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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 574393 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 Parcel Tax No:
Roscon Properties LLC, c/o Richard Stout Hammond, Town of 018-2011-93-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
30.29.17.1101 i
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f Benchmark 13 7
4; 1/6 7
_ • `3'
Alt. BM
F Zr~lr l~-~~' .7
Aeration ll 1 Bldg. Sewer
Holding D St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION Z_ N TANK TO P/Il, WELL BLDG. /Vent Air Intake ROAD Dt Inlet
Septic n r Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe J5• o l: 16Z _ 37
7 5 1,4 1, 87
Bot. System - /O/. j~
Holding
3 i T-7
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer GPM nd St Cover
Model Num~baF
TDH ift Friction Loss System Head TDH Ft
Forcemain Length . Dia. Dist. to Well
1#
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches PIT DIMENSIONS FCHAMBER Inside Dia. Liquid Depth
DIMENSIONS 3
-Z LA I
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM NG Manufacturer: e, INFORMATION OR
Type Of System: Model Number:
I 5c)
DISTRIBUTION SYSTEM /V,r
Header/Manifold Distribution x Hole Size Hole Spacing Vent to Air Intake
Gr/tSd- cy~y5
Pipe(s) ____1
Dia Spacing
Length Dia Length Ix
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over ix x Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges \ Topsoil Yes No Yes iL No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: y / 3b/ Inspection #2:
Location: 1514 78th Avenue Hammond, WI 54015 (NW 1/4 NW 1/4 30 T29N R17W) Emerald Acres 1st Add Lot 93 Parcel No: 30.29.17.1101i
4-4 A-
1.) Alt BM Description
2.) Bldg sewer length = \ ~ ~r 1 ~ ,Z,ji ~ 1 ~ Gam'
- amount of cover =
Plan revision Required? ~ Yes No
Io I ! %
Use other side for additional information. _
Date Insepctor' Signatur Cert. No.
SBD-6710 (R.3/97)
PROJECT Richard Stout PLOT PLAN
ADDRESS 1353 Awautukee Trail Hudson Wi 54016
NW 114 NW 1/4S 30 /T 29
N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 101.0 100.6 2' below qrade 9/29/14
BEDROOM 3
DATE
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 150
# of chambers EZ Flows
® BENCHMARK V.R.P. Top of 1" pvc pipe
ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
80'
Property Line
20 B.M.* 101' Scale _ 1 /4" _ 10'
B-3 102'
System is to be installed upslope of existing
01 system, which was filled in by gophers
B-2100'
20 B-1
103' Vents 2-3' Z 115' cells with >3' spacing
All piping shall be SDR 30/34, within 10'
of tank, piping shall be Schedule 40.
100'
ST
30'
Existing 3
bedroom house
Property Line CX1`
78th Ave
County
9 Safety and Buildings Division ! fl
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co,)
Madison W1 0 4 71
State Transaction Number
c~ Sanitary Permit Application
l dancc with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
_(*quund prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Prod ject 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. 1 Xm , Stats. r
L Application Information - PleaA Print AI! Inf anon 7C1 j
Prope:ty Owner's Name Parcel # ---y
93 -00o
Property Owner's Mailing Address Property Location
r ~,_t Govt. Lot l1 a l i
City, State Zip Code Phone Number ' _ )
Section
T Z/ N; R~ or W
I_L/~ype of Building (check all that appl ' Lo
;.1 or 2 Family Dwelling -Number of Subdivision Name
oc~r J
Q Public/Commercial - Describe Use VIA -
❑ City of i
❑ State Owned - Describe Use CSM Number O ❑ Village of
Z Town of rt + . ~n t
III. Type of Permit: (Check only one b it on tine A. Complete line B if applicable)
A. ❑ New System ePlacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
I
B- ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New Lis/t~Previous Permit Numbu~a/nd Date sueCd
Before Expiration Owner I/ Previous
Z_g7 ! l ~a J
I
IV. Type of POWTS S stem/Com onent/Device: Check all that apply) Pressurized in-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Q Mound
< 24 in- of suitable soil
tHolding Tank ❑ er Dispersal Component (explain) ❑ retrcatrnent Device (explain) _
saVrrea eat Area Information: ta{~/
w (gpd) Design Soil plication Rate(gp Dispersal Areaequued sf) Dispersal Area Propose sf) System Elevation
Info Capacity in Total # of anufachmrcr
Gallons Gallons Units o
Ivm Tanks
Exuding Tanks C?Ct t5 ~r I/l, c ° d
Septic or Holding Teak
r h~r'~ I A i Mtn)
Dosing Chamber I
VII. Responsibility Statement- 1, the undersigned, assume risibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code
Ale
VIII. ountv/4artmeitt Use On)
pproved permit Fee Date sued ssum- Ag ignanne
ven Reason for Denial 5 -j ~/75-661 DL Couditi as for Disapproval /1. Septic tank, effluent filter and c 11 I ttin, Grs _
3
dispersal cell must all be services / maintained
as per management plan provided by plumber. 1 l.~/ ~Z ~~o ~J~
i 2. All setback requirements must be'smaintained
as per applicable code I ordinances.
Attach to com0 a ptam for the system and submit to the County oniv on paper not Ness than 8 1r x t 1 inches in sire
SBD-6398 (R.. 11/11)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 9/29/14
Owner: Richard Stout
Location: NW1/4 NW 1/4 S30 T29 N,R17 1514 78th Ave Hammond
In-ground absorbtion system (conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. EZ-Flow Cross Se "on
4-5. Maintanance Contingency Plan
6. St.Croix Cou xistin , eptic Tank Form
Signature t
License n /ber #226900
PLOT PLAN
PROJECT Richard Stout ADDRESS 1353 Awautukee Trail Hudson Wi 54016
NW 114 NW 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 101.0 100.6 2' below grade 9/29/14 3
DATE BEDROOM
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1150 # of chambers EZ Flows
BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
80 Property Line
20' B.M.* 101' Scale = 1/4" = 10'
B-3 102'
System is to be installed upslope of existing
01 system, which was filled in by gophers
B-2100'
20 B- I
103' Vents 2-3' Z 115' cells with >3' spacing
All piping shall be SDR 30/34, within 10'
of tank, piping shall be Schedule 40.
100'
ST
30'
Existing 3
bedroom house
Property Line
78th Ave
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS
Owner `
Tank Manufacturer ❑ NA
Permit #.Septic ❑ Dose ❑ Holding Volume:/;. (gal)
DESIGN PARAMETERS Tank Manufacturer: NA
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: } NA Vertical Distance Tank Bottom(s) to Service Pad: (ft)
(ft)
Estimated (average) Flow : T_ (gal/day) Horizontal Distance Tank(s) to Service Pad:
Specific servicing mechanics must be provided if vertical is >15 feet or
Design (peak) Flow = (estimated x 1.5): / iJ (gal day) if horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: (gat/day/W) Effluent Filter Manufacturer: ,yam f? /TU ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model:
Fats, Oil & Grease (FOG) 5_30 mg/- Pump Manufacturer:P1A
Biochemical Oxygen Demand (GODS) s220 mg/L ❑ NA
Total Suspended Solids (TSS) x150 mg/L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer:
(BOD5) >220 mg/L ❑ Mechanical Aeration ❑ Peat Filter ✓ NA
(TSS) >150 mg/L
Pretreated Effluent Monthly average e ❑ Disinfection ❑ Weiland
Y 9 ❑ Sand/Gravel Filter ❑ Other:
(BOD5) 530 mg/L Soil Absorption System
(TSS) 530 mg/L ~,/RA
Fecal Coliform (geometric mean) 5_104 -oin-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Effluent Particle Size X in dia. ❑ NA ❑ At-Grade ❑ Mound
❑ Drip-Line ❑ Other:
Other. NA Other: A
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) When combined sludge and scum equals one-third ('f~) of tank volume
hen the high water alarm is activated
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
~ earls}
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
..year(s)
Clean effluent filter At least once every: [-month(s) ❑ NA
ar(s )
Inspect pump, pump controls & alarm At least once every: [ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) NA
❑ year(s)
other; At least once every: ❑ month(s) NA
❑ year(s)
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
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 a check for any back up or ponding of effluent on the ground surface. The soil
absorption system 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 treatment tank equals one-third ('fj) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 5_12 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW-005 (02/05)
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, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are
detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment
tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat
scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge.
t
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 s. Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems 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 (pumper).
• 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 the time of their permit issuance.
A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
v
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER. /71
' Name
Name n~ rr
Phone Lf"_J Phone
.r -
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHO iTY
Name Name
Phone Phone -
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) $ (3), Wisconsin Administrative Code.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
`('ii i~`, is to certify that 1 have inspected the septic tank presently
,carving the
S , _ //ot
res i ence
l
, ocated
section
upon inspection, T certify that I have ff;i,iid
the tank and baffles to be
in good condition, and it appears to ie
t:unctioriing properly.
-1st time serviced: t . i d f 1. ow back occur.
oin absorption system?
Yes
( no, skip next line)
Approximate volume or length of time:
gallons 1711 nui.,-,;
Cunstruct:ion. Prefab Concrete
Steel other
P1.-11111factur.er:
(If known)
A,je of TanIf known)
Name
( ) Please print
(License Number) t e
~'c.)rlT1 to be completed by licensed
.statutes) or Licensed Disposer (NR 113mbW.isconsin5Administrativ(--
p
Code)
i?lumber (applying for sanitary permit) Certification.
111 accepting the above statement regardinj existing septic tank
c'undition, T certify that the tank to the st of my knowledge will
.
conform to the requi ements of ILHR 83
-r~spection opening er outlet baffle), 1 Adm. Code (except for
i~~~>me Signature
MPJMPRS ~~~~1)
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wi^calsin Deperlmerll v~~ SOIL EVALUATION REPORT Page- f . d a
Division or safety o~
in aa:ordal Moo Cullum B Adrn. Code
144 o l
Altadl complete Platt,Q~•ppp rt hdm 0 1! brdres 1 rung County C
Include, b- it not led to:yddrti~all1nd hortz~on.'~~f refer ne11
e point (B , dh Poluel I.D.
pelcentrrum sca or dImens1e1~1~lt1UF111 wit W' and l xtion and distance to t
a@t rntat/on, R iewed by Date
Personal bformalion pro a used rot secondary purposes (Privacy Lnw, e. 15.04 11) (m)). ` ()S
1 0-7. Properly Owtler Pl operty Localion
GovL Lot N w 114 N W 111 s 30 1 29 N 11 1-7 E (o&
Properly Owners Malling Address Lot # E11otd k # Sulxl. is a CSM11
13t55 f\ v ~e e TY-- o~ dq o-
City Slate Zip Cola Phone Number U City U village w own Nearest Road
-~-On FIJI i-SAWo t5ff - v73 CA(> d_IT
ew Constructiorl Use: esidential I Number of bedruums Code duo ived design flow rate GPD
Replacement ❑ ,Public or commercial - Describe:
Parent maletJel _ _U - Flood Plain elevation if apfrlicabfro R.
Genial commends
and recommendations:
.ef e ✓r /UO. -7-L7
Boring # Boring
_ It. Depth to 1111111111!J factor in.
® Pit Ground swface elev. 10--'),2b
_ Soil Application Rate
Horizon Dopun Dominant Colo Redox Description Texture Shuclure Cunsistence Boundary Roods GPDAF _
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. '01111 'Etf#2
- L$-3
Z 5;I
z f 1 5(d 2,Y)nbK 4r c - L4 ~p
3 sb 18 5L 2rr,5rk '1~r _ C s - (o . Z) -38 a
Boling # Boring u
❑ Pit Ground surface elev. -0-'Z_QC It. Depth to limiting factor
Sol Application Rate '
Horizon DepU1 Doninant Color Redox Description Texture Strucluie Consistence Boundary flouts GPD1fF e~.
In. Munsell Qu. Sz. Crud. Color _ Gr. Sr-. Sh. TIM TIM
Z l0
Yrn Z 51r Z nb _►Y7_ . C
Z ►2 2- ilcL Zm4k-
5L Zr r_ c5 _ o
4 f Z 1~,,-, _ gal- -
Ellldrent M1 BOD > 3U 220 nxg/L and TSS >30 < 150 my/L ' Effluent #2 = BOU < 30 mglL and TSS < 30 mg/L
CST Naum (Please Print) Sigma CST Number
Hnm~~h~frr~l 25 -
Address Date Evaluation Conducted Ielepho o Number
v
Properly Owner _NQ1 Parcel ID It ~d
❑ Boring rfaceelel~ ~ Il Irr Sol A r >IipUon Rate
Boring # Pit GIOUnd suv. d it. Uepur l04nhGng factor -
GPDffF
Roots
Texture 3r. Szure Consistence Boundary •E1U►1 •E(1#2
Horizon DepUr Dorninanl Color Redox Desuitplioll G
in. MrnrseA Qu. Sz. Cont. Color r. Sz. 5h. _
~ ~ _ 5,~ I nor c ~ • 5
_ 2rk rr _
2 2 Id.
❑ Boring
LJ Boring # ft. Depth to IirniGny factor
El Sul A ficatlurr Rale
U pit Ground surface elev.
liorizorr DepUr Dominant Color Redox Description Texture structure Consistence Boundary Roots •f ll#GPDf1FEl(#2
in. Munsell ()u. Sz. Cont. Color Gr. Sz. Sh. -
I
❑ Boring _
Boring # It. Depth to limiting taclur in.
El Pit Ground surface elev. i Sol Application Rate
Horizon DepUr Domhtent Color Redox DescrtpGon lexture Structure Consistence Boundary Roofs •E1f#GPDR E(f#Z
in. Munsell Qu. Sz. C_L Color Gr. Sz. Sh.
- -
I -
I -
• Effluent #1 =1301)s> 30 < 220 [nglL and TSS >30 5150 mg1L ' Elltuenl #'L = BOD5 < 30 nrglL and 1 SS < 30 mglL
I
The Mpartment of Commerce is an equal opportunity service provider and cugrloycr. If you aced assistance to access services or
need material in a[r altemale fom[al, please contact the depa[t[ncnt at 608-266-3151 or Tl*Y 609-264-8777.
sno-a>orrr.orrom
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