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HomeMy WebLinkAbout032-2136-10-000 sin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597424 cNERAL INFORMATION State Plan ID No: li ersonal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City VillagTOWN IOF SOMERSET Parcel Tax No. 032-2136-10-000 Trevor & Alison Schu CST BM Elev: Insp. BM Elev: BM Description: ~d• Section/Town/Range/Map No: 13.30.19.1203 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Xj~ Septic + e~ -44 ' Z/D Benchmark 598ing -7 Alt. BM j a vw~oa T J j,~ 5 .79 97 - S~, Aa&aUeFl Bldg. Sewer Gad o 13 -1 Holding St/Ht Inlet TANK SETBACK INFORMATION SVHt outlet TANK TO XL` WELL BLDG. Vent Air Intake ROAD Dt Inlet Septic Dt Bottom pAl V -gC7 y -1 Dosing / 10 Header/Man. b ~z - .S / IT. /I Aeration Dist. Pipe Holding- Bot. System - * 5 X4.45 PUMP/SIPHON INFORMATION Final Grade 3, 76 C_` Tf Manufacturer Demand St Cover e GP 7-1~(.¢ F1 . Model Number TDH Lifter Friction Loss System He d TDH A.-7 /I/l y~~ Forcemain 1 Length- _ Dia. ( Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trep~es PIT DIMENSIONS No. Of P~ Inside Dia. Liquid Depth DIMENSIONS /10?- ~/eA ~ \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR `~L I t Type Of System: Coral 1 ' O Xt / UNIT Model Number: DISTRIBUTION SYSTEM 3( ZS = Ise, C K f 3 Header/Manifold,, #I Distribution x Hole Size x Hole Spacing Vent tgAir In ke g Pipe(s) Length J 3 Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over jxx Depth of xx Seeded/Sodded r Mulched Bed[Trench Center sue. 4C Bed/Trench Edges Topsoil Yes L] No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1597 84TH ST G; I1.- Ld~S ✓1 1.) Alt BM Description = 2.) Bldg sewer length a, w ~ 1 G.G i 2 ~J~ - amount of cover = Plan revision Required? ❑ Yes Z$ IL' _ 3 ! U r, Use other side for additional informationlo . SBD-6710 (R.3/97) Date Insepctor's Si ature Cert. No. ~ t County ~ R ra/ Iv_ I mr d rr ( ndustry ervi ces Divisie'h "RECEIVED p S 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) ~t P h~ P.O. Box 7162 i S% JUL 2 6 2017 Madison, WI 53707-7162 5~ 7,c/ 0 7/ 7tfiF! 5~141NP-*f , ST. QKU1 ; OMMUNITy rmit Applicstl n" V06 State Transa t' n Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of 7Np9E994 is required prior to obtaining a sanitary permit. Note: Application fog _ rv W"I'S are subrA ded to project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m , Stats. -7 Q#A--- 1. Application Information -Please Print All Information - 00 c> Property Owner's Name Parcel # 0 3 a - a' - Property O is Mailing Add ss Property Location 3 w/ Gov/t. Lot City, Stat Zip Code Phone Number '114WA `A, Section T ~Q N R / iEle o [I. T of Building (check all that apply) Lot # - or 2 Family Dwelling - Number of Bedroom / Subdivision Name ❑ Public/Commercial - Describe Use ok- 04 Block # J-ae, - ❑ City of ❑ State Owned -Describe Use ❑ Village of CSM Number R<.-Of L v6k ~ ~ ZS ca III. T pe of Per ' . Check only one box on line A. Complete line B if applicable) A. ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B El Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner L IV. Type POWTS System/Component/Device: (Check all that a ply) on-Pre d In-Griound El Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil o ding Tank [7"0 ' ther Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treatme t Area Information: Des' n Flow (gpd) Design Soil Application Dispersal Area Required (sf) Dispersal Area proposed (sf) System Elevation Rate(gpdsf) /7 ~'7 1 VI. Tank Info Capacity in o Gallons Total # of ufacturer B o New Tanks Existing Tanks Gallons Units ~ / 0..U v~ v`7i w C7 0.. Septic or`I+ehi"r+ank - ❑ ❑ ❑ ❑ Dosing Chamber IZy ❑ ❑ ❑ VII. Responsibility Statement- 1, the undersigned, assume r onsibili or installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's S' MP/MPRS Number Business Phone Number Todd L Sinz MP 39462 715-235-2644 i Plumber's Address (Street, City, State, Zip Code) E5609 708ah Ave Menomonie Wi 54751 VIII. Aunty/ epartment Use Only Approved ppro Permit FFee j Date ~sssu~efd Issuin gent Signal re w Given Reason for Denial $ 44D6 `s /7 1 IX. CondiAt~igYi~~~~t( Reasjrts fgr Disapproval ~j iti 1. eptio r:k, t=i l.`fi71: 11 e" t~ 3) O / tiirsp2exsu cell must all be s ic:>s i .'nta _ - A^ a ls,per.gtgr.3yement plan p c:iaell by a!umbe:. y A1l~jj***=nes trust ce mwrt..n.~ a I1 as PW CAW / vXt1}ina;1m. Attach to complete plans for the system and subinAl to th County only on paper not les han 8 1/2 x I I inches in ki f 1 ~J[J SBD-6398 (803/14) A- up J F l ~ ~ to t t -fb 4 . ,ti P M O~ ~C f 14 ,s Q~l , P" C ~ a- 0 Private Onsite Wastewater Treatment System Index and Title Page Project Name: C Owner's Name: ,+D.~ GYM /~/t i>~'~ Owner's Address: Legal Description: Municipality: owl Village, City of County: Subdivision Name: Lot Number: f Block Number: Parcel I.D. Number: Page 1 Page 2 Page 3 ~.rt , Page 4 AAW Page 5 Page 6 Page 7 ~/~~~y*,11J A;e~ Page 8 Page 9 l Name of Designer: License Number:~~l/ - Signature: Date: 7 Designed Pursuan o he Foll 'n POWTS Component Manual and Comm 81-85: In-Ground Soil Absorption Component Manual for POWTS (Ver. 2 2.0) SBD 10705 P (N 01/01) A, k } H N f e ~ CAR Qj) Soil Absorption System Cross Section 4' Schedule 40 PVC Vent Pipe Wdh Vent Cap_ i Leaching f Chamber ~ft Soil Absorption System Plan View Vent Or Observation Pipe Trench Leachinst Chamber Specifications Manufacturer And Model EISA Rating 'Z-0 sq ft per chamber Soil Application Rate gpd/sq ft gpd Design Flow + 'Z~ Soil Application Rate + 5,00 EISA = Chambers f rows of chambers each. Page y of WtAY'fi~iLlRAJi~ . •~AICTION Lq C t,C► ►s tS~C Ct~ g R its r '4w i°YC ti~~ +i s7r.7777 J7Igo, . iv >AJaI~,TUaA „ d` 40 SD1L 24~ %.'D. Yfr,NT L i F~T~ ~ ~ yT '/g /.y<S s- L) 7- ' - • p., pWftravi,a A 4 0 LZT JburS p,A~ FL.E' 44.' 3~ o~O 14 1 U. C.Xi f°tJii~ b 12t~ ~ Co.,r~ttT'it . SCPTIC E~~C.I~[CA,~Y'JEaA.1~ . 005 [ Th . r"AUUFACTIJftr PC: UuAk&LR or CaSES: PET( DA.4 7'AWK SIZE: 1,7-~o 6A,L.l.0WS .DOS[ VOLtJMAlt a IUCLUD1i.IG /~f GPLLONS A L. A R h P'l4.J61L YAC T V k[ C : -5✓7~_r 5.►GKFL06V-' AOOC1. UU14l5ZMC: CAPACIT'IM As; = IJJCNCS OR CsALLOU -S 5WITCH 'f `JiL; V~rC/~rin1 ~G~+ L IUGUEI Oa /3,.,,Z'1~WrrLpUS SUMP ?,,AQu ACYuKcit C UCrtC6 OK/ ~ G~LGOt~S MPDCL UUMDLIC: / 0 ~ I1zUr1E5 OR 'GALLG+.i: 5WiTC)j TwpC: ~°Nn~JIP~i"~ W07C PUMP AWD ALAKM ARt TO bL f11►JIMUh1 mss-kAykrx RAT'__ _ „w,~1~1~ INSTALLED OW SEPA0.ATC ClkCL;tTS JERT~CAL CIFFLKC11.JCf 6[TWCCU PLJ" OFF AUO OISTtil.IjTiOiJ PIPE., ~ FEC7 t KIUIKUK ►JCTWOKK SUPPL'~ P&CStURTL~. JrECT OF FORCC MAIN X ~'3Q f/l7v/tfIkICTI e ©W YACTR.. ! FEET f 70TAL DyUAMir- NCAb FCCT J7 E~c1JiL QIMC►J6t0►JL OI TA11K: LOUGTN ~E-a j L D T H IQUIQ w TOTAL DYNAMIC HEAD W PUMP PERFORMANCE CURVE FLOW PER MINUTE MODEL 151/152/153 50 MODEL 151 152 153 1446 153 Feel Meters Gal. Liters Gal. Liters Gal. Liters 5 1.5 50 189 69 261 77 291 12 40- 10 3.0 45 170 61 231 70 265 0 35- 15 4.6 38 144 53 201 61 231 = t0 152 20 6.1 29 110 44 167 52 197 30 25 7.6 16 61 34 129 42 159 z 30 9.1 - - 23 87 33 125 0 8 25 151 J 35 107 - - - - 22 85 ~ 40 12.2 - - - - 11 42 1 6 20- Shut-off Head: 30 ft. (9.1m) 38 ft. (11.6m) 44 ft. (13.4m) 15- 4- 2- 5- ,0 30 40 50 60 70 80 90 100 GALLONS LITERS 0 40 BO 120 160 200 240 280 320 360 FLOW PER MINUTE 014508 MODEL COMPARISON Model Seal Mode Volts Ph Amps HP Hz Lbs K9 Simplex Duplex N151 Single Non 115 1 6.0 1/3 60 32 15 1 2 or 3 E151 Single Non 230 1 3.2 1/3 60 32 15 1 2 or 3 BN151 Single Auto 115 1 6.0 1/3 60 33 15 * 2 or 3 BE151 Single Auto 230 1 3.2 1/3 60 33 15 2 or3 N152 Single Non 115 1 8.5 4/10 60 37 17 1 2 or 3 E152 Single Non 230 1 4.3 4110 60 37 17 1 2 or 3 BN152 Single Auto 115 1 8.5 4/10 60 39 18 2 or 3 BE152 Single Non 230 1 4.3 4/10 60 39 18 2.,3 N153 Single Non 115 1 10.5 1/2 60 37 17 BN153 Single Auto 115 1 10.5 1/2 60 39 18 2 or 3 E153 Single Non 230 1 5.3 112 60 37 17 1 2 or 3 BE153 Single Non 230 1 5.3 1/2 60 39 18 * 2 or 3 *BN and BE models include a 20' (6 m) piggyback variable level pump switch. Additional cord lengths are available in 25' l8 m) and 35' (11 m). 50' (15 m) cords are available for 230 V units only. NOTE: Model 151 has a plastic base. Models 152 & 153 have a cast iron base. SELECTION GUIDE 1. For automatic, use single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 2. See FM1228 for correct model of simplex control panel. 3. See FM0712 for correct model of duplex control panel. OPTIONAL PUMP STAND P/N 10-2421 • Reduces potential clogging by debris "Easy assembly" • Replaces rocks or bricks under the pump (pump & dmhaTe Pipe • Made of durable, noncorrosive ABS not included.) • Raises pump 2" (5 cm) off bottom of basin • Provides the ability to raise intake by adding sections of 11/2" or 2" (DN40 or DN50) PVC piping • Attaches securely to pump • Accommodates sump, dewatering and effluent applications NOTE: Make sure float is free from obstruction. A CAUTION All installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes s4be followed including the most recent National Electrical Code (NEC) and the Occupational Safety and Health Act (OSHA). CO Copyright 2015 ZoellerQ9 Co. All rights reserved. 502-778-2731 1 800-928-7867 1 3649 Cane Run Road I Louisville, KY 40211-1961 1 www.zoeller.com The Best Just Got Better The most efficient, the lowest maintenance, the most economical effluent filter! • Nearly Twice the Filtering Capacity Estimated to go 3 Times • Longer Between Cleanings • Cleaning Made Easy • Does Not Retain Solids Between Plates • • Lowest Price • O 0 is - Eliminates the collection.of solids inside the cartridge. - Nearly twice the filtering capacity of any other filter. OUMMM A A, GO&OMMMI= - By eliminating solids between plates drastically reduces the need to clean. - Cleaning made simple and efficient. O X - LT 1/8: 3500 GPD/Residential Strength ra ion'I /8" - LT - 1/16: 3350 GPD/ Residential Strength Filtration 1/16" - LT -1 /32: 3000 GPD/Recommended for Commercial use with Residential Strength - Filtration 1/32" '57 - LT -1 /64: 2500 GPD/Recommended for Commercial usage with Residential Strength - Filtration 1/6411 - 2700 InrhPC of I inPar Filtration (Nearly Twirp the C'mmnPtitinn) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Tank Manufacturer. ❑ NA Permit # E) ''Septic ❑ Dose ❑ Holding Volume: I -LE) Tank Manufacturer: ❑ NA DESIGN PARAMETERS Number of Bedrooms: ❑ NA ❑ Septic ose El Holding Volume:' gal Number of Public Facility Units: 3 NA Vertical Distance Tank Bottom(s) to Service Pad: ft Estimated (average) Flow : o gal/day Horizontal Distance Tank(s) to Service Pad: ~ ft Design (peak) Flow = estimated x 1.5:~ gal/ ay Specific servicing mechanics must be provide if vertical is >15 feet or if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: gal/day/ftz Effluent Filter Manufacturer: ❑ NA Standard Domestic Influent/Effluent Monthly average Effluent Filter Model _ Fats, Oil & Grease (FOG) s30 mg/L Pump Manufacturer: oe_ Z4__-___- ❑ NA Biochemical Oxygen Demand (BOD.) <_220 mg/L ❑ NA Total Suspended Solids (TSS) <150 m /L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit Fats, Oil & Grease (FOG) >30 mg/L Manufacturer: Biochemical Oxygen Demand (BODS) >220 mg/L ❑ NA El Mechanical Aeration El Peat FilterA Total Suspended Solids (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: Biochemical Oxygen Demand (BODS) <30 mg/L Soil Absorption System Total Suspended Solids (TSS) s30 mg/L ❑ NA Fecal Coliform (geometric mean) s104cfu/10om1 423' .n-Ground (gravity) ❑ In-Ground (pressure) ❑ NA Maximum Effluent Particle Size: El At-Grade El Mound in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) ZTVVberrcombined sludge and scum equals one-third (16) of tank volume Q-When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Inspect dispersal cell(s) ❑ month(s) At least once every: ..ear(s) (Maximum 3 years) El NA ❑ month(s),~,' -r% Clean effluent filter At least once every: ❑ NA year(s) Inspect pump, pump controls & alarm At least once every: c ❑ month(s) ❑ NA 49-Year(s) Flush laterals and pressure test At least once every: ❑ month(s) D ,NA ❑ year(s) Other: At least once every: El month(s) ❑ year(s)] NA Other: ❑ IAA 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 (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any Ponding of effluent on the ground surface. The ponding of effluent on the round surface may indicate a failing condition and requires the immediate notification of the local g Y g d regulatory authori tY. When the combined accumulation of sludge and scum in any treatment tank equals one-third ('X) 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 30 days of completion of any service event. (Rev.8/14) k' Pape of START UP, AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may Impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During 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, overloading the cell(s) and may result in the backup or surface discharge o' effluent. 'To avoid this situation; have the contents of the pump tank removed by a Septage Servicing Operator prior to restorinc power to the' effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls tc restore normal levels within the pump tank. Do not drivd'or'pork vehicles over -tanks and dispersal cells, Do not drive or park over, or otherwise disturb or compact, the are< mound or at grade soil absorption area. within 15 feet down slope of any, Reduction ovelimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled witt soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code complian 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 b, required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems mus comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWT' 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 sit evaluation must be performed to locate a suitable replacement area. if no replacement area is available a holding tan 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 th 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 NO ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLS POWTS MAINTAINER Name Z ~L Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone ~6 r NP 7. E & i : D: [ 09 53f OFFS AS 03 E0OLC_5 }s 4{'FF S'r. COI: C'OUNTY SEPTIC TANK MAH\lTI N/VNCF A.GRFFIM N-1F AND OWNS S U? C ERTIF'ICt'?TION FOI~Ni l t~~h11t ' IIYC" Trevor & Alison chug Mailing Mdres5 423_Meadow.Lrt_So~nmrseL IV 1' jJ>vriy A-ddreW 15W84th vit _ g Lmlent for neu (Verificatwn requrre d nI:['lanr<rI_g c «nin}Enr,l 0 nstrac ol) [ Jt v E ichirit>r i, u~il `4 Cs1, ial y ~tati:c~ ~ Parcel IdclztHcation Number 0!2-2136-10-000 2TEICq _I I~S I~.II I P1°Cpat l,t>ca don NE Ili , NW 4, Sec, t3 T :3('i NF$ W , Town o f sonm E Subo -"Wood °"`vriffie owvey Map 4 6,324,11 IV"oIuIn 3 Page, _..._.-_~-9 Wausway Med t.1.~~ ts3tt Vnlrzi ie r'~3((>~; i; Spec house; yes no Lot lines dt,ritifiW [IRE] 110 ENANC) AND OW'ER"I'IF:W TIO l -proper use wad 1naiirte11ance Of Your septic svst;,Tn could r ndt in it p:ern iture Aliril' to WOW wastes. Propel ti).al-t.t:,nance consists of pumping out % septic tank every three ;Bars or sorrier, If neudud, by 2 Acell.9r_1 pimp. What You tJtlt UiLS l-,c systt rm cart affect the function of the septic tank: as a treatment stage in the waste disposal s stern- 0x,-Ile ~u<intel,~l~I c .t~.~r.sibili9res <zre Specified in §Comni 8352(1) and in C:h"Mr 12 - So Crok (Musty Ss+Mmy Ord ai we. The Inoperty owner agrees to (sui n11t to St. Croix Aunty f1anI I g & 1 of &g 1AP$i111 t Pt a C CitifiClooll `Ctnl ~SE~IE'(l by di, oew u € )d by a Lister plurnber, journeyman plumber, restr;ch i p umber or a li e:1 d pt 11pt r ✓Crifyii f Lhat (1) the C i itC wast-vvatcer disposal system is in proper operating condition anNor (2) after in t) >io n and p~~tni,ing Crf~ ne.ces.sary;, the ,septic on!. is as than i!3 full of sludge. 11WC tfie Undersigned have read the above requirerncnts and agree w mmintcin % ka ivatt so v ge dl . c 1 sysWn1 widi ctaj.i lards set forth, herein, as set by the Departnlent of Commerce and the Department of Nalaral Rc oli,ces State <lf 'i_cor,si;t- C;cr*ifi.cati-rn statang that t your septic, system has been ri>;llntauir' Izie..t be coltl_l~tuc3 and r:urncd to .,f. Q vin ^`ctif, i' i, fw ° ' 'i°, ~ Zoa_inll opamnetit within 30 days pf the three year expiration date. I,tw,P, CBrtlfy that, all statements on this Orin are, trnae to the best of ntj till]; kCt x _C,_+~.c, 1 wi' ..3;UArt, dw w,rv' r ; C'1` [it tiropum, Mchbod above, by vrrttre of a xtrarr Ay deed recorded in Rt-l- i tt: of l Duels Office. Number of bed oo ins 4 _ JOC-jSigned by. -DOWSWmd by_ I ~ 9 r z I All, }3a 8A©FC St APPLICANT(S) ,'An ' information that is misrepres~-'Ilted may re.:UR in the salrii.arly permit being revoked by flit Plat,Ang d L oAnt 1)ellartni 1t Include lsiith this application: a recorded warranty deed from the Register of Deeds Office and a copy of th , ccitified survey it 1 is refortnce is ruade in the warranty deed. (REV, 08M5) LOT ~ ~ ~a6~see~m~s€to~,y~, r f J b solL~sr,......_, eio 3J856 `Q FT. \ S^9 TYPICAL Z -%7 \ 3,~)~ ACRES o O m+iU, T p- i I I 00 I I M z r-- Ch, 0 T 2% L"I z ry-I <E a_ h(v~ Cr 13081E )lei. 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CROIX COUNTY WISCONSIN ZONING OFFICE 0 ! q tl A II ! p ■ rnrAr ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road r„ - -x~ - Hudson, 'M 54016-7710 (715) 386-4680 FAX (715) 386-4686 Page of r COUNTY ON-SITE VERIFICATION FORM Inspector: " Date: Parcel ID Numbe" 63Z Z 13fo - /d -ems Property Ov.ner Property L ovation 6P i[. G(Ynt. Lot A)e I,4/V4A 4 S T 3a ki 5,1 l Et NN' Property Owners lvlai ling Address Lot;;' Block: 5Lbd. Nan - Gf CSt,.# I AL., Woo C=Q City State Zrp Code Phone Number ❑Civv ❑Village tCitdn Nearest d NerrConstruclion Usu:❑Residential !Number of bedrooms CeAJederisftrJdecignfkrovrate_..___._.__.__. GPG ❑ Raplacement ❑ Public arcommercial - Describe: Parent material __v _ • ~/~1-, Flo Plain elevabon if appliuabld Genera, lccrninents~ • ~i qQ.. A and fE-ommendatiGns:~ T ^ c.J r U.- E2. Q*-J4 &A&,~ .ILA4.. dt- &L4- hilt ^1 a.J6e Boring ( Boring ❑ Pit Ground surface elav. ft. Depth to Ilmitim factor------ in. Sal A licati Rate Horizon Depth Dominant Color Redox Description Texturz, Structure Consistence eoundary ~Ros GPDft in. MunseJl Qu. •Sz. Cont. Color Gr. Sz. Sh. *Eft l •Efft*2 1 Conditions: Soil Survey description: a 6 Notes: FEE: C C6r- Z0 I (o - {-7'7 Wis. Dept. of Safety and Professional Services SOIL EVALUATION REPORT Page 1 of 2 s in accordance with SPS 385, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must • includ§f p f 4t &'ifkd,to: vertical and horizontal reference point (BM), direction and Parcel I.D. ercen s o e, scale or dimensions, north arrow, and location and distance to nearest road. 310 - . 600 ST. CROIX COUN~~~~~~ print all information. Revi ed by Date COMMUNITY DEVELOPTv~ Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Jt~ / Property Owner Property Location Govt. Lot , - 14 1/4 S ( T C : I N R I C E (o Property Owner's Mailing Address Block # Subd. Name or CSM# t s~ ~r ~C A s~~7s7-C ct~CSC,(-// City r State Zip Code Phone Number [-]City Village own Nearest Road A-e ~r CC 4/ 5 -yc>! ;7 1 ( C s() /517 q- 7~ S 3 New Construction Use Residential/ Number of bedrooms Code derived design flow rate 65 0 0 GPD n Replacement 1I Public or commercial - Describe: Parent material Flood Plain elevation if applicable .,-z _ ft. General comments and recommendations: ~J "!C/ c✓C>~ E'er 0,0 Qjr ~J C' L- /r C C~/~ S C ~ ( 7 Cr l Qlt-' -,e pq c, e r1 C 5C, f # Boring e %P.. Boring d t G4'S SL F-1 I ~ Q Pit Ground surface elev. ft. Depth to limiting factor .t in. Soil A lication Ralld Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 2.0 r 3,(t7 bK n-71~- 9-5 L Boring # ®Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Fonsistence oundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 62 10 (Ow,'31Z Ll 171- c`~ . u . I!, cy (C.L 12 ~ ~r 5 2 J~l * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L vent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur CST Number ERICKSON CONSTRUCTION, PETER ERICKSON 1293207 Address Date Evaluation Conducted Telephone Number 1291 170th St., Saint Croix Falls, WI 54024 Gl~ 0 / 952-261-1100 G /27" SBD-8330 (RI1/I1) PropertyOwner 045i::211 Parcel ID # Page of _ Boring 3 Boring # Pit Ground surface elev. ~j ft. Depth to limiting factor 7 T" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff41 ff42 C-12 It, A4 ft? c, e, 4 = n4anng Boring 4 'Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth ominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 1 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 ( p , L Boring (ffXy ,O s Boring # Pit Ground surface elev. _ ft. Depth to limiting factor L/ L in. Soil A lcation Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. £z. Sh. * ff#1 02 l Z r0 , 3r -C) e.41 5 Z j'U (c it, C5 12- -,-Lt S C L Z i h~ N1 f✓ j j L< L ~ O- * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-833OT-t (R 11/11) TTY-`''''( f f r I . , 111111 { • ; , S . , i III _1•-' t . t • ' Imo, ~ ! 7• I - I....I.-..,_....f I .._.i...; i , i , , fir! ~ ' ~1 ••i . _ .__..i.. ' , _I ..i t ~ t , . 1 ; I. I , J 1 _ t • , . , s I r : , 1 , f AL ! Giz M r~ r L 1-1-i jiMTH Wis. Dept. of Safety and Professional ~gr~+~ses SOIL EVALUATION REPORT ~T of 2 Division of Safety and Builty ► l1 00 L~ in accordance with SPS 385, Wis. Adm. Code Wd UNl Attach com lete site U1~ C~10 P I~x 11 inches in size. Plan must County include, but not . S I orizontal reference point (BM), direction and Parcel I.D. / percent slope, see or dimensions, north arrow, and location and distance to nearest road. 632 + 2136 /Q _ ao Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Proper y Owner n Property Location I Govt. Lot 1 /4 ~,T/4 S T j v ~1CI~ R / C E (or Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 777 City State Zip Code Phone Number Elcity Village own Nearest Road L c I,C~i~h New Construction Useo Residential / Number of bedrooms Code derived design flow rate ~,"C)o GPD ❑ Replacement 0 Public or commercial - Describe: Parent material )t,-1- GZ.-C; Z Flood Plain elevation if a icable a^4, x ft. General comments "S ~Z;~ Sa v oQ1M.•5 and reco mmendations:,2~ E' C C""', C1 -eel 4- 11 -XX s Boring # Boring ~ pit Ground surface elev. C'6' ft. Depth to limi ing factor. 10- f in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 i 17, Boring # Boring 2 / i J Ej Pit Ground surface elev. ft. Depth to limiting factor -Iin. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 /,h Nc 61 * Effluent #1 = BOD s > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number ERICKSON CONSTRUCTION, PETER ERICKSON 1293207 Address Date Evaluation Conducted Telephone Number 1291 170th St., Saint Croix Falls, WI 54024 952-261-1100 SBD-8330 (R11 /11) Property Owner 11rcel ID # Page of Boring # Boring s 7 . [7-3 Ground surface elev. oJ ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 1 U - C~ Y C L 7 X13 /c Zt U L~ -71 T vr~ ❑ Boring # Boring n pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate z Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ElPit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. 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