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Home My WebLink About008-1034-20-000 WiscominD?Oartmentof Coininerce PRIVATE SEWAGE SYSTEM County Croix Safeiir anr. Building Division INSPECTION REPORT Sanitary Permit No 506203 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 Solum, Grace Eau Galle, Town of 008-1034-20-000 CST BM Elev. Insp. BM Elev: BM Description: Section,/Town/Range/Map No 12.28.16.174E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. I Septic Benchmark Dosing Alt. BM I ;Aeration Bldg. Sewer I !r! iHolding St/Ht Inlet fII SUHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet t I Septic Dt Bottom i Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System I Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM IMlodel Numbe; TDH Lift Friction Loss System Head T 7H Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No- Of Trenches PIT DIMENSIONS No Of Pits Inside Dia j_i,,;Uid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR Type Of System: UNIT Model Number DISTRIBUTION SYSTEM Header/Manifold D ti ibufion x Hole Size 7pacind Vona to Air Intake Fix f Length Dia _ ~Lr nyth- _ pia 5paang_ [ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded rMulc7ied Bed/Trench Center Bed/Trench Edges Topsoil Yes No es J o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_ / Inspection #2: Location: 2623 50th Avenue Woodville, WI 54028 (NW 1/4 NW 1/4 12 T28N R16W) metes & bounds Lot Parcel No: 12.28.16.174E 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = a; Plan revision Required? Yes No Use other side for additional information. Date Insepctor's Signoturo Cr?n. No SBD-6710 (R.3/97) . -P! AN": .QT..... !K&d~ e J b' YC G~ r.;.. Y (F . ,If F - -54 I~ .CIS I t~ S 1 i.. !II `i . 4 s~ ~ t J..... ..I d v+~ . ► , ~l?~ ~e d:. ,c- u~l~ ....r . : i, : - .i.... . =c .E...._... Slay l u ~E r . y..._:/r.. [lam r` a : a " v . i 13 I. . - 3..i ..1,,- p1m 6t R tx~ 1~ + y L F,~ t` . i n ~U U, F: D u9 ►1P~i"S lAt'Q larence Glotfelty Enviro-Tech Systems & Services C26--1- ~n A 4 ~nr-r 1 ~ ~ N4955 Suimy Hill Road 5A/0 7 Weyerhaeuser, WI 54895 tE / C SYSTEM SPECIFICATIONS In-ground Soil Absorption Component Component Manual Project Name:. So l ld m w ~S Distribution Cell Type Septic Tank Aggregate ❑ Leaching chambers(C] Min. Septic Tank Vol. Req. ~pQ gal. Septic Tank Volume ~ gal-,,06V Number of Bedrooms ~ Manufacturer L i I Soil A licatlon Rate (DLR) gpd/ftZ ; , } (Designed Loading Rate) y t e.'U) Effluent Filter Manufacturer t Wastewater Quality Model Cpl Treated ❑ Untreated V] Combined wastewater: Pump Tank Manufacturer Number of bedrooms Volume x 150 ~ Model Daily Wastewater Flow (DWF) Distribution Component Clear and graywater only: Distribution Box ❑ Number of bedrooms ~ - Hydro-sputter ❑ x 90 gal/day/bedroom Other Daily Wastewater Flow (DWF) _ 2-2D Manufacturer Blackwater Number of bedrooms gal/day/bedroom x Daily. Wastewater Flow (DWF) _ IgC) Dispersal Area (A te) ft2 (DWG (P Dispersal Area (leachinv;chambers) C Leaching Chamber ~ 3 ~ t "-,k" Q-r- Cha3 te'5r size, EISA Rating 2: _fe System sizing = DWF _ DLR _ EISA -hambers PWF) PLR) (EISA) Diverter valve Ares no Manufacture C~t11t7?~ fCE?:1Nf.tJV - Safety acid BuildinLs Division County 201 W. Washington Ave., P.O. Box 7162 Madison, WI 7-7162' ISCOnsin t Department of Camrnerce Sanitary Permit Number (to be filled in by Co.) 3 Sanitary Permit Applieatio State Transact ion umber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the ap riatel' e tai unit is required prior to obtaining a sanitary permit. Note: Application forms for state -o ed P Pro -rent to the Department of Commerce. Personal information you rovide may be use r secondary ject Address if than mailing address) ur oses in accordance with the Privac Law, s. 15.04(1 (in , Stats. L A licationInformation - PleasePrintAllInformation Property Owner's Name fJ)~~~ Parcel # i ice. Property Owner's mailing Address MAY 2 4 2100 3 a~ z Property Location / p !h ; ~~~J ST. CROIX COUNTY J~ City, State Govt. Lot 7 Zip Code ~ Y GV<, Section 1 21 circle one IL Type of Building (check all that apply) Lot# T ~3 N; R Eor Wi ❑ I or 2FamilyDwelling -Number of Bedrooms Subdivision Name Block # ❑ K 1t~ ~ Public/Conuneroiel - Describe Use ❑ E--ity~f ❑ State Owned -Describe Use ~l Ck CSM Number ❑ Vitfage of xTown Of_ L "LA ( w III. Type of Permit: (Check only one box on line A. Complete line its if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration IV/ Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply) •1 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade _ r ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) V. Dis ersal/Tt'eatment Area Information: ~ Pretreatment Device (explain) Design Flow (gpd) Design Soil Application Rate ds O ! ' (gP f) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation i 13 VI. Tank Info Capacity in Total # of Gallons Manufacturer Gallons Units ~ c New Tanks Existing Tanks WSy~~ ° y m v U / o t: a m Septic r-Hsldis~mk_ ~fy w U n v k a Dosing chamber VII. 12esponsibility Statement- I, the undersigned, assume responsibilit 1b, installation the POW'tS s i the attached plans. Plumber's Name (Pricy Nino P ib Signatue ' I'R-' umber Business Phone Number Plumber's Address (Su eet, laity, State, ip Code) ~S Gl d\ V\ 1 d 6A- AIA -5 Vg 5 c VIII. ount /De artmen Use Only Approved El Disapproved Permit Fee .iv Date Issued Iss ' g Agent S nat I ❑ Owner Given Reason for Denial ~ y o7 $ GGI~,~s`~ lv~i ~0 ~•>~re~provaUReasons for Disapproval Septic tank, effluent filter and dispersal cell must all be serviced / maintained t9~4. E~ G as per management plan provided by plumber. / ~A. _ /y , 7l/ A 2. All setback requirements must be maintained lI JJ lXX 7 ~f ~y~, udG ry f/e~I.lans for the system and submit to the Comity only on paper of less than 8 1 x ches itsiz ll 6 8 0 X07) V`ati uu o 0C~, YViscAnsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page of3__ in accordance with Comm 85 s. Adm. Code Attach complete site plan on paper not less than S 112 x 11 inches ins P must County` 4 include, but not limited to: vertical and horizontal reference point percent slope, scale or dimensions, north arrow, and location and dis, dice to an 't road. Panel I.D. p Please print all information. ~ ®a ~ ` Re 7bq Personal information you provide may be used for second Date ~-y ~E-GB V -f D aw, s. 15. Mm Property Owner S V ! iy P operty Location f0w,~- ' d u MAY 2 4 ZUU/ /u /1/4 A S T p Property Owner's Mailing AddressO N R 0 I jN Lit # Block # Sufxi. Name or CSM# Ve I ST. CROIX COUNT' ''City State Zip Code P lJ~ G~ V ity Village Town Nearest Road (~1J) viS'~o (r6 ft =,i Q vt New Construction UsejZ Residential / Number of bedrooms Replacemen Code derived design flow rate GPD Public or m rcial - D pri : Pare ~ - L-~._- C. fain elevation if applicable 0 meets/.~l~ou , `t ~/7?vl ry ft. and recommend ations: } 7 5 r tI' srt,C ,=his se / iy ~y rlL~~: zuvlt S f~j : nj;~~ 74 hC w 5i Z j 0'-f-9-4- 4;k SG.,n r j-~~/ t Q~d~~s.~ +~~1 /{lf "r 1S M[?I't. ^~`yf t~ loc:a S ~w S 5 re~w~. _ ~ (Le rn e c r ~K-~' ~~h'~ ~~rii'1en-f ~S .~ur7•d.c~~1 :h urI ur"~'t'~ J ccr ° Boring / dralhi'~Sa"i~Sc Boring # Pit Ground surface elev. ft Depth to limiting factor > 0_ in. Horizon Depth Dominant Color Redox Description Texture Soil Application Rate 1 in. Munsell Structure Consistence Boundary Roots GPDfftz - Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'EMAQ v ~r ~ ~ . L3 ;SV SL j -il5 7 5 U - ? 10 ti h ~a \ S 1 Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil licafF in. Munsell Qu. Sz. Cont Color ry GPDfft Gr. Sz. Sh. 'Eff#1 'Eff#2 1 e rr 511 L S s£ . ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/ #2,= E CST .Na (Please Print) - D< < 30 mg/L and TSS < 30 mg/l. ~ r 09 M " -CST Number Addressu~ { Date val -on 06 ' coed • Telephone Number (OOILOV r"210CR-GELS 'LLL8-V9Z-809 KU jo 1Si£-99Z-809 le lu=4rodop agl;oeluoo oseaid `;euuo3 a;eu-ra;pa uz uc [eP1UW paau so saoinias ssauoe o; 33mis!ssr paau no! 3I -joAotduca pue .taptnoid ooTnsas 41tunlloddo ienba ue si a:)1aulLUO:) jo luaurlledoG aq,i, -w OE > SSl pue -116w OE > gC108 = Z# iuanW-3 a ll6w OS L > OE< SSl PLO -1/6W OZZ > OE < '(109 = L# luanL43 u! yS •zs jo Joloo luoJ zS -nc) I19sunv4 Z#113. LAO. aJnixal uogd!nsaa xopa~! Joloo lueu!wod yldao uozuoH zwodJ Nepunog aoua;s!suo~ a~n rulS alerd uo. eogd I!oS ui Joffe; 6uq!unl o; 44d ll - nala aoe}jns punoJ~ lid 6uuo D # 8 a0 6uuog 11 /l _ . - o ~ YI ~ w ~ .J t r t r~L r LIS •zS Jolo~ ~uo'J 'zS nD IlasunW u! Z#1~3. L#dl3= slooLi 1Uepunog aoua;s!suon aJnlorulS einlxel uogduosaa xopaa Jolao lueu!wop L4da0 uozuoH r3lJadJ elmd uogeo! IloS w Jopul 6u4!w!l o; yldaa -^a}a eowns punaie lid 6uuog PJ 6uuog D # II II 14 Z 6? -b l I.u hs w 2. p ~h~ S`L „01, •4S •zS -JS Jolo~ .lug .zS .n~ IfasunW v! Z#43. L#43. aJn;xal uogduosaa xopa2! Jo!o~;ueu!woa 4ldaa uozuoH 2W(IdO sloo-8 tiepunog aoua;s!suoo aJnlon, lid a;e~l uoBeoIi IIoS Jo "UJ!I of yldaa .4 nale aoelins punoJS -ui Tn ll° 6uuog 6uuog QI IaoJed f4jedwd ~ -lo ~ abed U RLAMI, J AVE . , R o/I , a II J .i ~l F , bL.. d . t~ 1J d I~ (C . . 7 =,~r If i . 1 I - - - 1 I' I( I _ - < _ _ i _ emu- E K - - . C inf. - - j 13 _ 1 ~c f: br.. y r - - Lk, fig c-~ . _ a.. . . o 1. P I ti 1 +t~ _ i Y N~ : . i ^uon 1~S larence Glotfelty Bnviro-Tech Systems & Services O 2Q ~Ye 4 ~nr~~ , N4955 Sunny Hill Road - Weyerhaeuser,M 54895 • 1 i- p_. _.Q T` 11 x L~1 - s J~ - i 131 L.. G r i + 1,. is Vh~u:. ►d Ip ~i!> _ 41 Y1~~,ltLVl E_ . 4- C c" Slo i a rG"' . I~A t , 3 y jFf.. ( fez n I 1........... ►h ~yy CtC la. u Zt~ F . UU V IAIA ou9n2..~'s t larence Glotfelty C~~~s r Enviro-Tech Systems & Services Q , N4955 Sunny Hill Road Weyerhaeuser, WI 54895 Eau L4 )L ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have in,pected the septic tank presently serving the ` 00d4 Z& residence located at: 1/4, '/4, Section /Z ; Town~N, Range l b W, Town of kW Li C7-7?!~ LL& 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 service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner r Mailing Address AV M '~Tr r i Property Address (Verification required from Planning Department for new construction) 101 CL ~ ► City/State c>Lc .y I 2 ~ ' Parcel Identification NumberOaf-1634--z6-6Z LEGAL DESCRIPTION .V,, I Property Location Town of L-0 i, / . Sec. rc T2LN-R Subdivision Lot # Certified Survey Map Volume Page Warranty Deed # 1~q (97 (-7 Volume q q . Page # f 3) Spec house ❑ yes no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE 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, The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal 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 Commerca 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 Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this 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 warranty deed recorded in Register of Deeds Office. A~' _ - ~L t 11S, / G 7 - SIGNATURE OF APPLICANT DATE Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Za N~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page f of '2- FILE, INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capaci IrQ~ ❑ NA gal Permit # Septic Tank Manufacturer ❑ NA 10!o ~'oei!lo DESIGN PARAMETERS Effluent Filter Manufacturer & ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units NA Pump Tank Capacity gal A Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) Pump Manufacturer gal/day ❑ NA Soil Application Rate gal/day/ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) _<150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispers ell(s)G2=. N CAA ' Biochemical Oxygen Demand (BODS) 530 mg/L h Ground (gravity) ❑ lln!-Gr4Cnd (pressurized) Total Suspended Solids (TSS) 530 mg/L NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510° 100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size %8 in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: 11 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: ❑ month(s) (Maximum 3 years) ❑ NA 17 a-Vear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (%3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: r ? ❑ month(s) (Maximum 3 years) ❑ NA / ~yasar s) Clean effluent filter S At least once every: onth(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) Other: ❑ year(s) At least once every: ❑ month(s) ❑ NA Other: ❑ year(s) ❑ 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 (%3) 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 y' For new construction, prior to use of the POWTS check treatment tank(s) for the presence of 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. painting products or other chemicals 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 purnp tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 1 The site has not been evaluated to identify a suitable replacement area. Upon failure of the 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 Phone a Name i3z, r' I J Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone ~ r (_,.1.~'i' X ~ v~► Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Admimsuative Code. I , Cross Section of a Two Cell Inground Component Using Leaching Chambers ObservationNent Pipes Finished Grade = ~L Finished Grade = l_ft.Cell Slope % < Seperation~ ! O Ongmal Grade _oJ~ - . riginal Grade=/ 3 r_ Top of Chamber (=(;~~7 yj Top of Chamber = MIS -t j System Elev. _ System Elev. ° TreatmenUnd Dtspersal Zone 3 6 Limiting Factorj(p .U' ObservationNent pipes to be constucted and capped with approved materials for the particular use. Not to scale ,El & 7-AAK MS MQU N ~ - V Vin f o V e f' ul/ /~i roc ~j k q'I ~tYarn;o/~ b yc~i=_m~~F GROUND LEVEL Approved ~8---24° asigh N , Approved IJacei Gasket 1'~~hc Gasices S Symte-, Nervy= rsdiens of 1 fL1t1 Sewer Lateral ST~1.CD~;•/ftr per ft'. ~Gradicnt of sewer Lateral BAFFLr- bF APiT-WVEID - s / f r • P1ATLI~IAL S 1 I : LC, ' O1V JI, 5 13;10.1;, ILL fiATLRIAL To SAtJD ~ ~ ~ l J c D ;P~L1 S ~f~'` 'l r~ar~a~nt- I Parcel 008-1034-20-000 05/24/2007 04:14 PM PAGE 1 OF 1 Alt. Parcel 12.28.16.174E Current X 008 -TOWN OF EAU GALLE ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner GRACE I SOLUM O - SOLUM, GRACE 1 2623 50TH AVE WOODVILLE WI 54028 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description * 2623 50TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 6.000 Plat: N/A-NOT AVAILABLE SEC 12 T28N R16W PART NW NW; COM NW COR Block/Condo Bldg: THEROF, TH E 80 RDS, S 25 RDS, W 28 RDS, NWLY 53 RIDS TO PT 11 1/2 RDS S OF POB N Tract(s): (Sec-Twn-Rng 40 1/4 160 114) POB EXC P174B & C 12-28N-16W ate Doc # Vol/Page Type Notes: 1077/23/19977 arcel History: 8/28/2000 628932 1538/99 TI 7/23/1997 995/411 TI 954/534 03/05/1993 495717 995/414 WD 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/12/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 27,000 93,200 120,200 NO AGRICULTURAL G4 4.000 500 0 500 NO Totals for 2007: General Property 6.000 27,500 93,200 120,700 Woodland 0.000 0 0 Totals for 2006: General Property 6.000 27,500 93,200 120,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 513 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 VOL 1538PAGE1ft ST CROIX COUNTY TOWN OF EAU GALLE 08/28/2000 1999 REAL ESTATE TAX SUMMARY 8 - 1034-20-000 12-28N-16W Parcel 12.28.16.174E CARL M & GRACE I SOLUM CARL PROPERTY ADDRESS = 2623 SOTH 2623 50TH AVE AVE SEC 12 T28N R16W PART n7 2623 LLE COM NW COR THEROF, T W NW; WI 54028 RDS, S 25 RDS, W 28 RDS, 80 VOL/PAGE NWLY 53 RDS TO PT 11 1/2 RDS 995 / 414 995 / 411 954/ 534 S OF POB N POB EXC P174B & C / Dist-School: 231- #1 1700 - #2 - #3 6.000 Acres Assessed Land: 8500 Improve: Ratio: 0.6203 Fair Market: 77500 Gross Tax Other Credits Lottery Net Tax After Credits 1571.36 - 128.61 - 157.95 = 1284.80 Bill 20446 AMT DUE AMT PAID BALANCE Tax Balance Codes S 1442.75 1442.75 pecial Assmnt 138.00 138.00 0.00 N D=Delingent Special Chrg 0.00 - P=Postponed Delingent Chrg 0.00 N Private Forest N=No Balance 0.00 - Woodland Tax 0.00 N Payments Source Managed Forest 0.00 Interest 0.00 - nter y L=Lottery I 0.00 M=Municipality 0.00 C=County TOTALS 1580.75 R=Redemption 1580.75 0.00 Interest is Calculated for August 2000 Lottery Claims: 1 Amount: 157.95 Note: P O S T E D P A Y M E N T S Date Receipt Source Tax Bal Special Wood Interest Penalty Total 0 L 157.95 D 01/31/2000 23058 C 0.00 0.00 0.00 01/28/2000 37018 C 563.43 P 138.00 0.00 0.00 157.95 721.37 N 0.00 0.00 0.00 0.00 701.43 0.00 0.00 721.37 E N D 0 F R E P 0 R T**** ~lj U O _ a re SS . (~/~q. Y~ 2/S y L) V\ 1W 70 NO' °1 7A-n cy rji ~ Sf`~e~ Inn e J V'\ A 1 LO K&t-lf `0% POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: ~yIckL~ ❑ NA Permit # ASeptic Dose ❑ Holding G/ olume: (gal) Tank Manufacturer: @tCY'~ ❑ NA DESIGN PARAMETERS -(gal) Number of Bedrooms: El NA JZ Septic El Dose [I Holding Volume: Number of Public Facility Units: NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Horizontal Distance Tank(s) to Service Pad: NA (ft) Estimated (average) Flow : , (gallday) Provide specific servicing mechanics if vertical is >15 feet or if (gal/day) horizontal is >150 feet. Design (peak) Flow = (estimated x 1.5): L In Situ Soil Application Rate: a (gal/day/ft) Effluent Filter Manufacturer: 5y rnTC-C-Vk ❑ NA - - - Standard (Domestic) Influent/Effluent onthly average,- Effluent Filter Model: Fats, Oil & Grease (FOG) Pump Manufacturer: ANA Biochemical Oxygen Demand (BOD5) :5 50 mg/L ❑ NA Pump Model: Total Suspended Solids (TSS) mg High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: NA (BOD5) >220 mg/L NA ❑ Mechanical Aeration ❑ Peat Filter (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODO !cK mg/L Soil Absorption System f` A µ o e (TSS) s30 mg/L NA In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA Fecal Coliform (geometric mean) _510.4__- ❑ At-Grade ❑ Mound Ys in di ❑ NA ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size i NA NA Other: Other: MAINTENANCE SCHEDULE Service Event Service Frequency hen combined sludge and scum equals one-third (Y3) of tank volume Pump out contents of tank(s) ❑ When the high water alarm is activated ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: year(s) ❑ month(s) (Maximum 3 years)) ❑ NA Inspect dispersal cell(s) At least once every: year(s) ❑ month(s) ❑ NA Clean effluent filter At least once every: year(s) ❑ month(s) ~ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ~ NA Flush laterals and pressure test At least once every: ❑ year(s) ❑ month(s) NA Other: At least once every: ❑ year(s) NA Other: MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certificationesf Master Tank Sewer; OWTS de tiffy any mss ngnor bro kenghardwa eng ideOpntify any (cracks or leaks, nspec on of Ot etank(s) totor; er; Plumber; M must Plclude a Rvisual estrict surface The round inspections effl measure the volume be visually inspected to dchscum and a check for any eck the effluent levels in the observation pipes and oucheck for any pond ng o effluent dispersal cell(s) shall 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. the tank ume Operator and disposed of one-thirdaccordance(X) or NR11 3, Wisconsin , the When the combined accumulation removed bydaeSeand scum in any ptage treatment tank equals contents of the tank shall 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 <_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 (02104) 0 N O 0 _1 O d c d O fD c 3 m (D m ~ y h. K D. C CD d m A _ (D ( 1 ~ ~ A7 0< M N Z O 0 O O (7 m N O G c l• ~ `G N 0 O O C~~111 =r N c O c N 90 A w w o (n fl rn Q= 3 CD uro o 3 O co p N N j N C fD p W O W m N A N W C N m A O 1 N N N N N N N O- 7 j 'Z IIJ O O O O O O O-u 0 ro O J O O A W W N N O CD N m O K 7 3 y w ] O C d CCD W O v (n D a cn _ o A 0o w O cn (O ro a A N ~ -u Z5 N N N ro Co < J w W N A C a- p= O O G N N N N N N 3 O i ~ O O O O O O(D Z zz A C Cl O (D (D Co 0 N N ro CD 0 C) 0 r- N (D O O O C 4 < G O_ O O CO roCC G < 3 (n (n cn A (D m v o v o (D ro (A CO 9 v (D m = ro U 2) 1 N O 7 Q y N ro D p o O O cn D ~j H • ro (D N W N ro O) N n N C 3 ro N d (D _ 3 cr 7 N (D ~ y o A Z CD A Z O CL C 7 co N < N N < 00 p Z p _ A Z71 0 ~ Z Q) N (D 'O A W N n ro D 3 0 a ro EA p - N O ~ N p> C O - O z O. N O (D G N o (p Q y O 7 O ~ A .i C) C O 33 ` C O C O d N O ti O N ro dq ti 69 C O O 14 O ro ^1 O O. ti CRD~x COUN ST PLA1 NNG & 7 ONNG NOTICE OF VIOLATION May 2, 2007 GRACE SOLUM 2623 50TH AVE WOODVILLE, WI 54028 (-ode Administb-ation RE: Failing POWTS at 2623 50th Ave. 715-3S6-4680 Land Information 6- Town of Eau Galle- St. Croix County, WI Planning Computer # 008-1034-20-000 Parcel # 12.28.16.174E 715-3S6-4674 Dear Mrs. Solum: Real Property As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in 715-386-4677 violation of § 254.59(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code. arc Article 12.1.F.4.d of the St. Croix County Zoning Ordinance. This Private Onsite Wastewate- Recycling Treatment System (POWTS) has failed under the definition in § 145.245(4)(b) Wisconsin Statutes 715-3So-467 (Category 1)_ This violation was first noted on May 2, 2007. The violation nas been documented as septic effluent discharging to a zone of saturation. An on-site inspection conducted May 2 2007 verified that septic effluent was discharging to zones of saturation, and to the ground surface. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed from May 2, 2007 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING POWTS ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS Alva NEEDS PROMPT ATTENTION! REQUIRED ACTION: A sanitary permit must be issued through this office. You have already contracted with a certified soil tester (Clarence Glotfelty) to have a soil evaluation conducted. The soil evaluation determines the type of on-site wastewater treatment system necessary, the required sizing, and its location. You must then contract with a licensed plumber who will design the replacement POWTS and apply for the sanitary permit. The POWTS must be replaced by February 1, 2008. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. Your cooperation in abating this violation is appreciated. Sincerely, Rya Yam gton Zoning 1-echnician cc: file -.Cr7C;:\ COUNP GOI'LRNME-NTCL-NTER J i CARM;, --JAEL ROAD, HUDSON. VVl 540 % 6 Commerce.wi.gov - ~seonsin Owners Wisconsin Fund - Private Onsite Wastewater Department of Commerce Application Safety and Buildings Division Treatment System Replacement or Rehabilitation Instructions For Property Owners: Financial Assistance Program You may apply for a grant award for up to three years after you have received a determination of failure and after you have obtained a sanitary TO BE COMPLETED BY COMMERCE this form, attach evidence of y Part A of located. , our annual income explained in Section #7 items to the sanitation or health department office in the county where the property and return those PART A. TO is BE COMPLETED Owner' BY THE PROPERTY OWNER r„ Owner Please print. s Owner Owner Owner Owner Address xr. r City State, Zip Code Telephone Number 'Grant awards will be issued in the name and address of his L 5 owner. t ) owners. 1. Is this application for a principal residence or a small commercial establishment? th re are additional owners, attach documentation listing all (Complete both if applicable.) Principal Residence Small Commercia If applying as a principal residence, do you occu h Establishment If applying as a small commercial establishment, do YOU own and of the year? commercial establishment? y the small Yes No NA If applying as a small commercial establishment, what is the name of the small commercial establishment? Yes No NA Description of Small Commercial Establishment (farm, restaurant, etc.): 3. Has there been a change in ownership of the principal residence or small commercial establishment served by the failing system within the last three years? If es, lease ex lain: Yes No 4. As the owner, are you a licensed plumber or contractor engaged in the business of installing private onsite wastewater treatment systems? 5. Willa portion of the replacement system be funded by another program? Yes N If es, ex lain: Yes Nei 6. How did you/hear about the Wisconsin Fund-Private Onsite Wastewater Treatment System Re lacem P ent or Rehabilitation Program? 7. Evidence of income. If you are applying as a principal residence, attach a co prior to the determination of failure. If you were married and filed separate forms, you must also include your same year. You must include evidence of income for each owner and for each owner's spouse. e If federal iyou ncome tax return for the year of or commercial establishment, submit a copy of your federal profit and loss form for the year of or prior to the order spouse's determination return for the If you or any owner listed above did not file an income tax return, contact your governmental unit for further applying as a small or determination e failure. income will be ke t on file at the ovemmental unit and is subject to verification b the De artment unit f of rt Commerce. Property Owner's Certification. I certify that, to the best of m er instructions. Evidence of form and all attachments are true and correct. Y knowledge and belief, the information I have provided on this Owner's Signature Date Signed Co-Owner's Signature Date Signed PI P 67 sonal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). 5t3D-9163 (R. 02/2005) _PART B. TO BE COMPLETED BY THE GOVERNMENTAL UNIT 1. VERIFICATION OF OWNERSHIP On the document used to verify ownership, do the names match those on Part A of this application? If no, please attach additional documentation explaining. Yes No If the applicant answered yes to question 3 on Part A of this application, did the applicant(s) own the property when the order or verification of failure was issued or the system installed Yes No and incur the cost of replacement? Document or Page Document used to verify ownership: d~ Number: z1 7 7 2. Is a public sewer available to this property? Yes No 3. Has a previous grant been awarded for this property under this program? Yes No 4. Principal Residence evidence of income- Please indicate applicable annual family income: 2__6 ~ $ 9 - Federal income tax form 164b, Line 3_ , Year 2600 OR Affidavit of Year Small Commercial Establishment evidence of income. Please indicate applicable annual gross revenue: $ Profit & loss form used: m J- Line Year 5. Date of the Order or Determination of Failure: I' I 2' °7 When was the existing failin system installed? Prior to 12-1-1969 12-1-1969 to 7-1-1978 ~/io~~v P Vertical di tance from the bo om of the existing infiltrative surfaceto a limiting condition: 0 to Less than 24" 24 to Less than 36" Equal to or greater than 36" Private onsite wastewater treatme _syst b discharge of sewage to (check all that apply): ter or roundwater Category 1 A zone of saturation n i e or ne of bedrock Category 2 The surface of the ground Category 3 Back-up of sewage into the structure served ade 7. This request is for what type of replacement system: Conventional If this request is for a system not listed at the right, please explain: Experimental Holding Tank In-ground Pressure Mound 8. Uniform Sanitary Permit Number c J 0 Date Issued 5 b -7 Plan Approval Number Npr Date Approved Experiment Approval Number Date Approved 9. After reviewing this application, I have determined the applicant to be: Eligible Ineligible If ineligible, reason ineligible: Governmental Unit Representative's Certification. I certify that I have reviewed and verified all information provided on this attachments and that the are true and correct to the best of m knowledge and belief. gnatuZofthoyrized Govern/ment/al Unit e esentative Title D Ih q1 0 ate Signed d Caapaci continued G. Installation of a Replacement ExteriorRGrease Inerlcep o`r byD a on TABLES Y Gallons: Up to 1,249 1,250-1,499 1,500-1,749 1,750-1,999 2,000 or more Grant Amount: $550 $650 $750 $800 $900 $ H. Installation of an Experimental System. Amount Requested If you are requesting funding for an experimental system, please submit a copy of the Wisconsin Fund For Installation: pre-approval letter along with a copy of the plan approval letter and experimental approval letter $ containing corresponding identification numbers. Amount Requested List the total cost of the experimental system and monitoring that is being requested separately at the $ or Monitoring: Fin ht. Copies of aid invoices must be submitted with this request. Installations not Covered by the Grant Funding Tables. e Department on a case-by-case basis reviews installations not covered by the Grant Funding bles. If you are requesting funding for an installation not covered by the grant funding tables or listed Sections A-H, please explain your request here, attach a copy of the paid invoice showing the cost of the item, and request 60% of the cost of the installation at the right. TOTAL PART 1. Z,Z L~ PART 2. GRANT AMOUNT CALCULATIONS A Enter the total from Part 1. z Zt} B. Is the applicant a licensed plumber or contractor who installs private onsite wastewater treatment systems? If yes, enter 213 of the amount from section A or $4,667, whichever amount is less. If the a licant is not a licensed installer, --ffy the amount forward from Section A. $ Z~Z o d C. If this application is for a small commercial establishment and the annual gross income of the business that owns the small commercial establishment is less than $362,500, this is the total grant award. Carry the amount in Section B forward to section F. Y If this application is for a principal residence and the annual family income of the owner(s) is _ less than $32,001, this is the total grant award. Carry the amount in Section B forward to section F. Z Z C)b If this application is for a principal residence and the annual family income of the owner(s) is , between $32,001 and $44,999, list the amount in Section B here and go on to section D. ff this application is for an experimental system, carry the amount in Section B forward to section F. $ D. Enter 30% of the amount by which the applicants annual family income exceeds $32,000. Annual Family Income Subtract -$32.000 Subtotal X .30 = $ E. Subtract section D from section C. This is the maximum grant amount for this applicant. Carry this amount forward to section F. (The amount in sections E & F must be at least $100 to be eligible for any grant award. If the amount calculated is less than $100, enter $0.00 in section F. F. Total grant award requested for this applicant u to the maximum of $7,000. Z 2