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HomeMy WebLinkAbout020-1149-20-000 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: 592170 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No Waters Edge Construction TOWN OF HUDSON- 1 020-1419-20-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 20.29.19.2660 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid 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 Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(sLength) Dia Spacing Length Dia _ I _ i i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes n No Yes ❑ :No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 857 CHEBEK LN 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑ No L - Use other side for additional information. J IL SBD-6710 Date InsePctor's Signature (R.3/97) Cert. No. r 1 - - _ itf t f it Serxx cs ill l~li)ti l_(1t!I7i',- i 41'ashln2ton Ne _ Sr, Q OCT 26 zo ~ C~ 1 O. Boy ]62 1 Ja ,liar. Pcrm!t umbe. ?to hr ailed in by Cn t $ Vitt3t-Son. 111 5311)7 162 G ST. CROIX COUN14 - I Z ~b V ransacnon \yynt,er anlt~ry er~nz ~ppl icat~ ~ D NX1 ! In the Dena Deaaaccorrtment da:?c:: SPS 3S3.21(2) 11,s. Adm C'odt, ~uf;nusslon o'this +or o PKXpR~ _ i is r d lent to obtalninc :3 san;tar: pc rta,t Note. application, inrn?s to, 5v,:~ ojec dt,ras E 3;ti ren• tilan era hii addressl of Sa(c + and Professional Services personal information you pre porno es accordance ++it1 the Pre i + l S 1 04(1 )(n -y Stars / ~i~ESEr ~^J 1. Application information - Please Print ;ill Information ir1 95-7 Propene ON:ner s Name rrc! 4),4 reel s _Z 4!a Js;-4&4 oa~v1111s Jl/LuE6EiZ Q 3 V I~' I _ t,~ ov Property ONiner's NIailinc Address Propcrl~ 1 cation . _ a(V t _1. / ~e 7I Govt. Lot Citr_ State iP Cede Phone tiumber NC Scion .24 / / I 1 Le/ ~/S 7~0 --C? 76(circle one) 29. N. 9 iio(o Ii. Ttipe of Building {check all that apph) Lot << l or 2 l anvil, Dncliin" Nurnher of Bedroom, Subdivision Narne t Bloc 0 Public/Commercial - Describe Use r CSM Number G+ e w, State t}wnea - l~e'cnbc Use - - - - - t.J a ~S l<,,•.r t,: Vase Z- h:ti I CI1 - lil. TN pe of Permit: (Cheers only o box on line A. Complete line B if applicable; a ,tit... ZG' New System Replacement Svsieni ~ Treannc u'Ho1dinzTank Reptacement Ontti' Other Modification to r isttn, 5vsiem fexnlaln' - r List Previous Permit Aumher and Daic issued B. ❑ Penmt Rene+,al Permit 12e+ision ❑ Chansc of Plumber Permit 'I ranstc to he++ t h rer Before 1-:\p1ral loll i - i V. T~ pc of POt!' i S Si sten]A omponentCDevice: (Check all that :xpph) \on-Pr[ssurize(I In-Ground U Pressanrca In-Ground At Gradc t0ound > 24 in- ofsuitable soil ❑ Aiuund < , of suna is soil Holding lank 0dicr Dispersal Component (espUn)_______ L Pretreatment DI:% ice (explain) V Dispers if rear ent Area Information: 7 si-n Floc t ~pu; Dc ran Soil Application Ratct~ ~l) D;spersal Area R' tred (sl) Disiacrsal 1re.! oi? .,c fs;l S+sicrt? ElcN at loll q V1. Tank info { Capacttr : Drat ?a\4,., _t;i:cturcr i ~ - (,a(lvns GHIIrnis Units Kc+r "rm,ks 1 1:\istin tanks 1 ~S~pnc or ]gl1t. l doe ~ ---/ESE'~ L'oNCa~rE ~ v I t7, *inaChamber t i pQ N ✓ 1 f N11. Responsibilitti' Statement- 1, the undersil ned, assume responsibility for installation of the POWTS shot n on the attached plans. Hen's _ Pitirnfic; s \anti't_,Prirt) at c 4iP, S Vumber Business Phone Ntumber _ t 3 $14 G 72 -S.?L 4 Plurnber s Address (Street, CirF State, Zip C - - /V 6 98 <Sr. Yj aS !~/uQ,~~D 1.111 SY73L VI V. Count-/Department Use Onl - - P m?i. .e pate cur JC iI ssuin_ n: Si_naturc E, j a ~SS~ °b /I S _ r ;:«fn E rentat 3 . IX. Contbtiax#WWW <itiom f'etr i)lsapproca! -1_4i : 3) Ar ',dWOerwai cell mast A b acF Ices / nijntair± as per nw..algement plan provided by plumber. 2. A' selketgtlirementsmustbemaintzfined ~w ej ss per ictAble code / ordinances . f 4 I 11 mehcs in sire a its .s o a o 'A s L ` 1 r'~ " 0 V Q Q 1!y ~i 1 a a v 41 c V y ~2 3 M o 3 ~C n Z a a :aj K Q~ny I ~ n ~ v 144 O e tiu v v ~e ~ ,v y NZ x k Z ~J 2 vi vt Feli j G: u+!1 %E.f S G 1116 0 tlsrt r/un1 - J' -!✓~t. /n/L~tD4J4 facJT5 a/~ulwy ~yRnd~2 JtV f }s Nam. f,-: _ /1 II Glo - `AiYES ~~lZtt~6~2 ~vs~t F ~ SLJ, WE dcr~ V t of /7tJPSo ,l u~~t;: Sr. Cnolx » bey GG 3loCkNumber: 'arreI T. D. N ,miber: A07 /s1V °~r~fl.SS -J it'r~.a1 •r'/taaj t:i t age -5 fay,~4 a-Ge c C Zd l R =tee Qi e-simmer: To, i w Ar., c=urs(ll ± jumber: /lP- X7313 YG --signed Dm-s+.?,-t to he olio ; POW-ES omuonewtManual and N PS K-851: Co- o- I,~~ or? Ser..0) S-? 0705-1/0Il V O `R ~ r ~ 0.ti a 'Q h a 'Y U4 r a ~M Q e, ti ~v a ~ a~ ~o " h r M v 11 N O `Ken) V M 4 y3YD' o ~ oV)j r. ~ is t ~ R Q W a V h C~ o J L.° t o v ~ ~2 y a s O ~ 4 M mU o ®t4 Q a v M 1\ Shy ~ ~ V J °,C 'ji n. Q e rt* ,R W ~ ~ V v 0 tl @ ~ ~ n~ IV) v `R h Q Lt I ~ t W V s1 s v 14J Q V h to n R V c 1t CQ' L~ p t t It. 44 - - + o a W v .e v ~V yv vl xk t..,0#AuI;\In! IO4:? SEPTIC TAd\`:itjt-'UMtr' vi s;'-MBC~ .X-S=Ci PRAWNG NOT FU SMEE) M WE iSER L?M\!1R Fli~lfii vi~~iQC 3 H.25' t {u)} r D. r _ (slope ground suzac away ron J manhole(s) for proper drairtage) tennis 1 cs :12CwSE s~dlaing 3ursu~r: BPS X83.-3;~~'g i as n= 3UTINC SERE= a, cap r iwer PS $2.30 ii) j 7`1C4 ?na i•:ieni o:= I f ELECT RlCri • / f 4 _ JUhIC+tQ~•! BQ_. \ 1 t??ri>i;t ':'"=c~eo ~ye,;trl~i _ EWE ~ f 1 F•-'-' - r - - i I t.. -i~tcD;i~il=i:IC~!~\\FiS ~c GCS i t 1 j } :t IIIL-t? xb i Uij {°i r -14 MANHOLE f n, W. L '_;_i~_: 3tJirGL•.flFiidl~lia:_,»'_rL'ea ~ i j^!_~ .1; „hea:.__ j:-j Z7 'r-10 ARMI • -~i`~.-.~. (+.:~tec:2terl_:~tj---- ~ j:.~ / f/gJJ~vfrlJ/f/J/IJ/i/iriri• L~Jr//yrJr~r~l•-~i' =-L EJr ~ ~ ~ ~/IJJJJJIlJ1.f/.~/J/J/11//J1JIJ11G.'~yi/J//~ ~Jlr~ : . 1' l i~ r { J rrrrlsfi/!.!/rlliLi ...Ji i ifi~ r(ir> i ~f i j FLOAT L re 00 o; raP~i APPROVED E.F, LUENT17 HJER - - Er-' UEitr, j^L ):.i PEWIREDCt•`OURE- a. _ iii#l~##(villii~# OF 3' 0? SUf r;SL BEDDING 3cMF i 7 TANK RMP RD i I anti i'J'lanufacturer La//E SE it 4'-o.;G,4Erc DYVF {daily wastewaie flov so 2i-PD 1 Septic/Pump iartlt model /aoO /bop Number of daily doses 17y /8. 7%9 (MAIF / actual dose volume) islairi inanuiaci;ira -5 J. E' .&0 rr/s u s i OrCciilc:rr volume x . /G 3 l Alarm model number My< f zr4r t _ 8 2 1 ,e of Waiswitch ys%wWW/--AL Aciual dose volume (gaNora), 9116 I hotel dose volume -volume of iorcemain) g~..2 - 8.2 = 8 Y. p 1 ~OEL1 E/L E flueni cuing nanuiaciuier, -=Bent pimp medal nut~iber Is/ FUiviF T:-Ai„K CAPACITIES . ,1o.S sno~tGs = 3y3.G gaiioi~s Y~..~nil•c aLO~!c cfarC? i r.,J nfmum pump dlsrharge sate (G''t;/i) Alarm, float above on Bloat 2 niches = 330- gahans Q) Gn(0<<i#flat measu rent S. S inches = 9J•z ailons (6? -Gal lift (pump oil io distdbuiion iaieral) /o j- Off 1oai abode tank bonorrr 8.0 inoiles = 13Y.1 gallons (h) ' r --,stem head (disial pressure f _3 feet) _ i T ON UM Et 154S PU1A? CH A-:i6_R S P _C 1: U i ORS " .,iioil loss in the Torcemain So x, al = S !i 5' io ITS VYidi~ QT H) p #on $ _ ~uf ,Chit{ G " ~ ( . ~ ~E: lllCli 7G PUMP PERFORMANCE CURVE TOTAL DYNAMIC HEADfFLO4V /4 y aFL PER MINUTE MODEL 151!152.'153 EFFLUENT AND DEWATERING MODEL 151 152 153 Fee Meters Gai. Liters Ga. L ors Ga~. Liters _ - - - - 5 1 50 189 au I 261 7 191 .c ( '5 170 1 ct 41 ',t j , a ~ ..b f44 , od 1. r 5 L y-.D5 ,5 I 20 G.i 29 1'0 44 167 52 197 - - 25 7.6 1E. 61 114 129 42 j '-59 a,• 23 87 33 125 35 0.7 - 22 85 f l 12,2 1 <Z Shut-oh Head 3r) (9 Im 38 fl. 111.6m) 44 Pt (13 4m) { 0745088 _ Model 151 Models 1521153 to zu so A.) en - _ J Ord ZCO 24J 26C 3611 M 3 . %b ~t i~ T _ . Flectrical alternators, for duplex systems, are available and supplied with an alarm. Variable level control switches are available for controlling 1 single phase systems. - Double piggyback variable level float switches are available = - - for variable level long and short cycle controls. _ Sealed Owik-Box available for outdoor installations. See H11 .142"7 t t s_ i==4F SK2,:4.1 SK2064 1511521153 MODELS Control Seleci on i Mode! Volts Ph --Mode Amps Simplex Duplex t L I N 57 1115 _ Non 60 1 La 3- ( '7 11~1 1 Auto G.0 Included 2 or 3 1 Non 3.2 1 2 or 3 la, 23C I BF151 23 1 Auto 32 Included 2or3 Easy assembly" i N152 115 Edon 8-5 1 2 or 3 - ~ ~ pump & discharge pipe BN oc_ t15 Auto 85 Included 2or3 a nO,rNUr,W.i h,J2 230 Non _ 4,3 2or3 152 230 Auto 43 Inc:,idcru ` 2 or 3 - 1 ffi~ I 153 135 1 Non G.5 2 or 3 1 BN153 115 _ Auto 10.5 inc.uded 2 ors 1 l j - { 1. Single piggyback variabie level float sti tch or doutie piggyback variable ieve ' switch. Refer to FN10477. Reduces potential clogging by debris. Float Replaces rocks or bricks under the pump. I 2. See K10712 for correct model of Electrical Alternator E-Pak. Made of durable, noncorrosive ABS. 3. Var abie!edei control Switch 14-f1743 used as a control activator. specify duplex Raises pump 2" off bottom of basin. i31 or (4 float system. Provides the ability to raise intake by adding sections of or 2" PVC piping. cAUT+orl Attaches securely to pump. Accommodates sump, dewatering and effluent applications. NOTE Make sure float is free from obstruction. For unusual condiuons a reser1Ye fac,tcr i' ~r ~alC- r~ i is .i;8 des,sq o ever, J;er tc~ Copyru nl A!; rights r , .u'. SPEGlF1GAT10i15 FILE ii~1F0 titrtTli~' SYSTEM Owner 4),q I-,-/t S DOLE ~on1 ST'~uc rte 1 j Tank Manufacturer: 4Jlh7 C]" Nr f Permit = # 21S /060 (gal} ! I eptic ❑ Dose Lr1-lolding '+rofume: r DESIGN PARIMMETERS Tank Manufacturer: Gel/rsex iF NA y( Number or Bedrooms: 3 N.= C Septic 9lose ❑ Folding Volume: SOD (get) I Number of Public Faciliiv Units: N A, Vertical Distancs Tank Bottom(s) io Service Pad: /o' (if--,) f l nce TartlCtS) to Service Pad: /OD' (ii} Hprizpntai Qts a estimated (average) Flow : ~oCi (aa!tda;r) - '~--t 3I SDeciilc enticing mechanics must be provided U, vertical is >?5 tell or > na $QQCltIC InSiNCtlDriS tQ he pro~~idec en oac3c- 1 ! Design (dead) P1DV, = tc''Stlmotcd . 1.51: ySD (e elfdaV) nerizcni2l is iSUt',._l- k Cs i - NIA , !r. Situ Soil Application rate: . 7 (gattdallii`) y Effluent Filter tvlanuacturer: r ! I _J Standard (Domestic) l uenfin iueni IJtorthiyateraa= ; iEffluent Filter Model: GF-/4 i tic) Ir- Fats, Oil L Grease (FCGi <_30 maL } Pump ivianu -cturer OELG -C2 Nr=i Biczhemicat Oxygen Demand (SOD,) <_220 mg/L Ll f`1A - Total Suspended Solids MSS) <i50 mgiL Pump Model: , gh S rengin Influent/E1Ezauent ivioni'nly average { t Pretreatment Unit { OG? >~0 matt Thanufacturer: WD=_} >220 mntL NA i i~r:echsnica! Aeration T-7 Peal F=ilter _ T SS° 50 rncD(L L Dishtfeciion ] '1: etlond treated e iuen? iJon`hE; average j 0, SendlGravei Filter ❑ O+.'ner ieOD,) <_30 ma1L i, SoF Absorption System m'ean TSS) 530 malL ❑ NA 1 ceL-! S10- 9j ta-Ground (gra~r.-- i (n-Ground (pressureI i 1 NA ' ~ SIIlitar (geometric ,:Grade Mound 1:1 1 Maximum 71 At-Grade -~,uent particle o SI_a in die. 'L NA i L7 Dries Line Other- f CJSE /n/`1 L 3'R4 tea Qu~ut y G.0 , G NAry,66~ S T ENAMCE SCHEDULE Service Event Service Frequency np ou: conteni7 of tank{s'+ } Y `,,`hen combined sludge and scum equals one-third (;-1) of ±ank volume itihan the high vfater alarm is activated ! - 1 month{s} (Riaximum 3 years) J ivy aspect condition of tank(s) 1 At least once ever": 3 :0 year s) _ [s months; ❑Na I ^Sp=Ct dispersal cell(s) j Ai least once every: s t] Year(s) (Maximum 3 years) ` I. EE month(s) ti lean eiuentniier ; Alleast once everrv: ,wars) 13 _ F~j month(s) ❑ NIA. illsoect pump, pump -controls & ai rm ! At leas, once every- .3 ear(s) -=lush laterais and pressure test i-At ieast once every: i ,,earls} ❑ month(s) ❑ iv Other: AL least once every: j year(s) ' ;Alill ENANCE INSTRUCTIONS -spections of tanks and soil absupki-i svstems shall be made by an individual carrying One or tine ioilawing licenses or certrlcatlor+~. ..,._.ster Plumber: last- Plumber Restricted Seller, PCtl+d-5 inspector, PUWTS Mi intainer or Septage Servicing Operator (pump_~;. -:h Inspections must include a visual inspection of the tank(s) to identify any massing or broken h2rdware, identify cry cracks of It a„ ,,.-,sure the volume of combined sludge and scum and a check for any back up or ponding of er,"iuent on the around surface. The sr:; "s-orrution system shall be visually inspected to check the eit}uent levels in the observation pipes and to check for any ponding of efilue ,t ire ground furnace. The ponding of ertuent an the around surace may indicate a =ailing condition. and requires the immedicic =;c2hon of the local regulatory author= or more w the tank volume, the er =n the combined acc'umulaiiOn pT sludge and SCum in any ireatmcni tank equals one-third } -tents of the tank shalt be remOVeG by a Sept2ge Servicing Operator (pumper) and disposed of in accordant°_ With chapter NR 11 " 5consin Administrative Cade. - - m v, Oilier services, including but not limited to ?lye serAcing of eiluen_idters, mechanical or pre= ' <i, 2 rfi0n hs, =hall be D55t,0 sled by a cerlified PONE T 5 Maintaine". - r i erv2is Di Page In of 7 START UP AND OPERATION For new construction, prior to use of the POWf S 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. r 4 During power outages pum„, tanks may tiff above normal highwa#er 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 FOUNTS 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 otheRvise 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 SPS 383.33; 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. a 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 POVVTS 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 andtor soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POVVTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POV%,TS 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 POVv.TS. CI 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 ANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name ~/oNJ ~E[KE 3t3S'G Name ail., in"EG,eE 6jCEG.eE Phone i G Phone 7/s_ G d- 6"5? 71S 472 -SaGL SEPTAGE SERVICING OPERATOR (PUMPER) - ? LOCAL REGULATORY AUTHORITY Namei Name Phone Phone 71f 3g(- 4/4 b'O This document is intended to meet the minimum requirements of ch. SPS 383.22(2)(b)(1)(d)&(0 and 383.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWl S. Rev.(3113) ail LU v*" o e 4%,": - v O V) 2 s c r e ~ t~ ~ ct p y S c Gl rte" c y v (a Ea e - V a. w O J v r ~ V e, O L r v ^ - r. rp O ~ ~ O y ii Rj - --7 c ,vi G - O v _ C G O r' O n d w - - r - o c in v± J:G y o 0 ^ p Q n .•i 4.1 za, V V J V y V\ 41 .J 2 O - J. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND NOV 7 OWNERSHIP CERTIFICATION FORM) o r I l7~-[~~aUN Owner/Buyer PA,. Mailing Addres( c~ A r W{ Su S Z C U Property Addre C (Verification required from Planning & Zoning Department for new con ction.) City/State - S O,k Parcel Identification Number LEGAL DESCRIPTION ` I{ Property Location 1/4 , 1/4 , Sec. , T N R W, Town of Subdivision Plat:-,\ Lot # Certified Survey Map Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house\C yes ❑ no Lot lines identifiablevyes ❑ 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 wi/ty s of the three year expiration date. I/we certify that all statements on re true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a wd recorded in Registe r of Deeds Office. t Number of bedrooms 1 r CrI4ATURE OF APPLICANT(S) DATE * * *Any informa ' 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) alnstu 'roe- iui s Awa &VOLLVATM HOM N3 )093ln 1 )vLaansssm itian.zvwvxuv~r ~LRt~u to 1 DNN?37d mm .8 NOLL7fINJ.SNOD 39(13 S2I1 VAN 3 ua 4 yy a' Ldp ~ • )j ` F I T` l i ~ If HE E nu du 9 Diana u a1a~H tl UP i? U 03 0 HU ®HN .a~ CVO t I s \ iL u I ~ - VIM HSL6'19C-5[L'}Id.~ m . 4 k Q~x Raowr. hV1d N6I.T.YdAf70A ?I3H3H3 } -naa}arescmfvlm iapn AlOw x~acvatUMN cunc ivu!ram"P Ui~ Pd ON ~ o m I N t F 0 p f ' I F a 4 i t 4 ®I - 1E1E1E(E 9g i r . o - - - e - - - - - - - - - I i i_ I HSL6•I SIL'Fid 4"MoITIDn' 14 wY5'l-w➢~^i'*d ~i'fZ ~jV[d ']LA,3"j H[Y{~I ~j$$Rj7~ 'IVra>3➢rxcuir+anxl.lm~u~il9•wunaa>,~s :Big EW j m M f o NOI.I.XINLSNOa RJQg S2IUd1Y1 amine a n! a a a Q Z °55- ~F° 4g~ gf 5 ~ f g f tit all i as I J w c I - _ I e e ! mil} i s F ! s b r a ~ ji ~L+y lF➢Y 9 1 k r m wt w. v - t i L I w I-A {l~ Y'M~~ all lJ f~ f RECEIVED SJ- 'Phsconsin Department o- ty PLtTsional Services ? Page o Divisionof Indust, Servic G f _ . _ r ST CROIX COUNTY SOIL EVALUATION REP( 5EHPK)(PR3N)( 'OMMUNITYDEVELOPMIE o,dan wit, SPS385,Wis_ Adm. C,_ 1 --y I ~x o/X Attach complete site plan on paper not less than 8 V2 x 'j 1 inches in size ~r I _ Plan must include, but not limited to: vertical and horizontal reference point ( BIUt), direction and percent slope Parcel l.D_ O 20 /#/7k 000 scale or dimensions, north arrow, and location and distance to nearest road. - i Please print all information. I Revievre y Date nn Persona{ information You provide ma be used for secondar purposes (Privacy Law. S_ 15.04(1)(m)). I 141--77 `l V I -71 Property Ovrner f,OYl-t Property Location (or) j G✓/pr!'2`s E,oclr Lo.JSFituGr/ad G/ a4 crc Govt. Lot SW "l_ /VE % S aZ0 T 9 N R /9 X Property Owner's Nulling Address I Lot Block = Subd. Name or CSBf-_ Ca r* Air 4"y' 1 7" Gtr-1 City' State Zip Code Phone Number tY {~-~4{4sgc [ Tovm Nearest Road I 4d d WX I Sr/o.rT J 7/S) 7ee - uoJ-A. i 195 LNE,aEX 14410 I I I ~ I 07oY Z M1lev construction Use: {2 Residential/Numberofbedrooms 3 Code derived design flow rate Y' S40 GPD i, f replacement Q Public or commercial - Describe: ?.rent material LdES f oaera --r~JdsN Flood Plan elevation if applicable 104 it_ { General comments anci recommendations: L.JG.t ow,od /4QIWr5/ , 7 yowl ers x t re, o oes✓ ;4,15. f/fLD G Soo/~ li L/Fr Sr~tiea 4,,ie. de .jrEOEO /leZa.v".ja jr, Fem. - 3.S G.a` ~,~Lo~ 4~tAO6 ! f ; 3oring w Q Borina © Pit Ground surface elev. 98 L;t. Depth to limiting factor **,?o in. j Soil Application Rate I Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary I Roots I GPDI=i' ? In. Munsell , Qu. Az. ConL Color Gr. Sz. Sh_ I 1 I I -e. 1 I -Et,#2 1 ! I - I /a Y4 3 I - ( .511 ( oZ o f R4 I 3 2,6C. f i 8 ,oyx / I I S,/ I .7 g ;j 4- nP,. I ~s I - . G .8 3 J4 - co 7, s-M WY I - I s"' I I of I o s I- I I . 6 Y i do -/ao I /0 .A .f/'Y I ! s I s4 I I I r 7 I A4 I t l I ! I I I ! I ! I I I f I I i I l 1 , Boring; G Boring © Pit Ground surface elev_ 99 ~fi_ Depth to limiting factor in. Soil Application Rate , 1 ~ i Horizon Depth Dominant Color Redox Description Texture ` Structure I Consistence i Boundary Roots I GPD]Ff i I in. Nlunseil Qu. Az. Cant. Color I Gr. S? Sh. it 11 I 1 _ tt I 'Efi=1 'E;i'2 I ! G-.2b I /oYA J/.i I I S~/ I eZ cry ! "W 1 95 Iia?o1'-P I 2 ,?a -3a /ore 1Y/Y ! - ( Si! .7 rr sbk M Gs I - I . G- ( 's f I G 1 i .3 a -y1 I 7.4-xx y/'y I = G 5✓ I S9 I /'1 l I G 5 I I .7 H I ya -/.to f /o m S-/y I S I .59 I I { I .7 G 3 I I I I I I 1 I- I- -I I I I 1 Effluent #1 = BOD, > 30:5 220 m 1L and T.SS > 30 150 mo = Effluent r2 = SOD, > 30s 220 m 1L and T SS > 30 s 150 m 1L CST Name (Please Print) Signature CST Number Michael J. Hassett I I1 I Address 1503 Fairway SC ! f Date Evaluation C nducted Telephone Number I Eau Claire, W.1 5'1703 /a -,70 - (H) 715-834-8610 (C) 715-577-4383 SSO-8330 (R04115) CST, MFRS-224974, D-1152