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HomeMy WebLinkAbout040-1120-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597459 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j Permit Holder's Name: City Village Township Parcel Tax No: LEROY & nANCY jOHNSON TOWN OF TROY 040-1120-40-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 6sT 31.28.19.495 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ,s Septic ;V / Benchmark 1 P. .7 Dosing f D Alt. BM 05-V /0 5 -7 e a GJ7• n Bldg. Sewer op /1ST G 9a . "7 Holding St/Ht Inlet D TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLD1. ent Air Intake ROAD Dt Inlet aJd Septic 1 GL Dt Bottom ~(V + O Dosing Header/Man. ~f• Q L Aeration Dist. Pipe C r L Holding Bot. System 7 7 ~.b C 5 PUMP/SIPHON INFORMATION Final Grade ` D 177- Manufacturer ` Demand St Cover cJ~. GPM r C/ Model Number 1% - TDH Li L Friction Loss System H TDH t d "S /,75 A- I /Z•ZS~ Forcemain Lens DDist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Off Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS E%vl Cl~~ t• ` SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur INFORMATION CHAMBER ORT Type f,%System: UNIT Mom-` u DISTRIBUTION SYSTEM ✓yD`'` /V~M*t\' y~~ Header/Manifol Distribution je- Hole Size x Hole Spacing Vent t Air Inta e Pipe(s) Length Dia Length Dia Spacing IX SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only v ~fl~s Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulch Bed/Trench Center 1J 0 Bed/Trench Edges Topsoil I--- C No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Q L Pj Location: 384 CTY RD M !ww_ J S 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover ~j/eL-) 5 c, 0, 7 Plan revision Required? ❑ Yes ')eNo io ICJ 1~ Use other side for additional information. 11 L~J SBD-6710 (R.3/97) Date Insepctor's Sign ture Cert. No. oun Kr Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be 511e0 in by Co.) a $ K AUG It 1~~ + Madison, VlJ 53707-7162 'UIX coo 3 t", JOS State Transaction Number °A -rJoxs~ anitary Permit APplic' '10~ ental unit in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the ar,, 1- pitted to Project Address (if different than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for state-0wned may V the Departme'ht of Safety and Professional Servies. Personal information you provide may be us. ary, u oses in accordance with the Privacy Law, s. 15.04 1 m ,.Stats. I. A lication Information - Please Print. All Information Parcel # Property Owner's Name Property Location i~ I I. -T 0 Property Owners Mailing Address Govt. Lot f > ~7 '/4, Section Ci State Zi Code Phone Number ty, p - _ , (circle one I V'~`~ ~p 1LiL 5 T N; Ri0l Eo) Lot # II. Type of Building (ch ck all thSubdivision Name Ql or 2 Family Dwelling - Number o~~ Block # El Public/Commercial - Describe Use El city of CSM Number ❑ Village of ❑ State Owned -Describe Use Town of T y 01117 - III. Type of Permit: (Check only one ox on line A. Complete line B if applicable) p A. r New System Replacement System 11 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ List Previous Permit Number and Date Issued B. El Permit Renewal Q Permit Revision ❑ Change of Plumber 11 Permit Transfer to New ' ~ ` / Before Expiration Owner -.-a W. Type of POWTS Sys I em/Comonent/Device: Check all that apply) uitable 9WNon-Pressurized In-Ground' ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of, ❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVTreat ent Area Information: Design Flow (gpd) Design Soil Applicatiog Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) ystem Elevation j ^~f -7 ?10 VI. Tank Info Capacity in Total # of Manufacturer a p V Gallons Gallons Units U y h New Tanks Existing Tanks l o E 2 V a U v y v: ii C7 Septic or Holding Tank Dosing Chamber CO o r ! VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's e (Print) Plumber's Signature MP1T*~ Number Business Phone Number Ate 7 71; 2,73 Plumber's A ess (Street, City, State, Zip Code) VIII oun epartment Use Only Permit Fee Date sued Issuing ent Signature 06 ~ ApprovedC7, $ ❑ Reason for Denial T V ,.7 IX. Cond'fFEfZeasons for Disapproval 1. tank ttiitsca t h1teT ~ncl gsper:si cell ust dll be _ic es ' r, nt el ul r as per mar:agement plan pto idea by alumpe;. Lei cQA, 2. `'A0 4etbHCk rect„iret^ents trt~~ >t tee rt; it.e z • as per ?i.Kiicnbl-:1 c,c dt; t c.rd,nanc.. , Attach to complete plans for the system and submit to the County only on paper not less than 8 la z 11 inches in size SBD-6398 (R 11/11) PL o PL Pt A/ J ~ Rem Pg ' of Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner's Name: L eke)r Lo TK Site address: L Location: Lot , Block Subdivision/CSM -.7 being part of the 1/a of the sue'/a, Section 3_L, Town_Z_g_N, Rangn-W, Town of e- ftt) iM County, WL Parcel Identification # ~ - 70 el t Design: In accordance with Department of Safety & Professional Services (SPS) Wisconsin Administrative Code ch. SPS 381 through 387 and 391. Design manual (choose one): ❑ Holding Tank Component Manual [VER 2.0, SBD-10855-P (N. 03/07, R. 1/12)] In-ground Soil Absorption Component Manual [SBD-10705-P (N.01101)] Contents: Page 1: Page 2: Page 3: 4~ t,~ Page 4: Page 5: U• At P op, U E Page 6: Page 7: Page 8: Page 9: C ®1U'I Attachments: Plumber/Designer: Signed: Credential Number: .114 `2_ 7-h y Date: PL o PL C 2 ~ l N 0 • - Combination SepG;i.c;,Tank and PLI-MF CHAMBER CROSS SECTIOtJ AtJD SPECIFICAT10MS VE1JT GAP WEATHEF, Fl 00" Ju1JCTI0u 00X APPROVED LOCKIQC. 4, C. I. VENT PIPC , MAIJHOLE COYER X71 ?10' FROM ooOR. . wARNIUG L~.BEL.. 4-1Q0OW OR FRESH "3P Q1101J PIPE \ A.L_iQTAKE r w/ ilnX n F. tt1-" MIT? L~Mw, ~,1~0T I I .i 18" /'IIU. ~.r PROVIDE AIRTIGHT SEAL I I~~ 11JLET _ ~ I l I B~ L~ I I APPROVED J014 APPROVED JOIIJT ZP18EL FIlJC~1t A I IIi 1 W/C.T. fIPE ~ p, w/C.T.PIPEDR Tank construction I II ALARM shall comply with ~I II TLHR (,3.15 and 83.20 a I . i I ou C . I PUMP OFF 0 COIJCRETC g BLOCS( 3'A. PPp: RISER EXIT PERMITTED OSJLy IF TASJK MAIJUFACTURZ7, HAS SUCH APPROVAL ~~INO SEPrIc F SPECIFICATIOIJS DOSE w 1 ~5~2 CC i C 'T~ T~urC MASJUF~,CTURCR.: IJLtMlSER OF DOSES: PER aA-~ TALSK SIZE: GALLOWS DOSC VOLUME ALARM ru>JUFACTURCR: S`--E,)ZL. 3 O Lff ~ INCLLDIIJG 6AGKfLOW: U oALLON$ MODEL QUMBER: LOl Nw CAPACITIES: A= -2 3-L4CNC5 OF, iR 2PGALLOS.15 SWITCH T-~PC: _:..._ELeA4 - 8= Z WCHIS OR G~LL01J5 PUMP MAIJUFACTURE X: GOLL C K IUCHE$ OR /1L_5. I,ALLOUS MODEL }JUMDER. D- ~ INLHES OR 40 L GALLOWS SWITCH TYPE: WTe: PUMP AIJO ALARM ARE To 6L MIlJIMuM DISCHARGe RATE GPM INSTALLED OIJ 5EPARATC CIRCUITS VERTICAL DIFFERENCE DETWCCQ PUMP OFF AuO,015TR15UTIOU PIPC.. OZE I-EET t MIUIMUh~ t`1ETWORK SUPPLY PRESSURE FI=ET i- FE ET OF FORCE MAIN X ~F~O gFRICTiou FACTOR.. T [ v FEET TCrTAL OtIWAMIC. HEAD FEET As per•manufacturer gal/in. r(0 y m rm F- y m 0 o m m v t. 0o m Ol Yt'3 r a m cm a ern y Z~ a E {ijn 1'a ` t e !Em c m "a rn$ t C: ID ~J qq t1 ~ptQ 66re y ~ Yn ~ o ° ~ C O! y r ~ 4( 1Frt~ .r+L• _R ~d a y m t ~ $ u. ~ a ~ Y 'o r ~ i ~ s ° ~ ptp0k lklh = N o E m m m t k 4 r i f o. Dffiv~ = 3 E ce = CD CD m 0 m O m ' Y C p 0 n° 2 a c m m Fc~vrJi r2 43 rs s3 m 3 b E a c ° c rs ca o ~ m aE mf' CD n m_t (!7 m c CL m 3 m 6j Oi C 'CO U 0 r m~ 6 ' S p O C m Q i p u p C E 5 O C k m p E crna~m 03 c7 n m f7i m • C C, j~: 6 l E C1 000~DL 5v Nm`-°mo J k~. 01 75 - ~y L0a) ov m Em d wy3~ 01-°' ° CoYEm~ 14 C7 p..,-m o am o=gym r. 2c 4) 'o LL a) LL 0 CD w m o m m~~ m m~ E o W Q ~3Ecc IL-4>-a°O>n FcrEnc3~ S - Wgg y j~ 4 x } N G a ` N kk 'd `+12`i~J k; m ya m x 5~ w ~ k e a 8 XX ` E$ 8gS os G 0 oom fQ F~tC ` ,'w r ~ ~ 3 lip m a y t y ~ J2 49 G r~ 8 ° SLS ~8g i ~ x•Q,wm a50 y e° ~cE 1'oE~ o~ E_E tjaj _ f _ °9 #gE .a d'4+'~'( - ~r.CkbMW~t(~k iJ! ry~I ~i~c am- APR-12-2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 HGOULDS PUMPS Submersible Effluent Pump PE n iry '4LVQiT PUMP a•= SPECIFICATIONS MOTOR FEATURES Pump - General; General: ■ Corrosion resistant • Discharge: 1'A" NPT • Single phase construction. • Temperature: 1040F (400C) • 60 Hertz ■ Cast iron body, maximum, continuous when • 115 and 230 volts ■ Thermoplastic impeller and fully submerged. • Built-in thermal overload pro- cover, • Solids handling: 112" tection with automatic reset. ■ Upper sleeve and lower maximum sphere, • Class a insulation. heavy duty ball bearing • Automatic models include a • oil-filled design. construction. APPLICATIONS float switch. • High strength carbon steel ■ Motor is permanently Specially designed for the • Manual models available, shaft, lubricated for extended following uses: • Pumping range: see PE31 Motor: service life. • Mound Systems performance chart or curve, • .33 HP, 3000 RPM ■ Powered for continuous • Effluent/Dosing Systems PE31 Pump: • 115 volts operation. • low Pressure Pipe Systems • Maximum capacity: 53 GPM • Shaded pole design ■ All ratings are within the • Basement Draining • Maximum head: 25' TDH PE41 Motor working limits of the motor. • Heavy Duty Sump/ PE41 Pump: • .40 HP, 3400 RPM ■ Quick disconnect power Dewatering • Maximum capacity: 61 GPM 115 and 230 volts cord, 20' standard length, • Maximum head: 29' TDH • PSC design heavy 6/3 SJTW with PE51 Pump: PE51 Motor: 115 or du230 ty uty 1 volt grounding plug • Maximum capacity: 70 GPM • .50 HP, 3400 RPM ■ Complete unit is heavy duty, • Maximum head: 37' TDH • 115 and 230 volts portable and compact. • PSC design METERS FEET ■ Mechanical seal is carbon, 40 ceramic, BU NA and stainless MODELS: P01, Peat, PE51 steel. PE5i 35 I I ! I 'I I"I ' HR .33, .aa, .50 I ■ Stainless steel fasteners. 10 2 GPM AGENCY LISTINGS 30 •PE4tl i r f 1 Fr i II ZS X E~ 1 I I , i J ' i U ! I I i' I I I. ; C US Q ~I I , I- I ' j i 20 ..I . E .I I I 1 _ I I • Tested to UL 778 and I j j I . i f I I- i I I j C5A 221108 Standards 5 15 1 I - I h I ° ~I j By Canadian Standards ASSociaoon r-~~ I I File #LR365a9 10 + i_ I I I I i I ! ' GOUdds Pumps is ISO 9001 Registered. 5 II 1 fl Ili I il~ III , j. I il, ' i ICI 0 0 0 10~ 20 30 40 50 60 70 GPM 8o 0 $ 10 1'5 m3/h Goulds Pumps ® 2004 HT Water Technology, Inc. CAPACITY Effective June, 2004 ITT Industries "E31/41 4?' . or 2 Family Dwelling In ground Soil Absorption System (2-cell Conventional # of bedrooms x 150 gal/day/bedroom = gal/day Daily Wastewater Flow (DWF) _ Design Loading Rate (DLR) or Soil Application Rate = P & gpd/ftZ (per SPS Table 383.44-1, 2, or 3) Required distribution cell area =DWF y~, , D gal/day =DLR gPd/ftZ -P ftZ _-(F # Chambers = Required Distribution cell area - ftZ . ZE) ftz/ unit EISA = Chambers Chamber Manufacturer and Model: I /v t1L-M A40 tz ALI-, G ll- i!~ & ~ Actual Distribution cell area = Required cell area ftZ + ftZ/ unit EISA End Cap Pair Zft2 Cross Section In ground Soil Absorption System (2-cell): 4" Schedule 40 PVC vent pipe with vent cap 12 inches minimum L12incheess minimum inches Soil Cover Trench 1 Sys- tern Elevation inch Chamber Height ~~ft q5 2Q Trench 2 System Elevation ~ft ~ft Trench Separation Leaching Chamber Width ft to limiting factor Plan View In-ground Soil Absorption System (2-cell): Trench 1 Modify ft header/ design as ft Leaching Chambers /4 needed. Trench 2 4 inch Header Sch.~ ft with end camps Draw 0 for a Vent and 0 for Observation Pipe above. They will be located ft from the end of the cell. Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade. Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC. S f1 . ~1~ r K t I~Jn g t R 497 L~ ~ ' . ' „ ~ ~7° F J v (LilIck4 Plus Standard Chamber Side and End Views 48" (EFFECTIVE LENGTH) - = - F- - 34"~ n to g leis ill-i-n-One 12 Encap Front, Side and End Views 1ua~.k 11.2" x 13" 8" INVERT 8" INVERT 5.3" INVERT r -182 " 33 -~I Q(i Plus All-in-One Periscope t OUICK4 PLUS ALL,IN-ONE PERISCOPE---\ If (360'SWI VEI I !f - OUICK4 PLUS ENDC 15 ~ 9. 12.7" INVERT ALL-IN-ONE 12 ~ ENDCAP ~ - - Quick4 Plus Standard Chamber Specifications - - - - Size (W x L x H) 34" x 53" x 12" (86 cm x 135 cm x 31 cm) Invert Height 0.6", 5,3", 8.0", 12.7" - - - - - - - (1.5 cm, 8,4 cm, 18.5 cm, 22.6 cm) Effective Length 48" (122 cm) s INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY a) The structural integrity o9 each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Units"), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Y Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered ; by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE INFILTRATORO (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential, special, or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. ' . .j Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units, the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure Park Road P.Q. Box 768 to maintain the minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing 5 Business • the Units; failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, ~~d Saybrook, CT 06475 } or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the 860.577,7000 FAX 860.577.7001 terms set forth in this Limited Warranty. Further, in no event shall infiltrator be responsible for any loss or damage to the Holder, the Units, or any • third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's 800.221 .4436 installation instructions. (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.infiltratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook Connecticut prior to such purchase to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units Y J d. y, ~O 1r'p``XS P: ` Ms~~",.` hS txa °`5r ',sxrt,~; '~r, J s y JI r E 4 t 7 , r • 1 .F tN"`~t I '~e'4 g~r, ~d i Y} h i J i< f 1 I,~ t Yx t`,~R 1 1 t `r~...mn smu..~e,~hv~w,~eau•e:,.w.a..:.+*. r 9 Q t d - C - s I .wtd' . virsrnapmm .wveHrn a.Ah,r: 9"a,c a a s.;% kn , e ;Y„,.e=.v-~ 3.v e..~"'' + ,.~•a 04, U S Patents 4,759,661, 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778: 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer, Ouick4 and Ouick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. PUJS0510101SI-2 is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. © 2009 Infiltrator Systems Inc. Printed in U.S.A. POWTS OWNER'S MANUAL MANAGEMENT PLAN SYSTEM SPECIFICATIONS FILE INFORMATION Owner Septic Tank Capacity /O to +p al ❑ NA ❑NA Permit # Septic Tank Manufacturer W f ES 6 • Effluent Filter Manufacturer ❑ NA ❑ NA DESIGN PARAMETERS Number of Bedrooms 13 NA Effluent Filter Model ❑ NA Number of Public Facility Units X NA Pump Tank Capacity fv $ 0 al Pump Tank Manufacturer Lo / SER ❑ NA Estimated flow (average) .300 al/da ❑ NA Pump Manufacturer ~ e) u L D Design flow (peak), (Estimated x 1.5) til~O gal/day Lai/day /fts Pump Model to 6:_ 1/1 Soil Application Rate ❑ NA ~ ❑ NA Monthly average. Pretreatment Unit Standard Influent/Effluent Quality Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODE) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection [I Other: . ❑ NA Monthly average Dispersal Cell(s) Pretreated Effluent Quality Biochemical Oxygen Demand (130135) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) ❑ Mound Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Other: Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line NA Other; Maximum Effluent Particle Size Ya in dia. ❑ NA 0 NA 11 NA Other; Other. Other:' ❑ NA 'Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Frequency Service Event ❑ month(s) -3 (Maximum 3 years) 1i NA Inspect condition of tank(s) At least once every: p year When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Pump out contents of tank(s) ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal call(s) At least once every; ® year(s) ❑ month(s) ❑ NA Clean effluent filter At least once every: ® ear(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: 3 ® ear(s) • ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: $1. earls! ❑ month(s) ❑ NA Other: At least once every: ❑ ear(s) ❑ NA Other: . MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POINTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks surface. measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the g.rocks . The dispersal ~$II(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 (Y3) 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 512 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. GMW (4101) 1.l 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 chemical; that may impede the treatment process and/or damage the dispersal call(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 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 tie 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 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. ❑ 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 recbristructed 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 PROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name p IS 2 C L S oAl Name Phone S - 7- 7 3 - Cl!!f Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~pµivjo~l 5',6},vifrt d-✓ Name gyp? ct,v-~yZ0~) S-~6"/X ZdAll, J Phone 7/5 Z 7 j Phone /S~Z This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. i 3/26/2013 11 45 FAX 715 273 0444 NELSON-PLLiMBING igl vLsiiuv ST. CROIX COUNTY SEPTIC TANK MAEN"TENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Ce ~f W J /C) Y f f !2 Mailing Address 3 ee Property Address .S r4 m E (Verification required from Planning & Zoning Department for new construction.) City/State 07L /-A6(- Parcel Identification Number -14,1e - LEGAL DESCRIPTION Property Location 114 ;4 ,Sec. , T 29N R j_ ,Town of C Subdivision Lot # Certified Survey Map # Volume , Page r Warranty Deed # 0~ Volume , Page # Spec house yes 6)r Lot lines identifiable LTQ- 5 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 are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to Sc 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 verifymg 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 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce 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. L'we certify that all statements on this rn are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a wawa deed recorded in Register of Deeds Officc. Nu r et ms SI ATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary perndt being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 5 c 0 >t to 44 41 "4 a liwl fa -4 w 0-) N 164 91, 10 fc N u 4.) N 4w L-1 C -V m to 4- 4 -ACC 3 'z ta 61S ti ? pia -4 c V-4 0 u 4~) 0 00-1 u -^Cf,3M~t 1. P- (a to" 11-14 "i Q 0 r-i Q; ~4 41 .0 Vi 4) ya trot stay; p+4~ r~** v V14 `mayy ~4)' wi ~ W a • a +fi•'~ 3r Q kV 0 C- 0 1044 C . C.- c ..,o 41 $4 Pic C l.t u; ! ;.a c' v 4i t iii r. 4- %0 Jz PC > jw WOO IL) 4) 0 ell 4.; t4 ~1: 0 U -"1 0 jo r- 41 r-4 0 oft tr --A et 41 ~e- h:F #N A ilf~t f'4 CC -W r- Z. C*;' C cr, ':d c~ggs 4d • 5#,i °v,.3 CIO All, 4-1 0 --4 4; m m It 0 1 3: 4~) 0 4 to 0 :t 4J 0 J%4 4W ~lt 0 0 0 1 tee". t!' 4j 04 } 4144 y _ 4) 4) t4 CST-Pc~ i 7- Y Wiscons~tQfpat - d Professional Services 1 Divisionf i s P- 2BPFBRN8937VO )RT Page 1 of 3 JUL 07 2017 in accordance with SPS 383, Wis. Adm. Code ~,r Y County ST. CROIX Attach less than 8 1/2 x 11 inches in size. Plan must inclA~A~ horizontal reference point (BM), direction and parcel I.D. 40 - 1120 - 40 - 000 per n slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location r El LEROY W. JR & NANCY S. (TRS) JOHNSON Govt. Lot SE 1/4 SE 114 /31 T 28 N R 19 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 384 C.T.H. M City State Zip Code Phone Number ity Village E]Town Nearest Road River Falls, WI 54022 ( 715) 425 - 5652 C.T.H. M TROY © New Construction Useo Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD E] Replacement Public or commercial - Describe: Parent material outwash plains Flood Plain elevation if applicable N 4 ft- General comments conventional trenches 0.6 loading rate pumping required and recommendations: Z&7-L, 40 ft. casement for septic purposes attached. ~ 1❑ Boring # Boring EJ Pit Ground surface elev. 96.95 ft. Depth to limiting factor 63 in. Soil Iication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-18 10YR2/2 - 1 3fa&sbk ds ci 2vf-m 0.6 0.8 2 18-37 10YR3/3 sil 2fabk mfr cs Ivf-f 0.6 0.8 3 37-63 7.5YR3/3 - A If--msbk mvfr cs lvf--f 0.4 0.7 63-till 1 2 1 Boring # ® Boring 97.20 60 • pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-13 10YR2/2 - l 3f-msbk ds cs 3vf-m 0.6 0.8 2 13-35 10YR3/3 sil 3f-mabk mfr cs 2vf-m 0.6 0.8 3 35-44 7.5YR3/3 sl I f-msbk mvfr cs I vf--f 0.4 0.7 4 44-60 10YR5/4 - s Osg ml cw - 0.7 1.6 5 60-63 10YR4/6 flf 10YR5/6 Is Osg ml 0.5 1.0 ackside of pit had 10YR7/3 we fs. ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mglL 7• ' E uent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) - - ture CST Number MARY JO HUPPERT Hollistees Soil Testing&Design) M1,4juk i 224832 Address Date v tion Conducted Telephone Number 28497 King Arthur's Court, Danbury, WI 54830 06- 15 - 2017 715-426-1775 SBD-8330 (R07/13) Property Owner JOHNSON, LeRoy/Nancy Parcel ID # 040 - 1120 - 40 - 000 Page 2 of 3 E Bcxing Boring # spit Ground surface elev. 97.10 ft Depth to limiting factor 60 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-16 10YR2/2 I 2f-msbk&gr ds cs 3vf-co 0.6 0.8 2 16-22 10YR3/3 A 2f-mabk mfr cs 2vf-f 0.6 0.8 2 22-40 7.5YR3/4 sl 2fsbk mvfr cs lvf--f 0.6 1.0 3 40-60 7.5YR4/4 s Osg dl cw 0.7 1.6 60-till ❑ Boring # H Boring Pit Ground surface elev. ft. Depth to limiting factor in. H Iication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 3 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L SBD-WO (R67 13) l .r 43 y 4 . j r • K Via, ~ r , s I -F!r• *07 r u T~ Yp~ v G ,S m 16- . R j m • ,z' N SQ