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HomeMy WebLinkAbout030-1095-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 5'qZ 17 Z 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)]. city Village nchin Parcel Tax No: Permit Holder's Name: E !4-. 30-5 3b W? ',r- 940 CST BM Elev: lnsp.Bkl Elev: BM Description: Section/Town/Range/Map No: d+ ..,...fit.. Go 3 z. 3 &J t 34INS TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark a ,Q~t ~Ol. Q 4. Z ~sCi `n i CS /ODO 1 O Alt BM 5a6 Gay. ep z-4 laz • 3 Bldg. Sewer AgLatio" Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent Air take ROAD Dt Inlet 7.39 417--3Z SeptOicO Dt Bottom ~1 ( 7.93 cm •Z Dosing0 t 7 Z7 Header/Man. 60 Vp Aeration Dist. Pipe qI-"T ~i Q Holding -7177- Bot System 41 Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover 3 GPM Model Nu er PForce ELe Fr iction Loss System Hea TDH Ft ngth _ Pa . c c Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width -3 Length~ No.~Tren i r f PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth DIMENSIONS P~KGIY_ `I'► SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: 6 z F/O ~J INFORMATION CHAMBER OR Type Of System: y UNIT Model Number: 1 11 Z-7 DISTRIBUTION SYSTEM p ( ! /G 0460 x Hole Size x Hole Sp cing Ven to Air Intake Header/Manifo~d / I Distribution 1. t 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! odded xx M ched Yes No Bed/Trench Center Bed/Trench Edges Topsoil Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc. Inspection #1: Inspection #2:: Location: 1163 230TH ST - SOCK ~0.~. 1.) Alt BM Description = J 2.) Bldg sewer length = /tq SOS PlInseep a; I S amount of cover Plan revision Required? Yes No Use other side for additional information. ors Sig ure Cert. No. SBD-6710 (R.3/97) Date Wis. Dept of Safety and Professional ServtFe~s SOIL EVALUATION REPORT Division of Safety and Buildings JAN ~ Y ~ 17 Page of in accordance with SPS 385, Wis. Adm. Code Attach complete site plan "°t`° (.:ROC X COUNTY County 1 r Attach but not limited t rt "Mgf~~$fff 1lfl"inches in size. Plan must 0 /K- include, reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 000 Please print all information. Reviewed / J Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 1 pPro7perty~00Owwnneerr el l a Property Location Owners Ma ing Ad ss Govt Lot IJ 1/4 S N R (or)® ~Z f i m/ Lot # Block # Subd. Name or CS City State _Zip Code Phone Number kr/'sd,,~ ~''L ~-~~6 ❑ city t ❑ Village ®Town Nearest Road FI w Construction Use: ® Residential / Number of bedrooms Code derived 3 design flow rate ~/SO GPD placement ❑ Public or commercial - Describe; material ] 7~~ ~Q~®S~'ff o . f- Jo y Flood Plain elevation if applicable comments / nn O PQ e e~ t ~nI A ft. and recommendations: Alec S T tit P~ crrj - l -0co / re reef i G ccS 0--1 Pl~+ l laat m ti ,Lve1 f- ~~oQ © Boring # ❑ Boring Q ® Pit Ground surface elev. O fL Depth to limiting factor Z 7 in. Horizon Depth Dominant Color Redox Description Soil Application Rate Texture Structure onsistence oundary Roots GPDJft z in. Munsell Qu. Sz. Cont Color Z Gr. Sz. Sh. ff#1 , ff#2 3 "Z 32-71 7fJ'79S1 f "S L C Gr. /vea - O r 7 1 r f?7 7/-121 7fYR All+ fl ❑ Boring# ❑ Boring 5~~0 ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Soil Application Rate Texture Structure onsistence oundary Roots GPD/ft a in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 ff#2 " Effluent #1 = BOD > 30 < 220 mgJL and TSS >30 < 150 m CST N e (Please Print - g/L 'Effluent #2 = BOD s < 30 mg/-L--and TSS < 30 mg/L - 7~ ~n e Signa CST Num f') rGk.t. - Address -23131Y Date Evaluation Conducted Telephone Number I'd12' SBD-83 ?0 M l l II t Parcel ID # Page of property owner [j Boring ❑ Boring # _ ft. Depth to limiting factor in. 5011 iication Rate ❑ Pit Ground surface elev. Texture Structure nsistence undary Roots GPD/ft 2 Horizon Depth Dominant Color Redox Description Gr. Sz. Sh. " ff#1 ff#2 in. Munse(1 Qu. Sz. Cont Color Boring Boring # F1 Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture GStructure onsistence oundary Roots " f 1 GPD ff#2 in. Munsell Qu. Sz. Cont Color Boring in. E Boring # Ground surface elev. ft. Depth to limiting factor ❑ Soil lication Rate pit Horizon Depth Dominant Color Redox Description Texture Structure onsistence undary Roots " ff#1 GPD2 Qu. Sz. Cont. Color Gr. Sz. Sh. in. Munsell = - * Effluent #1 = BOD t > 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 BOD e < 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 (Rl 1111) OWE r1 o 4- lJ/ uJ1~ f/`e Page3 of 3 dress 1 Z S2 Brian Pamen S-yv 6 CST 231314 hmark Date /0-.70- geIIC j B= 2 / a L o 1-^ ,si-a~4 e /0,0 0 Soil Bores L- Suitable Arm Scale j! } s 1 } ~ j t~ t 1 ~ f~~ ~ 1{ ( t 7 F i S t ~ t s _ F ~ f } e . ' 1 I r t ~ ' ffI 1V V ~ ♦V~~Vl• EU County Safety and Buildings Division 7`, if /•O i ' IS P OCT 31 2 o i 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) fit S Madison, Wl 53707-7162 ST c:zalx cou err ~ y° c/ 1 ESSf0~P1 ~ p Sanitary Permit Applicatli ]G State TransactionNumbtr In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to me y . W 2 6 Y3 H P K68 is required prior to obtaining a sanitary permit Note: Appli cation forms for state owned POWTS are suou,...,,_ oject 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 Privac Law, s. 15.04(t) (m , Stars. I. A lication Information -Please Print All Information 5 / Property Owner's Name - t~T"6 a 4 _ , Parcel # z 1- it 6rV' ~r Q3o - ioqSt~~v -`7o c~ Property Owner's Mailing Address r Property Location Ll. (q. City, State Zip Code 3 Z.. //4 j f6.l &1 T e .~2 9 T Y/ Go ~ t~~y Section lrcte o II. Type of Building (check all that apply) Lot # / T N, R E ,P!k1 or 2 Family Dwelling - Number of Bedrooms ! Subdsion Name Block # ❑ PublictCommercial-Describe Use ~A ❑ City of ❑ State Owned - Describe Use CS~~./~~umber ID ❑ Village of _5 7. y' P Town of- 6 - III. Type of Permit: (Check onl one box on line A. Complete line B if ap icable) ❑ New System Replacement System ❑ Treatment(Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• ❑ Permit Renewal- ❑ Permit Revision List Previous Permit Number and Date Issued ❑ Change of Plumber ❑ Permit Transfer to New 6 - Before Expiration Owner ~6✓ Y ~ W. T e of POWTS S stem/Com onent/Devi -e: Check all that apply) RNon-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 (ex lain) ❑ treatment Device (explain) V. Dis ersal/1 reat ent Area Information: Design Flow (gpd) Design Soil Application R L`SD 0 7, Dispersal Area Required (sfl DispersArea al Proposed ( System Elevati G y. z VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o ' New Tanks Existing Tanks c ° Septic or Holding Tank / F~ C7 SaO 1004 7So6 2- W~cs.« A Dosing Chamber / f Y9/ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the a shed plans. Plumber's Name (Prat) Plum is Signature r 1MP/MPRS Number Business Phone Number l~ ~t 1a,-"e. i( 17 iT zy7-203 Plumber's Address (Street, City, State, Zip Code) 3 9'9-= /)?,Z a (e So /2, r~Jc ~ 4-1:1:77 sr-~i'6 2S oun epartment Use Only Approved Permit Fee Date u Issuin bent Si on for Denial $ ' j 7 I IX Cond' ark r' ,er easgqns for Disapproval L fl~en: rilte nd DI c _ c t ` l ditijkrr cell must all be sereic.?s / r zinWr. ill!rVer ,mar.39ement plan pro sided by plumber, 2. AM;(Mltback recuirements must t be m nt?jKed GLN'1 > (►G_. I AA l ~a'ta r~uG as psr agilcaws r6t 1 rdinAnq at. 1Pf bw-, ACA. J OC.vNer-s Attach to complete plans for the system and submit to th/~ oounty only on paper not less than 812 x 11 inches in size SBD-6398 (R 11/11) Flo OWNER ~ Faa~3 of 3 ~ Name -'2 Ercti?t Brian of Parnell Address / 2 S2 - /lti 4f T, CST 231314 ~ti C~-z .Syo /6 Date lD- ,?D- Benchmark 1 P e 1A le c,, v e% /D 2, 80 Benchmark 2 Toq~ G o ftuk~ /DD, D Soil Boring Suitable Area I" =407 Scale A r z ' F # i 3 F i i 1 i t f r r 1 t 1 r 01 T- -T D ~ e i- # CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: _Je Ar6l /(e / / e Owner's Name: J -e Old- 15; u-~ e fft° Owner's Address: s 0 b//// F_/ Legal Description: Township: S~r -j-0 County: "Ill'- Subdivision Name: / Lot Number: ` Parcel ID Number: 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 GSM or Plat r 112 s Designer/Plumber: la ll License Number. Gate so lt; Phone Number 2 yT 2©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 Name -Je ~fune ffe Page 3 of 3 Address J 2 5'2 - o /J Tip Brian Parnell /yam. IG C ,t C~-~ .Syv /O CST 231314 Date /D- .70- Benchmark 1 P7at 116 le c--o u e/ /D 2, 8U Benchmark 2 To.~ G o Stu~~ /DD. O Soil Boring .j Suitable Area l " = 40' Scale I ! t ( } # . 4ft un t ! f C f ! 2 ' O cc e t C ` > f Bra -1 e ffe r 9-es ~t Oo t e Gc~~ 8 ~Q GTO C~ • / X ~/i S~ / d GJ~9~~^. v /h r~.-c f L gem C~ C S Aso ` 7° Q s-oL z SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS ILEACHING UNIT Page of Project Name: ~ Lc h e 02- No. of Cells a Per Cell ~j 3 ft Cell Width E 6 Total No of// "/6 "2:5 - 7S ft Cell Length 37r Sq ft EISA Per Cell y it Cell Spacing 7~0 sq tt Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator E7120314-5ft 5.0' 25.0 2 EZ1203H-10ft 10.0' 50.0 / r Cravelle55 Leaching Unit Manufacturer. ~ fGravelless Leaching Unit Model: - 22 0-? - t16 7. ~6 p~' Typical Cross Section I`inished Gracie ' 6 i Observation Pipe with approved cagy or vent ~ g a ■ . e • . • ° a;iri`-'~-'i-.'ii_-?'i-.'>:<'_•:<'E.=>iz a-i ii - _ : a Soil Sachril. 1/ : Geotextilel=abric Infiltrative Surface 12 in 0 ( Eft Limiting Factor in Slotted and Anchored Vent/ _ Observation Pipe with Cap M9 :..r } a x r.^. _3 a rc c n c w n n a u N, . r n m c x: m a.., w a r. c • . n . R Plum berlDesicgner Signature- ii~ r s: s. Oatr; P" VZabeAAW"ma9Pdfi*kr- INSTALLATION INSTRUCTIONS PL-525/PL.-625 FILTER INSTALLATION INSTRUCTIONS centerfifer with QwP car e -P -EW 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 hosing, making sure the filter removed fivm the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS Step 9: Step 2: Step 3: Locate the gullet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter caftlge hack ass : if necessary. into the the housing making sure ® s Pull the fitter out of the housing, the filter is property aligned z KM (C) Hose off the aver the septic flank and completely inserted. USl Rt98LpuES - Make sure all solids fall back into the (B) c tank cover Replace WN€N C Fll3 E(2.-< septic tank. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM'SPECIFICATIONS Owner -'e /Gtn 2 ff e Septic Tank Capacity 3-N,-,11 gal ❑ NA Permit # !f t~ ❑ NA Septic Tank Manufacturer j.n~'FN DESIGN PARAMETERS Effluent Filter Manufacturer D / ~oG ❑ NA Number of Bedrooms Y ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) O gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer ❑ NA Soil Application Rate 0,7 al/d /ftz Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cell(s) NA Biochemical Oxygen Demand (BOD5) 530 mg/L R in-Ground (gravityl ❑ in-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ye 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: 13 month(s) (Maximum 3 years) E3 NA 17 0 ear(s) Pump out contents of tank(s) When combined sludge.and scum equals one-third of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA GFyear(s) ❑ NA Clean effluent filter At least once every: ❑ month(s) (#year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) At least once every: ❑ month(s) ❑ NA at_ als and pressure test ❑ year(s) At least once every: ❑ month(s) ❑ NA ❑ year(s) Caner: ❑ 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 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. 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: 0 All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator- 0 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 0,Zj Ccrn@ EName Phone S~ Z 5~7'3Z O-? Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was draftee --=-c rance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page Of ;TART UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting Products Or Other chem"cals 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. kBANDONMENT 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 seated. - • 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 fromexisting 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 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 'OWTS INSTALLER POWTS MAINTAINER Name r rCcj Ccr~G Name Phone Phone S~ Z Y7~ 3Z ;EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone -his document was draf:ez j-m fiance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. ST_ C-ROIX COUNTY SEPTIC TANK MA 2NIBMANCE AGREEMENT AND OWNERSW CERTIMMION FORM Ow71XT, d yer e ivlai)zng Address 12 5 2. - 4 11 r 7_./ Property, Address (Verification r tmred from Platmiag & Zoning Depwtmeof for new construction.) City/State s to Y ley Parcel Identification Number Orb LEGAL DESCRIP ON Property Location Y . dec. Z , 7'1'' 3 N R W Town of f )-o e ~ St=6dzvision _ _ Lerfified Survey Map # Volume , Page # Warranty Deed* Volume .Page # Spec horse yes CII~/ Lot lines ideasifiable ~ no SYSTEM MAIC fENANCE AND OWNER CER'r~[C~TI©1~T Improper use and maintenance of year septic system could result mm pzema r fame to handle wastes. Proper maintenance consists ofpmnpmg out the septic tank every three years or socnaer; ;fneeded, by a licensed pumper. What you put into the system can affect the function of the septic tank as a Utatmeat stage in the waste disposal, system. Owner ice responscbikifites arc specified is §Comm. 83.52(l) and in Chapter 12 - St Croix Comity Sanitary Ordinance. The property owner agrees to submit to St Omix County P launing & Zoning Drpartaaent a certification form, signed by the owner and by a master plumber, jomneyrnan pltmiber, restricted plumber or a licensed pttrnper verifying that (1) the on-site astesvat er disposal system is in proper operating canditiou and/or {2} after inspection and pumping nwemwy), the septic funk is Less than 1/3 full of sIudse_ Uae, the undersigned have read the above req¢tremeals and agree to maiaham, the p sewage disposal system with the ~d W set forth herein. as set by the Departmeut of Cow and the Depmiment: of Vatzual Res vm+ces, Staaz of Wiswnsin. C --lifica oa stating that your septic system has been maintained must be completed and retum,ed to the St. CroiX County Pisarsing & Z-o=--- Department within 30 days of the three year expitation daf_ Llvm certify that all statements on form are true to the best of my/our knowledge. Uwe am/arethe owner(s) of the property descnbed above; by virtue of a deed recorded in Register of Deeds Office. Number of bedrooms ATURE OF APPLICANT(S) DATE '**Any Information that u min gmwented may result m the rani wy pstmtt being rCVoJ=d by ft Plaamg & Zoraug Dq=1m=L _C.e Urim this application a recorded -Waa'aniy deed from the Register of Deeds Office and a copy of the c e tified sarVey map if is made in the warranty deed. 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/' r 1,2 - / 6 `1 /3s ~ //s located atf,C 1/4,w i/4, Section,??- , Town ,?D N, Range /57 W) Town of J5 . ✓`o e eyh , 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 Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000R,* Construction: Prefab Concrete Steel Other Manufacturer (if known): Gtr i rS~'r Age of Tank (if known): T/ ye 4.- Permit number (if known) 6 S y r (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS ice-- (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Forwarded message From: "Ryan Yarrington" <r . arring;t.gr;'-')c ).saint-croix„vAus> Date: Oct 24, 2016 12:38 PM Subject: FW:1252 Rolling Hills Trail To "p arneI!ser7 rry , > Cc: - Looks acceptable for 0.7 Ryan Yarrington St. Croix County Land U=se. Specialist From: Mary Jo Huppert [mailto:' ] Sent: Sunday, October 16, 2016 1:57 PM To: Ryan Yarrington <Ryan.Yarringt ~ rtic ,ca_irtt-cr©x_rrs_, Subject: 1252 Rolling Hills Trail Hi Ryan, hope you had a great time off! Can you review this to let me know if we can continue with the replacement? Thanks, Mary Jo uuN Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T N-R W ADDRESS (3 S';I~T. CROIX COUNTY, WISCONSIN SUBDIVISIONY'C- a ' t % u c ~'i t,°6 LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ICU s 17 icy 'fem. (q-- 'NA sj aa:.J I ) o 1 I ~.I G' r C J ~i A ~ I l8ry'.~' ~ \i i r t 241ao INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used .'1 AV :7/'A lam, .nc5, Elevation of vertical reference point: /e'C C. Proposed slope at site: SEPTIC TANK: Manufacturer: --!I C1 Liquid Capacity: 7C ~cp J r Number of rings used:- Tank manhole cover elevation: Tank Inlet Elevation: _9 (,y jTank Outlet Elevation: c.j~. [l Number of feet from nearest Road: Front,O Side,Q Rear, O ; ~10 feet From nearest property line Front,OSide,ORear,O I y~~ c feet Number of feet from: wellbuilding: y~~ '-i l (1 t a (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE # Wisconsin Department of Safety and Professional Services Division of Industry Services RECEIVED SOIL EVALUATION REPORT Page I of 2 in accordance with SPS 383, Wis. Adm. Code NOV 0210_16 County ST. CROIX Attach completes plan on paper not less than 8 1/2 x 11 inches in size. Plan must in ertical and horizontal reference point (BM), direction and Parcel I- - 030 - 1095 - 90 - 000 Per ,o Sipes, north arrow, and location and distance to nearest road. Please print all information. Re by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). / 7 , Property Owner Property Location JEFFREY H. BRUNETTE Govt. Lot NE 1/4 1/4 S 2 T4110 N R 19 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name o M# 1252 Rolling Hills Trail I V 5, Pg 1359 City State Zip Code Phone Number ity Village ■ Town Nearest Road Hudson, WI 54016 ( 715) 338 - 4882 Rolling Hills Trail © New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD El Replacement ® Public or commercial - Describe: Parent material sitly deposits over sand Flood Plain elevation if applicable N,A ft. General comments Conventional In-ground Trenches 0.7 loading rate and recommendations: Boring conducted to verify soils at replacement area. (PAO a Boring # 1B Boring &T I % ~p ® pit Ground surface elev. ft. Depth to limiting factor >90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDN in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 0-20 7.5YR2.5/2 A 2fsbk mvfr 0.6 0.8 2 20-36 7.5YR4/4 _ A 2fabk mfr 0.6 0.8 3 36-90 7.5YR3/4 - lcos Osg dl 0.7 1.6 I'D l~ 2 Boring # ® Boring F pit Ground surface elev. ft. Depth to limiting factor in- Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 L Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sig CST Number MARY JO HUPPERT Hollistees Soil Testin esign) 224832 Address Date Eval tan Conducted Telephone Number 28497 King Arthur's Court, Danbury, WI 54830 10-14-2016 715-426-1775 SBIM330 (R07/13) J 1 I li . ' f I ZN - : ► 1,4{z• s h / - a o z~> xy~~' ~ `~J : ~o i 4 ( V1 q (cry, 4c~t.I zyrZ„' v L~ ~ N (ter .z 3 ~ ~ ` p', ~ ^ _ ' • j ~ t t I ~ ~ ~ r , wrrr r f S -7 5 I