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HomeMy WebLinkAbout036-2002-90-000 (2) 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: 597454 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] ' V Permit Holder's Name: City Village Township Parcel Tax No: JEREMY & KELLY GESS TOWN OF STANTON 036-2002-90-000 CST BM Elev: Insp. BM Elev: IBM Descri tion: Section/Town/Range/Map No: (wrtkilAb l~ rVir Pa r 31.31.17.628B.629 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. V1 ALks Septic Benchmark O Alt. BM Aer Bldg. Sewer / 1/ H o~ r ,a Q~ ^7 TANK SETBACK INFORMATION St/Ht outlet A / SZ 9 7 TANK TO /L WELL BLDG. Vent to Air Intake ROAD QwmfCY p I of % .3 tic U 97..S-S A) ! Dt Bottom V Dosing Header/Man. Aeration Dist. Pipe ,v j„ , T L P 9.OS . S A. Holding Bo ystem Final a e / PUMP/SIPHON INFORMATION 2 • l~ 3 Manufact Demand St Cover j~ ~ 102 G 1, f Mo el Number TDH Lift Friction Loss System He TDH t Forcemain Length Dia. Dist. to Well 4or 1 -1 41 't _j SOIL ABSORPTION SYSTEM -1b, pe lip" W ,r ,f ff*O . 7 13 BED/TRENCH Width Lengt I To. Of Trenches PIT DIMENSIONS No. Pits Inside Dia. Liquid Depth DIMENSIONS N 11" / I J L SETBACK SYSTEM TO P/L BLDG WELL LAKE/STRE LEACHING Manufac rer: , INFORMATION a/~•D 7 Type Of System: CHAMBER OR mmnyy~~~~//~~ A ~`UVIIVIYf'f~ ~trpr Z, 1) UNIT M ✓IL~iery DISTRIBUTION SYSTEM vnl y" n C Header/Manifold ^ Distribution x Hole Size x H Spacing TAU Air.In take . Pipe(s) r 7 • ! CSI[ 4C ~ Length i Length 41 SOIL COVER i x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Ce Ou • Bed/Trench E opsoi yes No E Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: 1 Location: 1809 147TH ST `lam ` ' d I n 1~,w5 1y I' C~ r 1.) Alt BM Description 320 V *b 5~1~ AS" 1L)V 1 " 2.) Bldg sewer length - amount of cover JY15J7Mr Q1_1C ~S~ s~son{'~ Plan revision Required? L Yes P.O'No Use other side for additional information. J Da ctor's Signature Cert. No. SBD-6710 (R.3/97) 1 t ~I moo" ~ s 3s .j,'© r ip FK /Lo ~ _ /m /must 4 r ,t ~ d y y1 k ~ j o J / ~f f;~/~5 CO ~G _ Q c fi ~ c~ ~ s~ -da o - a7q > • - County Safety and Buildings Division l 8 $ 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to oe filled in by Co.) Pu N Madison, WI 53707-7162 / ' Sanitary Permit App 2scie State Transaction V In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to u- , ~9q, is required prior to obtaining a sanitary permit. Note: Application forms for state-owned Pow G project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secou-, u oses in accordance with the Privacy Law, s. 15.04(1) m , Slats. I: Application Information - Please Print Al ormation Property Owner's Name / Parcel # Property Owner' ailing ddr s Property Location Govt. Lot City, State J Zip Code Phone Number y, y., Section - t o S J `7 (circle one I . Type of Building (check all that apply) 1 Lot # T N; R L~ E oU ]or 2 Family Dwelling -Number of Bedrooms Subdivision Name - /117D - Block ❑ Public/Commercial - Describe Use ❑ City of ❑3 State Owned - Describe Use L CSM Number ❑ Village of J ~J 1~ I S~'I7 }'IS W Town of UJ 111. Type of Permit: (Check only on box on line A. Complete line B if applicable) A' El New System Replacement-System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) te 5 and /ate ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number B. ❑ Permit Renewal ❑ Permit Revision Before Expiration Owner Iss SS 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 f~ ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) JA V. Dispersal/Treat nt Area Information: Design Flow (gpd) Design Soil Application Rate(gpd Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation l VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o cv New Tanks Existing Tanks o U u 2 w ~ 14d&41,ak- 6 o. U in V, w C7 M1. Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume respo sibility for installation of the POWTS shown on the attached plans. Plumber' ame (Print) Plumber' Signa e 1 j MP/MPRS Number Business Phone Number /,.5 - 4P. er' Address (Street, City State, Zip Code) VIII. oun /De a me'nt Use Ott Approved pprove PermittFFee Da Iss~u/ed y Issuin gent Signatur G for Demal $ -7 V of y / ` IX. Condit easons for Disapproval Septh ark; a fltrm lifter vn-1 di%iews+i cell must ail be sn~ic s as per ,7laracement plan ptu tided try plumbea. 2. "i0.k i t r'Wwomems trust r u maintz it':e d ii Per OPP406M cods / zfflinamai. Attach to complete plans for the system and submit to the County only an paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE r , Project Name: Owner's Name: Owner's Address:` A, n Legal Description: ; X/ Township: County: Subdivision Name:_ Lot Number. 9 Parcel ID Number> 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 g CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: ✓J / License Number. Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01)_ Page 1 I p 111 i l 4 I i Soil Absorption System Cross Section 4 ft cl_ ft 4° Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 7 ft Leaching Chamber System Elevation ft ft ft Soil Absorption System Plan View ft ft { I ~_ft Leaching Trench 1 Chambers 4° Dia. Trench 2 Header Vent Or Observation Pipe o,-) - t~ as Trench 3 Leachinq Chamber Specifications ns Manufacturer And Model EISA Rating,z,,~_ sq ft per chamber Soil Application Rate ; gpd/sq ft ? gpd Design Flow : Z_ Soil Application Rate ::0 EISA Chambers 3 rows of chambers each. Page _ of PL 525 EFFLUENT FILTER P kla~ E N HE Vex M E i h,x k ; ~ Poiylok, Inc is pleased to add its new commercial filter to its existing line of duality effluent filters. The PL-525 is rated for over 10,000 GPDl Alarm (gallons Accepts PVC per day) making it one of ~ accessibility extension handle the largest commercial filters in its class. It has 525 linear feet of 1/15° filtration slots. Like the Polylok g , PL 122, the new Polylok PL 525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1115" A Rated for over filtration slots removed for cleaning, the ball will float up and temporarily shut off 'k 10,000 GPD the system so the effluent won`t4 leave the tank. No other filter on W'_, the market can make that claim! Accepts 4" & ` SCHD. 40 Pipe w PL-525 FVW,,rnten;anc:e: The PL-525 Effluent Filter should operate efficiently for several years udder normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned `r. 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 needs servicing. Servicing should be Gas deflector done by a certified septic tank " Automatic shut-off pumper or installer, ball when filter is removed 1. Locate the outlet of the U.--- Patent NoP 5,015,433 septic tank. •53,371,540 2. Remove tank cover and pump tank if necessary. _ 2 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank, Make sure all solids fall 4 or 6 outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted, its housing. 7 Replace septic tank cover, 5. Replace the septic tank cover. D"M POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page yZof FILE INFORMATION SYSTEM SPECIFICATIONS Owner y Tank Manufacturer: ❑ NA Permit # [A Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: LV %<'ScC' ❑ NA Number of Bedrooms: ❑ NA Septic ❑ Dose ❑ Holding Volume: C (gal) Number of Public Facility Units: [Z.NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) if horizontal is >150 feet. Specific instr cti n to be provided on back. In Situ Soil Application Rate: (gal/day/ff) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: f~ Fats, Oil & Grease (FOG) <30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) <220 mg/L ❑ NA 01 NA Total Suspended Solids (TSS) <150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BOD5) >220 mg/L JZ NA [I Mechanical Aeration ❑ Peat Filter NA (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BOD5) <_30 mg/L Soil Absorption System (TSS) <30 mg/L ® NA Fecal Coliform (geometric mean) 510, Mn-Ground (gravity) ❑ In-Ground (pressure) ❑ NA ❑ At-Grade ❑ Mound Maximum Effluent Particle Size '/8 in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) jZ When combined sludge and scum equals one-third (%3) of tank volume ❑ When the high water alarm is activated Inspect condition of tanks At least once every- El month(s) ryyear(s) (Maximum 3 years) ❑ NA Inspect dispersal cells At least once every.- El month(s) A year(s) (Maximum 3 years) El NA Clean effluent filter At least once every: ❑ month(s), ❑ NA 5d year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ 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 soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or 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 soil absorption system 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 indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (%3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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. GMW-005 (02/05) 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 absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 s. 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 (pumper). • 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 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, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA LE POWTS MAINTAINER Name - Name Phone -7 c Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name -57 Phone Phone -Zll This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 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 absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 s. 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 (pumper). • 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 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, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA,LE POWTS MAINTAINER LP,l Name hone i - _3 _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone - This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNT' SEPTIC TANK MA]NTENANCE AGREEMENT AND OWNERSI-RP CERTIFICATION FORM Owner/Buyer T cT Address Property Address Department for new construction-) (Verification required from Planning & Zoning City/State Parcel Identification Number LEGAL DESCRIPTION _'/4 r/4 , Sec. T / N RAW, Town of Property Location _ _ C/) Lot # _ Subdivision Plat:____ Page # Volume Certified Survey Map # (before 2007)Volume , Page if- Warranty Deed # Spec house Q yes Xno Lot lines identif iable,dyes G no SYSTEM Ni~4I'~Ii TENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes.. Proper put into maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. Vi you 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 M 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. Uwe certify that all statements on this form true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty d recorded in Register of Deeds Office. Number of bedrooms ' PLICANT(S) DATE S NA ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning& Zoning Depatement. **Y 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. m v+cr n.r rrft 85006' w 0 o v CE 06, w 1 5 6. 1' OC 00 7 O loo.oo' W are 1 0 O o O 0 0 E30 p qt _ - T 10 0* m Q N Z N 0 O 3 at 0 % lb 900 n 1 0 a 0g O 0 a P 1 °pF, 0q 10 0.00 Z 0 0 6 9p 0 i 95°06'w 187.99` t Og. 09 1 T5.00` to 0 900 S 85006 w cb 0 OV ICS ti CE a+ r, S T~ O °C' p0'gr, 66.00 96•'90` 'G 41 136.73 S85006W aO off S 85° 06 ' w ° aAK RID E L~►i3b 0 002 i Jy 215.00 t Z i 1~1 ¢ A -SO 06'w N 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) located Z= at: _ ; .1/4. Section s; Town j N, RanV Town of 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 Conu-U384.25, and it (they) appear(s) w uc functioning properly. Most recent date of inspection or sen-ice Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: zallons minutes Tank Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): Permit number (if known) (Licensed Plumber Signature) (Print Name) (Title) (License Number) h/IP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 DEPARTMENT,OF INOUSTRV, t~ INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELA rr♦+~ V PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISJN, WI 53707 n ignvAl Au `Z 101 tX lid nNVENTIONAL In-Ground PlresALeTERNATIMound '„-,PI-1 D 4a Tank CR01)(CO pQME NAME OF PERMIT HOLDER ~O ADDHFS~ i?F PE.HMI I HOL:)EH INSP _CI )N UATE Donald B. Schuftz + R. R. 3, Box 320D, New Richmond, WI- BENCH MARK IP err P,.....) DESCRIBE IF DIEFEHENI FH(1M P, ..h REF. PT ELEV HF I IT ELF V SE'-, SE-4, Sec.31, T31N-R17W, Town of Stanton, Lots 8 & 9, Oak Rdg. Est. Gary L. STeel -1_3254 1 St. Croix 64885 SEPTIC TANK/HOLDING TANK: MANUFACTUHEH Llc%U[I CAPACITt TANK IN,F ELEV TANK LIl LET E'.EV WAHNINGLAO PRO, YES F_1 NO COVIFE BEDDING VEN1D VEN HI ,H LNATf F+ n1UMBEROF ROAD PROPERTY WELL BUILDING VENT TO FRESH AI AHN'I + ~7 I! NE EET FROM AIR INLET YES L -.NO ~ I 'YES NO EAREST 30 DOSING CHAMBER: - MANI)iAHFI'. BF UUING LII~IJff) aPACl rv PUMV M7FI sV SIPEI r WARNING LABEL LOCKING COVER PROVIDED PROVIDED ;YES _'NO ~ LI~YES f~JNO DYES '-]NO HIM 01%(. JENTToFRESH, GALLONS PER CYCLE: POMP AND CONTHOLSOPFRATI NAI NUMBER OF PH<,PFHTY LIE (DIFFERENCE BETWEEN FEET FROM aIR INLET PUMP DIN ANDOFF) YES NO' NEAREST '.,AC. KY SOIL ABSORPTION SYSTEM. Check the soil Eno lstu re at the depth of plow In - 1. a .u or excavation. (If soli can be rolled into a wire, construction shall cease until FORCE MAIN the soli Is Tiry enough to continue.) CONVENTIONAL SYSTEM: LNID1,1 LEN(, 11, Ntr ilT I)I`,`H PIPE SPAt INI. !)VER INti11 ~E .)I ~P'Ty LIOVIG BED/TRENCH Ns / Ar AL / IT DEPTH DIMENSIONS PROPS WELL BUILDING VENT TO FRESH F FIl1. {)FPTH IAI~112 L)ISTH P!PE DISTR PIPF MA 7ERIAL NO UI NUMBER O AH, I ,vER QJttr L V^E z PIPES„ F LINE AIR INLET i / k4 / FEET FROM NEAREST--►~ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for ( PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. 1 IONS MEASURED. YES JNO r ; _I)RF , E vnaANeNrnaAHKL E+ SOIL COVER ,r . - L- Y ES JNO _C1 ES NO ~L I, DEPTH OVER THEN( FI BED DFPill .>v11,ENCL+BE--- nE~iH ~•i ;i.~~1 ~ ,---'YES i_1N0 YES l~_JNO 1~HIu CENIFH FLf YES L_-NO PRESSURIZED DISTRIBUTION SYSTEM: A'! 4 t1, NO. OF t A f F.AL SPaGNG G 1AIE L UEVTHH 1E <)W PIPE FILL DEPTH ABOVE COVEH BED/TRENCH I F V TRENCHES DIMENSIONS j 5TT ."NITOID PUMP MANIF()ID DISTR PIPE MANIF OID M ATEHIAL NCI T-,t- L'ISTR PI, ,1 .iBUiION PIPE MATEHIAL &MAHKINL. E L.E V DIA ELEV PIPES DIA ELEVATION AND i DISTRIBUTION INFORMATION 511E ItIIF tiP11,111. DI,'ILI E L C;()HHF L')I Y C()VER MATE VIAL VFH71CAI L IF T CORRESPONDS TO APPROVED "!I.E P. nNS _ YES ❑NO ! IYES ❑NO COMMENTS: } PERMANENT MARKERS OBSERVATION WELLS FN1M BER OF PRO PERTY WELL BUILDING FROM LIE LINO EST YES UNO LJYES r.. 1 Sketch System on Retain in county file for audit. Reverse Side. - Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T- N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION r;= LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH-R. 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5 ;n { INDICATE NORTH ARROW T DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUS-TRY, C DIVISION LABOR ANC PERCOLATION TESTS (115) MADISP.O. BOX ON W 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION TOWNSHIP/Min, ~ Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: C 1/a (-:-1/4 /T,3 / N/R/71 (or) W ' ~Es A;, )F COU T OWNER'S!H11-1-~S NAME: MAILING ADDRESS: _ T A Se, ti u l t z 12. A` _:--5 13 X .3 Z 0 e7,c) USE DATES OBSERVATIONS MADE ~q NO.BEDRMS.: COMMER IAL DESCRIPTION: DESCRIPTIONS: PERCOLATION TESTS: [Nesidence ❑ New Replace I C9 RATING: S= Site suitable for system U= Site unsuitable for system G7 CONVENTIONAL MOUND: IN-GROUND-PRESSURE SYSTEM-IN-FILL. HOLDING TANKRECOMMENDED SYSTEM: (optional) S ou Ns ❑u cis ou DS ~u ❑ s If olation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the [,nPdo,'rcs.1463.09(5)(b), indicate: Floodplam, indicate Floodplain elevation: /yJ ~EcSItY~al f PROFILE DESCRIPTIONS ~n BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER REPTH4N, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ( v Zs 7 3 B B- B- ~Si~A~ i PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER S AFTER SWELLING INTERVAL-MIN. PERIOD 1 ___PERIOD 2 -PERIOD 3 PER INCH P- / - C Cv u, 3 P- 2- SJ o P_ 6 P_- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable so'.I areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on thtt plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION f-s d- 0 If ws li- N , L ~ti ~ I r 7 1 nA,1 grads o I Wis. Dept of Safety and Professional Services SOIL EVALUATION REPORT Page of Division of Safety and Buildings 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 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). $ ljA/ Property Owner Property Location - -S Govt. Lot 1/4~ 114 S N R j7a UI Property Owner' Ma' ' Addregs Lot # Block # Subd. Name o M# City State Zip Code Phone Number ❑ City Village OTown Nearest Road ❑ New Construction User Residential / Number of bedrooms Code derived design flow rate L'- r~ GPD g Replacement ❑ Pu~lic or commercial - Describe: Parent material Flood Plain elevation if applicable /yx1 ft. General comments and recommendations: e F Boring # ❑ Boring I pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence oundary Roots GPD/ft P in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 cp -7 A114. /s e on . t dace elev. ft. Depth to limiting factor in. Soil Appi Rate Horizon DepM D C&kfr Redox Description Texture Structure istence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *M42 * t #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mg/L * Effluent #2 = BOO < 30 mg/L and TSS < 30 mg/L CST Na lease P t) / Signa re j j I CST Number Address Date Evaluation Conducted Telephone Number SBD-8330 (RI I/] 1) Property Owner Parcel ID # Page of Boring # Q Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. SoU Apprication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munseff Qu. Sz. Cont Color Gr. Sz. Sh. ' tf#1 * ff#2 Q Boring a Boring # Q pit Ground surface elev. It. Depth to limiting factor in. Soil Appfication Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. fP#1 * ff#2 Boring Bo»ng # Ground surface elev. R Depth to limiting factor in. ate ❑ Pit Soil A Ucation R-pp Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots ff#1 GPD 2 in. Munsell Qu. Sz. Cant Color Gr. Sz. Sh. * Effluent #1 = BOD 6 > 30 220 mglL and TSS >30 < 150 mg/L * Effluent #2 = BOD S 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. W-3330(R11111) / ~O~ r-l. ~k,~ir~ ~ LCS S ~J ~-~/7'~-~~II /y- sue= ~ ~3/ - T ~~i~/- ~i7~.~J /1/~ uJ ~e..s:~o~~a ~tJ ~ " GSA 7 -~~T~'~" ~ C~ ,SJ~? ~~~~2~ ~ ~d~ /~:o ~ 6 - t ~ \ n , , - ~ ~ - I 1 _--r-- i 5 d ` l ~ R - En y A o 00 n 3 ~ co V 3 7-4 tD MAi L ;au, "Alir OD cri CA) Q 4 _ . N 001001. `FOOL q Q OD a C3~ } 44. ' 09 0 al G 4z Aio S z m ( 77 77 z 00 r'