HomeMy WebLinkAbout030-1083-10-002 (3)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 597410
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:
JON & KIMBERLIE GILBERTSON TOWN OF SAINT JOSEPH 030-1083-10-002
CST BM Elev: Insp. BM Elev. BM Description: Section/Town/Range/Map No:
10-10 29.30.19.299E I ink 1"~ TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchm rk
9 Alt. BM
PO' Ak Bldg. Sewer.-
91
Ho>6n\ J St/Ht Inlet
(4jq f v , a
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Ven o it ROAD D,t Inlet
Septic Dt B
l IU 3 < <l~~
Do~ ns Header/Man. j
Aeratign Dist. Pipe
Holding Bot. System
r. . ~q
PUMP/SIPHON INFORMATION Final Grade
(y3 C~' c~~
Manufacturer Demand St Cover
GPM ZV' CV
Model Number
TDH Lift Friction System Head TDH Ft r
i
Forcemain Length / DDist_ to Well _
SOIL ABSORPTION SYSTEM
BED/TRENCH Width J enQt,h, INo. Of Trenches P SIONS No. Of Pits Inside Liqu 51~D
DIMENSIONS be ~C
Q~ 7
SETBACK SYSTEM TO P/L 5 BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR Uu!
Type Of System:
>f /DQ UNIT Model Number z
DISTRIBUTION SYSTEM
Header/Manifold Distribution ix Hole Size Ix Hole Spacing VAir~t e
1 h Pipe(s)
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 xx Mulched
Bed/TT C Le, Z (ti / s Bed Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepenC s, ersonspresent, etc.) Inspection #1: Inspection #2:
Location: 1375 FOX RIDGE TR 0
1.) Alt BM Description = ~k-t t1~ Cf3Ut Q~
2.) Bldg sewer length = v~
-amount of cover= Plan revision Required? r] Yes ❑ No I 1
Use other side for additional information. ~Q
SBD-6710 (R.3/97) Date Insepctor's Signatur v_-,` , Cert. No.
r-/~yn arir` J F Count
Industry Services Division St. Croix 17 -
D F Sanitary Permit Number to be filled in by Co.)
SP UL Z017 1 P.Q. Box 7162 1 ( J
fc Madison, WI 53707-7162
OUP1T`(
I 1'9 7 ~l~
ST.cp LOPME iJ G n
Sanitary Perml1t App 1Cation State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofthis form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address)
u oses in accordance with the Privacy Law, s. 15.04(1)(m), Slats. Same /5 75 F~w /24-
1. Application Informa ' - Please Print All Information
Property Owner's Name Parcel #
G
-7
ilbertson, Jon & Kimberlie 030-1083-10-002
aa4
Property Owner's Mailing Address Property Location
1375 Fox Ridge Trail
Govt. Lot
City, State Zip Code Phone Number SW NE Section 29
HOUItOll , WI 54082 le one)
T30N R19Eor(ILLr,Q
II. Type of Building (check all thaEBeldroo y) Lot #
I or 2 Family Dwelling- Number o11 Subdivision Name
NA
❑ Public/Commercial - Describe Use Block #
❑ City of
❑ State Owned - Describe Use
C M Number a ❑ Village of
Town of St. Joseph
III. T e of Permit: (Check only a box on line A. Complete line B if t licable) Imo..
A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Opener
106118 5/11/1988
IV. Type of POWTS System/Co mponent/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
Plod, fank Otherl~ispersal Component (explain) ❑ Pretreatment Device (explain)
0
V. Dis ersal/Treatm t Area Information:
Design Flow (gpd) Design Soil Application Dispersal Area Required ( Dispersal Area Propose (so System Elevation
600 Rate(gpdst) 1200 1200 95.65', 94.25', 92.75'
0.5
VI. Tank Info Capacity in
Gallons Total # of Manufacturer U o
Gallons Units
0 ~ y
New Tanks Existing Tanks A.
t,)l Septic or Holding Tank 1250 1250 1 Wirser Con ete ® ❑ ❑ ❑ ❑
Dosing Chamber ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
usiness Phone Number
Plumber's Name (Print) Plum be ' _natt MP/MPRS Number T715-760-0486
John Schmitt 223760 Plumber's Address (Street, City, State, Zip Code)
616 150`h Ave. Somerset, WI 54025
VIII. ' unty/Department Use Only
Approved Permit Fee Date ~Sured y Issuing nt Signatur
4e~ /
rven Reason for Denial $ O
7/
IX. CondFi 7Disapproval 3) a~ 4
~IarM Cell must all be sar, :teas !_n~t~n g4
as per iRsalgement plan pro Aderl by plumbei. C~
2. `AH lsetbiltc'regtiire! yen s mrn;E,kw t-ta~nti IIJEe~
as pw /Wlkxlbbit cndr= / crdiruln w.
Attach to complete plans for the system and submit to the County only on paper not less than 8 uz x 1 I inches in size
SBD-6398 (803/14)
PLOT PLAN N
Project Name: Gilbertson 4 Bedroom Replacement Septic System
Legal Description: SW1/4, NE1/4, S29, T30N, R19W P.I,D: 030-1083-10-002
Subdivision Name: NA Lot 11
Township: St. Joseph Parcel Size: 4.440 Acres SCALE: V=60'
County: St. Croix
System Elevation: T1= 96.36' Existing 5'X66' Rock & Pipe Trench
Slope: 18% T2= 96.37' Existing 5'X66' Rock & Pipe Trench
BM1 Elevation: 100.00' Top of 1" steel lot corner T3= 95.65' Proposed 80.00' EZ Flow Trench
BM2 Elevation: 110.10' To of Septic Tank cover T4= 94.24' Proposed 80.00' EZ Flow Trench
Backhoe Pits: T5 92.75' Pro osed 80.00' EZ Flow Trench
New Septic Tank Wieser Concrete W1250-MR
See Plat Map for complete view of parcel Filter POLYLOK 525
Existing tank to be replaced
4 inch Sch 40 -ASTM D2665
4 inch 3034 - ASTM D3034
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Page 2
CONVENTIONAL COMPONENT DESIGN
R side n~lal APPhc-zilch
INDEX AND TITLE PAGE
Project Name: Gilbertson 4 Bedroom Replacement Septic System
Owners Name: Jon & Kimberlie Gilbertson
Owner's Address 1375 Fox Ridge Trail
Houlton, WI 54082
Legal Description: SW1/4, NE1/4, S29, T30N, R19W
Township St. Joseph
County: St. Croix
Subdivision Name: NA
Lot Number: 11 Block Number
Parcel I.D. Number 030-1083-10-002
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 System Sizing & Cross Section
Page 6 EZ Flow Information
Page 7 & S Management and contingency plan
Page 9 Septic Tank Maintenance Agreement
Page 10 Warranty Deed
Page 11 CSM or Plat
Attachment 1 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 7/17/2017 Phone Number: 715-760-0486
Signature:
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN N
Project Name: Gilbertson 4 Bedroom Replacement Septic S stem
Legal Description: SW1/4, NE_1/4, S29, T30N, R19W P. 1. D: 030-1083-10-002
Subdivision Name: NA Lot 11
Township: St. Joseph Parcel Size: 4.440 Acres SCALE: V=60'
County: St. Croix
System Elevation: T1= 96.36' Existing 5'X66' Rock & Pipe Trench
Slope: 18% _ T2= 96.37' Existing 5'X66' Rock & Pipe Trench
A BM1 Elevation: 100.00'
Top of 1" steel lot corner T3= 95.65' Proposed 80.00' EZ Flow Trench
ZNS BM2 Elevation: 110.10' Top of Septic Tank cover T4= 94.24' Proposed 80.00' EZ Flow Trench
Backhoe Pits: T5 92.75' Proposed 80.00' EZ Flow Trench
New Septic Tank Wieser Concrete W1250-MR
See Plat Map for complete view of parcel Filter POLYLOK 525
Existing tank to be replaced
1 4 inch Sch 40 -ASTM D2665
4 inch 3034 - ASTM D3034
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Page 2
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Page 3
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L-52 Effluent Filter
innovations in Precast, Drainage Zabel"
8 Vllsteti-rater Products A Division of Polylok Inc.
PL-5 25 Filter
The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has
525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PIS 525 has an automatic shut-off ball
installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off
the system so the effluent won't leave the tank.
Features: 1/16" Filtration Mots r
Alarm Switch
Rated for 10,000 GPD (gallons per day). 75 (optional)
* 525 linear feet of 1/16" filtration. 1~,~0~ GPD
Accepts 1" PVC
Accepts 4" and 6" SCHD 40 pipe. I Extension Handle
7t
Built in gas deflector.
Automatic shut-off ball when filter is removed.
Patetfor
10,000 GI't)
Alarm accessibility.
Accepts PVC extension handle. t,~~< x,:.
"l, 52Installation: x
525 Linear Ft.
Ideal for residential and commercial waste flows up to of 1/16„
10,000 gallons per day (GPD). Filtration Slots
1. Locate the outlet of the septic tank.
2. Remove the tank cover and pump tank if necessary.
Accepts 4" & 6"
3. Glue the filter housing to the 4' or 6 outlet pipe. If SCHD 40 pipe
the filter is not centered under the access opening use a
Polylok Extend & Lok or piece of pipe to center filter.
4. Insert the PI, 525 filter into its housing. Certifieed to
5. Replace and secure the septic tank cover. PlSFlANNs1 standard 46
The PL-525 Effluent Filters will operate efficiently for
several years under normal conditions before requiring
cleaning. It is recommended that the filter be cleaned
every time the tank is pumped, or at least every three
years. If the installed filter contains an optional alarm,
the owner will be notified by an alarm when the filter Gas Deflector
needs servicing. Servicing should be done by a certified
Automatic
septic tank pumper or installer. Shut-Off Ball
1. Locate the outlet of the septic tank.
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when filter is removed.
4. Pull PL-525 cartridge out of the housing.
5. Hose off filter over the septic tank. Make sure all
solids fall back into septic tank.
6. Insert the filter cartridge back into the housing making 0 nrtd00r Sinai tl iIicu,, Ala m, Fxtend & T-ok"'
sure the filter is properly aligned and completely inserted. poly lok, Zabel & Best filters accept Easily installs
the SmartPilterO switch and alarm. into existing tanks.
7. Replace and secure septic tank cover.
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
Page 4
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Gilbertson 4 Bedroom Replacement Septic System
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
System Sizing
0
EISA Rating per Foot of EZ Flow ft2 Soil Application Rate 0.5 gpd/ft2
600.0 gpd Design Flow _ 0.5 Soil Application Rate _ ~ EISA = 240.0 Feet of EZ Flow
trenches 80 feet long each
3 No. of Cells 8 Per Cell
3 ft Cell Width 24 Total No of 1203H
80 ft Cell Length 400 sq ft EISA Per Cell
3 ft Cell Spacing 1200 sq ft Total EISA
Typical Cross Section
Finished Grade 96 ft Observation Pipe with
approved cap or vent
Soil Backfill
36 inch Geotextile Fabric
>3 ft
12 inch > 3ft~ Slotted and Anchored Vent/Observation Pi
9 with Cap
95.65 ft ft. I-.. - -
>36 inch 94.25 ft/ O (
\ 92.75 ft. Infiltrative Surface
Plumber/Designer Signature:
License MPRS 223760 Date: July 17, 2017
Installation Instructions for E Z7U
EZflow Systems in Wisconsin
F ILTRATOR
Wisconsin Department of Commerce, Safety and Buildings 5, The Absorption area (SF) necessary for a given site shall
Division, has reviewed the specifications and/or plans for this ; be sized based on maximum daily sewage flow (GPD) and
product and determined it to be in compliance with chapters ; the Permeability for the site. If certain criteria is met, the
Comm 82 through 84, Wisconsin Admin. Code, and Chapters : EISA sizing can be used in Wisconsin, resulting in a 40%
145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield.
& Soil Conditions & Locations & Isolation distances as noted in
local regulations. 6. Place EZflow bundle(s) in the EZflow configuration ap-
proved by system design permit specified for the particu-
The approved products are 1203H (3-12" bundles with pipe in lar site. The top or center-most bundles containing pipe
center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any
with pipe in each bundle in 5' or 10' lengths, additional aggregate only bundles that may be required,
should be butted against the other aggregate-only bun-
A single pipe bundle contains a four inch perforated pipe sur- dles and do not require any type of connection,
rounded by EPS aggregate and is held together with poly-
ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a filter fabric pre-
only and is held together with polyethylene netting. manufactured in between the netting and aggregate. The
• fabric is inserted to prevent soil intrusion. The installer
Materials and Equipment Needed - shall make sure the the GEO is positiioned upward and is
• EZflow Bundles in contact with the fabric contained in the adjacent cylin-
• EZflow Geotextile Fabric der before backfilling.
• EZflow Internal Pipe Couplers
• Pipe for Header and Inlet : 8. The EZflow Drainfield Systems should be installed in a
• Backhoe/Excavator level trench in all directions (both across and along the
trench bottom) and should follow the contour of the ground
Installation Instructions surface elevation (uniform depth), with all continuous
The instructions for installation of EZflow products are given adjoining 10-foot cylindrical bundles placed end to end,
below. This product must be installed in accordance with state with central bundle distribution pipe interconnects
rules defined in chapters Comm 82 through 84, Wisconsin Ad- : without any dams, stepdowns or other water stops.
ministrative Code, and Chapters 145 and 160, Wisconsin Stat-
utes, as well as the local health department's current design ; 9. The trench top shall be graded such that water will not
manual. pond. Backfill should be seeded or sodded immediately
after completion to reduce erosion.
1. After the local health department has determined sizing, ;
configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved
or mark with paint the location of trenches and lines. Be trenches as may be necessary to avoid trees, boulders, or
careful to set correct tank, invert pipe, header line or dis- other obstacles.
tribution box and trench bottom elevations before instal-
lation of pipe bundles. 1 1. EPS aggregate is lighter than water, therefore, it might
• be expected that natural buoyancy forces would tend to
2. Remove plastic EZflow shipping bags prior to placing cause EZflow assemblies to float out of ground when
bundles in the trench(es). Remove any plastic bags in the ponding occurs. Field experience has shown, however,
trench before system is covered. that this is not a problem when systems have a minimum
of 6" of soil cover as recommended by manufacturer.
3. This product must have geotextile fabric that meets re-
quirements of s. Comm 84.30 (6) (g), Wis. Adm. Code,
installed directly on top of the product and extending 1203H-GEO
down along the sides of the product to a point at least six
inches from the bottom of product, Geotextile
• _ _ Barrier Material
u
• m,
4. When installed in a trench the trench should be dug to
a width of 36 inches. This not only saves labor in excava-
tion, but also provides better load-bearing capacity after
backfilling is complete.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner: Jon & Kimberlie Gilbertson Tank Manufacturer: Wieser Concrete ❑ NA
Permit # ❑ Septic []Dose ❑-lolding Volume: 125OLP
DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete 21 NA
Number of Bedrooms: 4 Q NA ❑ Septic []Dose ❑-lolding Volume: gal
Number of Public Facility Units: NA Vertical Distance Tank Bottom(s) to Service Pad: ft
Estimated (average) Flow: 400 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft
Design Flow = estimated x 1.5: 600 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if
In Situ Soil Application Rate: 0.50 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back.
Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: POLYLOK ❑ NA
Fats, Oils & Grease (FOG) s30 mg/L Effluent Filter Model:
Biochemical Oxygen Demand (BODa) !5220mg/L NA Pump Manufacturer: NA
Total Suspended Solids (TSS) 5150mg/L Pump Model:
High Strength Influent/Effluent Monthly average Petreatment Unit ' NA
Fats, Oils & Grease (FOG) 5_30 mg/L Manufacturer:
Biochemical Oxygen Demand (BOD5) 5220mg/L ❑ NA ❑ Mechanical Aeration ❑ Peat Filter
Total Suspended Solids (TSS) 5150mg/L ❑ Disinfection ❑ Wetland
Petreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other:
Biochemical Oxygen Demand (BOD5) s30mg/L of so, rr tion System
Total Suspended Solids (TSS) !530mg/L ❑ NA fJ In-Ground (gravity) ❑ In-Ground (pressure)
Fecal Coliform (geometric mean) 5104cfu/100m1 ❑ At-Grade ❑ Mound
Maximum Effluent Particle Size: /a in dia. A ❑ Drip-Line ❑ Other:
Other: ❑ N Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with sludge and scum equals one-third ('/3) of tank volume
Pump out contents of tank(s) When the high water alarm is activated
At least once every: 3 month(s) (Maximun 3 Years ❑ NA
Inspect condition of tank(s) ears
Inspect dispersal cell(s) At least once every: 1.5 month(s) earls (Maximun 3 Years) ❑ NA
R1 y)
Clean effluent filter At least once every: 1.5 month(s) NA
ears ❑
month(s) NA
Inspect pump, pump controls & alarm At least once every: year(s)
me this) 0 NA
year(s)
month(s) Q NA
year s)
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 Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank
inspections must include a visual inspeciton 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 a check for any back up or ponding of effluent on 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 indicated a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumualtion of sludge and scum in any treatment tank equals one-third 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
Admininistrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment units,
and any servicing at intervals of 5512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
(Rev.2/05)
Paee 7
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, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil 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 extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain
(sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely
abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for
a code compliant replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil
and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their
permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
® 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: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
1 OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name: John Schmitt Name: John Schmitt
Phone: 715-760-0486 Phone:715-760-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Owners Choice Name: St. Croix County Zoning
Phone: Phone: 715-386-4680
This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Use of this document does not guarantee the performance of the POWTS.
(Rev. 2/05)
Pate 8
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
owner/Buyer Jon & Kimberlie Gilbertson
Mailing Address 1375 Fox Ridge Trail
Property Address 1375 Fox Ridge Trail
(Verification required from Planning & Zoning Department for new cons true tion.)
City/State Houlton, Wl Parcel Identification Number 030-1083-10-002
LEGAL DESCRIPTION
St. Joseph
Property Location SW '/4 NE 1/ Sec. 29 T 30 NR 9 W, Town of
Subdivision Plat: NA Lot # 11
Certified Survey Map # Volume Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house ❑yes[Dno Lot lines identifiable ByesFIno
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 (t) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the tluee year expiration date.
I/we certify that all statements on is 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 trranty deed recorded in Register of Deeds Office.
Number of ~drooms
GNATURE OF APPLICANT(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)
Page 9
LOCATED IN THE SE1 /4 OF THE NW1 /4, THE NE1 /4 OF THE NW 1 /4, THE NWI'/ -KE
NE1 /4 AND THE I-)Wl /14 OF T'-:1-: 1,7E1 /4, ALL IN SECTION 29, T30N, R1 9W, TOWN OF
ST. JOSEPH, ST. CROIX COUNTY, VI!ISCONSIN.
SCALE IN FEET
0 200' 400'
~ UN PLATTED D- APPROVED
APR 2 3~ k984
W ESSTvA 25.70'
!rnN UNPLATT_Eg7, ;P ~C "iJ,.TY
_0 T - 4- 1 x - O ^ O - -42h1P,fE~lENSIVE PADS PLANNIWu
C. S. co t~",i1P ZOJJING C0N11.%lTlEE'
!Z i o
1. 3, P. 1614
IG)
I
LOT 12 3, -
I~i0 9.68 AC.+ _
~N 421,738 S.F.± N 76 °49'W
f O W
"U NUJ S N N 0
I~ Ow 0°2 S74 75°
_ cp
0 19,
wo 1 SSA 40 3 0 „ W
(A cn
ID vn jl75'aS' O
Im N g 30. 70 ro
`2 7 0 ~
45,
UNPLATTED LOT
i~
8.87 AC.+ ~m
LAND S `8~a 386,306 S.F.± MEANDER co w
\ ~o84e,~ S 448 4 4 5I 7 E ca z v
~.4OFU7 t „W i 62, 6 W 'r
S86°f8'12 7' - _ o i-1
200.00 20 4 N78°S6' 07"W 626 3 0 °ZO I-i
X23 2'""" (D :-4 I~ Im
2 co 01" I
c~ II \ 89 69.7
? I LOT 9 2 123.57' ~o o0
Q\ iN,, m i r
a I C. S. M. '7
m I 1 0 N m iZ
w . V.5, P. 1250 6'~ s to i - - - LOT 10 a < 'o- 10.26 AC.+ 0°
F
446,742 S.F.+ y
6` p -
DRAFTED BY WALTER J. GREGORY iD
Q -4
c
' o
0
CENTER OF P01 N T OF
SECTION 2. 8 E G I N N I N G ~Co
2646.92' IB2.00' 456.02' w
N 89°45'46° E 2828.92' N89045'46"E
EAST-WEST 1/4 SECTION LINE E 1/4 OAWJPI
RECEIVED
S of l ~a~7
D 1 ~~~7~nP / a SOIL EVALUATION REPORT Dag-- 1 of ~
p alm wit' om S. f~.dm"ode fla9
f1 1~ in accord
cJU Pro essiogal Services 1 Schmitt Soil Testing. Inc
S1. (`,RUIX COUNTY 1 1 '~OUnt?/
Att UNFSft E+H`f~~M~less than 8r- x 11 Inch ll St. Croix
ncl'u'7e~.~~b~ut not limited to. vertical and horizontal reference point (BM). direction an pa net 1 D
percent slope. scale or dimensions. north arrow and location and distance to nearest road. 030 108 10 02
Please print all information. Review By D e
° r .
Fern=oral ~nfOrrr~..ior: you prcvioe may ee used fc-e::Ondary pu noses ;Pr,v2cyl-av J^A
Property Owner P nperr Location
Gilbertson, Jon & Kimberlie .:ovt L01 S 14. NVV11 . S2 , T30N. R19W
of Eic-,K,, t) Subd Name ar C 14'
!Property Owner's Mailing Address 1 ~
I ; 1
11375 Fox Ridge Trail CSN1 5/1414
City State Zip Code Phone Number City dillage -own Nearest Read
Noulton WI 54082 715-549-5227 St.Joseph Fox. Ridge Trail
Jse Residential ,Number of bedrooms 4 :ode derived design flow rate 600 GPD
I New Constructior,
Replacement Publ•c or commercial - Describe
ooc pair, e eve ion if applicable NA ft.
Parent material Outwash (Hubbard loamy sand)
General comments Area is su;tah_!e for o COnV~n,t ndi. ~_y5.ern w - r yp r: r? ~ `+a! ~ ' ,.c aCaan ~„f~iPd a a a. mot, O 2 3 K"
R7 ~i i c
u
land reeorrmendaiions- s :pct; trenche 9~5 Si-- c rt,j.Tc,. is 1E°
i1
Boring # Bor ng Pit Ground surface elev 94.50 ft Depth to iirubna factor 1 ~n So.l Application Paie:
Consistence Boundary Roots GPDr
Horizon Depth Dominant Color Redox Description Texture Structure -E,~,, .E`~2
in Munseli Cu. Sz Cont Color Gr Sz Sh.
1 0-15 10yr3/3 none sl 21 sbk mfr as 2m,2f 0.6 10
si 2risbk mfr gw 2vf 0.6 1.0
2 15-S1 l0yr~+J-s none
3 S1-71 7.5yr4/6 none si 3msbk m,,rfr Cs if 0.6 1.0
m2d i0vr616 sil lmsbk mfr - 0.4 0.6
'
4 71 84 10yr5/4 luyi6i2
q Z.~S rC
Boring
Boring 96.85 f Depth tc !!roiinna facto 84+ in. Soil Applica!in Rate-
Pit Ground surf - -
sace e~a~~_
->Got_ c UPn f'
. '
riz Depth Dominant Color Redox Description Textt re SGr.trucSz`ure Sh_ Consrsterca Boundary r Etfk1 E t 2
IV"unsell Qu Sz Cort Color
2 r9r ni~Ar as 2f,2vf 0.6 1.0
10yr3j3 Wane sl
0 - 5
2 5-39 10yr5/6 none Is Osg mi Cs IV-11 u.7 1.6
0.5 1.0
m! - -
39-54 10yr5/6 none ifs 0s9
J
ff!uent #2 = BOD. <30 :rail- and TSS <30 ma/L
Effluent 10 = 80D 30 < 220 mail- and TSS %30 < 150 marl- E - CST Number
CST Name (Piease Print) Signature- CST Nu
( Thomas J. Schmitt Date Evaiuatton Conducted Telephone Number
Address Schmitt Soil Testing Inc. C,115,120 17 715-100-1015
1595 72nd St. New Richmond. W! 5x+017
Property Owner Gilbertson, Jon & Kimberlie Parcel ID # 030-1083-10-002 Page _-2-.-of 4
F3 Boring # Boring Pit Ground surface elev. 93_40 ft. Depth to limiting factor _ - in. iSoil Application Rate!
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots _GPD/ft2
Effm1 'Eff#2
in. Munsell Qu Sz. Cont. Color Gr. Sz. Sh.
1 0-10 10yr3/2 none sit 2mgr mvfr as 3vf 0.6 0.8
2 10-25 1Oyr5/4 none sl 2msbk mfr gw 2vf 0.6 1.0
3 25-55 7.5yr4/6 none gris icsbk mvfr gw 1vf 0.6 1.0
4 55-88 7.5yr4/6 none grlfs icsbk mvfr 0.5 1.0
Boring
4 Boring # pit Ground surface elev. .__104.60 ft. Depth to limiting factor $5+ in. ;Soil Application Rate:
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. -Efl#l `Ef #2
1 0-5 10yr3/3 none sl 2mgr mvfr as 2c,2m 0.6 1.0
2 5-18 10yr4/4 none grsl 2msbk mvfr gw 2f,lvf 0.6 1.0
3 18-38 10yr5/4 none vgrsl imsbk mfr gw ivf 0.4 0.7
4 38-60 7.5yr5/4 none vgrs Osg ml gw 0.7 1.6
5 60-85 7.5yr4/4 none vgrsl Om mfr 0.2 0.6
Boring
Boring # pit Ground surface elev. Depth to limiting factor in. Soil Application Rate!
HDominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Eff#1 'Eff92
-
' Effluent 91 = 90D_5 30 < 220 mg1L and TSS >30 <_150 mg/L Effluent #2 = BOD_ < 30 mg/L and TSS <30 mg/L
the Department ofCommerce is an equal opportuni[N ser%ice providerand empimcr. li you need assistance to access SerNices or
I ~ I or TTY 605-264-$7-7
recd material in an alternate ti~rmat. please contact the department at 608-266
Schmitt Sod Testing, Inc.
Pace 3 c-. 4
(.conducted bv: Conducted i-o:-.
Schmitt & Sons Excavatina. Inc.. Name Jon & Kiurberlie Giibertsor!
Thomas J. Schmitt. CST 227429 Address, 137 For Rid,e'l)-.6
586 Valley View Trail City: State. Zip. Houlton. NN 't 54082
Somerset.WI 54025
Phone: 715:760-1978 PID 030-1OY3-10-002
I.>>
~;grtature - Lot NC, !I CS N1 5%1414
Legal Description: SEU4 NAVI/.t 529130N 1119W
9 Backhoe Pit Township. County: 5t. Josepli. St. Cr-oi, Uount.
A Bench Mark 1 Et. 100.00' Top of 1" Steel Lot angle point pipe.
A Bench Mark 2 El. 110.10' top of septic tank manhole cover
Slope= 18%
Scale 1"= 60'
NOTE: For full view of Lot see Aerial Photo (Page 4 of 4)
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