Loading...
HomeMy WebLinkAbout024-1029-10-350 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597453 GENERAL INFORMATION State Plan ID No Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j 2981394 Permit Holder's Name: City Village Township Parcel Tax No: JUSTIN & LINDSEY KOCINA TOWN OF PLEASANT VALLEY 024-1029-10-350 CST BM Elev: Insp. BM Elev: BM Description: e Section/Town/Range/Map No: QQ a M 1 G u 21.28.17.177C-05 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2.~ 2 Benchmark 16T /00 Dosing 3 Alt. BM Gala J v Gal '1411 yy !S L 6 Bldg. Sewer 17.5 151Z) Holding St/Ht Inlet /T O s TANK SETBACK INFORMATION St/Ht Outlet WELL BLDG. Ve 6Air Intake ROAD Dt Inlet TANK TO WlP/L4 Septic Aa Z~ Dt Bottom Dosing Header/Man. 3 1,6 fs Aeration / Dist. Pipe > C Holding y' Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer U N- Demand St Cover a P~~ GPM Model Number fl /LL~ / TDH Lift Friction Loss System Head TDH F - z_ a-51/071 7 ~,5 2.3b (0.5 Z , 1 ~j 13 VA Forcemam Length r Dia. Dist. to Well tl 1 70 SOIL ABSORPTION SYSTEM 4 4 7 / ~l 41 BED/TRENCH Width Length No. Tren s PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth DIMENSIONS (OQ 8 ___1 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type ystem: ! ,7 yL r1 6 UNIT Model Number a .A• c34- DISTRIBUTION SYSTEM Header/Manifold( 1 Distribution Ix Hole Size x Hole Spacing I If Ven Air Intake S) Z6 Length Dia Length Dia Spacing / y g v SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Ct".- Depth Over Depth Over xx Depth of xx Seeded/Sodded ched Bed/Trench Center Bed/Trench Edges Topsoil No r No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 11 1-7 Inspection #2: V 0 ; 12~y►~`~ t/^ V Location: 1793 30TH AV 11 / ~Leyta / ~S sit . dd L~l 1.) Alt BM Description - 1 2.) Bldg sewer length = 3 - amount of cover V.t. S Plan revision Required? ❑ Yes No 2g Use other side for additional informatio~nn..~~~ SBD-6710 (R.3/97) Date InsepctCert. No. Ep► IV County ,T RF.C Safety and Buildings Division 7` kw f 7 S _ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to he filled in by Co.) Madison, WI 5 707-7162 7 2 ,(3M I ermit Applicat7 * 01,. Stage Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the app,_. ,ntal unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POv, ' to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be, useu purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats, a l / ✓ 1. Application Information - Please Print All 1 ation~raara~eU Property Owner's Name Parcel # J CL rl~ tS~~r' ~~sG 1/% d 1 Property Owner's Mailing Address Property Location a' a r• 17. 1?7 (r 0 tv 7o-f 7 6-/e:2-rl, Govt. Lot City, State Zip Code Phone Number /~SLu~<~i~"y`~ Section `~d ~ (circle ong)~ N; R II. Type of Building (check all that apply) Lot # I or 2 Family Dwelling Number of Bedrooms Subdivision Name *"_7 a / Block # ❑ Public/Commercial - Describe Use ~Y ❑ City of ❑ State Owned -Describe Use CSM Number ❑ Village of J Town of ~ /to X Ar.,' 01 C 111. Type of Permit: (Check only one box on line A. Complete line B if applicable Y 66,ir mt, A- avA A' New System i ~ ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existin i B• 11 Permit Renewal El Permit Revision ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that a 1 W ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat nt Area Information: Design Flow (gpd) Design Soil Application Rate d Dispersal Area _Required (sf) Dispersal Area Proposed (sf) System Elevation ~ 1 V1. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks 11 Existing Tanks a / v o ; L Septic or Holding Tank Dosing Chamber O3 is F) VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached' plans. Plumber's Name (Print) Plumber's Signa MPS Business Phone Number i x-73 i Plumberr's- Address (Street, City, State, Zip Code) VIII. County/ epartment Use Only pproved ❑ Permitt(Fee Date ssued Issuing t Signature (a , $ Z ~7 X ❑ Ow en Reas~ffoo ni al p el IX. Condit easons for. Disapproval ,eeJ 1. Sept« tank', a twt litter Ph,i ~ ti1S} v.s,i Ce0 rust d I I be sf't 1C }S:+, -In 04 !r Its per rparagement plan pm ricied by plumber. C Wl 2, 'AJi0ftiVk ► l .'WMS Must.bL-1'.I 0-0-.ir" stt per .r+bla 006! 1 ;fflinall083. I tP!!V'iL- t lz- Attach to complete plans for the system and submit g1h C ty onl, pa r nots than 8 1P2 x l l inches in size SBD-6398 (R. 11/11) - I „ ~z t` i:. n r c : s~o cc r Ov` S [ e.t2h ~i.~cr el qr T ~ Y ~ ter, sj-y, 4s_~ cr fj ;f ~ZI,1~F~#/ ! w b~ f ,S'f' ~ k a ~°f`V ~ 3 ~1 h l't 1✓ e ,y a 0- I'v t Dlr. i j- Lw f GTE- G b 1 f i { ~F a~o psn.cl JJ( ' ~ ~~O {O B c 6 ov~' ~ ~ y G 4 r !y ~ f L jar r {r ~b ~c-.* JO u. C ti A ! r j c > `O ps) ~ C ss 4'-` Y` rr r 4✓ .S s~~,:: ~-6f 71 c `C w P LU: ~ , _s` Ole&c Ar tOa L° o 1b'a t t~ ey ~a a e s is ~,r 7-4 /0 c ■ ! z2 'f'r G n e . ^ ~c.sg . > da C ~ 7` dx r= ~-r `urnDIVISION OF INDUSTRY SERVICES 10541 N RANCH RD HAYWARD WI 54843-6462 Contact Through Relay I http://dsps.wi.gov/programs/industry-services 1 \ ` S www.wisconsin.gov lr"fFSsro _ Scott Walker, Governor Laura Gutierrez, Secretary August 16, 2017 CUST ID No. 220673 ATTN.• POWTS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER SOIL TESTING & DESIGN ST CROIX COUNTY SPIA N5815 770TH ST 1 101 CARMICHAEL RD ELLSWORTH Wl 54011-4708 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/16/2019 Identification Numbers Transaction ID No. 2981394 SITE: Site ID No. 841192 Jut & Lindsey Kocina Please refer to both identification numbers, 30TH Ave above, in all correspondence with the agency. Town of Pleasant Valley St Croix County NE 1/4, NE1/4, S21, T28N, RI 7W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1720426 Maintenance required; 600 GPD Flow rate; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed AP and located in accordance with the enclosed approved plans and withany component manual(s) referencedDtETT OF SAFM AN The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code DIVISION OF requirements. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may includelocal inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should SEE CO conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required S 250.00 This Amount Will Be Invoiced. 1 r' •z. Z ~~i When You Receive That Invoice, Edwin A Taylor } Please Include a Copy With Your Wastewater Specialist, Division of Ifidustry Services Payment Submittal. (715)634-3484 , Monday - Friday 8:00 am To 4:30 pin WiSMART code: 7633 edwin.taylor@wisconsin.gov Webster Soil Testing & Sewer System Design Charlie Webster, Owner `s N5815 770th Street i~1~ 1 211 Ellsworth, Wl 54011 vs~~y S~RVicF` WI Licenses: MP220673, ST220673, D 2110 P !~D Phone (715) 273-3430 POWTS Index Sheet Page 1 of 8 Mound System for a 4 Bedroom Residence Owners - Jut and Lindsey Kocina Parcel in NE1/4 NE1/4 S21 T28N R17W LOT 3 CSM VOL18 PG 4822 Town of Pleasant Valley - St Croix County Parcel I. D. 024-1029-10-350 Page 1 Of 8 Index Sheet Page 2 of 8 Plot Plan Page 3 of 8 System Cross Section Page 4 of 8 Distribution Pipe Layout Page 5 of 8 Pump Chamber Layout Page 6 of 8 Pump Performance Curve TTIONALLY Page 7 & 8 of 8 Management Plan ;DROVED PROFESSIONAL SERVICES INDUSTRY SERVICES y~oCONs F.•....~~ CHARLES L. ` WEBSTER n 2110 P RESPONDS CE ELLSWORTH i WI& i Component Manual Used: Name: Mound Component Manual for POWTS Version: 2.0 SBD-10691-P Dated: January 30, 2001 Name: Pressure Distribution Manual for POWTS Version: 2.0 SBD-10706-P Dated: January 20, 2001 + t t - .r'r*L, c4 iY uL j C IQ A i p r s^' y ~rciL~ i i r f f rip ° M, ~ J p b CYYr~r G7ar-j9 C 1 f- 7" r-E s 4 r t4 C rf ~,h~ ' Se 74 hr- 14 Ct,* 'r- 4-t , >~L Jwr a o~ 607, 60 W`,.S 40V-A, c AtO T/e~ QbC S-M'Vf t Ae cr7d p`Y ~ a4 C y+ ea.su~c 117// fs ~g huKr 7ft~ S/~, CM ra4 ` frl Cz C r j VI'SJ d.1' t gr7 3 v & . l CP r'_ q , s t:z ~F~ tr,~ A~ /0 c t`~r s'b t+ r r e rr c; 9 2. 7 7 7 r "I w Page Of, j ~da vrLok, Crev 9J Sec j pyt Approved Synthetic Covering +S-i~ 33 Distribution Pipe ?Medium Sand _ H _ Topsoil - - F E1ev 3 E D b 4- d~ % Slope Bed Of i-2 Force Main Plowed" Aggregate From Pump Loyer `Sec F'.pt de f.). For a ~ie»dtc ~~rc~ D Ft. Cross Section Of A Mound System Using E Ft. A Bed For The Absorption Area F Ft. G Ft . "fear Leading Rate=./44 '+,%GPD/LN FT B Ft. ,_sign Loading Rate= ?BPD/SQ FT I Ft. J 7,, Ft. K / Ft.~ Lu W Ft. L J Observation Pipe ~ fl A 60 E f sec~es rVDistribufion Bed Of -'2"- 2 % I to 2 .2 1~ ~3 /ltPipe,, Aggregate Observation Pipe A<~~rsBox w#th #.r „ kr~-up oh (Anchbr securely) S /r p 1~ G f 17dile 7,i+•4.r~ o~i'de..e ~ ~I' '¢ir~c~es be pfu~,al: r evr`~'~ el, was~r t#~~7`rdPr h1(/C r'/!C b,'*'fl~s, cfih / ~ 7&14 Q SCcKt E': e a Perforoted Pipe Detoll End Vier G~ ~Perfaroted X X t i PVC Pipe` ear a `pCa e s rte` Cv Holes LocoteQ On 8ottnm, r y r s e r e/e, 9 a Ate Eauciiy SDac cd i / j rf ^F' i ' Nstnjution a J{ 0 Pipe l ~ f a ~ d` G P / Ft. Distribution Pipe Loyout n tp x ? t' I n c h P W Inches / Hole Diameter "'I" c-4,&2 S'y.s 7't"_ r+►s t"L "o m Lateral I n c r, Manifold n Inchf~ d' Force Main " inches., » #of holes/pipe 01 c ~ ess b.~r tti"Ca 0/edPA, Invert Elevation of t.ateral s/(,~ . F t r toe 13h d C/ e Place 1st hole a r Fi er.ds~dst*, a,oe 11 with succeeding holes at ;t intervals. Page n' Co!~S,wJ>..a S-Cep/i~ TJy~~/mD[a.~..~(7 Ck 1ajGCh r .~;.bC,w.~ (No Scale) Approved Locking Manhole Covers P~Jj'" rei' q1. C V e, ~ Wi th Warning LabelS Attached P w•~+a'vu or f'~eslr Weatherproof Approved - Junction Box Vent Cap G.,dp h %,aoln;mourn t t 4 Mini mum 1 1 1 i { 1 Quick iini~ um Disconnect 1/4" Nee Baffle Hole ~ Poi /d k sx ~2~, °N pP r. we d Alarm i elm' ✓i /e v t On 6I B I ~,.'~h•Ki~:..z~ *APPROVED o,'coya. *o JOINTS WITH off APPROVED PIPE ! 1 ra p~...,p ro 3' ONTO D I f SOLID SOIL 3 of Bedding Under Tank Tr,- Number of Doses:-6. Per Day wa"lons Per Day/ ar~ufacturer: Volume of Backflow:-~°" r'14-•:Gall¢ 'I ;oral Dose Volume:....... a rt- s. Size-Septic/Pump: Gallons r, Manufacturer: Number: T-,_, Cap cities: A~inches or •'c:%Ga; :C S -L^ Type= + B inches or ='ua Manufacturer: ! + C inches orb^_` ~a e, Number: C~> + D=inches or, um Discharge Rate: Total _ _inches or -:cal Difference Between Pump Off and Distribution,Pipe:17. ,Feet 'MUM Required Supply Pressure: _ Feet =eet of Farce Main x/, 3.S"Friction Factor/100 Feet: - t inch Diameter Force Main Total Dynamic Head: ~eet er;^a' Tank Dimensions: Length/6' Width Liquid Depth ~.::r _ 1 f~;r a,.. ~ X~ j"rte ~'i~~ i C4 C? /I i :IQ 40- <tu ' LL. C f 7 R ~ MUM ` 1 20 A 7 140 40 50 so 70 GLOW o ~1° FLOW PER MINA POWTS OWNER'S MANUAL & MANAGEMENT PLAN `'age= -1t_E INFORMATION SYSTEM SPECIFICATIONS pkSeptic Tank Capacity ❑ NA fawner f 3 c'.; t' 0 c/ h am al "ermit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA, a k Number of Bedrooms ❑ NA Effluent Filter Model ❑ N A Number of Commercial Units NA Pump Tank Capacity; gal El N, i Estimated flow (average) 69 gal/day Pump Tank Manufacturer i ❑ N . Design flow (peak), (Estimated x 1.5) avda Pump Manufacturer .w = ❑ Nr= { 1 z> r~ » Soil Application Rate ®w ~ aVda /ftz Pump Model ❑ NA ! nfluentlEffluent Quality Monthly average` Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) .5220 mg/L ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 m /L ❑ Disinfection ❑ Other. Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD5) 530 mg/L ❑ In-ground (gravity) ❑ In-ground (pressurized), Total Suspended Solids (TSS) 530 mg/L ❑ At-grade .Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-line ❑ Other. Maximum Effluent Particle Size inch diameter - Values typical for domestic (non-commerclaq wastewater a septic Y. effluent Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months year(s) (Maximum 3 yrs.) I i Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume 3 Inspect dispersal cell(s) At least once every ❑ months V!,year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 ❑ months )(year(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA' Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA'-/ Other At least once every ❑ months ❑ year(s) RNA Other At least once every ❑'months ❑ year(s) *NA t ~}r t/l <ceot,, wa o✓r C/C1e,hp Arl"°r ohre eV&t'X 3 y~✓L 3- _vcC P[ c*.N rn v` tw MAINTENANCE INSTRUCTIONS you ~ c/e- every P'.+// to lV.id daY R - & 1~,...p d `nspections 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 :3ervicing 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 :ir ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels ;n 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 regulatory authority. When the combined accumulation of sludge and scum in any 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatipment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. tj service report shall be provided to the local regulatory authority within 10 days of completion of any service event. TART UP AND OPERATION ?r new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other r;emicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are ttected have the contents of the tank(s) removed by a septage servicing operator prior to use. r* I Lr ww c 3 Page .:system start up shall not occur when soil conditions art; frozen at the infiltrative surfade. wring 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 hackup 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) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONM TENT 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 safety abandoned in compliance with ch. Comm 83:33, Wisconsin"Administrative Code: • Ali 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 property disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN t the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code ompliant replacement system: 0 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 that time. 0 A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POVVTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to identify a suitable replacement area. Upon failure of the POVV"S 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. 12; 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 TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. 40DITIONAL COMMENTS ~OWTS INSTALLER POVYTS MAINTAINER Name{ Name Phone,... Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name 1 Agency rt Phone , ~ Phone `s is document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets e minimum requirements of ch. Comm 8322(2)(b)(1)(d)lt(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not ,grantee the performance of the POWTS. GMT"✓ ST. CROIX COUNT A_ SEPTIC TANrKNLALNTTE'~ANCE AGREEN N'T k-N D ~t ORNERSTT CERTIFICATION FORM C'r 114iin~ Address 7 , 7 (y' 161A Aj (R 5-c/c 0 v7.-,r e:1z, Addrl-ss 74 C~'e_-u5cation required from Planning g Zoning D°*:,artment for new conszuction. ) C :v.`S ate 1L'1M lti'J t,+,'' ( i Parce' Iden^iLcation Nunaber LEGAL DESCRIPTION J~ a H C' •"h 7 Tour of ~Vc as d At Location Nh 7' . Sec. Z~ T N R j W t~ Subs sio; Plat: / ~ Sa t ye~/P Lot 3 a g~ Certified Sun-ey'_ Nap n Volune Page Warranty Deed n 7, Z Z ~ue`are 200TjVolu e Page # Spec house C ye~Kno Lot lines identifiable~jyes C no SYSTEM nZAJ~'TE'~. 5'CE AND C) TER CERTIFICATION Improper use and maintenance ofyour septic system cotrid result in i-s premat:ure failure to han dle wastes. P ronr E ma n_f ance consists of Humping out he septic tank every three year or sooner, if needed- by a licensed pumper. RItaz you pu nt he svstcm can affect the function of the sepfic rand; as a u eament stage in the waste disposal system. Owner ma ntciance os~oas:b:lies are specified in §SI'S. 353.52(1) and in Chapter 12 - St_ Croix County Sanitary Ordinance. -'he propert}~ owner agees to submit to St Croix County Planning & Zoning Department a certincation form, signed by the cv uer aad^y a masse. plnLnber. jo=eyman plumber, restricted? plumber or a licensed pumper verifj ing that (i) the on-site wastewater disposal SVS'em is in proper op,_7atmg condition and'or (2) after inspection and pumping (if necessan.,), the sentsc tank is less than 1I3 full of sludge. T'we, the undersigned have read the above requ emens and a=ee to maintai the private sewage disposal sys'iem uhh, he ,-.andards set forth- herein, as set by the Department of Safety And Professional Stn ices and the Depa_mnent of Nan -ai Resources, State of 4.°isconsin. Ce: location stag tha. your septic system has been maintained must be completed and returned to the St Croix Crnmry, Pla-ming k Z:)Iung Deparnrient within 30 days of the three year expiration date. l'we : ertifv tha' all statemen'S on this fo_ are true to the best of my%our imowledae. Uwe am!are the owners) of tine property described above, by virtue of a waran deed recorded in Retstr o Deeds Office. Number of bedrooms 'ZI-el IGNAT'..TRE APPLICANT(S) DATE } * zmy information that is misrepresented may result m the sanitary pe- it being revoked by the Planning & Zoning Depa~r,en Include "ith his application a recorded waranry deed from the Register of Deeds Office and a co^y of he certified survey map if reference is made in the wa-:anty need. (REV. 04'1-') Wisconsin Department of Commerce SOIL EVALUATION REPORT Page --L- of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. ~j percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O2~- /D 2-/ f Q Date O~ edb Please prirft.all information. Revi _ ' Personal information provide may be std for secondary purposes (Privacy Lao s. 15.04 (1) (m)). 11 Property Owner Property Location juiA Govt. Lot 'V E 114 f~ 114 S R N R 17 E ( w t~J~ Cam. I G lJ iJ Prope Owner's Mailing Addres L # ock # ubd. me or M# (yb 1 J City State Zip Cod1,_ Phone Number _ ED City age oown Nearest Road J` ~/C~I (7~S) I~ - 5~ I~GGSCIa /,7. r~ 11 L) Glvrtyv~CoJ GPD ew Construction Use: ~sidential / Number of bedrooms Code derived design flow rate - ❑ Replacement ❑ Public or commercial - Describe: - Parent material Flood Plain elevation if applicable ft General comments t e~~~'r ~cc~J c Ce j t Orr Co"bfd~ttr t 6 ( and recommendations: ~ ~~GY:~n c 5 s ~P~^ Cl 103. if ~G^~t~/12 v►,%~~~~'~ ~ 7 LoT z ~ / L] Boring Bori 9# r-~/ Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate t~ Redox Descri tion Texture Structure Consistence Boundary Roots GPDM Horizon Depth Dominant Color p •Eff#1 'Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz._Sh. -i~ y . ~~s bk 7, 5 5 f /o`//t J C Boring Boring ® # 2-CL: Pit Ground surface elev. _L. 2s- ft. Depth to limiting factor in. Boil A lication Rate Structure Consistence Boundary Roots GPD/fP r Redox Description Texture Horizon Depth Dominant Colo Gr. Sz. Sh. 'Eff#1 in. Mu Eff#2 i n ell Qu. Sz. Cont. Color s 1 i v tV S C Cl Effluent #1 = BOD > 30:< 220 mg/L and TSS >30 < 150 mg/L (fluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Na (Please Print) Signature CST Number Address Dat -valuation Conducted Telephone Number X6.7 i •a , Parcel ID # Page of Property Owner Boring # Boring ( ft. Depth to limiting factor- in. El It Ground surface elev. f ~ _ Soil lication Rate 2PDKf Horizon Depth Dominant Color Redox Description Texture Grt SztuSh.Consistence Boundary Roots .Eff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color C L C I l T C V t/ f ✓ / (7)•- /o 5- VV 112 LJ-) --L-V ~Ll F -0 'j bll Z'Y 7. 10 / C b °Z Boring # Boring Depth to limiting factor in Application Rate ❑ ❑ Pit Ground surface elev. h. Soil cri tion Texture Structure Consistence Boundary Roots GPD/fff Dominant Color Redox Des p ff#2 Horizon Depth Dom Qu. Sz. Cont. Color Gr. Sz. Sh. II in. Munse ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate ❑ Pit tue . Sh. Consistence Boundary Roots .E GPD Eff#2 Horizon Depth Dominant Color Redox Description Texture G~ Sz in. Munsell Qu. Sz. Cont. Color ' Effluent #1 = SODS > 30:< 220 mg/L and TSS >30:S 150 mg/L ' Effluent #2 = SODS < 30 mg/L and TSS 5 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-8170 (R.6/00) Property Owner o a Parcel ID # Pegg" Of Bod 12 Boring # Depth to limiting factor in. Pit Ground surface elev. ~ • ~ ft ~ ~ Soy Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDVIf in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 6MI *E1W Fv ~ S f 7, ~ IoY ~ w. t~ ' i I i El Boring # C] ❑ pBoring it Ground surface elev. tt. Depth to limiting factor in. Role Consistence Boundary Roots GPDff Texture Structure Horizon Depth Dominant Color Redox Description .E in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. Boling a Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ pit Soil Rate ~ Horizon Depth Dominant Color Redox Description Texture Stnxstue Consistence Boundary Roots GPD/fF Gr. Si. Sh. *Ef #i 'EM in. Munsell Qu. Sz. Cont. Color i i i I Effluent #1 = SOD, > 30:_< 220 mg/L and TSS >30:5 150 ngA- ' Effluent #2 = BOD, 30 mg/L and TSS 130 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to accM services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-2644777. SHO-1330 (RAM) .:Y-- 3 cs:L tieJ.. 63 ,9v rC }J gg~ ~ bf3► s~~rj-~ toycD4 r pucr,rz t©e e4 l puc P-e'.e 1 J' / ~I