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HomeMy WebLinkAbout022-1030-80-251 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No 592157 Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 2774183 Permit Holder's Name: Village Township Parcel Tax No Josh Lessen City TOWN OF KINNICKINNIC 022-1030-80-251 CST BM Elev: Insp. BM Elev: IBM Description: Section/Town/Range/Map No: " Z- 11.28.18.166B-16 TANK INFORMATION ELEVATION DAT TYPE MANUFACTURER S CAPACITY STATION BS q `HI FS ELEV. Septic ` O fZ,56 Benchmark I J Qv S r S Dosing ; Alt. BM o z 7~a AofaltrMT _j F' I V Bldg. Sewer Holding [I SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet S Septic ,7Dt Bottom f s. 3 0 Dosing -7~ Head V I Aeration oo~ Dist. Pipe Q Q 7, ~ SS' S Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover L bCr GPM f"r1 Asti- 7•g g7 5 Model Number Ze ` J TDH Lift , n Fricti Loss System Heayt / IT7 Ft 1 i Forcemain Lengt 20- ' Dia. 2/ 1 Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Leng No. Of T 's PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~fJl &MIN SETBACK ISYSTEM TO P/L BLDG WELL LAKE/ REAM LEACHING Manufacturer: INFORMATION Type CHAMBER OR 00 217 1'0' UNIT Model Number: ' 111 DIST ION SYSTEM r Heade Manifold fistripebution s.LX x Hole Size acing z f Ven ;v it Intake Length ength f✓s~ Dia . Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Pe ~JIIJAAII) -a Depth Over Depth Over xx Depth of xx Seeded/Sodded xx ulched Bed/Trench Center v, Bed/Trench Edges ' Topsoil 1 12 A 2 Yes No Yes n No /It COMMENTS: Include code discrepencies persons present, etc.) Inspection #1: /b 3 ) Inspection #2: Loda Ifon' ss Available ^ -r&j 2, ~ ~Li 5 A 'vy a M`` rrL tat,.. Verses 1.) Alt BM Description = F, ~ ~ 2.) Bldg sewer length= t IC. ,Inl , IJ L Q PS - amount of cover = (x10 @ Ib6' (Yom ~►;~i 2'' of fa~~n -b iunlL (rts~ ~s ill" o~ toPI S ?W- ply. Plan revision Required? F] Yes Use other side for additional information. L~11tt- It~ L Date ctor's Si nature [[#P* SBD-6710 (R.3/97) p g TCSafety and Bwldmgs Dlvtston _OCT 12 Z01" 201 W. Washington Ave., P.O. Box 7162 Sanitar}+Permtt Number (to be filled in by Co.) F ' Madison, %A/I 537 7162 ~o S ST CROIX COUNT( 4P COMMUNITY DEVELO M~N~ CF y~ Sanitary Permit Application M~ F.State TransacUonNumber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriazc 6O"V/ 4 291q _ 1 `63 F ^w _ is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS az, ~p Project 'dress (if fferen than mailigg address) the Department of Safety and Professional Servies. Personal information you provide may be used for sc, y yt res han u oses in accordance with the NvacyLaw; S. 15.04(1)( Stats. ul I. Application Information -Please Pr' Il I o r atio P - kL.S Li Property Owner's ame / ~ Farcel # , r1 L6 _2w1 D ~ bzz - !D N,~~- ~jQ Property Owner's Mailing A dress Property Location 5 Z Ce~v V Is,;c~ AS Govt Lot City, SZulu Zip Code Phone Number ` f \/a, AWL '/4, Section N circle one) i rIL~Type of Building (check all that apply) Lot # _--1~- . R E oro CJ 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name On~ Plav~.- Bloek# ❑ Public/Commercial -Describe Use f f 's ❑ City of El State Owned - Describe Use [ilk" CSM Number / i~ ❑,_Vi~llage of / 6ZS 2 Town of 1t 1101 t t~ 1 v~ -dQQ, V,61 27 Ili. Type of Permit: (Check only one ox on line A. Complete line B if applicable) A. ,,a~te~ ~lNew 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 Owner / IV. Type of POWTS System/Com onent/Device: Check all that a I ❑ Non-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 (explain) ❑ Pretreatment Device (explain) V. Dis ersaI/Treatment Area Information: Design Flow (gpd) Design oil Application Rate(gpdsf) _ %riea Re Dispersquired (sf) Dispersal Area Proposed (sf) System E vaWn 6v VI. Tank Info Capacity in I Total # of Manu actur er Gallons Gall ns Units New Tanks 1_ / n Existing Tanks o U y 9V/~11/ JJJ - p 2 c m U y C3 C7 a Septic or Holding Tank 1 Dosing Chamber V11. Responsibility Statement- I, the uadersigne assum sponsibility for installation of the POWTS shown on the attached plans. PI Vs (Print Plu is Si are MP/MPRS Number Business Phone Number Pl(Street ity, State, Zip Code) q~cc\V z VI ounty/De artment Use Gal - pproved tsappro PermityFe~e, Date sued Issui pent Signatur viven Reason for Denial $ 'Cab /a Z 1 IX. Conditi ~+AK@Iasons for Disapproval 3 ~4~ •h 1. Sep a tank, efflue rn all be and filspr :9i cell ll must all b b selvicas r into ;A as Per MOnagenlent plan provided by plumber, I/ 2. Atl se app requiPerIfffft de must be marntr ir:ed / as N+a Left •t~s _ /~o G6 per appiicc~lblg code / _ rd;nanra.;, / w w~ L Attach to complete plans for the system and submit to the County only on paper not ie;s than S r x 11 inches iqs T D~- (/~(~d ©t ` ~ Jam. 1V4.vV~ . t✓A SBD-6398(R 11/11) ~al?'I to 1 a_,- AA 156,f. between structures Page 8 of 8 LNrth P/L Approx. 300 ft. I Sanitary Site Plan For: Joshua Leisen / Edwin Ross Parcel in the SW1/4 - SW1/4 See. 11 T28N-R18W o 25 so Town of Kinuickinnic - St Croix County P/L Graphic Bo&W (rant} 1 inch - 50 tL \ y Existing shop /outbuilding to be renovated to include Xbedroorn quarters. bJ ABM ~ • WELL Wieser Co Gal. \ i, J 1 ank wla Poly_ 't 5 r ~1 Filter W. = 96.64' b C~ A prox 5f from R. 0, W. to rom Cemetery Rd. ILI 0 ~04- Proposed 10. 00 Acres Approx. L4 - Wooded Slope Culvert ~ Proposed 4"PVC Gravity aj Future Two Bedroom Homesite Conveyance Pipe 3 BM#2 = Nail w/Pink Ribbon in 10" \~Q p DBH Green Treat Post Elev. = 91.00' #2 M \ / 15-20' Proposed Wieser Concrete 750 Gal. + Dose Tank Elev. = 87.30' \ Access, from FN# 470 + Cemetery Rd P/L 11% fi P2 \ Proposed 2"Sch. fi Proposed 4 Bedroom At-Grade Mound Dispersal 40 PVC F.M. Area using the 88.00' contour as the System Elev. \ 90.00, Open Field Site 14016 88.00' 86.00' Subdivision ofParcel# 022-1030-80-250 A BM = Bottom of Siding /Top of Starter Strip S.W. Shed Corner \ * HRP =Same Note: > 500ft. to Cemetery Rd 84.00' Proposed P2 CSM Pending ASSUMED ELEV. = 100.00' r RAUUV UMFM i all j i~ ',Pump Specifications ffit; 280 Series 1/2 hp ,Submersible Effluent Pum P LITERS E ~U E 0 50 'cc 150 2,00 250 40 12 10 3 01 qq 4 W W W z Q w 20 Q W Q F H O t _ 11 i DIVISION OF INDUSTRY SERVICES 10541 N RANCH RD u~ ~.r•~ HAYWARD WI 54843-6462 ~i Contact Through Relay a7t ICI http://dsps.wi.gov/programs/industry-services www_wisconsin.gov \ ~FT}SIOti ~~j Scott Walker, Governor Dave Ross, Secretary September 22, 2016 CUST 1D No. 224059 ATTN: POWTS Inspector KEITH E STONER ZONING OFFICE KEITH STONER SOIL TES'T'ING SANITARY DESIGN ST CROIX COUNTY SPIA 23220 WOODCREEK RD 1 101 CARMICHAEL RD SIREN WI 54872-8728 HUDSON WI 54016-7708 CONDITIONAL APPROVAL - PLAN APPROVAL EXPIRES: 09/22/2018 Identification Numbers Transaction ID No. 2774183 SITE: Site ID No. 828613 Joshua Leisen Please refer to both identification numbers, Cemetary Rd above, in all correspondence with the a~enc . Town of Kinnickinnic St Croix County SW1/4, NW1/4, S11, T28N, R18W FOR: Description: At grade, 4 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 1622735 Maintenance required; 600 GPD Flow rate; 39 in Soil minimum depth to limiting factor from original grade; System(s): At-grade Component Manual, Version 2.0, SBD-10854-P (N.03/07, R. 1/12), Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R,. 10/12); Effluent Filter ~ r The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. 'The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06., scats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • In the event this soil absorption system malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described the At Grade Component Manual are complied with. A copy of this information must be given to the owner upon completion of the project. Reminder • The orientation of the at grade system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the at grade per At grade Component Manual. • Surface water drainage shall be diverted away from the system area. • Materials shall conform to the requirements of SPS 384. SPS 384.10. No fixture, appliance, appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, KEFFH E STONER Page 2 9/22/2-16 unless it is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(i). A copy ofthe approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stars 101.12(2), nothing in this review shall relieve the designer of the responsibility ~ , for designing a safe buildin5g, structure or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 "This Amount Will Be Invoiced. When You Receive That Invoice, Please Include a Copy With Your Patricia 1, Shandorf Payment Submittal. POWTS Plan Reviewer, Division of Industry Services WiSMA.R'T code: 7633 (715) 634-7810, Fax: (715) 634-5150 , M - F 8:00 a.m. - 4:45 p.m. pat. shandorf(,wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Cory James Jackson , Jackson Plumbing (Plans Mailed To) KEITH E STONER Page 2 9/22/2'116 unless it is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 38143(8)(i). A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and and others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice, Please Include a Copy With Your Patricia L Shandorf Payment Submittal. POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633 (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Cory James Jackson, Jackson Plumbing (Plans Mailed To) -iFCEIVE CEP 0 8 2016 RESIDENTIAL AT-GRADE DESIGN INDUSTRY SERVI Pressurized - Sloping Site INDEX AND TITLE SHEET Project Joshua Leisen At-Grade Mound Owner Joshua Leisen Address 452 Old Cemetery Rd. Roberts WI 54023 716-307-9816 Legal Description Parcel in the SW1/4-NW1/4 Sec. 11 T28N-R18W Township Kinnickinnic County St. Croix Subdivision Name Lot No. Parcel ID Number 022-1030-80-250 Plan Transaction Number y Index sheet Page 1 Calculations Page 2 ' At-grade drawings Page 3 Laterals and dose tank Page 4 Specifications Page 5 `,t-;~NUNCE Management & contingency plan Page 6 Pump curve & specifications Page 7 Plot Plan Page 8 `~~~UU a utNr~~~ Designer Keith E. Ston %SC /i, License Number Designer# 1575-007 ` Signature K~,, Az__` s Phone Number h - -y . , -1 Date 0 /06/16 D sR ~i%, FS~ . `signed pursuant to: - ill2 ) At-grade Comp ±rr.. 2.0 for POWTS SBD-10854-P (N. 03107, and both SSWMP Publication 9.6 sign of Pressure Distribution Networks for ST -SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-107WP (N. 01101)6\'.1tk, Version 7.0 (03112) Page 1 of 8 PRESSURIZED AT-GRADE DESIGN At-grade Design Worksheet - Sloping Site Flows and Site Data Entry. (r or c) r Residential or commercial? 400.0 Estimated wastewater flow (gpd) 600.0 Design wastewater flow (gpd) 14.00 % Site slope 88.00 Contour elev. below lateral (ft) 39.00 Depth to limiting factor (in) 0.50 In-situ soil application rate (gpd/ft^2) Distribution Cell Information (1 or 2) 1 Influent wastewater quality 10.00 Linear loading rate gpd/ft 10.00 Effective absorption width (ft) 10.00 Max. effective width permitted (ft) 120.00 Aggregate length (ft) Pressure Distribution Data Entry (c or e) c Center or end lateral connection 2 Number of laterals 0.156 Orifice diameter (in) e.g. 0.25 Not a final 2.00 Estimated orificespacing calculation (ft) 2.00 Forcemain diameter (in) 3.29 Forcemain flow velocity (ft/sec) 108.00 Forcemain length (ft) y or n Does forcemain drain back? 80.00 Pump tank elevation (ft) y or n Are laterals at highest point? 4.55 System head (ft) x 1.3 NA 7.83 Vertical lift (ft) 17.6 Forcemain drainback (gal) 2.39 Friction loss (ft) 54.5 5x Lateral void volume (gal) 0.00 In-line Filter Loss (ft) 72.1 Minimum dose volume (gal) 14.77 Total dynamic head (ft) 32.2 System demand (gpm) Lateral Diameter Selection Gallons/inch Calculator (optional) Pipe diameter Design options Design choice Total Tank Capacity (gal) Designer 1 in Total Working Liquid Depth (in) must select 1,25 in Gal/in (enter result in cell G46) one lateral 1.5 in x x diameter 2 in x Treatment Tank Information 3 in x 7501 Septic tank capacity (gal) Wieser Concrete Manufacturer Effluent Filter Information Dose Tank Information Pol -Lok Filter manufacturer 750.4 Dose tank capacity (gal) PL-525 Filter model number 20.3 Dose tank volume (gal/in) Wieser Concrete Manufacturer Project: Joshua Leisen At-Grade Mound Transaction Number: Page 2 of 8 AT-GRADE PLAN VIEW 116 B Observation pipes (2 typical) T D B 120.00 ft 1/6 B 20.00 ft W C 12.00 ft i i D 5.00 ft E 2.00 ft D L 130.00 ft B W 22.00 ft A x B 1200.00 ft^2 L E _ Cap = Total aggregate cell A x B Typical obs. pipe. Slotted in the lower 6", and = Plowed area L x W anchored securely. IM 6" AT-GRADE CROSS SECTION Svnthetic fabric cover 89.79 ft Finished grade Lateral elevation invert elev. 88.50 ft Observation pipe at aggregate toe E _ Surface contour 88,00 ft C A 14 % Slope and system elevation D F = 12 in. topsoil and subsoil plowed over aggregate and tapered to toes. layer 6 in, aggregate below below L x W pipe(s), and 2 in. above pipe. Project: Joshua Leisen At-Grade Mound Transaction Number: Page 3 of 8 PRESSURE DISTRIBUTION AND DOSE TANK Lateral Diagram - Center Connection P IE x-41Ex12 I x1241 Laterals & force main of PVC Sch 40 Last hole drilled next to end cap per SPS Table 3$4.30.6 Hales drilled on the bottom of the lateral. equalfyspaced • = Turn-up wtballvalve orcleanoutplug Lateral Specifications 0.156 Orifice diameter (in) Center Lateral connection mint X 2.00 Orifice spacing (ft) 2 Number laterals 30 Orifices/lateral P 59.00 Lateral length (ft 16.1 Lat. discharge rate (gpm) 1.50 Lateral diameter (m) 2.00 Forcemain diameter (in) 32.2 Sys. discharge rate (gpm) 108.00 Forcemain Length (ft) 14.77 TDH (ft) Typical Pump Chamber Layout Approved manhole cover with Weather-proof waming label and locking device junction box Final grade 4" disconnect _ Tank component is Alternate property vented outlet location 18" min. Electrical as per NEC 300 and Approved SPS 316.300 WAC outlet Tank full joint c Inches Gallons Provide 114° A 23.4 475.3 Alarm on A weep hole or B 2.0 40.6 antisiphon _E C 3.6 72.1 Pump on B device. G D 8.0 162.4 80.67 ft C 11 Totals 37.0 750.4 Pump off D 3" Beddin under tank 80.00 ft Zoeller Pump manufacturer SJE Rhombus Alarm manufacturer 152 Pump model number Tank Alert 1 Alarm model number Project: Joshua Leisen At-Grade Mound Transaction Number: Page 4 of 8 At-grade System Maintenance and Operation SRecifications Service Provider's Name Powers Sanitation Phone 715-246-5738 POWTS Regulator's Name St. Croix County Zoninn I Phone 715-386-4680 System Flow and L20 Paramkt,9!3 Design Flow - Peak 600 gpd Maximum Influent Particle Size 118 in Estimated Flow - Average 400 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 750 gal Maximum TSS 150 mg/L Soil Absorption Component Size 1200.0 ftz Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 efu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once eve 3 ears Effluent Filter Inspect and clean at least once eve 3 ears Pump and Controls Test once eve 3 ears Alarm Should test month! Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Ins ct for ndin and see a e once every 3 rears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, haves and are secured in as shown in the at-grade component manual. 2. Dispersal cell aggregate conforms to SPS 384.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in SPS 384, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The at-grade structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. 6. Areas within 15 feet of the downslope toe will be protected from compaction. 7. All other construction details are as per the at-grade component manual SBD-10854-P (N. 03/07). Lateral Turn-up Detail Finished . • • • • . Grade 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution 88 50 ft Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Joshua Leisen At-Grade Mound Transaction Number: Page 5 of 8 At-grade System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall maintained in accordance with its' component manuals iSBD-10854-P (N, 03107), SSWMP Pub. 9.6 (01181), and Pressure Distribution Component Manual Ver. 2.0 SBD-10706 (N. 01/01)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Selptlc Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the fitter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1 /3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent fitter is installed within the tank it shall be inspected and serviced as necessary. At-gragle and mgure Dl tdo Qn 8vstem No trees or shrubs should be planted on the at-grade. Plantings may be made around the at-grade's perimeter, and the at-grade shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the at-grade is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the at- grade be heavily mulched as protection from freezing. Influent quality into the at-grade system may not exceed 220 mg/L BODS 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BOD5 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition, if the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the at-grade component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced In its' present location by increasing basal area if toe leakage occurs or by renovating the biologically clogged absorption and dispersal media, installing new piping, and replacing other components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: Joshua Leisen At-Grade Mound Transaction Number: Page 6 of 8 156ft. between structures Page 8 of 8 ' LNrth P/L Approx. 300 ft. Sanitary Site Plan For: Joshua Leisen / Edwin Ross Parcel in the SW1/4 - SWl/4 Sec. 11 T28N-R18W a 25 so Town of Kinnickinnic - St. Croix County G-040 SOMW (r"t) P/L i moh - so tL Existing shop/ building to be renovated to include a Xbedroom 'vhtg quarters. ABm • WELL ; C Proposed Wieser Concrete Gal. Y ~ J 1 Septic Tank w/a Poly-Lok 5 Filter Elev. = 96.64' b c Approx. 925 ft. from R. 0. W to Structure from Cemetery Rd. Proposed 10.00 Acres Approx. Wooded Slope Culvert Proposed 4"PVC Gravity Future Two Bedroom Homesite Conveyance Pipe BM#2 = Nail w/Pink Ribbon in 10" DBH Green Treat -Past Elev. = 91.00' #2 M 15-200 Proposed Wieser Concrete 750 Gal. + Dose Tank Elev. = 87.30''- \ Access from FN# 470 Cemetery Rd. P/L 11% P2 \ Proposed 2"Sch Proposed 4 Bedroom At-Grade Mound Dispersal 40 PVC FM. Area using the 88.00' contour as the System Elev. 90.00' Open Field Site ` 14% 88.00' \ `86.00' SubdivfsionofParcel#022-1030-80-250 A BM = Bottom of Siding /Top of Starter Strip S.W. Shed Corner Note: > 500ft. to Cemetery Rd. \ 84.00' ProposedP/L CSM Pending * ARP=Same ASSUMED ELEV. = 100.00' r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mai ddr ss S OLa Property Ad ess ICS' 2tM ' 21 ~t S~~ J, ' . erification required from Planning & Z ring Department for new construction.) City/State Parcel Identification Number d Z2 1030 ` 1~y - 2V LEGAL DESCRIPTION Property Location s , ~I Q Sec. _4L, T ~_N R~_W, Town of - - ~t, t , L Subdivision Plat: , Lot # Certified Survey Map Volume Page # ~eZ Warranty Deed # (before 2007)Volume , Page # Spec house 0 yes 0 no Lot lines identifiable C yes 0 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on th' orm are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a ty deed recorded in Register of Deeds Office. Number of bedrooms 4 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) I I ~ 1 ks" 4 1 wi I V-A-- f rte, f~ II ' ~ s 3f ~ t~ } =s r a a ~---.-•4...w ~ E v ~ _ m S ~,t" ~ ~ `v .s„^'~ I 1 } i SANITARY PERMIT SUBMITTAL CHECKLIST The following list must be completed prior to submittal oFall sanitary permit applications. ❑ A COMPLETED SANITARY PERMIT APPLICATION • LICENSED PLUMBER'5 ORIGINAL SIGNATURE • ATTACH STATE APPROVED PLANS (FOR ALL SYSTEMS REQUIRING DEPARTMENT OF COMMERCE DESIGN APPROVAL, SUCH AS: MOUND SYSTEM, AT-GRADE SYSTEM, IN-GROUND PRESSURE SYSTEM, HOLDING TANK, ATV, AND EXPERIMENTAL SYSTEM) ❑ DETAILED PLOT PLAN • ABSORPTION FIELDS; BOTH PRIMARYAND REPLACEMENTFIELD LOCATIONS • NORTH ARROW, LEGEND AND SCALE/DIMENSIONS • BENCHMARKS: DESCRIPTIONS, ELEVATIONS AND LOCATIONS • ACCURATE LOCATION OF ALL DWELLINGS/BUILDINGS • WELL LOCATION • ANY ADDITIONAL FEATURES THAT MAY AFFECT SETBACKS, SUCH AS: LAKES, RIVERS, EASEMENTS, PROPERTY LINES, CRITICAL SLOPES, ROADS, ETC. MANAGEMENT/CONTINGENCY PLAN ,6'ORIGINALSOIL EVALUATION REPORT dA COMPLETED SEPTIC TANK MAINTENANCE AGREEMENTAND OWNERSHIP CERTIFICATION FORM (SIGNED BY OWNER') ZC PY OF RECORDED WARRANTY DEED (REGISTER OF DEEDS) COPY OF RECORDED CERTIFIED SURVEY MAP, OR COPY OF LOT FROM RECORDED PLAT (REGISTER OF DEEDS) COMPLETE SET OLF HOUSE PLANS (NOT REQUIRED FOR REPLACEMENT SYSTEMS >~APPLICABLE FEES Incomplete applications will not be accepter}, YOUR COOPERATION WILL IMPROVE THE SERVICE WE PROVIDE! i Wisconsin Department of Safet ~ Services ~ ST `~c)I Nvision of'industry Vf- SOIL YZN04BJJ4AZEJ EPORT #3119 Page 1 of 3 in accordance with SPS 385, Wis. Adm. Code Keith Stoner CST NuG Attach complet~e~ _5i N an 8'/2 x 11 inches in size. Plan must County St. Croix include, but nd611m nzontal reference point (BM), direction and _*o percent slo i ensions, north arrow, and location and distance to nearest road. Parcel I.D. G Part of 42-140-80-250 Please print all information. Revie d By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location rcrj u Joshua Leisen (Edwin Rosa) Govt. Lot N 1/4, S11, T28N, R18W Property Owner's Mailing Address Lot # Block # Subd. Name CSM# ` 452 Old Cemetery Rd CSM Pending J~ J t "VN City State Zip Code Phone Number City 'Village Town Nearest Road Roberts WI 54023 715-307-9816 Kinnickinnic Cemetery Rd New Construction Use: f Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: Parent material Loess over loamy till over sandy residium Flood plain elevation, if applicable NA ft. General comments Propose a 6 x 100' mound cell located along the 106.00' contour with a system elevation =106.50'. Upslope mound contour staked and recommendations: onsite *Note -soil test required for subdivision purposes AC Boring 1 Boring # , pit Ground surface elev. 104.90 ft. Depth to limiting factor 32 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 Q 0-9 10YR3/2 - sil 2msbk mvfr cs 3f-m 0.6 0.8 2 9-15 10YR3/4 - sit 2msbk mvfr gs 3f 0.6 0.8 3 15-27 10YR4/4 - sid 2msbk mvfr gs 2f 0.4 0.6 4 27-32 10YR4/4 - sl lmsbk mvfr gs if 0.4 0.7 5 32-35 10YR5/6 c2d10YR6/8 Is Osg ml gs if 0.7 1.6 6 35-71 10YR7/4+5/4 m2d10YR6/8 Ifs/fs Osg ml - - 0.5 1.0 #6 - bedrock residium Boring # I Boring Pit Ground surface elev. 106.90 ft. Depth to limiting factor 50 ~in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 10YR3/2 - sit 2msbk mvfr cs 317-m 0.6 0.8 2 12-21 10YR3/4 - sil 2msbk mvfr gs 2f 0.6 0.8 3 21-32 10YR4/4 - sid 2msbk mvfr gs 2f 0.4 0.6 4 32-48 10YR4/4 - sl if-msbk mvfr gs 2f 0.4 0.7 5 48-50 10YR5/6+7/4 - Ifs Osg ml gs if 0.5 1.0 6 50-72 10YR5/6+7/4 c2d10YR6/8 Ifs Osg ml - - 0.5 1.0 #6 - bedrock residium Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2:= BODS <_30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signature: CST Number Keith Stoner _ 224059 Address Keith Stoner CST ate Evaluation Conducted Telephone Number 23220 Wood Creek Rd Siren, WI 54872 7/28/2016 715-566-0900 SBD-8330 (R07/t3) Property Owner Joshua Leisen Parcel ID # Part of 022-1030-80-250 Page 2 of 3 F3 I Boring / Boring # pit Ground surface elev. 105.20 ft. Depth to limiting factor 38 m. Soil Application Rate Horizon Depth IV Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1A 0-12 1OYR3/2 - sil 2msbk mvfr cs 3f-m 0.6 0.8 2 12-20 10YR3/4 - A 2msbk mvfr gs 2f 0.6 0.8 3 20-38 10YR4/4 - sicl 2msbk mvfr gs 2f 0.4 0.6 4 38-42 10YR4/4 f2d5YR5/8 sicl 2msbk mvfr gs 2f 0.4 0.6 5 42-57 10YR4/4 f2d5YR5/8 sl imsbk mvfr gs if 0.4 0.7 6 57-87 10YR5/6+7/4 c2d10YR6/8 Ifs Osg ml - - 0.5 1.0 #6 - bedrock residium Boring Boring # L Pit Ground surface elev. ft. Depth to limiting factor in. F-1 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 7 Boring Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 n Y `7~j yj f l Effluent #1 = BOD5> 30 < 220 mg/- and TSS >30 <150 mg/- * Effluent #rBrOD < 30 mg/L and TSS <30 mg/L M o y M V] ~ ix prnrn° N O o Q x H r 3 II II Ii, a N M V d = v ~0 ° co V1 a N o W O O II _ N y O~ R w~ a q c 7 c c, ° o ° W r c, ca, 'b ' 7 o m r II A u xc ~ ~ ~ x o o , QC Qn I~ C b 0 U o o ' S8 £9I CL~ 00 U ~C I I x ~ w w~~"C;5 tn ao w p~ N ~ ~ a4 VQ 8 N N I Q x a -13 a g o ~ o _I o h o p0 °~f~ x CZ 0 1 N O i 4 tr o U x O J ? ) N O R 0. N M t C i U V°J JAI }t a v " `y o C S`r Pu & r 3 7 Wisconsin l7epartrri¢rlt W~ ~Q 4vision of industry Se vv r YZN04 BJ J 4 AZE1 #3120 SOIL EVA _-.....nY[CPORT 61 Page 1 of 3, in accordance with SPS 385. W is Adm Code 11.31 16 1446-IF Kekh Stoner CST a s I c o OUNN County Attach complete It ~1c~1M Ehf~n 8%, x 11 inches in size Plan mull St. Croix include, but n I fA1`4a~t~horizontal reference point (BM), direction and parrxl I U. o-'C - J ! r • i percent slo r dimensions. north arrow, and location and distance to nearest road. - g - Part of 02 -1030-80-250 N, d6• IY, Please print all information. Review By Date Personal information yc+. provide may be used fo• saco• dary purposes (Privacy Law, 5 1504 (1) (m);. Property Owner Property Location rei r` o Joshua Leisen (Edwin .Ross) Govt. Lot S 1/4, 114, S11, T28N, R18W '7 J Property Owner's Mailing Address Lot # Block # Subd. Name CSM# 452 Old Cemetery Rd City State Zip Code Phone Number city Village Town Nearest Road Roberts WI 54023 715-307-9816 Kinnickinnic Cemetery Rd New Construction Use. Residential + Number of bedrooms 4 Code derived design flow rate 600 GPO Replacement Public or commercial - Describe. Parent material Loess over loamy till over sandy residium Flood plain elevation if applicable NA g, General comments Pop, ose a 10 x 120' AtlJmde mound wth a system csevation = 88.00'. Upslope mound contour slaked onsite. and recommendations. C~c~Z accpp .7-.4, xl~ ❑ Boring # Boring Pit Ground surface elev. 85.50 tt. Depth to limiting factor 58 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GP_D_/ft_'_ in. Munsell Du. Sz. Con[. Color Gr. Sz. Sh. 'EWtI 'Efl#2 1 Aft 0-11 10YR2/2 - sit 2msbk mvfr cs 3f-m 0.6 0.8 2 11-17 10YR3/3 - sit 2msbk mvfr gs 3f 0.6 0.8 3 17-28 10YR4/4 - sit 2msbk mvfr gs 2f 0.6 0.8 q 28-40 10YR4/4 Sid 2msbk mvfr gs 2f 0.4 0.6 S 40-S8 i 10YR4/4 tt 2msbk mvfr gs if 0.6 1.0 6 58-78 10YR4/4 12d5YR5l8 sl m mfr 0.2 0.6 ❑ Boring # Boring ✓ - - - Pit Ground surface elev 90.00 tt Depth to limiting factor 52 in. Soil Application Ra et Horizon Depth Dominant Color Redox Description Texture Structure Consislen Boundary Roots GPOMV _ in , Munsell Ou. Sz. Cont. Color Gr. Sz. Sh -r tr#+ -Ea#2 1 AT 0-12 10YR2/2 sit 2msbk mvfr Cs 3f-m 0.6 0.8 2 12-20 10YR3/3 sit 2msbk mvfr gs t 3f 0.6 0.8 3 20-35 10YR4/4 Sid 2msbk mvfr gs 2f 0.4 0.6 4 35-52 10YR4/4 sl/Is Imsbk/Osg mvfr gs 2f 0.4 0.7 5 52-55 LOYR414 2d5YR5/8 sl/Is lmsbk/Osg mvfr gs 1f+0.4 0.7 6 SS-70 I0YRS/6 I Bedrock fragmentsIfs/fs Osg ml 0.5 1.0 'Effluent 01 = BOO 5> 30 < 220 mglL and TSS >30 < 150 mgA. • Elfh+enI42 = BOD5 <30 m9A. and TSS 30 mgrL rCy CST Number CST Name lease Print) Signature: Keith Stoner L4 224059 Address Keith Stoner CST -Date Evaluation Conducted Telephone Number 23220 Wood Creek Rd Siren, Wl 50872 712812016 715-566-0900 seD-#]w (IC~P, of Property owner Joshua Lessen Parcel ID # Part of 022-1030-80-250 / Page - 2_ of 3 Boring a Boling # PA Ground surface elev.. _ 85.65- ft. Depth to limning factor 45 in. l-- - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont- Color Gr Sz Sh. 'Ef#t •En#2 1409 10YR2/2 sit 2msbk mvfr 1 cs 3f m 0.6 0.8 2 9-19 j IOYR3/3 sil 2msbk mvfr gs 3f 016 0.8 3 19-28I 10YR4/4 sid 2msbk mvfr gs 2f 0.4 0.6 4 28-37 2f 0.6 1.0 i 10YR414 - sl 2msbk mvfr gs 5 37-45 10YR4/4 Ifs/fs Osg ml gs 1 if 0.5 1.0 f2d5YR5/8 t 6 45-65 10YR8/1 Bedru* tragmen6 Ifs Osg Ml OS L0 F Boring 70 4 Boling # pit Ground sudaco elev. 84.30 ft. Depth to limiting factor 39 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Ef#r - •Er1e2 10-6 1OYR2/2 - sil 2msbk mvfr cs 3f-m 0.6 - 0.8 2 6-10 IOYR313 sil 2msbk mvfr gs 3f 0.6 0.8 3 10-18 10YR2/1+3/3 sit 2msbk mvfr gs I 2f 0.6 0.8 4 18-30 10YR4/4 sicl 2msbk mvfr Qs 2f 0.4 0.6 5 30-39 IOYR4/4 sid 2msbk mvfr gs if 0.4 0.6 6 3949 10YR4/4 C2d5YR5/8 sid 2msbk rnvfr gs if 0.4 0.6 7 49-60 10YR4/4 c2d5YR5/8 sl lmsbk mvfr 0.4 03 Boring Boling # Pit Ground surface elev. ft. Depth to hmitmg factor ,n. - - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence, Boundary Roots GPDAt' in, Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Ef#t 'Ed#2 I. CSI`tf :~.rj~p:; c • Effuent lit = BOOS> 30 <220 mgA. and TSS >30 < 150 mglL ' Effluent #2 = BOOS 30 mglL and TSS < 30 mWL 136 It. between struclunu Page 3 of 3 .North r.q. Approx. inn ft. Soil Test Site Plan For: Joshua Leisen / Edwin Ross Parcel in the SWIM - SW 1/4 Sec. I I T28N-R18W 0 25 50 Town of Kinnickinnic - St. Croix County . PIL Gnyhr 3wM (Mt) tIzich - 50 M Erisling.chop/outbuihling to be- renovated - BM to include a mw bedroom living quarters. • WELL O Septic Tank Location Elev, = 96.64' Approe 925ft. from R Q W to Structure from Cemetery Rd. Proposed 10.00 Acres Approx. Wooded Slope. C uhveri Bbl#2 -Nail w/Pink Ribbon in 10" DBH Green Trcul -Post Elev. = 41.00' #2 Future No Bedroom Humesite BM ! t-20• ~a nn + /lose Tank Location Elev. 87.30 Access fmm FN# 470 h "I Cemetery Rd. \ + ric rli P'L \ x ~ \ Elevation \n Field Site B4 1 l 85.50' Data \ 000\ Sg1.00' B}2 = 90.00' 14% 88.00' W13, = 85.65' t; 86'00 SubdivisiongJPamel#011-1030-80-230 ABM = Rooom of Siding /Top of Starter Strip S.w. Shed Corner \ 84.00' Prnpased Pq. C&N Pending IIRP=Same ASSUMED ELEV. = 100.00' ' = BackhOe Pit July 28th, 2016 Keith E. Stoner CST# 224059