HomeMy WebLinkAbout042-1090-20-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CCOIX
Safety and Building Division
INSPECTION REPORT Sanitary Permit No 597378
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]~
Permit Holder's Name: City Village Township Parcel Tax No:
OEVERING HOMES TOWN OF WARREN 042-1090-20-200
CST BM Elev: Insp. BM Elev: BM Description: 1, Section/Town/Range/Map No:
• 32.29.18.497A-20
TANK INFORMATION EL NATION DAT
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
p Benchmark
Septic
A- 4
U
Alt. BM
t ° 9 7'Rd ~"L G _
W1
Aefatton Bldg. Sewer
tlIIldm9 Ht Inlet Into,
J 1 S Ht Outlet q Q a
TANK SETBACK INFORMATION YLA,
TANK TO P/Lr WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Lit-
Septic Dt Bottom
t' S 3 ya, + -
r
Dosing Header/Man: f._ , j
01- 1 Aeration Dist. Pipe T "J
i
Holding Bot. System 1 j
Final G de C /
PUMP/SIPHON INFORMATION . Z ~~Z• `"I
Manufacturer Demand St over
G (j . 2-
Model P 'C Number
TDH Lift Friction Loss System Head TDH Ft r
1 era,,
1,71
Fdreemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
' Leh No. Of Trenches PIT DIM SIONS No. Of its Inside Dia. Liquid Depth Pzw BED/TRENCH Width
DIMENSIONS 7
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer;(
INFORMATION CHAMBER OR ! J r'~
Type-Of Sy tem: ..t . i t UNIT Model bar:
DISTRIBUTION SYSTEM CSC e ,F~ r/~-•~?
Header/MarpifolO w Distribution Hole Size x Hole Spacing Vent to Air Intake
Length Dia_ Length Dia Spacing '
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over ` ; I xx Depth of xx seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
] Yes ~ No Yes )ilfo
COMMENTS:' nclude co L discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Ne r~ not ;ns (
Location: 691 104TH ST - f~
1.) Alt BM Description = p1-.~GS W 1 _Dn n 1 ^ 'ns ht~n v(~
2.) Bldg sewer length
- amount of cover = J Sp;1 , a„(~ (\QQ,at 04lfe~
ej 'kb
Plan revision Required? L Yes ZINo
Use other side for additional information.
Date Insepctors Signature Cert. No.
SBD-6710 (R.3/97)
row' aT fir,
County-, 1 t
ECEIVED
2s) Safety and Buildings Division -
C 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co-)
P JUL Madison, Wl 53707-7162
ST. CROIX COU ! :5 3 9
ermi I A F7 H 08 PV E RJ W M rmtsaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of tits torm to me apprupiLo- svy--w uwL
is required prior to obtaining a sanitary permit Note; Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
oses in accordance with the Privacy Law, s. 15.04(l m), Stars.
L Application Information - Please Print All Information 671 /0 [
~l
Property Owner's Name Parcel #
dC'LIR.7l- /„c d -~~~Qti ZAP' Z
Property Owner's Mailing ess Property Location
Govt- Lot ,
nY,,Ste / Zip Code Phone Number /I ection L~
17 T N; R E br W /
II. Type of Building (check all that apply) ~ ~
Family Dwelling. -Number of Bedrooms Subdivision Name
Ofr- " B i,
❑ Public/Commercial - Describe Use
❑ City of
\Q vim.
El State Owned - Describe Use CrSM Number ¢b 6151 ❑ Visna=ge of
• 5 Y (.LJ Y Town of
111. Type of Permit: (Check only one box on ne A. XYMft pplicable) p 4'6&.
A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renew e t Revision Change of Plumber ❑ Permit Transfer to New List Previous Permit Numberraanndd~Date Issued
Before Expiration
Owner T
l'7 a►~Ca~ '
( C
IV. of PORTS System/Component/Device: Check all that apply)
-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in, of suitable soil
❑ Holding Tank 11 Other
Dispersal Component (explain) ❑ Pretreatment Device (explain) ~
V. Dis rsaVTreat eut Area Information: i
gn Flow (gpd) Design Soil Application Rate{gp Dispers Area Required Dispersal Area Propo d (sfy System Ele-,'
s . S C7
VL Tank Info Capacity in Total # of Manufacnrrer
Gallons Gallons Units -
K g
New Tanks Existing Tanks
A v p ~ ~ m
v c~ C7
Septic or Holding Tank
Dosing Cbamba
VII. Responsibility Statement- the undersigned, for installation of the POR T S shown on the attached plans
Plumber's Name (Print) PlumMP/MPRS Number Business Phone N bet
r Aj C4 `J2-
Plumber's Address (Street, City, State, Zip Code)
VIIL unty/De artment Use Only
Approved g~v,'d _Permit Fee Date sued IssS
iReason for for Denial I-7
DL Condit) ons for Disapproval DA-
1. tai k; EPflt lint ItRe* aNtd 3) L J
tii3per`:ai cell must ell be set lc~Ls ! roi;p _ S;
as'.per mgragement plan p!o tided by plwnbe;. l~~ f +t.
2 '%a r k imblr~t~lenls"rrtu•~~ pct r^~ant: ir.Ed C~
as per appiictlbli c;txlt: I cMinan,a~.
Attacb to complete plans for the system and submit to the County only odymw not less than 8 trz z 11 i es rim G SBD-6348 (R 11/11) t
Soil Test and System PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NW 1/4S 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX
SYSTEM ELEVATION 95.4/95.0 4' below grade DATE 7/10/17 BEDROOM 3
CONVENTIONAL X0( CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 100' Filter Lifetime Filter
BOREHOLE O WELL *H.R.P. same as benchmark
365' Property Line
L.d 104th St
112'
34' 70' 12 F. 1pq - AL-
'
301
B-1 ? 50'
B-3
1• \ 4% Slope 70'
~t
B.M.*
B
100'
' Vent 99Vents 433' Property Line
All piping shall be ASTM SDR 30/34, ithiri " ~6„ Quick4 Standard
10' of tank, piping shall be ASTM F8 1 Leaching Chamber
of Cover with 20.0 ft2 of Area
5.6ft^2/pair of end caps
12"
4' Long
Grade at System Elevation
34"
C J3
RECEIVED I`
AF7H08PVERJWM
Wisconsin Department of Commerce JUL ?SgIL EVALUP 'age of
Division of Safety and Buildings
e e"v6 1r q~,m 85, Wis. Adm. Code /
Attach complete site plan on papefIklLft1 eDEN1E111"iiWASze. Plan must County-5)
r
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. uu
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 6 TZ / 9
Please print all information. Review by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). zz r
Property Owner Property Location
112(-, '-2-e Govt. Lot ~5 1/4 14 S VT N R E (o W 1/4 Prope Owner's Mailing Address Lott Block # Subd. Name or X
city tate Zip Code Phone Number ❑ City ❑ Village Town Nearest Roal
New Construction Us Residential / Number of bedrooms _ Code derived design flow rate , GPD
❑ Replacement ❑ Public or ` cormercial - Describe:
Parent material ~ Flood Plain elevation if applicable / l) ft.
General comments
and reoorrwnendata datiens: Z
stem Elevation
System Type Sy ~~r
M 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
17-7 J
.2
Boring # Boring
511pit Ground surface elev. _ ft. Depth to limiting factor tn.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
S7/ (7 J - - v
L C J
2-3
'r'l I'd )Vi 7Y
1 t
Effluent #1 = D. >4k,9'220 nxA and TSS >30 < 150 ' Effluent #2 = BOD. < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird A~~ 226900
Address Date Evaluation Conducted Telephone Number
1432 120th St, New Richmond, WI 54017- - - 715-246-4516
Property Owner _ Parcel ID # Page of
1-3 Boring # Boring
bl pit Ground surface elev. ft. Depth to limiting factor_ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence EBoundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
61o
z- r
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
❑ Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
F-1 ❑ Pit
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 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg& 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 (R.6M)
Property Owner _ Parcel ID # Page of
1-3 ❑ Boring
Boring #
Pit Ground surface elev./k7 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
5;1 4-7
❑ 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/ff
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 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 = 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 Oeverino Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NW 1/4S 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX
SYSTEM ELEVATION 95.4/95.0 4' below grade DATE 7/10/17 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 .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
a
365' Property Line
104th St
112'
!F •L
1 p
34, 70
12'
30'
S
B-1 5' 50'
B-3
dd 4% Slope 70' -
B.M.*
B 100'
Vent99Vents 433' Property Line
All piping shall be ASTM SDR 30/34, ithin ji:: Quick4 Standard
10' of tank, piping shall be ASTM F8 1
Leaching Chamber
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
tem Elevation
Grade at Sys
34"
E'VE® Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in b}' Co-)
r P " o Madison 53 7-7162
~a'"~rsrotist ✓ 73 7V
~OMMU NITY D ~ 'rate Transaction Number
Permit Ar
E
In accordance with SPS 383 21(2), Wis. Adm. Code, submission of this form to me ayy. r , { t
is required prior to obtaining a sanitary pemtit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies- Personal information you provide may be used for secondary
-purposes in accordance with the Privac Law, s. 15.0 1) m), Stars. ly/ i
L Application Information- Please Print All formation
Property Owner's Name + V Parcel # - ~-LYZ~
Property Owner's Mar ' g,Addr s rty Location
f ' t ~ V
1 f
L., ) t
Govt. Lot
City, State Zip Code Phone Number
Sect..D
+ 4.. 1 1 . • i / / !T r ILGle O )
TL- l N; RE W j
H. Type of Building (check all that app ~ Lot,# ~
'1 or 2 Family Dwelling-Number of Bedroo ts►~~ 4~ Subdivision Name
r` 4Z 3+-'-.- ~~,o J°yE- Block w . J s % r L
❑Pubiic)Commercial-DescribeUse
Q City of
Q State Owned - Describe Use CSM Number Village of
Town of e%f /C'i f l zn_~
III. Type _~9 Permit: (Chexk only one box on line A. Complete line B if appli e) -
A. ~ cw System Q Replacement System Q Treatment/Holding T acement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision Q :hange of i Q Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration ! Owner 79
` I t r
A- Lft~ A~-
W. Type ofPOVVTS System/Com onent(Device: h k apply) Non-Pressurized In-Ground Q Pressurized In-Ground Grade Q Mound > 24 in. of suitable soil Q Mound < 24 in. of
suitable soil ^ 1
Q Holding Tank Q Other Dispersal Component (explain) Q Pretreatment Device (explain)
V. Dis rsaUTreatment Area Information ti.~l tt <
Design Flow (bpd) Design Soil Application aze(gpdsf)Dis/persal Area Fcquired (sf) [Dispersal Area opo~ (sf) System Elevation /
VL Tank Info Capacity in Total # of Manufacturer '
Gallons Gallons I Units
New Tanks Existing Tanks
a o y ,a m is ~
Septic or Holding Tank
Dosing Cbamber I (
VII, Responsibility S e ent- L the undersigne,, s responsibility for installation of the PORTS shown on the attached plans.
Plumber's Name (Print) ignature MP/MPRS Number Business Phone Number
P bsr's Address (Street C State, Zip Code
VIII County/De artment Use On]
pproved QyDisepp£eaetLy Permit Fee Date sued Issuing. Signatrre
~ e eason for Denial 7
DL Conditi ris o ason .(f~ r~~PProval
P ark, E, ant 1 0~ C , .5~ ✓aL. ✓d` hE. J
6t*er-. i cell rust dil be snl,• fcn ! tog n&r..t ; ,
* per,.-rtariigement plan prodded by plumber. INd L(~ -~.~t. e.¢..
2. JI iow*' en► t be r aint; Ir s'l 7
CAdt! ! ti'idilNl11C31. , of u r- :1 a rt cv
J
Attacb to complete plans for the system and submit~to the Coun only oa paper not ies r2 z Il ioch ~n siu19
SBD-6398(8 11/11) 5' ~►t•l~; {'~,t,,` 0116a4-- +0
System PLOT PLAN
PROJECT Oeverino Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NW 1/4S 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX
SYSTEM ELEVATION 88.9/88.7 6.5' below qrade 5/17/17 3
DATE BEDROOM
CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of nail in 8" pipe ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
n
104th St. 08' ~vuI° - 1 - 10'
35' B.M.* to be >5' from P.L.
Please note: soils will be checked B- 15' B-3
prior to installation 20'
and possible redone to find a
more suitable location. 340' Property Line
2-3'x 66' cells with >3' spacing 25'
1% Slope 20'
B-2
1~ S
20'
Pro 3
Bedroom
House
Vent
All piping shall be ASTM SDR 30/34, within >6„ Quick4 Standard
10' of tank, piping shall be ASTM F891 Leaching Chamber
of Cover with 20.0 ft2 of Area
5.6ft^2/pair of end caps
12"
4' Long
Grade at System Elevation
34"
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 5/18/17
Owner:Oevering Homes
Location: NE1/4 NW1/4 S32 T29 N,R18W 691 104th St. Warren
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contihti ency Plan
7.Filter Cross Section
Signature-
License numberA226900
System PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NW 1/4s 32 /T 29 N/R 18 W TOWN Warren COUNTY ST. CROIX
SYSTEM ELEVATION 88.9/88.7 6.5' below grade DATE 5/17/17 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 .7 ABSORPTION AREA 651 # of chambers 32
Ilk BENCHMARK V.R.P. Top of nail in 8" pipe ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
104th St. 08' Scale = 1/4" = 10'
35' B . M. * to be >5' from P.L.
Please note: soils will be checked B- 15' B-3
prior to installation 20'
and possible redone to find a 340' Property Line
more suitable location.
2-3'x 66' cells with >3' spacing 25'
1% Slope 20'
B-2
S
20'
Pro 3
Bedroom
House
Vent
All piping shall be ASTM SDR 30/34, within Quick4 Standard
10' of tank, piping shall be ASTM F891 >6 Leaching Chamber
of Cover with 20.0 ft2 of Area
5.6ft^2/pair of end caps
4' Long 12
Grade at System Elevation
34"
ELEVATIONS SHOWN ARE
NAVD 1988 DATUM.
PROPERTY ADDRESS:
SCALE: 691104TH STREET
ROBERTS WI 54023
0 50 100
LEGEND
X =WOOD LATH OR PIN FLAG SET
® =WOOD HUB SET AT 10'
OFFSET, 15' OFFSET, OR ON
BUILDING EXTENSION
FOUND 3/4" IRON REBAR
T.O.H - TOP OF WOOD HUB ELEVATION
T.O.P - TOP OF IRON BAR ELEVATION
SETBACK LINE:
100'FRONT
10' SIDE MIN, 25' TOTAL
25'REAR
12' UTILITY EASEMENT
JOINT DRIVE EASEMENT \ -
W \ PROPOS D DRIVEWAY 3,700 SQ FT
Q \ \
\I
o- Y I> ( J
° e a l
0 ys
- I ---a-.a za.~
I 100' 0.] ti UP 33.3 I
I U
PROP. N 6q
Ct 4hF' m ~ 6253
C 9 ti HO1SEo
r s \
34.0 ` 70'
1 I o
/ / ` \ H.W.L-986. LOT#
131` l
j / cflA / / 8728
\ - o, 0
-B-:OO.- 20-240
q~q L 1
~ ~ m o M I
~ 3 I
0
+Irv
F-
W W
F ti
~0FN /
Q Q F
U z O Z I, Ty R. Dodge, Wisconsin Professional Land Surveyor, hereby
2 p certify that this Stake-out Plan was prepared by me or under I
a X W. my direct supervision and is correct to the best of my J
p knowledge and belief.
m v v NORTH /
9 OEVERING HOMES
tl-r
LOT 2, C.S.M. VOL 20 PG. 5024
b"u
~,W SE~- j2, i BW, 'OWN 01 WARREN, ST lRJ~X WISCCJNSiN
HOUSE STAKEOUT PLAN Auih•Consulting/associates S&N Land Surveying ,s,ao„
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 To be >1' above grade
5.6ftA 2 pair of end plates
Finish grade elevation
Typical Installation 99.5'
Vent Grade Vent
3' 4" 3'
A~30/34 Septic Tank
5' Long 1 5' S' Long 1 36" Grade at System Elevation Grade at System Elevation
Spacing- 5'
2-3' X 66' Cells
Same on other end Observation tube/Vent
At end of cell
Z; :7 A
B
16 chambers per cell
System elevations:
A-88.9'
B-88.7'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Septic Tank Capacity al El NA
Permit #
Septic Tank Manufacturer ❑ NA
3ESIGN PARAMETERS Effluent Filter Manufacturer _ ❑ NA
Number of Bedrooms'. O NA Effluent Filter Model 0 NA
Number of Public Facility Units 4NA Pump Tank Capacity al NA
j Estimated flow (average) Pump Tank NA
1) 67-0 gal/day p ank Manufacturer
Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer NA
Soil Application Rate aUda /ftz Pump Model NA
0
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 420 mg/L ❑ NA D Mechanical Aeration D 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 A El At Grade ❑ Mound
Fecal Coliform (geometric mean) 6104 cfu/100ml / ❑ Drip-Line ❑ Other.
iMaxlmurn Effluent Particle Size Ja in dia. q Other. ❑ NA
Other: Other:
NA ❑ NA
`Values typical for domestic wastewater and septic tank effluent Other ❑ NA
IAINTENANCE SCHEDULE
Service Event Service Frequency
(inspect condition of tank(s) At least once every. _75 13 month(s)
ears (Maximum 3 years) ❑ NA
(Pump out contents of tank(s) When combined sludge and scum equals one-third {'!3} of tank volume ❑ NA
Inspect dispersal cell(s) At least once every' ? Qmonths) j9,year(s) (Maximum 3 years) ❑ NA
I--lean effluent filter At least once every: r~ mYeaarr((s)
} ❑ NA
ic...i
s)
inspect pump, pump controls & alarm At least once every: ❑ month(s)
El NA
❑ year(s)
1=lush laterals and pressure test At least once every: ❑ month(s)
0 NA
D year(s)
ether. o month{s}
At least once every: ❑ NA
❑ year(s) ether.
17 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
iinclude a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of
i:mmbined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be
Asually 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.
I,Nhen the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of
j:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 913, 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 <12 months, shalt be performed by a certified POWTS Maintainer.
.IN 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 u
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting ducts or have the other contents chemicals of tihOt
may impede the treatment process and/or damage the .dispersal cell(s). If high concentrations are detected thO
tank(s) removed by a septsge 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 ble
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface dWmarge of effluen1t.
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 vehk*m over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POVM:
antibiotics, baby wipes dgere to butts; condoms; cotton swabs; degreasers; dental floss diapers; disinfectants, fat; foundation dralin
(sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; 0; painting produclls;
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 propefly
and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:.
• Alt 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, alt 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 de rxxnplirrt
If the POWTS fags and cannot be repaired the following measures have been, or must be taken, to provide a code
rep system:
suitable replacement area has been evaluated and may be utilized for the location of a reptac emert sad absorption Muir
The replacement area should be protected from disturbance and compaction and should not be infri
setbacks from existing and proposed structure, tot 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 rule;l 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 TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE
ADDITIONAL COMMENTS
POINTS INSTALLER POWTS MAINTAINER
E Name Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY UTHORITY
E Name r Name
Phone r° f 1 7 Phone
This downent was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383.,54(1), (2) & (3), Wisconsin Admin ive Code.
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ~C~ ; 1 n s s -14 ~2
Mailing Address
Property Address
(Verification required from Planning &Zoning - -
epartm6t for new construction.)
City/State
_ Parcel Identification Number
K 2-
LEGAL DESCRIPTION
Property Location/= V4/ !,tJ V4, Sec.
T N Rj W, Town of
Subdivision
Lot #
Certified Survey Map # Volume J
Page #
Warranty Deed #
Volume Page #
Spec house 'yes no Lot lines identifiabl yes no
SYS
TEM MAINTENANCE AND OWNER CERTIFICATION
Iruvroper use and maintenance of our s
maintenance consists of out the y ephc system could result in its premature failure to handle wastes. Proper
pumping ~Ptic tank every three years or sooner, if needed, by a licensed
the system can affect the function of the septic tarilc Y pumper. ai What you put into
responsibilities are specified in Co as a treatment stage in the waste disposal system. Owner maintenance
§ min. 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 owner and by a master plumber, journeyman Plumber, restricted plua licensed pumper verifying that (in form, signed by the
wastewater disposal system is in proper operating. condition and/or (2) after inspection anpumping verifying that a the on-site
less than 1 /3 firll of sludge. Pumping (if necessary), the septic tank is
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 Gonined
Certification stating that your septic system has been maintained must be completed d re Natural to the St_ Croix County Planning &
Zoning Department within 30 days of the three year expiration date,
Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
r
TGNA QF AI'PLICANT(S~ ' 1l 4
-2
DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & `Coning 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. Os/05)
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Wisconsin Department of Commerce
Division of Safety and Buildings SOIL EVA ON REPORT
s Page
in accorrnce with Comm 85, Wis. Adm ` Codt*,, of
Attach complete site plan on paper not less than8 112 1 i County
include, but not limited to: vertical and horizontal refere es in size. Plan must
Percent slope, scale or dimensions, north arrow, and locatio t (SM), direction and Parcel I D
istagce to nearest road. Q ya, Oq
7
Please Print all information.
Personal information you Provide may be used for seconds Reviewed by Date
Property Owner rY Purposes (Privacy ~s oa 11,111
• c,
b t 11 `P««roperty Location / L$
Property Owner's M ailing Address Govt. Lot Lot # G'f 114 1/4 S _ N R/ :i E (or)c(ty'
{ t f L c- Block # Subd. Nam or CSM#
City State Zip Code Phone Number C20 5
❑ City ❑ Village Q Town
( ) ~ ~ Nearest Road
New Construction Use: Residential / Number of bedrooms.
❑ Replacement - Code derived design flow rate ` i `DC' i
❑ Public or commercial -Describe: t
Parent material GPO
General comments Flood Plain elevation if applicable
and recommendations: ft.
a Boring # ❑ Boring
Pit Ground surface elev. 7 ft
Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture son lication Rate
in. Munsell Structure Consistence Boundary Roots GPD/ff
Qu. Sz. Cont. Color Gr. S - Sh.
J c 'Eff#1 •Eff#2
Uwr
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a Boring # 0 Boring
Pit Ground
surface elev. ft.
Horizon Depth Depth to limiting factor `
in
--~--=-Dominant
Color Redox Description Textur SoII lication Rate
in. a Structure
Munsell Qu. Sz. Cont. Color Consistence Boundary Roots GPD/ft=
( Gr. Sz. Sh. 'Eff#1
'Eff#2
;
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Z
Effluent #1 = BOD > 30 < 220 rng/L and TSS >3o:5 150
CST Name (Please Pant) - mgti ' Effluent #2 = SOD < 30 nV& and TSS < 30 nx
Signature -
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Address e- CST Number Date Evaluation Conducted Telephone Number
r
Property Owner Parcel ID # Page of
Boring # El Boring
~
} Q Pit Ground surface elev. ft. Depth to limiting factor
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
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❑ 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 # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit
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
i
I
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Effluent #1 = BODS > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 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 (RAM)
i
Property Owner y Parcel ID # 4~ 7 -11L .2i Page - of _
Boring # r❑ Boring pit Ground surface elev. Depth to limiting factor / l~ ~n• 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
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I I D I I i
❑ 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 # Ground surface elev. ft. Depth to limiting factor in.
F-1 ❑ Pit
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
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODS < 30 mg& 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 (-NW)
PAGE ? OF
_NAME LOT# ` LEGAL DESCRIPTION '~a,S 1 T `6N,R i E (or}L
SCALE: 1
BM I ELEVATION jCLc-
BM 1 DESCRIPTION e~ t' i 1i-\ r
BM 2 ELEVATION « L
BM 2 DESCRIPTION 0
' 1 ~ ],/aGSYSTEM ELEVATION'` i
ALTERNATE ELEVATION
CONTOUR ELEVATION
I
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~
SIGNATURE DATE