~ Lt- ' Ze- pl 1 KNUDTSPINPLUMBING tk CCNTFhm0T!"-Jn, LLC q 927150TH 6 -648447MPRS ROBERTS, VIII 54023-8526 ' f. CELL 65f-470.1737 Y ; t ~ ~ f ~ ~ F L k 6 4 F 7 g L~ ~ ~ G ppp p{//~ p°2~ p ~-71-ef k i i CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Nelson Sewer Owner's Name: Chris Nelson Owner's Address: 587 217th Ave Somerset Wi. Legal Description: SE 1/4 NE 1/4 S 15 T3 IN R19W Township: Somerset County: St. Croix Subdivision Name: Shadow Pines Lot Number: 7 Parcel ID Number: 032-2116-40-000 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: Keith Knudtson License Number: 648443 Date: 05/09/2016 Phone Number (651) 470-1737 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 "v s s ~ KNUf TSIN ~LUMRING P, CCMTFerMTI-PTn, LLC € I 927150TH ST. 648447MPRS j ROBERTS, WI 54023-6526 U a' 'i~ Lr^j CELL 651-470-1737 61 1 ~ ~ eY ~ iv z ~ p -l~ Sze S e/ z i i a ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 587 217th Ave located at: SE V4, NE V4, Section 15 , Town 31 N, Range 19 W, Town of Somerset , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 4-12-16 Did flow back occur from absorption system? Yes x No (if no, skip next line.) Approximate volume or length of time: 50 gallons minutes Tank Capacity: Construction: Prefab Concrete x Steel Other Manufacturer (if known): Weeks Age of Tank (if known): 15 yrs. Permit number (if known) 395170 Keith Knudtson Licensed Plum er Signature) (Print Name) Plumber 648443 (Title) (License Number) MP/MPRS 5-5-16 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Chris Nelson Mailing Address 587 217th Ave Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Somerset Wi. Parcel Identification Number 032-2116-40-000 LEGAL DESCRIPTION Property Location SE '/4 , NE '/4 , Sec. 15 T 31 N R 19 W, .Town of Somerset Subdivision Plat: , Lot # Certified Survey Map Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house 0yesl1ho Lot lines identifiable ElyesE]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 §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary). the septic tank is less than 1/3 full of sludge. Uwe, 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. 1/we certify that all statements on this form are true to the best of my/our knowledge. 1/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 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 deed. (REV. 04/12) S Soil Absomtlon Strstem Cross Section 98.79 4' Schedule 40 Final Grade PVC Vent Pipe 5.00 With Vent Cap n_ ft Leaching 94.75 Chamber ft System Elevation 5.0 Soil Absoration System Plan View ft 3.00 ft 1111111 1 ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4' Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model Infiltrator EISA Rating 20.00 sq ft per chamber Soil Application Rate 0.70 gpd/sq ft 600.00 gpd Design Flow # 0'70 Soil Application Rate T 20 EISA 44.00 Chambers 2 rows of 22.00 chambers each. Page of ` \ I ~u uavl~, err. J••VrC . I ~ I ~ LFfft~ RntStctlon Corner Monument Z 0 o f"e H I 2 0 Set 1-S//6• x 30' Sofa Round Bar weighing 4.6 pounds per tines foot. • Set minonurn of 11" x 24' Won j oo ~tn9 I pounds per \ linear foot. 0 Found 1' iron pipe 2 I f7 Found 1' Rod ~ w i I - Cenleline Driveway (Approx. Location) y~ Building Selbcck (100• from :oh./ R. Recorded As 'S' Exist ng fttionds) 2 I 'HIS INSTRJMENT DRAFTED BY KRIS-1 A. EYLANOT I 'LATTER-LANQSIOF ON+NE~ I All. LNEAR MEASUREMENTS MAVE BEEN (LACE TO HE NEAREST ONE (1) MUNOREDTH OF A FOOT, ALL ANGULAR MEASUREMENTS ACRE MAD? TO T14E I NEAREST FIVE (S) SECONCS AND COMPUTED To HE VALUES SH:)wN. I ---S89-26'46"E 1271.82'---_ (Q, - ® ro W N A ( Each parcel shown on this map is Stott. County and Township ' laws. rble Q o ,g t _ ---~p•26.46•w 1Z~.Bp,------ t regulations (i.e. wetlands, minimum tot size. 1 T _ W access to parcel, ttc.) Before purchasing or i ( r 246.02 ' -y ` 3J' * developing any prce con:oct :he St. Croix 23.57r JJ y t County Zoning Ofrtce and the appraorlote unLlTY at _ -own Boord for advice. i I EAS£iy£N7 ~ ~ ~ t i.7 1 r 1 & t r I ~ a t t to EASFSSwT R£s1'aIr?v_•+~e• t NO CiRAOIN ~ I ...............t.. t = POND EASEME~ C~STRU:TtON PERVl1'FO wt-+IN --E i 0 1~~3 I /t C~\ z 1~ I ~ c+ I Is 4 7 > 1 J 131.130 SQ FT. 1 1 0 3.01 ACRES f ,aa o IOU 1 131264 SQ FT. 6- seiiitto N TH m , &Of ACRES > a. ty SCALE IN ~E inert- 100 teat T ! \ I u z BEARINGS ARE REFERENCED TO nfE ftORTH uNE Or n•E V ; u a rIE 1/e OF SECTION 15. TCINSrIP 31 N., 41ANCE 19 VACH ;S ASSUMED TO BEAR S89Z3'33-E. r, u' tt}y{t . Y I ~ ,Di1 o t=j L oo cortains a number of rots cominited by I mature oak forest. Cm such iota the Town of Somerset .ill require that trey that racy be sub act to excavation and/or Qr. construction damage be cpproprietey podded or boarded to Prottct them from bruising and/or OOrdsive damage. This is _ being requested primorky to prevent the intrusion of oak errs into the essmtialfy htahf y stand of oaks. The Town of Somerset further regdests that efforts be made by to avoid unne:esaMy soil compaction around the Dose of mature oaks. 204 58 At the time of budding permit coprove. guidNiny for toe -19s,00 continuing core of ti-it existing forest will new hom b• pror.dsd hr i tcwnera. + I SQCl7H iAW Or Thar S£ 714 or METLAND ?W AC 111 £AST- 1fEST T/f LettEJ ZS YR N.trL. =1- 918 37 i •t+~~co~e~ STA" UP AND OPERATION Por new construction, prior to use of the POW TS check treatment tank(sl for the presence of painting products or other chemicals nat may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents 36 the tank(s) removed by a septage servicing operator prior to use. vstem 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 o= 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 POW` TS fails andlor is permanently taken out of service the following steps shall be taken to insure that the system is property 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 sealer. The contents of all tanks and pits shat( be removed and property disposed of by a Septage Servicing Operator. After Dumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert soled material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code complian_ replacement system: A suitable replacement area has been evaluated and may be utiirzed 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 Fines 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 mus_ 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. /jt r V a i L . c ank be r e raueo v i 'lRD4415 TTY f:-Dfe- lffb/V577ZUG?E CAN ❑ 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. ADDFTiONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name ic► :-L !~,r Name Phone % - If-76 3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTT14~ORiTY Name Name Sf . C~t~U t U 1 20AfI~(1 Phone _ Phone <(v (fD This document was drafted in compliance with chapter Comm 83.Z2(2)(b)0)(d)&(f) and 83.540 (2) & (3), Wisconsin Administrative Code. Private Onsite Wastewater Treatment System In-Ground Management Plan Pursuant to SPS 333.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS). Shall include information and procedures for maintainine the system within the parameters ofSPS 383 and 384, and the conditions of approval by the department. agent. or governmental unit. The approved plans and permits for the system will be filed with the county zoning or health department. This management plan complies with SPS 383.54, Wis. Adm, Code. and the In-Grouna Soil Absorption Component Manual for Private Oosite Waslew8ter Treatment Systems (Version 2) SBD-I0705-P (N.01101) Table 1: System Design Specifications ~LvPermit Number I Nmnber of Bedrooms Design Flow (GPD) Soil Abso Lion Component Size (s q. ft.) Q Septic Tank C Gal. ~J Pump Chamber Capacity Gal, Type of Wastewater Table 2: Soil Absorption Component - Limits of Reliable Operation Sentie Tank Component -oil AbsoI7! 1 ion Component Design Flow-Peak (GPD) Max. Influent Particle size NA 1 n Maximum BOD 5 (mall) NA 220 Maximum TSS m ll NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule i Septic Tank T andlor service once every 3 years Outlet Filter Should' once a year and clean as needed Pmnp Chamber Inspect once every 3 years- if applicable Soil lion Component lasoect annually Private Onsite Wastewater Treatment System In-Ground Management Plan Pursuant to SPS 333.54 Wis. Adm. Code each Private Onsite Wastewater Treatmen.. System (POWTS). Shall include information and procedures for maintaining the svsterr within the parameters ofSPS 383 and 384, and the conditions of approval by the department. agent. or governmental unit. The approved plans and permits for the system will be filed with the county zoning or health department. This management plan complies with SPS 383.54, Wis. Adm, Code. and the In-Ground Soil Absorption Component Manual for Private Oosite Waslew8ter Treatment Systems (Version 2) SBD-I0705-P (N.01101) Table 1: System Design Specifications Lv Permit Number i Nmnber of Bedrooms _31 I Design Flow (GPD) Soil Abso tion Component Size (s q. ft.) J G Septic Tank C Gal. Pum Chamber Ca aci GaL Type of Wastewater Table 2: Soil Absorption Component - Limits of Reliable Operation Sentie Tank Component -oil AbsoIT.!!lion Component Design Flow-Peak (GPD) Max. Influent Particle size NA 11 Inch Maximum BOD 5 (mall) NA 220 Maximum TSS m 11 NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule Septic Tank andlor service once every 3 years Outlet Filter Should' once a year and clean as needed Pmnp Chamber inspect once every 3 years- if applicable Soil lion Component Iasoect annually Wisconsin Department of Safety and Professional Services Division of Industry Services RECEIVED SOIL EVALUATION REPORT Page of in accordance with Comm 85, Wis. Adm. Code County Attach complete siApRn W;aj!W hdt 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 percent slope, S%ICR~jsf R4Wh arrow, and location and distance to nearest road. Parcel I.D. ~ COMMUNITY ~~FFV~~ ppl~uul~~nlT ~ ~ ~ ~ _ Pl~Yf~' i~ . lr information. Revi d by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner EProperty Location J t 1/4 - 1/4 N R E or W Property Owners Mailing Addres Block Subd. Na e or CSM# CityJ/ State Zip Code Phone Number ~City~ Village Town Nearest Ro d New Construction Usefo Residential / Number of bedrooms Code derived design flow rate GPD ® Replacement Public or commercial - Describe: Parent material /C%"yy.: Flood Plain elevation if applicable _4 2 ft General comments and recommendations: F I Boring # n Boring Pit Ground surface elev.. ft. Depth to limiting factor o11 in. 0 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/H2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Z /'7 A Fl F7-1 Boring # ® Boring Pit Ground surface elev. 7 ft. epth to limiting factor } l 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 / r Effluent Wq/L = BOD, 30 < 220 mg/L and TSS >3Mupnt #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (PI Prim Signature CST Number Address Date Evaluation Conducted Telephone Number SBD-8330 (R07/13) Parcel ID # Page of Property Owner Boring # Boring F1 Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots * in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 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 *E GPD/f1zEff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *EGPD/ftEff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L SBD-3330 (807/13) J!C.-e r ® x11 S i t7 _ t7 G 1 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building 11-vision . INSPECTION REPORT Sanitary Permit No: 395170 0 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)]. Permit Holder's Name: City Village X Township r rcel Tax No: Perrault, Dale Somerset Townshi 032-2116-40-000 CST BM Elev: III p. BM Elev: I BM Description:` zo .C)' •a ~,3,~,s e1 Cam- S:u ~s. ~1, ~9.~Q~ y TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmpfk f~ ~ ~ f ~ p (c• ~ l ~ ~'D • D Dosing ,•v 10 &F- I Alt. BM Aeration Bldg. Sewer .2 qg, 2S' Holding St/Ht Inlet `p q 1 30 1 TANK SETBACK INFORMATION St/Ht Outlet q ~D `l x,09 f TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic I Dt Bottom Dosing l Header/Man. f Aeration Dist. Pipe . D qb .o~ Holding Bot. System , 9y. 99, PUMP/SIPHON INFORMATION Final Grade Manu cturer Demand St Cover GPM Mode! N tier TDH Lift Friction Loss System Head TD Ft F main Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM IT BED/TRENCH Width Lengt No. Of Tre Ghes PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS q C,~ Z SETBACK SYSTEM TO P/ B G WELL LAKE/STREA LEACHING Manu cy~.: INFORMATION CHAMBER OR ' ( • Type Of System: >~I 33, ('K) UNI M el Nu r u DISTRIBUTION SYSTEM Header/M if Id n Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) i Length Dia Lengt Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of 1xx Seeded/Sodded T Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes [ ~ No Yes No 1111111 COMMENTS, (I clud code discre encles, persons present, etc.) Inspection #1: l -2- Inspection #2: I`I IL '0.j~ dtwr 4„z~, oca ion: 587217th ue Somerset, WI 54025 (SE 1/4 NE 1/415 T31N R19W) Shadow Pines Lot Parcel No: 15.31.19.1064 1.) Alt BM Description =j) 2.) Bldg sewer length = 3+ amount of cover = t(t- - d Plan revision Required? Ye No I~ e- A Use other side for additiona rmation. SBO-6710 (R.3/97) ~,,~ey VJA--. 54, t to Insepctor s Signature Cert. No. coy*, MMPLV'ck~ o a ° u> oar 0 o- U ~ as E .0 i3 C) lo 0 m d w O O rn° a O G N L O N x ~ U U 3 "O ~ N L OI -O ~ L U C m m - UI L~ X (0 L O O) N _ Q d O o •0 d 3 m U U L s d L in F ° - U m o 0 m o 'm o■❑® vii I- U > to U O J (n U J K K K U N V J - o0 Q33 O U~~ ,o (nOp c a ° o 1.7 song "i"i OW s $ - 771 n , y ,n 5 .49 97 AiP 'S t ,y, e 6, k vA, f; a;. 4 • a . .x ANN ~k 663.25 3 ~ z- oc~ + 57 t y p M, i 3 a J V s I $ ~ a v 1 ~ Q T l j Y(t j le I ~ NZ 41