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HomeMy WebLinkAbout040-1273-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 592143 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: T City Village Township Parcel Tax No: Oevering Homes LLC TOWN OF TROY 040-1273-20-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 60 eji b i a-^- 17.28.19.1519 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ~A,7 CAPACITY STATION BS HI FS ELEV. 1 Septic X7,, Benchmark A3 Adn F• /7 I Alt. BM /6 rJ Aeration j Bldg. Sewer 6o , 3 /6/,-3 Holding h SUHt Inlet ~I a t - lP TANK SETBACK INFORMATION St/Ht Outlet Z TANK TO P/L WELL BLDG. Ven to Air Intake ROAD Dt Inlet \ Septic 57 ) Dt Bottom Dosing Header/Man. T. O Aeration Dist. Pipe T. 9Y • (r 9. 1.3 1 Holding R. Bot. System C •0 01.3 9ss 3 Final Grade PUMP/SIPHON INFORMATION C Manufacturer Demand St Cover GPM r"~' ~]J r ! 10S.7 Model Numb TDH Lift Friction Loss System Hea H Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Di Liquid Depth DIMENSIONS 3 1 I7.2- 17e it fi SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION T e Of S stem: CHAMBER OR ~ 4 YP Y UNIT Mo Numbe Gc,n e `a n ZI 7L /\J DISTRIBUTION SYSTEM .364- Header/Manifo)d Distribution ix Hole Size x Hole Spacing Vent Air In- tike S Pipe(s) ® e Length_~ Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of 17d/ odded xx Mulched Bed/Trench Center Bed/Trench Ed es Topsoil Y. Q g s No es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 430 LOST ROCK LN OR 3188 4- LC J. . ' ' , ~Jt~• ~~~CC0.11.. ` 1.) Alt BM Description= 2.) Bldg sewer length T -amount of cover 6 /t fZ Q_ ICI (~1-~ Plan revision Required? Yes No J 1 I Use other side for additional informatio 03~7~] Date Insepctor' Signature Cert. No. SBD-6710 (R.3/97) 5,4-1- z-ot ~ - f ~~a~wm7 Count e J Safety and Buildings Division RECEIVEQ., W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) F Madison, WI 53707-7162 OCT 2 6 vial W 'S~Zl~3 X9R0E33ARMEq E•Pplication 3talcTransactionNumber In accordance with SPS is. Adm. Code, submission of this form to the appropriate govemmenta! unit is required prior to obtaining a sanitary permit Note: Application forms for state owned POWTS are submitted to P oject Address (if different than mailing address) the Dcpaztment of Safety and Professional Smvies. Personal information you provide may be used for secondary P~Eposes in accordance with the Prly Law, s. 15.04(1 m), Stars. L A lication Information - Please Print All Information c CJ ! Property Owner's Name Parcel 0 # e-L; Parcel Properry~ ner s Mailing s Property Location / ;C7 ' f -723 ` city, state i Zip Code Phone Number N Section / " 1 * LA,) t ' ~ 7-,9N- le o II LIO2 Tpe of Bui{ding (check all that apply) L T R Elbr WJ Family Dwelling -Number of Bedrooms Subdivision Name 7147 ❑ Public/Commercial - Describe Use ❑ City o ❑ State Owned - Describe Use CSM Number ❑ Village of bl~612j~p own of III. Type of Permit: (Check only a box on line A. Complete line B if applicable)- A. .74rr4 Iew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing system (explain) I B. ❑ Permit Renewal t Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner. ✓ J IV. T ofPOWTS S stem/Com onent/Device: {Check all that a 1 Non-Pressmized in-Ground ❑ Pressurized 10-Ground ❑ At-GTade ❑ Mound 124 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain j V. Dis rsal/Treatrant Area Information: 1 Design Flow (rpd) Design Soil Application Rate dsf) Dispersal Area Required (sf) Dispersal Area Proposed ( S ls,stem~ S Elev on ~ l 2 S Z VL Tank Info Capacity in 07::> Z Total # of Manufacturer Gallons Gallons Units Nm Tanks Exisdng Tanl / tit 1 i o ~ y a m ~ Septic or Holding Tank Dosing Chamber VII. Responsibility Stateme - I, the undersigned, assu esponsibility for installation of the POWTS shown on the attached plans. Pl s Name (Print) t Plumb t mature MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Z' Code)' 711- L.AJ 1\ VIII. County/De artment Use Only Approved ❑ t Permit Fee Date sued Issuins . t Signat er Given Reaso or Denial ❑ /b Z8 /fir IX. Condifi asons or Dis rov ark, ei UP,'), n er tint nro disp~er*i cell must all be sePPs ! rn;int rK 3) ae per management plan Pro tided by plumber. 2 AN fh)> Ck`MgWrerWts• must be maintr ir.e d IMfiO w as per fiicablas code / ,~rdinanm. r Attach to wm GdII,~~L plete plans for the system and submit to the County only oa paper not less than 8 1rz z 11 inches in size SBD-6398 (R 11/11) Soil Test and System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 17 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 98.8/ .5/98.2 4.5' below grade 10/23/16 3 DATE BEDROOM CONVENTIONAL XXXjCONVENTIONAL LIFT HOLDING TANK )Z71 MOUND SEPTIC IN~~ZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1216 # of chambers 60 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1/4" = 10' B. 103' 102' 60' B-2 Vents 60' 4% Slope 5' 3-3' X 82' cells with >3' spacing 25' ~ -3 Pro 4 5 Bedroom house Vent 15' >6" Quick4 Standard ST 10' 45' of Cover Leaching Chamber B-1 with 20.0 ft2 of Area 9 5.6ft^2/pair of end caps c4" 12' 4' Long 34" Grade at System Elevation Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Lost Rock Lane ` .J OCT R"ECEIVED cr , Wisconsin Department of Commerce ol1i`i`i'Y~'IL P/AI I IATIt-1rt+J .FZPC) RT Page of Division ofSafetyandBuildings„OMMUKU&AST,C'r20IX CJLWh WWX9ROE33ARMEA Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. L/76 ou Please print all information. Revi ed by Date Q Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location J1A S. T _6N R E( r) W QPv(9 Govt. Lot 1145, Property Owner's Mailing A ress Lot # Block # Subd. Name or CSM# Y Cat e-12; /-O . City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road 14 0 New Construction Use' esidential / Number of bedroom Code derive design flow rate ` 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L~LLt~ivGrZ~~+~ Flood Plain elevation if applicable ft. General cowmen f) _ _ ~J ' Ze and reconxnenclad datians: "(y fry System Type System Elevation d . -0 / P-1 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 GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 c j n F C64'7 -3 5- ,t Boring # ❑ Boring 61f / '4j & ILI &5.-3 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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 n n 464 IT • Effluent = BOD, < 30 mg/L and TSS < 30 mg/L Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 rrK )ef CST Name (Please Print) S' ure CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluatiop Cond cted Telephone Number 1432 120th St, New Richmond, WI 54017 -r 715-246-4516 Property Owner _ Parcel ID # Page of ❑ Boring F Boring # pit Ground surface elev. (o)-ft. Depth to limiting factor l/-7-.n. n*Eff#l Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. y*Eff#2 CCU ,V Sl~ M SL t~ m NJ r t Z C'j 1 a 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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 ❑ Boring ❑ Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ` Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.6/00) Property Owner _ Parcel ID # Page of Boring Boring # 4Z]Pit Ground surface elev. ft. Depth to limiting factor l -Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 i Boring # Boring Pit Ground surface elev.! ft. Depth to limiting factor in• Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 'Eff#2 is C l , a/ t 0 ,4 . 5- Boring ❑ Boring # pit Ground su e e v. ft. Depth to liming factor in. ❑ Soil Application Rate Horizon ')epth Dominant Color Re x Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell u. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 -Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(8.6/00) Soil Test and System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 17 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 98.8/ .5/98.2 4.5' below grade 10/23/16 BEDROOM 3 l DATE CONVENTIONAL XXXZ Val ~ CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC INK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1216 # of chambers 60 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1/4" = 10' B.M.* 103' 102' 60' B-2 Vents 60' 4% Slope 5' 3-3' X 82' cells with >3' spacing 25' B-3 5' Pro 4 Bedroom house Vent 15' >6„ Quick4 Standard ST 10 45' of Cover Leaching Chamber B-1 with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12 ' Grade at System Elevation 34" Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Lost Rock Lane 1cl S CountyS~~ c X Safety and Buildings Division , r,.11 NTY 201 W. Washington Ave., P. 0, Box 7162 Sanitary Permit Number (to be filled in by Co.) J 62 LOPMENT Madison, W1 P3507-7 - State Transacts umber 3RHBSBP Sanitary Permit Applicat" DETJ In accordance with SPS 383.21(2), Wis. Aden Code, submission of this form to the apps t,.._- t is required prior to obtaining a sanitary permit Note: Apphcation forms for state-owned POWTS are submnrteu ,o rgject Address (if d7tv ent than mailing address) the Department of Safety and Professional Servies. Personal information you provi b el!r secon oses in accordance with the Privacy Law, s. 15.04(x) m), Stars. y' L Application Information - Please Print All Information ~ Property Owner's Name Parcel # L 01 Prope Iq 31L rty Owners Mailing Address Property Location ) ~2 Y. I G1 ` I e? rr) f Govt Lot City, State Zip Code Phone Number i /V__ Section 1 t ~ N: R irc1E on T W H. Type of Building (check all that apply) ^ Lot # 1 or 2 Family Dwelling -Number of Bedroo 4 Subdivision Name CB lock 9 11 Public/Commercial -Describe Ilse 6K ab _ 11 Cit} 13 State Owned _ Describe Use CSM Number 1j, V-llage of •rp3 Z • 3 wn of f~ III. Type of Permit: (Check only one ox on line A. Complete line B if applicable) \ A_ ew - System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• El Permit Renewal ❑ Permit Revision ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. e ofPOWTS Svstem/Com onent/Device: Check all that apply) 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 f/ ~J V. Dis ersai(Treatment Area Information: 2 ? Design Flow (gpd) Design Soil Application R gpds~ Dispersal Area Required f) Dispersal Area Pr posed stem E evasion VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units v New Tanks Fa istmg Tanis I m U 15 w ~v Septic or Holding Tank Dosing chamber 7C i VII. Responsibility Statement- the undersigned, m responsibility for installation of the POWTS shown on the attached plans. Pltrlnbet's Name (Print) Pi ignature MP/MP~S Number Business Phone ber Plumber's Addy (Str City; tale, Zip e) elfq VIII. County/De artment Use Only _ Approved I xsapprove hermit Fee Date tied Issuing Ag t ig ature en Reason for Denial T';.66 lb 5 1U 1X. Conditi • s:for DpprovaI K J nk, a uMtasqR 3J eja perniii Celt must SH ~Ci ~s aintaine~ dis as per manaigement plan provided by plumber.. W 2. Al seem krtgwwoutsmust be maintfined ^ f J as per aapNCSbls code / 9411At1M. /~p JVl a►J~ a Attach to complete plans for the system and submit to the County only on paper not less than Sir z 11 inches in size SBD-6398 (R. 11/11) System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 17 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 97.0/96.7 3' below grade DATE 9/21 /16 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1/4" = 10' B.M.* Property Line 15' Please note: soil borings were not dug deep enough 5' B-1 90' to install system at a proper depth. Borings will be dug deeper prior to installation and a .7 loading rate Vents 10' will be installed B-2 5% Slope 50' 2-3' X 94' cells with >3' spacing 98' 25' B-3 30' 100, 11STK,3 0' Vent Pro 3 >6„ Quick4 Standard Bedroom of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12 to Lost Rock Lane Grade at System Elevation 34" Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 9/21/16 Owner:Oevering Homes Location: NE1/4 SW1/4 S17 T28 N,R19W 430 Lost Rock Lane Troy Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber ss Section 4-6. Maintana e nd Contingency Plan 7.Filter Cross ction Signature License number 226900 System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 NE 1/4 SW 1/4S 17 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 97.0/96.7 3' below grade DATE 9/21/16 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale=1/4"=10' B.M.* Property Line Please note: soil borings were not dug deep enough 15' , B-1 90' to install system at a proper depth. Borings will be dug deeper prior to installation and a .7 loading rate Vents 10' will be installed B-2 5% Slope 50' 2-3' X 94' cells with >3' spacing 98' B-3 25 30' 100' ST 30' Vent Pro 3 >6>> Quick4 Standard Bedroom house of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps to 12 to Lost Rock Lane Grade at System Elevation 34" Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation A(l 100.0' Vent Ael G rade Vent 3' 4" 3' X30/34 Septic Tank 5' Long 5 5' Long Grade at System Elevation 3611 Grade at System Elevation Spacing 5' 2-3' X 94' Cells Same on other end Observation tube/Vent At end of cell A B 23 chambers per cell System elevations: A_97.0' B-96.7' - ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer v 1 n ~J Mailing Address Property Addres (Verification rd fro m rig & Zoning D ` apartment for new eonstruc on. - City/State Parcel Identification Number ~ _ LEGAL DESCRIPTION - ,-=t Property Location / i Sec. T / N R d W, Town of Subdivision Certified Survey Map # - - Lot # Volume Warranty Deed # - , - Page # - , Volume Page # Spec house yeS no Lot lines identifiabl yes no SYSTEM MAINTENANCE AND O Vt'NER CERTIFICATION groper use and maintenance of you. Septic system could result in maintenance its re maintenance consists of Puin out the s mp the system can affect the eptic tua every three years or sooner, if needed, by a l to handle wastes. Proper function of the septic tank as a treatment stage Y a licensed responsibilities are specified in §Comm. septl 1 in the waste disposal system. Owner mai What you put into y and in Chapter 12 - St. Croix Coun sanitary main tenance The property owner agrees to submit to St. Croix County Pla Ordinance. owner and by a master plumber, jonrne nning &Lonin De wastewater disposal system is in proper operating condition and/or 2 g Pumper a certification h yman Plumber, restricted plumber or a licensed pumper ~ signed by the less than 1/3 full of sludge. that ar the on-site ( ) after inspection and pumping (if f necessary), the septic tank is 7/we, the undersigned have read the above standards set forth, herein, as set b requirements and a ree to Certification st8t Y the De t maintain f private sewn Paas e e of Commerce and the De ge disposals stem with Z,anja Department that your septic system has been P~ment of Natural Resources, State of Wisconsin the g P~rient within 30 daYs of the three maintained must be completed and re Year expiration date. turned to the St- Croix County Planning & i/we certify that all state property described above ments on this form are true to the best of my/om• knowledge , by virt ue of a warranty deed recorded in Register of Deeds office t/we am/are the owner(s) of the lumber of bedrooms, MNAT OF AP L CP II A T{ ) ***Any information that is misrepresented may result in the sanitar DATE YPennit being revoked by the Planning & Zoning Department. IIIelude with this application a recorded warranty deed from the Register of Deeds Office and a co of reference is made in the warranty deed, P.Y the certified survey map if (REV. 08/05) POWTS O'WNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS owner Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ❑ NA ESIGN PARAMETERS Effluent Filter Manufacturer / ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units fWWNA Pump Tank Capacity al NA j Estimated flow (average) Pump Tank Manufacturer A gal/day P 4NA Design flow (peak), (Estimated x 1.5) at/day Manufacturer A Soil Application Rate r S j al/da /fe Pump Model Standard Influent/Effluent Quality Monthly average' Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter D Peat Filter Biochemical Oxygen Demand (BODs) 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) 530 mg/L in-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ~ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml e ~I ❑ Drip-Line ❑ Other: 'Maximum Effluent Particle Size A in dia, ❑ NA Other. ❑ NA (Other. NA Other: *Values typical for domestic wastewater and septic tank effluent Other. ❑ A IAINTENANCE SCHEDULE A Service Event Service Frequency !inspect condition of tank(s) At least once every: ❑ month(s) s (Maximum 3 years) ❑ NA ear !Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA (Inspect dispersal cell(s) At least once every' ❑ month(s) year(s) (Maximum 3 years) [I NA Clean effluent filter / [3 month At least once every: / (s) ❑ NA ear(s) ! nspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA El year(s) l=lush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) ether. ❑ month(s) At least once every: ❑ year(s) NA tither: 13\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 linclude 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 I-egulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y6) or more of the tank volume, the entire contents of lbe tank shag 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, land any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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 tl*t 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. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cep(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 rive 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 withln 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 POWT$: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fNit 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 propetly 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 seated. • The contents of all tanks and pits shall be removed and property 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 sail, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code cornpiient replacement system: . A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm. The replacement area should be protected from disturbance and compaction and should not be infringed upon by requhjed setbacks from existing and proposed structure, lot lines and welts. 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 ruler in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologK 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 infittralive 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 TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE Ol= A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone f ni r Phone 7 SEPTAGE SERVICING OPERATOR LIMPER LOCAL REGULATORY AUTHORITY 7 Name Name Phone rL Phone This document was drafted in compliance with chapter SPS 383.22(2)(b)(%d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. _ i ! 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Adm. Code Gustum Septic Service Attach complete site plan on paper not less than 8%x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and _ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. D(LO, Please print all information. Revi gy J ~ert~ifTJ Date v Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).~ ~a Property Owner Property Location Humbird Land Corporation Govt. Lot 1/4 SW 1/4 S 17 T 28 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 332 Minnesota Street, East 1404 43 -n-/a Troy Wood Subdivision City State Zip Code Phone Number City Village ✓ Town Nearest Road Saint Paul MN 55101 651-222-5555 Troy E Cove Rd / Lost Rock Lane ✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material outwash plains Flood plain elevation, if applicable n/a General comments and recommendations: Part of 2.0 acres. BM #1= 100.0'. BM #2= 101.9'. Recommend97.2' system elevation along 99.7' contour. P35 from preliminary soil work done 5-5-00. P35 Boring # Boring ✓ Pit Ground Surface elev. 100.0 ft. Depth to limiting factor - >7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft' *Eff#1 *Eff#2 1 0-12 10yr2/2 none i sil 2msbk mvfr as 1f 0.5 0.8 2 12-19 10yr3/4 none sil 2msbk mvfr cw 1 1 f 0.5 0.8 3 19-29 10yr4/4 none r. sil 2msbk mvfr cvv - 0.5 0.8 - 4 29-39 10yr5/6 none gr. Is 1 msbk mvfr cw - 0.7 1.2 5 39-75 10yr6/6 none gr.s, s 0 sg ml - - 0.7 1.2 NIL ITI a Boring # Boring ✓ Pit Ground Surface elev. 99.7 Depth to limiting factor - X72 - in. Soil Application Rate Consistence Boundary Roots GPD/ftHorizon Depth Dominant Color Redox Description Texture Structure *Eff#1 *Eff#2 1 0-9 10yr2/2 none sit 2msbk mvfr as 2f 1m 0.5 0.8 2 9-15 10yr3/4 - j none sll 2msbk mvfr cw 1f 0.5 0.8 3 15-21 10yr4/4 none sit 2msbk mfr cw - j 0.5 0.8 4 21-30 ,L 10yr4/6 none gr. Is 1msbk mvfr cw - 0.7 1.2 30-39 10yr4/4 1 none gr. Is 1 msbk mvfr cvv - 0.7 1.2 6 39-58 10 r5/6 none r. s 0 s ml - cw T - 0.7 1.2 7 58-72 10yr5/4 none s 0 sg I ml 0.7 1.2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number Tom Gustum - 227618 Address Gustum Septic Service Date Evaluation Conducted Telephone Number N13450 937th St., New Auburn, WI 54757 11/21/00 715-658-1344 Property Owner liumbird Land Corporation Parcel ID # pending Page - 2 of 3 _ 2] Boring # Boring Pit Ground Surface elev. -96.9- ft. Depth to limiting factor >75 in. V1 - - - - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure 1 Consistence Boundary Roots GPD12 *Eff#1 *Eff#2 1 0-14 ! 10yr2/2 none sil 2msbk mvfr as 2f,1 m 0.5 0.8 1 - - 2 14-19 10 r3/4 I none sil 2msbk mvfr cw 1 f 0.5 0.8 3 19-27 10yr4/4 none sil 2msbk mfr cw - 0.5 0.8- - ! i i - -I 4 27-36 10yr4/6 none sil 2msbk mvfr cw - 0.5 0.8 5 36-47 10yr4/6 none gr. Is 1msbk mvfr cw 0.7 1.2 6 ~ 47-62 10yr5/6 none gr.ls , lmsbk mvfr cw I, - , 0.7 1.2 - r - 7 j 62-75 10yr5/4 none s 0 sg ml - - 0.7 1.2 3 ] F Boring # Boring ✓_J Pit Ground Surface elev. 100.87 - ft. Depth to limiting factor >72 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= *Eff#1 *Eff#2 1 0-9 - 10yr3/2 none sil 2msbk mvfr as 2f,1m 0.5 0.8 2 1 9-15 10 r3/4 none s l 2msbk mvfr cw 1 f,1 m 0.5 0.8 3 15-23 10yr4/6 none gr. Is 1 msbk mvfr cw - 0.7 1.2 4 23-38 10 r5/6 none gr. Is 1 msbk mvfr cw 0.7 1.2 5 38-72 10yr5/4 none s 0 sg ml - - 0.7 1.2 Ian d A 11 ❑ Boring # 1 Boring AVL 1i _j Pit Ground Surface elev. ft" Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots SzPDIW *Eff#1 *Eff#2 j I I. I I I I * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 -S_30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. Property Owner liumbird Land Corporation Parcel ID # pending Page 2 of 3 2] Boring # J Boring Pit Ground Surface elev. 96.9 ft. Depth to limiting factor >75 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft=-- *Eff#1 *Eff#2 1 0-14 10yr2/2 none sil 2msbk mvfr as 2f,1m 0.5 0.8 2 14-19 10yr3/4 none sil 2msbk mvfr cw 1f 0.5 0.8 3 19-27 10yr4/4 none sil 2msbk mfr cw - 0.5 0.8 4 27-36 10yr4/6 none sil 2msbk mvfr cw - 0.5 0.8 5 36.47 10yr4/6 none gr. Is 1msbk mvfr cw - 0.7 1.2 6 47-62 10yr5/6 none gr. Is 1 msbk mvfr cw - 0.7 1.2 7 62-75 10yr5/4 none s 0 sg ml - - 0.7 1.2 i F3 ] Boring # J Boring _f✓ Pd Ground Surface elev. _ 100.87--_- ft. Depth to limiting factor >72 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' *Eff#1 *Eff#2 1 0-9 10yr3/2 none sil 2msbk mvfr as 2f,1m 0.5 0.8 2 9-15 10yr3/4 none sil 2msbk mvfr cw 1 f,1 m 0.5 0.8 3 15-23 10yr4/6 none gr. Is 1msbk mvfr cw - 0.7 1.2 4 23-38 10yr5/6 none gr. Is 1msbk mvfr cw - 0.7 1.2 5 38-72 10yr5/4 none s 0 sg ml j - - 0.7 1.2 141 ❑ Boring # -3 Boring AWL ~f Pit Ground Surface elev. ft v~ Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= *Eff#1 *Eff#2 I * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 <_30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. m a O p m U N N - lO ~ O C mZ NZ oo<n C - CD a I,I a~ ~F-CO Z 0) x O 0 o aJ O i M.j O 5-N- 2 Z~VC ~o 0 ados e Cs ~ Q m m o~ cl~ CD m i a m a, _ I s o v -71 O m r o U r~ ~ O - O O II 0~ C1 C)~ L - P~l Oo C o M o „ 0) i