HomeMy WebLinkAbout036-1043-70-010
county: St. Croix
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division INSPECTION REPORT Sanitary Permit No:
592178
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)]. Parcel Tax No:
Permit Holder's Name: City Village Township
Peter Kruschke TOWN OF STANTON 036-1043-80-000
Insp. BMElev: BM Description: Section/Town/Range/Map No:
CST BM Elev:
19. Z 18.31.17.274
TANK INFORMATION G ELEVATION DATA
TYPE CAPACITY STATION BS HI FS ELEV.
S
Septic rT l~![ mm ~rh
$ Benchmark .31 Alt. BM nl^ y O gC'~
Aeration Bldg. ewer * 9.7$ 90 -7
Holding St/Ht Inlet Av, Q I - r
St/Ht Outlet
TANK SETBACK INFORMATION S
TANK TO P/L WELL BLDG. Ven o Air Intake ROAD Dt Inlet
Septic Dt Bottom
Header/Man.
Dosing a.4 vz
Aeration Dist. Pipe a .4 8's.115
Holding Bot. System 13.,S 17. 6`l
a-CA V.0. Final Grade
PUMP/SIPHON INFORMATION Y
Manufacturer Demand St Cover
L G-
GPM
ModelNumbe
TDH ift Friction Loss System Hea TDH Ft
Forcemain a Dist. to welt
SOIL ABSORPTION SYSTEM 11
I'll PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
BED/TRENCH Width I Length / No. Of Trenches
DIMENSIONS 3 ~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur r: r`
CHAMBER OR
INFORMATION
Type Of System: 3 3~ / D C UNIT Model tuber: f if AA
+ Z Z = /01%
DISTRIBUTION SYSTEM OsJ vent to Air I take
x Hole Size x Hole Spacing L
rLenqth eader/Manifold Distribution \ 7a J .S
Pipe(s)
A t_ Did_ Length ` Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ,IX Mulched
Depth Over Depth Over xx Depth of xx Seeded/Sodded
Bed/Trench Center Bed/Trench Edges ` Topsoil `s ~ No s No -r-
Inspection #2: ~1~Ww GS `
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ^ ' - A
Location: No Address Available
1.) Alt BM Description = -T^- 6~_
2.) Bldg sewer length = 1 9,0,,~
- amount of cover = 321 nn nn J O 1 ~'S A~ aaa~~~.~~~►►r~~ 9
a~ V L4 '~3 .7
Plan revision Required? ❑ Yes X'No LIZ ~f,, I
Use other side for additional information. IrInsepeto Signatu Cert. No.
SBD-6710 (R.3/97) Date
r * Nr~ 4- S 1. y. varoLy anu ouuarrlgS UIVtStOn c••
G K, Y~ 1 _ 201 W. Washington Ave., P_O. Box 7162
E Madison, VVI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
nr ,
Sara ctry grin t Applicatl 'l j, Statc Transactio r Number -
In accordance with SP5 383.21(;) cQwh"ission of this form to the app, pr1/
k/, unit
is required prior to obtamXMM 0~V ~ forms for state-owned POW. _ the Department of Safety and Professional Servies. Personal information you Provide may be uses , G9~/jj
Project Address (if different than mailing address)
urposes in accordance with the - P1 Law, ' 15. 1 (m), Stats_ C
L A IicationInformation PleasePrintAll ll anon
-
Property is Name
Parccl
Property Owner's Mailing Address 0 3 ` - /,0yJ - O O - o 6
Ty, n / Property Location
City, State Govt Lot
Zip Code Phone Number ~
Nt' 5`
4 Y4, Section
Yqo.? (0
?/J ' 7 t%^ / (circle one)
II. Type of Building (check alt that apply) Lot # T 6)r ! - N: R Z E or 8f
❑ 1 or 2 Family Dwelling - Number of BedroomsL Subdivision Name
d~ #
El Public/Commercial -Describe Use _ Block
K ❑ City of
❑ State Owned - Describe Use CSM Number El Village of
3 O~ r- n_ "fownof~lG/~ %
III. Type of Permit: (Check onty one box on line A. Complete line B if applicable)
A. New S stem A-0-
Y El 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/Component/Device• Cheek all that apply) -
Non-Pressurized in-Ground 17 Pressurized In-Ground ❑ At-Grad:
❑ Mound > 24 in, ofsuitahle coil Mound <21 in. of suitable soil
❑ Holding Tank El Other Dispersal Component (explain}
❑ Pretreatment Device (cxp i 110
V. Dis mersaUTreat ent Area Information: - - -
Design Flow bpd) Design Soil Application Rate(gPds
Q Dispersal Dis Area Re uire
_ T is
4 f) persal Area Piopusad s System Tlevation V[. Tank tofu paeity m S 1 _ # o- 4760 Manufacturer - -
Gallons Gallons Units
New Tanks -
Existing Tauls n o
cp[i orHoldinr_Tauk _ _ o~ ~5 r`-U Cn
V11. Responsibility Statement- 1, the undersigned, assume responsibility fur installation of the FONTS shown an the attached Plans.
Plumbers Narue (Print) Plumber's Signature
MP/MPRS Number Business Phone Number
q},, 62 27/y 7/ /.~=o?Gp 6G 37
Plumber's Address (Street, City, State, Zip Code)
3,T z- ,o S7 -r.. Ya o -
V if. county/Department Use Only
roved Permit Fee Date Issued Issuing,, Agent Signature - -
~rGivenReason lul Denial ID- [l. Condi t E44JReasonsfor Disapproval -
1. Septta'tank, etfluwnt lifter rnd
tlisper ai cell must all be serJcqts
as per management plan provided by plumber.
2. Ail-MMack regUiW. ants must be matntc lnEd
~*I»r tlitult,r e~. A0 CO n clr i cmS in LU P_ UI -05Z 1 /1 ~
Attach to complete plans for the system and ~ n~to 1hC~n ly on ~ YaPer~to ~ :r 8 112 z 11 in oil m
SBD-639
8 (R. 11/11)
S s
CONVENTIONAL COMPONFNT DESIGN
Resi~lr~nlirrl €II~I~I~i;~°rl~~n
INDEX ANI) 11 I I 1
Page 1 Index and Title T
N,rlr~ ~7, ~ySCl~ /~~P
Page 2,Plot Plan -
Page 3 System Sizi7g,& Cross-Sectinn t )wr I~ ~r'~;
Page 4 Filter Specs N, m w
Page 5 Maintenance Information
( )I(I lI r SS`U CT
Page 6 ManageiuentPlan /\il(ll,••.~, ~
Pagel Septic Tank Maintenance Fong ~
s ~i'o ~~i-c wL
Page 8 CSM or Plat
Attachment: Soil Test
Legal Description: Sl S T 3 NR /7k/
Subdivision: Lot #
Town: 'Jan~o`►
County: S ,Cad/x
Parcel ID# ~03~ /b y3- )y - am6 o30- /Oe/3' RO 0V 6
Designer/Plumber: ,OAy4 is I i,.ense # Z7-1'1'71
Signature: Date:
Comments
I
Designed pursuant to the In-Ground 'Iml AIi-.w phi,ii ! !iliilr(ili,•iil Manual for POWTS Version 2.0
I idu)PITilleConv 2/3/2012
r
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+V ~`a r) pia T S h +f xk a y wI - ,y h y .1.7 r a' r + 'x a r k s ;
!:4~
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~ist.bLtion CeIZ ne Sep6c Tank
d(;$,~c~aic [ Liz t i chambcrsK TfM 5epric Tank Vot , Z1"U f a1.
~`~%astewacer Qu y S pti _ Tank Volume pi.
r 4 I ro _
~Treate~ Q Ua~xr~::red ~ t:farufactvrer
j~. iiaiber.oE Be'drooms Al
k ~ C LIP1L Filter
De itin ' ng Rate (DLR)
(F~faxicru n S~~ A t,umtica R,=) aruF. ~CUrer O/ _ - -
CoLnbsc,~ ac astewater;
r ,W Ntrizrocr of hcdzC~vms P=r, T"L
a?/"da}~/bedroom ' x~;0
t~ian~~~aeoarer
Dom: A,*,a C% w r How pwl~
~ d
yys
2 ~'r yq r 3 2 a : s i5 1" ~ 5 t o i,
~ s!` ~ p: 6~ ~-a Y A <f! x^ I
`°t~rx$y E +U.~°F6y.y~].~k s. -3 "~n4 r{y~'~ x ~
DWftter vaive yes no
ld~y/bCdrUOrn ~~22~ r ~ '
yQ.u ~,~a11}* W35tCW$LC1'~' OW ~ ^ 1 l ~ yr ,a7, < w ~ ~ ` -
k"f3bt IS f .t r T~sf4 ' ! ' l R l~l C4.Gi $ ' _ ` x ' ~ T'"-« ;..,4.--~-,.-~ ~r:~ v
7 r +a tC lvcaa- The us Uf i f1PC CtY valor b~ILtCaC ' i~
' r" '[.'~emir~c~,eat p!rn uw~l c.;uc,~ ~ ow xc~~~~ t~'slrc ~a
y4 'L 4 R4.a+l+bet 0 z05 , 00Ms' SlLAl7 Vlr ~ ,2 i
Jf IN n
ma J~/ t. Q1'Y1 x x GV 1 .r i _ F A k d s' f ~s l 1; f r~~ z z
+ -;dy Was iE&' 1C7aLl tD - t y ~ C,rv,{c~ e of
Distribution Cell Sizing' (flgg-rep ce)
r. ''DtXl~
Distnbution col sizing (leaching chambers)
r lxaah Chamber'
Manufacture
Ivfodel
Adjusted Design Loading Race gpd/ft
~Charnbrrstze;`bottozn"areR o2l1 Et',
~Ii' 61r ystem`siang - DWF / ADLR / Chamber cize
x
£`Cn? .i (Apl,tt) + , ;(sq.fc.) # 'of chnmbcr~ _
r s r~
bcr ofiIP'rs to be used5 r ;a` Pab
',•>~~~'~-ys 4 - ~~f F~4~4'+ ...Y"`~~yr ~ r` gr~~-~~4 l'.,~"* c t~} ~.Yi~~`~"!'i d yc '^.'(,i • ~ a~,c r~ a
k 4.a.
° • e r r E sky -ma`r' '1 r ` t F { XY4 r< a~4 ~"r~~.T ~'3b .i y t',i ID" .°`rJt~..,~ ~'7pt,;.
y e x e, t' +r x r. ~ k ,cr
. w~ "a'}~,r,~^r'?w~~av~ r ~e x x .•e; 4`~'f 'xa~'gi ~.d 4 S':''1' .~.,g". , " b.G.,x ,y ~ ~r:
r e s s w 4 { et r * # N ~ ~.o: ~ 1. fa t2" r't 57 v ,h-
,
e V
1
Soil Absorption System Cross Section
W o
ft
Final Grade
4' Schedule 40
PVC Vent Pipe ft
With Vent Cap
Leaching - ► t
Chamber 9,li y ft
System Elevation
3' ft ft
Soil Absorption System Plan View
ou 8y~
ft
ALE
~ft Leaching Trench 1
Vent Or Observation Pipe r Chambers
IIIIIIII IN 11111111 IN III III 4' Dia.
I Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model y
EISA Rating v2p sq ft per chamber Soil Application Rate ~Z gpd/s.q ft
_Cop _gpd Design Flow ; 7 Soil pp jcation Rate _ -26 EISA = Chambers
2 rows of _ Z Z--_ chambers each.
i
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATIO SYSTEM SPECIFICATIONS
Owner Z,y'O gal ❑ NA
Septic Tank Capacity
armit # Septic Tank Manufacturer'
v 77s` ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer OA d-e
❑ NA
Number of Bedrooms I El NA Effluent Filter Model L z 11 NA
Nlumber of Public Facility Units oj~] NA Pump Tank Capacity gal -,0 NA
Estimated flow (average) ~j gal/day Pump Tank Manufacturer Vel NA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA
_ m'Q ~7
Soil Application Rate
gal/day/ftz Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
i
Fats, Oil & Grease (FOG) _<30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODS) _<30 mg/L ❑ In-Ground (gravity) El In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) !004 cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
'year(s)
1-7 Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3
years) ❑ NA
year(s)
Clean effluent filter At least once every: 3 ,0 month(s) jEl NA
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. ❑ month(s)
At least once every: 13 year(s) ❑ NA
Other:
❑ 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 (Y3) 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 <12 months, small 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.
GMW (4/01)
i 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 or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface. I
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
Dower 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
Jthin 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 wipe's; 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.
,BANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
?roperly 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.
,ONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wJ.
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
<WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name A0411hI-C Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ,S9 2-4 p ~rf
Phone Phone A ,38"6' 4/e re-Ell
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
I Page of
FART UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface. I
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to,the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To 'avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
:,iithin 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 fife of the
POWTS: antibiotics; baby wipe's; 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.
BANDONMENT
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 th-e abandoned-pipe openings sea e - - `
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
ONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
<WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
.DDITIONAL COMMENTS
OWTS INSTALLER POWTS MAINTAINER
Name J/''/J/?jt Name
Phone ~~Jw?G (G 3 7 Phone
EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name 5io/eT !-d 4//1
Phone Phone Jff 4/G re-
his document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Pi jr~~]~-In4 INSTALLATION INSTRUCTIONS
asum°f=`11~ Zabel'
d kM
&w PL-525/PL-625 FILTER
INSTALLATION INSTRUCTIONS
Center filter
with opening {
i.
D t ~ P
iY_Z ,
LL
t
Additional pipe or
Polylok Extend & Lok, Glue '
_ i for centering. t f
- !
Step 1: Step 2:
(A) Locate the outlet of the septic tank. (A) Before installation, place the Step 3:
( )Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (g
is positioned so the filter can be )Insert the filter cartridge in the
housing, making sure the filter
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS Milli'
r_
t .r h
77
Step i : Step 2: 1 = ` -
Locate the outlet of the septic tank. (A Step 3:
) Remove tank cover and pump (A) Insert the filter cartridge back
a if necessary. into the the housing making sure
(B) Pull the filter out of the housing. the filter is properly alighed
(C) Hose of the filter over the septic tank. and completely inserted.
USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover
WHEN CLEANING FILTER septic tank.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 101„ 1,( j•v C ~~P
Mailing Address ~S 0 L,
Property Address 0- Z 1 /560 9,
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number "'T -10y7- 20-00o
4'e i~011-e 036 a, 0 0
LEGAL DESCRIPTION
Property Location ffL~- ,Se- '/4 , Sec. T N R 1,-*2 W, Town of S76y7/d
Subdivision Plat: Lot #
Certified Survey Map # Volume Page #
Warranty Deed # /0 3 (a .2 7 (before 2007)Volume Page #
Spec house U yes a no Lot lines identifiable LJ yes 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 §Comm. 83.52(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 Commerce 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 /w,anty orm are true to the best of my/our knowledge. I/'Vve am/are the owner(s) of the
property described above, by virtue of a deed recorded in Register of Deeds Office.
Nu r f bedr s
SIGNATURE OF APPLICANT(S) DATE
***Anv inl'orination that is misrepresented ma% result in the sanitarN permit being rcvoked b\ 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. 09/07)
OHL, EDWARD
IC & KARE14 K
VOLKERT, LOWELL CRISDHOME CRISDHOME 36103980000
M & KAREN M FARM INC, FARM INC, BOHL, E ERIC
036104250000 036104220000 036104210000 & KAREN
036103970000
NW
NW NE
B HL, EDWARD
E IC & KAREN K
CRISDHOME 610401000
VOLKERT, CRISDHOME FARM INC,
LOWELL M & KAREN M FARM INC, 036104240100
036104280000 036104230000 • 0TH ST U S A, FISH
MINN CHSOF ER, & WILDLIFE
ANDY 036103990000
03 104240 0 STOLTZ, D VID J
18 2151 50TH Tom` KATHLEE C TR
03610399 000
Section 2147 150TF ST
Corner • 7
BISHOP, 21
BROTHERS JULIE L RF~
K LLC, 036104370100 TE NCE
036104290000 n~ 0361 0 00
1
CRISDHOME 2126 150TH ST DERRICK, RICHARD
FARM INC, • L & JOAN M TR
03610438000 036104040000
CRISDHOME
STRUB, JAMES & FARM INC,
VALERIE,JOSEPH & SF 036104370000
036104290001 VV
STRUB, JAMES &
Z 2O VALERIE,JOSEPH &
036104360000
S BRETT DERRICK, RICHARD
BRETT
NEUMANN LLC, L & JOAN M TR
OLSO , NATHAN N NEUMANN LLC, 036104395000 036104050000
M AMY K 036104390000
0 1 435010
432 14 0 _
10TH 21 TH 144 472 WES HOFF,
150
A E 210 H 210TH AVE JEFF RYA
AVE 0 *AVE 0 1 85 03610 5010cP 210 H
- =wA6= 1441 1 /--,Section 210TH A\ /Q
210 LAVE Corner A ection
BEN ETT, JAM S 1443 TAP E,Tv P & orner
L NANC_EE 210TH JACK NZE KRUSCHKE,
~03 104480100 AVE NEUMANN, BJORN 036104420000 PETER C
C & JAMIE M TR 036104790200
NW 036104430000 NE NEUMANN, BJORN
DEWITT LAND 19 C & JAMIE M TR
20
DEVELOPMENT LLC, 036104410000 NW
036104470100
D WITT LAND
DEVELOPMENT LLC,
036104490000 DNR, STATE OF WISCONSIN DNR, STATE OF WISCONSIN -KRU E, DAVID A
Wis. Dept. of Safety and Professional Services SOIL EVALUATION REPORT C-!; t. - Deli, - Page of
Division of Safety and Buildings 4
in accordance with SPS 385, Ws- Adm. Code
County r ~ '
a plan on paper not less than 8 1 /2 x 11 inches in size. Plan must J '
RIECEUt not limited to: vertical and horizontal reference point ( direction and Parcel I.D. v G / d 3 " 70 • O G 6
percent lrtc ale or dimensions, north arrow, and locat T d#ilKan o ne st road. / o a 6 t
v3G - 1 . po
0C Please print all intonnati 7~P h Revie by Date
ali ysnoh you v de may be used for secondary purposes r.. /v V OF~ -
r,.,, 9 ~C
~QM 7-L
v --c Govt. Lot n!G 114 S& 1/4 S r T 3 N R E (or) Iff-
A~c A
Property Owner's Mailing Addres Lot # Block # Subd. Name CSM#
o cT a/
rifir Stat Zip Code Phone Number ❑ City ElVillage [OTown Nearest Road
Sao S
/ah 16,01
New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate GPD
Replacement ❑ Public or commercial- Describe:
Parent material1 .rtro7+C Flood Plain elevation if applicable
General comments
and recommendations:
Boring # El Rnring
❑ 7 //U
2
® Pit Ground surface elev. 9C13 ft. Depth to limiting factor in.
Soil Application Rate
I lorizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
0~ S4 1'~o~ 41
44-44ir 701W
Boring Q
Boring # / ~lZ
® pit Ground surface elev. y' tt. Depth to limiting factor ill.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr- Sz- Sir. ff#1 f[#2
` Effluent #1 = BOD > 30 < 220 mg/L and 5 ,-'l iO mg/L ` Effluent #2 = BOD e < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
0 ~i1 Z Z/ el 71
Address Date Evaluation Conducted Telephone Number
7
3.5 , yd s T 71r/~?l~ «-F
SBD-s_ 30 (1111/1 1;
A
Property Owner / ' 7•{ Parcel ID # Page of
F-71 Boring # goring ® Pit Ground surface elev. ~V 0 ft. Depth to limiting factor ~~/1~ in. -
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2
-:3 4-110 WAllk
r
Boring # E Boring
hnn J Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Hurizuri Depth Dvrninarit Color Redox Description Texture Stnteturp rnnsistence Boundary Roots GPnffi z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2
E-] n Boring
Boring ff
n pit Ground surface elev. ft- Depth to limiting iacloi in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz- Cont. Color Gr. Sz. Sh. * ff#1 ff#2
'Effluent #1 = BOD e > 30 < 220 mg/L and TSS >30 < ISO mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and .Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 605-266-3151 or TTY through Relav,
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