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HomeMy WebLinkAbout026-1118-11-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St, Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No. (ATTACH TO PERMIT) 597485 GENERAL INFORMATION State Plan ID No Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Permit Holder's Name. City Village Township Parcel Tax No: BRUCE AND BONNIE WERNER TOWN OF RICHMOND 026-1118-11-000 CST BM Elev: Insp BM Elev: BM Description: c:~ h Section/Town/Range/Map No: { v ,~-P_h 01.30.18.691 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Septic 1-tk j + a` . n j,,') llJ'~J Alt. BM J k. Aeration f9ert St/Ht Inlet r St/Ht Outlet TANK SETBACK INFORMATION - TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom r Dosing - Header/Man. Aeration - Dist. Pipe ~7 y , f Holding _ Bot. System l~ PUMPISIPHON INFORMATION Final Grade , Manufacturer r. n1 Demand StCovf+ 7- Lf GPM "1 v'. Model Number TDH Lift c { Friction Loss System Head TDH Ft - Ir s Lt s 1, 3? Forcemain l_n t Dia,-. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENS .00 Of Pits Inside Dia Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L- BLDG WELL LA E(ST EAM /LEACHING Manufacturer INFORMATION `CHAMBER OR -1r Type Of System: UNIT Model Numb ^7 / 9 , ~"y1..( 1t'a=1~~'e r ~ sL,/ ~ ~ 1 t )~f'S ~~~l • ...J Y"f DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole-Size x Hole Spacing Ven to'Air Int e / d Pipe(s) L. Length A Dia Length Dia Spacing j;`ll SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over , Depth Over 1XX Depth of xx Seeded/Sodded xx Mulched Bed Trench Center / Bed Trench Edges Topsoil `Yes L No `Yes _ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1413 174TH AVE 1.) Alt BM Description = f4 `~~Lta. tf~ f Yn 2.) Bldg sewer length = Y <t `R v l n~_t - amount of cover = Plan revision Required? Yes J No h Use other side for additional information. SBD-6710 (R.3/97) Date Insepct6r's1gna Cert. No. OLI 11% s Division ST CROIX Safety a-d Builq6j ~ . 201 W. Wasl- ej R Box 7162 Sanitary PC11111t Numb,•rlto he lillcd In b% ( o P SE~ U Madi 762 9--Li $ gwf 4.a 's ST. G~O ~O ~ PMT nrtary Permit Application S``I" rLill °ctloll , tI he` In uccoIdait cc kith SPS 8321(2)- AA'1s_ Adm_ Code. submission of this f III: to the appropriate gO\ erl entaA is required prior to ohtainin- a sunitun permit. Note Application foinis Ior state-o\\ lied P(M IS Lire suhmiited to o ect Wdress (II dI(ferent than mailim-, addrss) the Department of Satet\ and Professional Sen ies Personal inlormation vuu prov ide may he Used for sccondan purposes in accordance wth the I'nc ICC Lavv_ s 1 01(I )(m)_ Stats_ 1. Application Information - Please Print All Information \\lll///lll~~~ Properh Owner s Name Parcel BRUCE AND BONNIE WERNER 026-1118-11-000 Property O\cncr s NFoline Address I'ropem Location l 1 1413 174TH AVE GI,\ t Lrn CII State Zip CodC I'hone Numher NW SW Section 1 NEW RICHMOND 54017 715-246-3575 (circle one) r 30 ♦ IZ 18 1[ or X 11. Type of lluilding (check all that apple) Lot A3 - - I or' Famih Dsccllini-, NumhenofBedrooms 11 Suhdn uion Name Block= WILLOW VALLEY ❑ Puhhci('ommcrcmI Descrihe 1, c N/A ❑ Chi of CSM Number ❑ Vlllase of ❑ State Owned Descrihe I'se L3CIo-loI RICHMOND-- 111. Ix Ve of Permit (Chet onlN one boy on line A. Complete line B if applicable) ❑ Ne%c S\slem [Replacement System ❑ I reutmcnt!lfold i112lank ReplacementOnh ❑ Other Ntodilication to laistin( System (csplam) H• ❑ Permit Renewal ❑ Permit Rey ision El Chun<,C of ['lumber El List 1)1,2\ loss Permit \ainhcr and Date IsxlCLI Permit [ rmsfer to Netc BCtbre I'SPILM1011 O~cner 1N . Ty e of PONN'-hS System/Con onent/Device: (Check all that a Ih ) Non-Ptossun/L I In-Ground ❑ Pressurized In-(:round ❑ At-Grade ❑ MOLInd > 24 in_ of suitable soil ❑ Ntound < 24 in. ofsuitable soil ❑ floldim Tank ❑ Other Dispersal Component (esplainl _ ❑ PritR2Llnent Dev iCe (CSPlain)_____ Dispel-sal/Treat lent Area Information: Design I'lo\c (<zpd) esign Soil Applicati n Rat' ~pdsf) Dis ersal Area Required (st) Dispersal Area Proposed Is ll System N 1. Tank Info Capacits in Total 4 o1 Manufacturer Gallons Gallons [!nits _ Scplic or Noldinn Tank X WIE.SER X Dosing Chamber Y~N/A W fX k1 NIL Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWUS shosyn on the attached plans. Plumber S Name (Print) Plumbers Wnuture~ N11'iN71'RS Number Business Phone Number PAUL R KOEHLER 225410 715-246-2660 Plumber s Address (Street Cit\_ State_ /ip Code) 321 WISCONSIN DRIVE NEW RICHMOND WI VIll. County/Department I se Onh PPro\ ed approved PCrmit Fee Dat, IssU d Issuing Agent Signatulrt st4 19 0vvIl eason for enial IX. Conditions o pproval/12casons fur I isapprocal g1„_ rf n/ O~ 0 SYSTEM OWNER: Q) C`V°'CJr~-Y~~~'t" bM f l L jf 1. Septic tank, effluent filter and dispersal cell must be seryiced / maintained as per management plan provided by plumber. 2. All setback requlrementscmuBil,bo-e loir".1 I scstem and suhmit to the Counh onh on paper not less than S U2 c 11 inches in size as per applicable code/ordinances. SlID-6,98 (R. I I I I) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: BRUCE AND BONNIE WERNER REPLACMFNT Owner's Name. BRUCE AND BONNIE WFRNFR Owner's Address: 1413 174TH AVE NEW RICHMOND W1 Legal Description: NWL4 SW1/4S1T530RI8W Township: RICHMOND County: ST CROIX Subdivision Name: WILLOW VALLEY Lot Number: 1 I Parcel ID Number: 026-1118-1 1-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: PAUL R KOEHLER License Number: 225410 Date: 09/07/2017 Phone Number (715) 246-2660 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 T- I Row of trees 4rows of ez flow NW1/4SW1/4SEC1 T 30 R19W j 75 ft long TOWN OF RICHMOND. 1.69 j ACRE LOT I I Bench mark 100 top of well I h_ Drive way SYTEM ELEVTION 95.75 I I Four 75 ft trenches. I I Q BORING 1 ELV 97.9 I System elevation 95.75 i Drop box j O BORING 2 97.75 I garage 'P.. 0 B3 I I BORING 3 97.75 K well 3 bedroom ! REVERSE TANK USE THE 120 ft I 800 SIDE AS PUMP SIDE. home 2" force I NEEDED FOR PROPER j ain I ROOM OF DRAIN BACK. ® ry I 'T I Wieser 1,000 septic 500 FOR SEPTIC. ONLY TWO MANHOLES BROUGHT UP. USE SIM B~ I TECH FILTER FROM Sim tech . Wieser I WEISER. j 840/500 com- NOTE: REVERSE TANK. I Failing drain field I < i I Water a'V............ .,.....y shed I I I I I _.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._..1 SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page_ot_ Project Name: BRUCE AND BONNIE WERNER 4 No. of Cells 7.5 Per Cell 3 ft Cell Width 30 Total No of EZ FLO\ 75 ft Cell Length 50 sq ft EISA Per Cell 3 ft Cell Spacing 1500 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: INFILTRATOR Gravelless Leaching Unit Model: EZ 1203H-10 = 28 EZ 1203H 5FT=4 Typical Cross Section Finished Grade It Observation Pipe with approved cap or vent ~........e--- _ . :;:;;;:;;:;:Soil Backfill 1 in Geotextile Fabric ft Infiltrative Surface 12 in _ft Limiting Factor f+ in Slotted and Anchored Ventf Observation Pipe with Cap ■ ■ ■ ■ ■ ■ f . ■ ■ ■ . ■ ■ ■ ■ ■ ■ . ■ ■ ■ I ■ ■ ■ . ■ . ■ ■ ■ . ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ f ■ ■ ■ / ■ . ■ ■ ■ ■ ■ . ■ ■ f ■ \ ■ ■ ■ ■ ■ ■ ■ Plumber/Designer Signature: PAUL R KOEHLER License 225410 Date: SEPT 14 2017 Septic-Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer wieser Pump Manufacturer goulds Tank Model Number 800/500 Pump Model Number epo4 Total Tank Capacity 1,340.00 Alarm Manufacturer sje- rhombus Max. Bury Depth 8.00 Alarm Model Number ps patrol Switch Type float Filter Manufacturer sim tech Total Dynamic Head (TDH) - Feet Filter Model Number Elevation Head 6.00 Distal Pressure Network Loss Minimum Pump Performance Required Force Main Loss 1.00 z~ 47.00 GPM 7.00 Ft TDH Total 7.00 Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade Sealed Watertight Securely Mounted With Locking Device Weather-proof Junction Box Finished Grade © Depth of Cover Vent Min. 12" Disconnect Above Grade Ft With Vent Cap Means Outlet Outlet Filter Inlet Inlet Baffle A ' Switch Settings and Reserve Capacity y4aa Tank Volume = GPI <;< Weep rsr <r< < > Hole > a Dimension Inches Volume Gal. B (reserve) A 21 411.81 (alarm) B 2 39.22 t>` Off Elevation C i (dose) C 8 156.88 <>; Ft Bottom (dead) D 12 235.32 ;i D Elevation Total 43 843.23 , Ft } < < < i t < i at XL.. < a a a s r>, a,>> a> a>, a s a r: s a a` t t i< t t i i t i t t i i{ t i<< t<< t i t s i<< t< i<<< t t t< t t t< i t<<{{{< t t 1 t i <'< s > > > > > a > > > > > > > > a > a > > a > > a > > a > a a s , > > > a > > a a > > > > > > r r > > > a > a ) > > a J`/ GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 LJ Page of Wastewater METERS FEET 10 i i 9 30 -4-- 5 GPM 1 ' 8 i I 2.5 FT 25 Q 7 U 6 20 Q ' Z 5 D 15 4 I ~ POS O 3 10 i { ti +I EP04 ; -r 2 ~ I 1 5 i 0 0 0 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m3/h CAPACITY MODEL INFORMATION Minimum Float Switch Cord Dischar a Minimum Minimum Minimum Maximum Shippin Order No. HP FVI~ukmps Circuit Phase g On Off Basin Solids Weight Breaker Style Length Connection Level Level Diameter Size Ibs/k EP0411 Plug / 10' 11/2 Manual Manual 15" 20 / 9.1 No Switch EP041 lA Piggyback / 10' 11/2" 12" 6" 15" 21 / 9.5 115 12 20 Wide-Angle EP041 1 F Plug / 20' 1'/2" Manual Manual 15" 20 / 9.1 4 No Switch EP0411AC Piggyback / Wide-Angle 20' 1112 12" 6" 15" 21 / 9.5 EP0412 1 Plug / 10' 11/2" Manual Manual 15" 34 " 20 / 9.1 230 6 10 No Switch EP0412F Plug / 20' 1'/2" Manual Manual 15" 20 / 9.1 No Switch EP0511 F Plug / 115 13 20 No Switch 20' 1'/2" Manual Manual 15" 22 / 10 '-EP0511 AC .5 Piggyback / 20' 1112 12" 6" 15" 23 / 10.4 Wide-Angle EP0512F 230 6.5 10 Plug / 20' 1'/2" Manual Manual 15" 22 / 10 No Switch PAGE 41 M-M/OOOUA :3113 95-v8-SZ2-008 0 \ :dnOd-1SOd :31V0 00/00/00 :31V0 OSL45; Im ')IOOa N301VW Ol AMH Sn 9LL£M z VOS 31380110913531M ,b f1NdW OIld3S w o :aflOd-3ad .0-,L=.* /l :3lVOS dOM :,19 NMVaO = \ Nvi-005/0-va N 0 w w H Q z mO D J ° ~ -i w 0 v) 12 a vl m w a m Q V) 0 O° W U P W °w U W F- J W a a J Co F W Z ~OF- Q m Q Z Q w Q (n o m of ° ~ W U H O z ~_j °z= z z- m~ 3 o F ° Q Q aao° °o mvwi JWw 00 z ~ 0w a ° a a U U o= vi I w w w z z cn V) 00 y O 2 _ Q W cn = \r7~~d0 NfI MW m Q UD aoO Z LO U U) En P- co P (n -ok N - Q° O LO J rn?J~ ~NF- =),n F- 0 O ~a w 00 En O~0 3°~ °QY °0w a w m F vwi °o ~D zJ Mmo~ 2 °UCn °U~ 0_ ° 0_ x WU Y 2<0OZQw,?°wa~~a1 a20 a~° U c~ a ccn 0 Z cn z F- F- mUM2J~mzi Z U ~~yyJ, OOW LLI J J QO Z >z in ° Z Z J J < UFQ- U J Q W V) I Q I N Q ~ U W cl F- Q Z w9~ 0_ N o a z w ~ ui N LLI I I - > a M I `JQ`' / 5 Q w 1~ J o f o use ~ N 0_ Q I L5 w£ W w Q \ «S 1 1 U 0 1 m o \ N~/ I I I I' w O i F ° F- N W J Z_ U U- Z) ab3b a u£b Sd6S wi Q cn Y z Q H w 4 i I ~ Z w / ~v SQL _w N N 5 ` ~i F- jD N W m d6 E, Sri Q Q M M M R c <t Z I LLJ w. C)f Q - C) F- Of w O ; U C) - - - - - ° I~- U LL Lv ¢ O Q - - - - U NO U a-- M M M W J LL I O U M U J r- U CO M I CC) tfj co C6 LCD O ~ I I ~ i SIN i N u \ \ r- C) z a - \ ~ 9 w U 0 CO ~ = w Q U - - 0 F- (7U) _ - i X Z C-0 - - w CO t-- CO o F- w =D w Z CO - - U - F- _ - W C-) Cf w U 2 Q O (n / U J O L- W N J O > = 00- U) w ~ O iL Q F- J W J J o O= p - - - Zww LO (I- U) > 0 ~ 2 Q J j w ~ ~ Co 0 (D 0~ ww : F- Ln Z WQ - ~ W cn L~F- =D ~ W ~=0 co JQ¢O0`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) 1413 174TH AVE located at: NW 1/4, SW 1/4, Section SE , Town30 N, Range 19 W, Town of RICHMOND , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service SEPT 2017 Did flow back occur from absorption system? YesX No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): WIESER Age of Tank (if known): 1999 Permit number (if known) PAUL R KOEHLER (Licensed Plumber Signature) (Print Name) MASTER PLUMBER 225410 (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 'L FILE INFORMATION SYSTEM SPECIFICATIONS Owner BRUCE AND BONNIE WERNER Septic Tank Capacity 1350 gal ❑ NA Permit # Septic Tank Manufacturer WIESER ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer POLY LOCK ❑ NA Number of Bedrooms 4 ❑ NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal EXNA Estimated flow (average) 450 gal/day Pump Tank Manufacturer FX NA Design flow (peak), (Estimated x 1.5) 600 gal/day Pump Manufacturer EX NA Soil Application Rate .2 gal/day/ftr Pump Model 1(NA Standard Influent/Effluent Quality Monthly average' Pretreatment Unit E~NA Fats, Oil & Grease (FOG) <30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) <_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <1 50 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) q(NA Biochemical Oxygen Demand (BOD,) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size e in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA f _ 'Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Ins ect condition of tank(s) At least once every: ❑ month(s) P 3 Gear(s) (Maximum 3 years) 11 NA Pump out contents of tank(s) When combined sludge and scum equals one-third 0) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 El month(s) (Maximum 3 years) ❑ NA CXyear(s) ❑ month( sl El NA Clean effluent filter At least once every: 1 yeaarr((ss) ) Inspect pump, pump controls & alarm ; At least once ever ❑ month(s) NA p y' ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) >C] NA ❑ year(s) Other: At least once every: 11 mont )(s) 5d NA year( Other: ® NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identity any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the 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 ('r;) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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 or other chemicals that may impede the treatment process and/or damage the dispersal cellls). If high concentrations are detected have the contents of the tank(sj 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 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. 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 tilled 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 that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T . ~ a o ding tank aiuati v v be i e Tame rrZD+((~ rr>r_ 1~-D2 //6-w S77ZUG~0 tj ❑ 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 a, 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. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name COUNTRYSIDE PH.COM Name PAUL R KOEHLER Phone 715-246-2660 Phone 715-246-2660 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name POWERS SEPTIC Name ST. C~ D(i1 2D~llU Phone Phone (S- 3 41(O This document was drafted in compiiance with chapter Comm 63.22(2)(1b)(1)(d1&(f) and 83.54(1), (2) & (3), ANlsconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner 'Buyer BRUCE AND BONNIW WERNER Mal IML, Address 1413 174TH AVE Property Address SAME - (Verification required from Planning & Zoning, Department for new construction.) NEW RICHMOND 026-1118-11-000 City, State Parcel Identification Number LEGAL DESCRIPTION NW SW 1 30 19 RICHMOND Property Location , %d , SCC. T N R W, Town of subdivisionPlat.WILLOW VALLEY Lot-- 11 Certified Survey Map # Volume Page # Warrantv Deed # (before 2007)Volume Page # Spec house ❑yes0io Lot lines identifiable ❑yes❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities arc spccilied in §SPS. 38352(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 andior (2) after inspection and pumping (if necessar)), the septic tank is less than 1 3 full of slud(,c. I')ye, 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. 1'wc certity that all statements on this form are true to the best of my/our knowledL~e. Uwe am arc the owner(s) of the property described above, by virtue 01'a -,yarranty deed recorded in Register of Deeds Office. Number of bedrooms 4 ~ 8 ,7 X17 SIGNATURE 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 decd from the Re-inter of Deeds Office and a copy of the certified survey map if reference is made in the warranty decd. (REN'. 04/12) Wis. Dept. of Safety and Professional Services SObL EVALUATION REPORT Page of Division of Safety and Buildings ~ o~E in accordance with SPS 385, Wis. Adm. Code st Croix 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 026-1118 -11-000 rpi4t~o percent slope, scale or dimensions, north arrow, and location and distance to nearest road. - Please print all information. Re7A~~ d by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~1v/ ( Property Owner Property Location Bruce and Bonnie Warner Govt. Lot nw 1/4 sw1/4 S 1 T 30N R 18E (or) W Property Owner's Mailing Address ;i;novillage Subd. Name or CSM# 1413 174th ave city State Zip Code Phone Number [Drown Nearest Road New Richmond wi 54017 ( 715-246-3575 richmond 140th st New Construction UseE Residential / Number of bedrooms 4 Code derived design flow rate c GPD Replacement rl Public or commercial - Describe: Parent material GIj,c,,,~ D\ m Flood Plain elevation if applicable ft. General comments e- t L_a and recommendations: . }ZX'n f'ti li Vt ICJ u' J j t ate. '~?Tv Xl (U J!?f~ WF t~. 1 ❑ Boring # Boring 97.75 70 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 A 0-9 7.5yr3/1 sil lfmpl mfr c 2 .4c .6 B 9-15 7.5yr4/4 scl 2mprabk mfi gw 1 .4 6 c 15-66" 10 yr 4/6 sl lmprabk mvfi gw .4 .7 c1 66-70 10 yr 5/8 fl dspots sl Ommpabk mvfi 9w .0 .0 2 Boring # ® Boring 97.9 76 ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft I in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 A 0-9 7.5YR3/1 S1L 1FMPL mfr c 2 .4c .6 E 9-15 7.5yr4/4 scl 2mprabk mfi gw 1 .4 .6 B 15-25 7.5yr3/4 sl 1 mvfiabk mfi gw .4 .6 C 25-76 7.5yr4/3 cos Osg ml gw .7a 1.6a c1 76-82 5yr4/4 5yr5/8fl dspots s1 Ommpabk mvfi gw .0 .0 * Effluent #1 = BOD > 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 ~0 4001Z XXI40 .2-2 S'" Address Date Evaluation Conducted Telephone Number / 3 07 12, 12~J7 N~-~yj 216 6 SBD-8330 (RI 1/11) Property Owner 4;11-- ' Parcel ID # U)4- 11I 1.0 Page of 2 3 Boring # Boring 97.75 68 Pit Ground surface elev. ft. Depth to limiting factor in. 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 A 0-14 7.5yr3.1 sil lfmpl mfr gs 2 .4c .6 B 14-16 7.5yr4/4 scl 2mpabk mfi gw 1 .4 .6 C 16-68 7.5yr3/4 sl 2mpabk mfi gw .4 .6 C1 68-74 7.5yr4/3 5yr5/8fldspots cos Omsg ml gw .4 .6 E Boring # 1 Boring Pit Ground surface elev. ft. Depth to limiting factor in. 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 Boring El Boring # ® pit Ground surface elev. ft. Depth to limiting factor in. 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 91 = BOD e > 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-8330Test (RI 1/11)