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HomeMy WebLinkAbout026-1149-00-008 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597417 GENERAL INFORMATION State Plan ID No: p ► 0 - Permit information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] N'0- Permit Holder's Name: City Village Township Parcel Tax No: DAVID KRALOVETZ TOWN OF R HMOND 026-1149-00-008 CST BM Elev: Insp. BM Elev: BM Deription _ dJv ction/Town/Range/Map No: Se 15.30.18.1113 TANK INFORMATION ELEVATI N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark aa* Alt. BM AeLation Bldg. Sewer - L 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 Hea a J~ n~. 6 efl Aeration Dist. Pipe V, A I T Aa, / Holding Bot. System u Q PUMP/SIPHON INFORMATION Final Grade / ~i✓ og,I Manufactur D and St Cover PM IAVIANA (X- Mod Number OUS i S a •y TDH ift Friction Loss Syste ead DH Ft n~ Forcemain Length D Dist. to Well ~1 u 'V SOIL ABSORPTION SYSTEM BED/TRENCH Width Len h c No. Of Trenches PIT DIME ONS No. Of Pits _ Inside Dia. _ , Liquid Depth DIMENSIONS f~®/ 00:/ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR fffl U N ID qat ~~h / UNIT Model PWb / 00000, /WL DISTRIBUTION SYSTEM U Hea / ifild Distribution x Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing 16po f J SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only e 4l Depth Over \ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ` ed Trench EdgesTopsoil _ Yes YPC No _ COMMENTS: (Include cod screpencies, persons present, etc.) ~Inspection #1: Inspection #2: Location: 1258 152ND AVE 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover tN 6 J6- Plan revision Required? ❑ Yes o Use other side for additional informati Date Insepcto Signature Cert. o. SBD-6710 (R.3/97) / 0% 1-' IN[ ED 5RN -a0 1-1 - a 3a %AF County Safety and Buildings Division St. Croix 201 W. Washington Ave., P.O. Box 7162 s P I~~ tl 1L 4 W I Sanitary Permit Number (to be filled in by Co.) $ t~ ~IU N.~ Madiso 15 07- 62 CRO D&SLOPME 59 7Y/ 7 Qn-Y pxpAZNPNE13JR6 State Transaction Pwnbe Sanitary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit 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 purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. Same / Z 9 /52 1. Application Information - Please Print All Infor on Property Owner's Name + Parcel # David Kralovetz Carrie Gauerke 1 026-1149-00-008 Property Owner's Mailing Address Property Location 1:5.30. / g, 1113 1258 152nd Ave Govt. Lot _ City, State Zip Code Phone Number SW y, SE Section 15 New Richmond Wi 54017 30 (circle one) T N; R -IS E or n II. Type of Building (check all that apply) 1 or 2 Family Dwelling Number of Bedrooms 8 Subdivision Name Block # Cherry Knolls r,v 4C¢.rbt,C ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of CC'3060 %_J Z?a,.ZZ IR Town ofRichmond A& MLACPS III. Type of Permit: (Check only one b ix on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 420612 12/13/02 IV. Type of POWTS System/Component/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 (ex lain) ❑ Pretreatment Device (explain) ;i:;LP1 V. Dis rsal/Tre ent Area Information: Design Flow (gpd Design Soil Application R (gpdsf) Dispersal Area Requi d (sf) Dispersal Area P posed (sf) System Elevation 450 .50 900 920 95.50 11 /tit, VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units LA4A U ' New Tanks Existing Tanks Polylok 525 c v 0 y n. U cz -t~ ~n w C7 a Septic or Holding Tank Weeks Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibili for install bon of the POWTS shown on the attached plans. Plumber's Name (Print) Z~, s Silure / ` MP/MPRS Number Business Phone Number Keith Knudtson 7/-. 648443 651470-1737 Plumber's Address (Street, City, State, Zip Code) 927 150th Street Roberts Wi.54023 Coun /De artment Use Onl pproved El D proved Permit Fee Dat Issyu~ed Issuing nt Signature ❑ iven Reason enial $ f - IX. Condit easog1~s feDisapproval T. k', i~l'IIt G11f 1 r dbi per-c:,i cell must all be as per iparsgemen! plan pto /ided by plumber. 2. All SeOMCk r!'GLiIm ems must, iw i rtc a, A as per sppiiwbls c0X1,,r /,::rdimilr.r . Attach to complete plans for the system and submit to the County only on paper not less than 8 in i 11 inches in size SBD-6398 (R. 11/11) q, N Z J 0. Ln Z> IDZI in ~C~ C`~ No K _j Lo O Z~ U~Lf) cn C° r co o , Ww U Q ~ ? JAM a~ c ~ .r P an ! IL - O 7R p ~ n CONVENTIONAL COMPONENT DESIGN i Residential Application INDEX AND TITLE PAGE Project Name: kralovetz Owner's Name: David Kralovetz Owner's Address: 1258 152nd Ave New Richmond Wi. Legal Description: SW1/4SE1/4 S 15 T30 R18W Township: Richmond County: St. Croix Subdivision Name: Cherry Knolls Lot Number: 8 Parcel ID Number: 026-1149-00-008 Page 1 index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: Keith Knudtson License Number: 648443 Date: 07/24/2017 Phone Number (651) 470-1737 Signature 4,///' SE!) Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 0.Y L) cr N Z W n m 6 C'i C\j r- 07 J ~ ~Q W Z~ cr. Y cl d LP a ~ 9 ty Z u ~s f ta IL o> !2 +W _ u 0 40 b c ~ ~v to Z 0 1 Soil Absorption Svstem Cross Section i 4' Schedule 40 Final Grade PVC Vent Pipe With Vent Cap ft Leaching --p,. Chamber F- l` ---5 ft System Elevation eft _ ft Soil Absorylon System Plan View ft ft I 1111111111111111111111111111111111111111111 [1111111111111 I ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4' Dia. Trench 2 Header IL.eachina Chamber Specifications Manufacturer And Model EISA Rating Ss= sq ft per chamber Soil Application Rate d gpd/sq ft S~ gpd Design Flow + Soil Application Rate +EISA = Chambers 2 rows of chambers each. i Page of POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I "af 2 FILE INFORMATION SYSTEM SPECIFICATIONS Ov ner Septic Tank Capacity al ❑ NA ve le Permit # Septic Tank Manufacturer G ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer L 1 o ~r ❑ NA Number of Bedrooms ❑ NA Effluent Fitter Model 5Z ❑ NA Number of Public Facility Units ~[A Pump Tank Capacity gal ) fA Estimated flow (average) 49D , gal/day Pump Tank Manufacturer Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer )<N^-A Soil Application Rate gal/day/ft' Pump Model NA Standard Influent/Effluent Quality Monthly averages Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Fitter Biochemical Oxygen Demand (BODS) S20 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dis rsal 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) 510° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y8 in di a. ❑ NA Oar: ❑ NA Other: ❑ I Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ onth(s) (Maximum 3 years) ❑ NA year(s) Clean effluent fitter At least once every: yeoanr(s)(s) ❑ NA A Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other' At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the gro ind surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notificatior of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, 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. PL-525 EFFLUENT FILTER s 525 Filter is rated for ~ '0,000 GPD (gallons per day) 7196" Filtration Slots it one of the largest filters -o i7.V '0 riass. It has 525 linear feete Y' " u filtration Slots_ Like the = Y Am.M PVC Exten*n Handle • -'A PL-122, the Polylok _25 has an automatic shut -all installed with every filter. the filter is removed for , n!ng, the ball will float up and pararily shut off the system so ;fluent won't leave the Unear InW v other filter on the market can Mer;onsws - afn that claim. k Ratedforover - 1U.W0 GPD 41 e SOHO. 40 Pipe e PL-525 Effluent Filter should -erase efficiently for several years - - - _ der normal conditions before -squiring cleaning. It is recom- --.ended that the filter be cleaned ery time the tank is pumped or a- least every three years. If the ` ' betwev, 409 - 1,500 GPD. _.stalled filter contains an optional eiarm, the owner will be notified . flcv.,s and can be dy an alarm when the filter needs servicing. Servicing should be applications it is NSF certified for :done by a certified septic tank -pumper or installer. Autarnalk s off U.S. Patent No# 6,015,488 1. Locate the outlet of the ~"'""1e1`" Removed ' 5,871,640 septic tank. 2. Remove tank cover and pump tank if necessary. E,`_, r 3. Glue the filter housing to - 1, S- F1 11, CD r0l 3. Do not use plumbing when the 4" or 6" outlet pipe. If filter is removed. Ideal for residential and com- the filter is not centered 4. Pull PL-525 out of the housing. mercial waste flows up to under the access opening 10,000 Gallons Per Day (GPD). use a Polylok Extend & 5. Hose off filter over the septic Lok or piece of pipe to tank. Make sure all solids fall 1. Locate the outlet of the center filter. See page back into septic tank. septic tank. 19-21 for Extend & Lok 6. Insert the filter cartridge back 2. Remove the tank cover and information. into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter the filter is properly aligned into its housing. and completely inserted. 5. Replace and secure the 7. Replace septic tank cover. septic tank cover. 5 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 1258 152nd Ave New Richmond wi. located at: sw 1/4, SE 1/4, Section 15 , Town 30 N, Range 18 W, Town of Richmond , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 7-19-17 Did flow back occur from absorption system? Yes No x (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): weeks Age of Tank (if known): 15 yrs Permit umber (if kno ril) 420612 Keith Knudtson (Licensed Plumber Signature) (Print Name) 648443 (Title) (License Number) MP/MPRS 7-24-17 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer David Kralovetz or Carrie Gauerke Mailing Address 1258 152nd Ave. Property Address Same (Verification required from Planning & Zoning Department for new construction.) City/State New Richmond, Wi Parcel Identification Number 026-1149-00-008 LEGAL DESCRIPTION Property Location SW '/4 , SE '/4 , Sec. 15 T 30 N R 18 W, Town of Richmond Subdivision Plat: Cherry KnOIIS , Lot # 8 Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house Oyes Ebo Lot lines identifiable Byes[:]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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statem(of n this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtu warranty deed recorded in Register of Deeds Office. /~Nrmber of bed ours 3 SI RE F'A PLIC N (S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) L 100, O • / 515 000, Q Xx 0.;0( r~ ~ X15 / ~ MAI OJ ,LO'SZZ E MMi►£,OO.OON I I 20VWAW g6e o ri Xn Nn sw _x x .~8'0~'► 3£ M.,*S,Z LOON min H f7os-RIYON 49t'969 M„ bS,Z E.OON c~ `n E'88ZS Mo$,GsZ LOON _ Z V3&V s/Hl AO.LbVd3dl SMV-7 0311 PToWn swu. 4Yns 33S - St i 4YfeKx~ttetrt i~patlntarlt of S2fiety End ~'rofess[astal SetvlCes pfvlst+an cf trtdtrRf~ s SOIL EVALUATION REPORT 03242 Page 1--°4 3 ks a=rdanCe with SPS 3M Wls, Adm. Coda MIM Stotler CST Mae,h oftm we site plans mi Rader not ims than a%x 11 inches in slze. Pian must County InCluda, hat oot limited to: vedlcai and hortzontei re%renee poBnt (BM), dhgdlon and St. Croix percent mope, scale or dlrrtertsiuns, north arrow, anti Weak" and distance to nearest rand. Parcel I.D. Flawse iarJnt aly tttiornradlon. _ _ 026-1949-~D-008 RsviuN9fBy `17 All Fewat lar4,4990A Y"U Pro,ne mft A be u9e[f for sanonttprp' PNPoW (prwftr I.aw, s.16.OA (5.}{ao}. b Property Owner Ptopafiy 1.9wilon p, ~ - l 0 David Kralovelz Gavrr, t..ot St IA. SE 815, T30N, R18W prop" 0"er'e Mai@ng Adrtrest: Lot# 131exst# $u6d. Name orC 125EI 152nd Av& Cherry Knolls C - - Stale Zip Code Ph M Number Lj Cliy LI Vdlaga N Town dearest Road New Richmond VVI 64017 Richmond Some F1 New Cor>alrtaon Ret idenllal I Number of hedtearns 3 Code de►Ivod design flow rats 460 GPD M keplacenwrif I-J Public or owmurcial - Describe: _ Parent materiat Dense Sandy Loam Till _ Flood plain elavellon, it applImbie NA fl. Ganoml mpi nenls Verdiicellort bor~igs td de mtltto suitatalily of so'.Is for replamewl sanitary system, and recommendations: I:fl Borkv a U Pit Ground surface elev. - 101.02 .-f(. Depth to I;,n1Mg 1hoW >114 In. Sod gpp3fcatton Rate Hannan Depth Dominnal Color Redox [Desrriptlon Texture, Struclure Wlels aaundary Rants Gf'fA,' _ in. Mur"ll Qu. sx. Owl Coke Gr. St. Sh. v-M •EtFf 1 0-9 10YR312 Sit 2msbk mvfr cs 3f-M 0.6 0.8 --2 9-14 10YR413 zmsbk mvfr g5 3f-irt o.6 1.0 3 14-28 10YR4f4 2msbk mfg 9S 2( 0.4 0,6 4 26-36 l0Y114f4 - Is W9 mi gs if 0.7 116 5 36-48 7.5YP314 sl 1m5bk/m Mur 9S if 0.2 4.6 6 48-1141 75YR514 - fs 1111 _ #6 - nufneraw bands of umssive strvfs 7, R3r'3 + 3,14 *A SONS r~r saturatlon at W, r Pil Ground surface elev. 10.0.65 R, 5Mh to 11 ft factor >108 in. Sot! Jtppl4caVon Ra' tiortzori 70-~Iqo Dominant Colpr Redox Aeserl 5tnrdure 1Crsnsiate $uundary Roma GPDMT Murrsell au. Sz. cant_ Colo re Gr. sz, sh, RE~t 1 1OoYR2f2 - sit 2msbk QW11' CS 3f -m 0.6 0.8 2 10-15 10YR4f3 2msbk mvfr 95 3f-rn 0.6 0.8 3 15-29 10YR4f4 - cl 2msbk mfr gs U -M 0.4 0.6 4 2939 7.5YR314 $I Inisbk Mfr QS 1(-M CA 0.7 5 39-50 7,5YR414 It Osg m1 gs ff 0.5 1.0! 6 150-108 7.5YR4J4+3f4 Ml - 0.7 1.6 _ aw 6td trslons of massive si SYR414 ` MUM 01 C 300e 30 r 22 nd 8 r 160 nigrt. ' E uanl *2 e 13Q.5 <30 trrgA_ and T88 s.30 m1pL CST Name (Prieasa A111110 Signature: CST NuMbef Kei#h Stoner 224059 Address Kealr Stoner CST outs Evatuetlon Conducted Telep%ane Number 23220 Wood Crete Rd Siren, Wl 54872 7f f912i117 716-566-0900 sooexmtersrrnsl f Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420612 0 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: Derrick, Steve Richmond Townshi 026-1149-00-008 CST BM Elev: Insp. BM Elev BM Description: IL •o~ tp•o~ pf- uQQs~ 's P~~ 1 TANK INFORMATION ELEVATION DATA S "I TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ios.~i I00 - c7 cf, Dosing Alt. BM Aeration Bldg. Sewer 4,-331 99- 39 f Holding St/Ht Inlet S-113 19% 5-11' 1 TANK SETBACK INFORMATION St/Ht Outlet / 14-111 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic f t 1 ^ f Dt Bottom > 5a > Sb J~' Dosing Header/Man. •z 0 9(, sz' Aeration Dist. Pipe 6.62/ Holding Bot. System )0.2 L S. S-n f PUMP/SIPHON INFORMATION Final Grade 01.32/ Manufacturer Demand St Cover j GPM 6. 3'Z 4e-+) lo-. 3f Model Numb TDH Lift ction Loss System Head H Ft Forcemai Length Dist. to well SOIL ABSORPTION SYSTEM 2Z ENC Width r Length t No.pf Tifenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 , o C_ SETBACK SYSTEM TO P/L BLDG WELL LAKEISTREAM LEACHING Ma fa q~ C INFORMATION CHAMBER OR x J Type Of System: Z'~ r 2 r > I LIDr - UNIT Model Number..1zQ DISTRIBUTION SYSTEM L I iv w / p r_ Header/Manifold ll Distribution x Hole Size Ix Hole Spacing Vent to Air Intake Pi 3 O i 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 xx Seeded/Sodded Mulched lBedITranch Center Bed/Trench Edges Topsoil IN 7 Yes © No Q Yes 7F0-jNo COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:441d/13 /2.!RO- 3 Inspection #2: Location: 1258 152nd Ave New Richmond, WI 54017 (SW 114 SE 1/415 T30N RI 8W) Cherry Knolls Lot 8 4w-. al No: 15.30.18.1113 n ' M^`~'~•~Qa .~aLR T'~) -1- - 'Z 1.) Alt BM Description = L,4e- T 2.) Bldg sewer length = y 3S f " ► c De \ T 'a-e-) tlve-t Z amount of cover J CAow.(s C4~ dA +;16" RQz _ Sdatiu• Plan revision Required? A Yes X No (*5 -1 Use other side for additional information. 4~ - SBD-e710 (R.3197) Date Insepctors SignatureCert. No. Safety and Buildings Division county , 201 W. Washington Ave., P.O. Box 7162 -7 !e s4 NVIsconsin Madison, WI 33707 - 7162 Site Address fT'~ De artm6nt of bommerce a-/ 7-0 Z.-- > S,n;~y Permit Number Sanitary Permit Application in accord with Comm 83.21. Wit. Adm. Coda, penoml informaton you provide o Check it Revision be used for I aw slS,04(lft) L AppBatiou Information - pleen Print All Information State Pan I.D. Number q fT - OV -uv Parcel Numbat OZ - tf I`( ptopetty OwnersName / L E •Qr u-Qa(.P ( S 3 a•/ I. 0 3 property / property owner's Mailing Address t ' IA)Mftn l si5c u S /S--T N R -1d City, State Zip Code [ Loh Number Block NNu ber gibdivisioon Name CSM Number GG✓ ~~ya! 7/. Ch ey1 G14r If - d IL Type of Build* (check 0 that apply) ❑City P-1 or 2 Family Dwelling - Number of Bwrooms ❑viltage 0 publlc/Commercial - Describe Use ~ kowashi ~C ❑StateOwned Z2 4L~ C3` k ~ Nearest Road 1 IOS III, Type of Permits (Check only one box on line A (numbering scheme for internal hue). Complete line B if applicable) A. Fos County use. I OLNew 2 ❑ Replacar im System 3 ❑ Replacetaent of 6 ❑ 'Additlott to Tank OnI Exis ' S hem Date Issued B. ❑ Check if Sanitary Permit Previously Issued Permit Number 11V. 'T'ype of Permit: (Check all t apply)(numbering scheme is for internal use) rC%~ 44 ~'Noa -Pressurized It -(IMO 210 Mound 47 ❑ Sand Filter 50 O Construe tad Wetand (1~y, r 6.P~v 3l -UI , 22 ❑ Presaurlaed in-8rour►d 410 Holding Tank 48 ❑ Single Pass 310 Drip Una A&24-1 43 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dis ersaU'IYeatment Area Information: Design Plow (gpd) Dispersal Aral Dispersal Area Soil Application Percolation Rate System Elev Final Grade Rcq jimd Proposed / Rate(Gals./Days/ hJ (MinAnch) Elevation 4/'54 4,~ . • ~/3 , 7 al., g~ 1-70 d 5-44 VI. Tank Info Capacity in Total Number anufacturer Prefab Steel Fiber Plastic Halloos Gallons of Tanks Concrete Constructed Glass Now Sxistint Tanks T sepde or Hollins Tank _ G ~ .r Dosing Clonibet VII, omibili &atement- 14 the araume tnapomib for tlen of the POWTS shown on the attached fans. Plumber's Name (print) Plumb=- Phzabves RS Number Business Photo Number ckH u Wa7QYd 71s-3 G -~?l Address (Streat, City, Staffs. Zip Code) ,I z5 ve i5-r,2 77"-',C4 Ygle,cowd !De Use only D ye17Y~ eat Sigoaaue o stamps) Approved Disapproved Sam a Permit Fee (iaclndes Groundwater ❑ ❑ Owner Given Initial Adverse . ot~ S, .i ~3 Gov Deondpatin rJ ~I ~It+' ~~s + C6oadttios s of App for Disnp proval J7 ~ dA" BfWa-3• - 14 mum Am SBD-63b f Wisc"n Dfi(wtmsnt of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordarme with Comm 85, Vft. Adm. Code County St. Croix Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include. txwt not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 06P percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Phwso print all lntbrmatlon. Date Personal Mformetlon you prcvids may be used for seoor►dary purposes (Privacy Lew. s. 15.04 (1) (m)). PropertyOwner Property Location PC Steve Derrick Gov, Lot SW 1/4 SE 1/4 S 15 T 30 N R 18 r) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSMfi 1438 County Road G 8 - Cherry Knolls City Stabs Zip Code Pho-m Number E]DIty Village ■ own Nearest Road New Richmond WI 54017 ( 7J5-246-3120 Rkhmmi County Road G 19 Now Cordon UselD Residential / Number of bedrooms 3 to 4 Code wed design now rate 450 to 600 GPD 0 Replacement Public or commercial - Describe: Parent material TAX= mmr rill Flood Plain elevation if applicable R General a comments _ Site suitable for a conventional below grade ' w/ alternating bands of s, 7.5yr5/6, 0sg, SyS-(~v~. ~le~ ~1 l _ ~3.g 2 8 2002 ;r ❑ Boring # >110 Q Pit Ground surtaoeelev. 102.00 ft Depth to limiting factor in. Soll cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOIN In. Munsell Qu. Sz. Cont. Color Gr. SL Sh. 'EW1 *011#2 1 0-9 10yr3/2 sil 2msbk mfr cs 2f .5 .8 2 9-24 7.5 4/4 Sid Imsb mfi cs if .2 .3 3 24-62 7.5 4/4 +s1 Om mfi cs - .3 .5 4 62- 10 7.5yr5/4 s 09ml - - .7 1.2 t/ 2 # 0 Boring 100.00 >1 10 a El Pit Ground surface elev. fL Depth to limiting factor in. 3011 Apfficallon Rate Horizon Depth Dominant Color Redox Description Te)dure Structure Consistence Boundary Roots GPDN in. Munsell Qu. Sz. Cont. Color Gr. Sr- Sh. 'E1f#1 'Eff#2 1 0-9 10yr3/2 - sil 2msbk mfr cs 2f .5 .8 2 9-24 1 0vr4/4 Sid lmsbk mfi cs if .2 .3 3 5 4!d +A 0m mfi cs - .3 .5 4 65-110 7.5yr5/4 s 089 ml - - .7 1.2 e • Effluent #1 = BOD > 30:5 220 mglL and TSS >30:5 150 mg& ` EllW = BOD < 30 mglL snd TSS 5 30 mgI& CST Name (Meese Print) Signs CST Number Thomas C Nelson 227387 Address Date Evaluating-Cend Telephone Number 1432 120th Street, New Richmond, Wl 9-25-02 715-246-2454 I Property Owner Steve Derrick Parcel ID # Page 2 of 3 Boring ❑ Boring # Pit Ground surface elev. 101.70 ff. Depth to limiting factor ~I 10 In SW (cation Rate j Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. `EW 'Etf#2 1 0-10 10yr3/2 - sil 2msbk mfr cs 2f .5 .8 2 10-25 7.5 /4 - sicl lmsbk mfi cs if .2 .3 3 25-45 7.5yr4/4 - *sl Om mfi cs - 3 .5 4 45-110 7.5yr5/4 - s 089 ml - - 7 1.2 F-1 Boring # Boring spit Ground surface elev. ff. Depth to limiting factor in. Rats -Soil Apoicalion Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDRF in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 I I Borg # Boring spit Ground surface e~`• I Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Opp/If In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Etf#1 `01#2 i Effluert #1 = BOD, > 30 < 220 mWL and TSS >30 < 150 mgA ` Effluent #2 = 8006 < 30 mgiL and TSS < 30 ffv& 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-8338T= (smroo) I I y s www.ctiv::o~~rc~f,~~`y~cs:Sti.eoMr rtS'-2462454 CHERILY Ilk NOLL0 ? LOT 8 ,y ~ ~c~ o~ ~a~ CACtne~t 10 ~ X25 t°~a i,+.> bpi 2- 94 1077s 00 bi 10~,.AC? 92, tpQ,a~ 63 (3~ o 3 Thomas Nelson Scale 1"=' o 227387 1