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HomeMy WebLinkAbout026-1153-31-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597486 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 T City Village Township Parcel Tax No: SCOTT LOEW & JANENE MANOR TOWN OF RICHMOND 026-1153-31-000 CST BM Elev: Insp. BM Elev: BM Description: Zo*L- Section/Town/Range/Map No: /o0 1 4j W G trrt- P 19.30.18.1169 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark t e j F•14ati Alt _ r / l r0 Ib~ IZ5 . BM~'~! zl;P Aeration Bldg. Sewer Holding St/Ht Inlet 7 7 ` TANK SETBACK INFORMATION St/Ht Outlet /d .9 017 TANK TO P/L WELL BLDG. e to Air Intake ROAD Dt Inlet 11_~ Septic Dt Bottom Dosing Header/Man. 477.2- Aeration Dist. Pipe .9-7 Holding Bot. System 4 PUMP/SIPHON INFORMATION Final Grade 77- Manufacturer GPn and St Cover , ~O J 4.54 /,0:2 Z Model Number TDH Lift riction Loss Syst TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No Of Trenches _r PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 -,Z L i reK ~J SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufa err,, tt INFORMATION Type f System: CHAMBER OR 41h Ir-11 4 L7 /t V , ' UNIT Model Nuryber: A(A, quo 36 S~ w If C.10- 11 DISTRIBUTION SYSTEM •a 1704-T r''s Header/Manifo! / Distribution Ix Hole Size Ix Hole Spacing VInt ke Pipe(s) Lengthy Dia Length Dia Spacing SOIL COVER 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 Center Bed/Trench Edges-,*_. Topsoil j _ No es j'` No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1468 92ND ST 1.) Alt Description Z.) Bldg g sewer length = V 'J - amount of cover kta..+_ 5a.., Plan revision Required? 3 s~ No , I S iI ~L p G3 Use other side for addition Information. - Date Ins pctor's nature Cert. No SBD-6710 (R.3l97) l l y County . Safety and Buildings Division 201 W. Shi on P Box 7162 Sanitary Permit Number (to be filled in by Co.) $ P 2 4 NAB S 70 62 • ~ ix County L ~ ~s 7 C -a t y Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for second purposes in accordance with the Privacy Law, s. 15.04(1 m , Stats. L Application Information - Please Print All Information ! 7 r 1 Property Owner's Name Parcel # ~S u Iq~~ 01-1~ 6 - /S -Wit- a Property Owner's Mailing Address Property Location "5-0 S L11~67: Govt. Lot Ci}ty State Zip Code Phone Number Section T N> R l ircle o II. Type of Building (check all that apply) .7 Lo 1 or 2 Family Dwelling- Number of Bedrooms Sub/div~ision e 19, ~-5 0 (o Block # V ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Town of III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) 60-&- A. ANew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renew -it Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 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 oil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) JZ L V. Dis ersal/Trea (ent Area Information: Design Flow (gpd) Design Soil Application Rate( dsf) Dispersal Area Required (sf) Dispersal Area Propos (sf) System Elevation "G ~ G>, -7 18 ~yC) VI. Tank Info Capacity in Total # of Man tur Gallons Gallons Units U New Tanks Existing Tanks J c a; i m a U ~ y ~ w V F..~ Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. P17 s Name rint) / Plumb Sign e MP/MPRS Number Business Phone Number Plumber's 7~1 Street, State, Zip Code) Ct< oun"e artment Use Onl pproved rPermit Fee Da Issuing eSigna e $ Zwner Given Reason for Denial IX. Condi easons for.Disapproval 1. Sepf~:' rk, am lilt~* VM t,>Spzta °+r cell must all be s°i_IGi_s _ri'> `n om M per mar.3gement plan pro iaer by plumber. 2. ~►Il tcc?en~s 1'nru;t r.st t ir`.E i sn pet *ppkrbts cnt t I ::rASratwzQ,g. Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size SBD-6398 (R- 11/11) ,a r~ il Qj 1 J t ,1?. h SGT 5I Z'.,~e~ • , Wis. Dept. S ek 2100,e,siorel Services SOIL EVALUATION REPORT Page I of Division fey and Buildings r in accordance with SPS 385, Wis. Adm. Code County ' 11 inches in size. Plan must ' not less than 8 1/2 x t paper n Attach cornp on inciudg blriot rFriited to: vertical and horizontal reference point {BM), direction and Parcel i.D. w fi m p~ n} E percent slope, ,tale or dimensions, north arrow, and location and distance to nearest road, Revie d by Date Please print all information. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) {m)). / Property Owner Property Locatio G n l ~.l ri e /`TGt @ 1jtXt'a a'' Go rt. Loo Sw 1/4 /V l.} /4 S T 3Q N R f E ~4) WD Prop~!e~rty Owner's Mailing Address Lot # Block # Subd. flame or C M# is Pa 31 0 V I fa V City State Zip Code Phone Number Il City ❑ Village Town Nearest Road Y, d~ S'N New Construction Use: ® Residential / Number of bedrooms._____3 Code derived design flow rate y,? O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L p e- s s o Qe- " 6 j CU,; Mood Plain elevation if applicable ft. General comments and recommendations: ® Boring Boring # Ed ® Pit Ground surface elev. Depth to limiting factor i © in. Soil Application Rate z Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft in. Munsell Cu. Sz. Cont. Color I Gr. Sz. Sh. ff#1 ff#2 p b a`-(IQ ° S L a F5b IL m fir' Q ~>F 9' y 7. S'i *j1 q i d_ s L c l~ I i t 9 I L r--~ Bong # Boring I I pit Ground surface elev. b . 17 ft. Depth to limiting factor l © in. Soil A lication Rate Horizon Depth Dominant Color P,edox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 0--7 L 1;1 F5 b Ile- 01 ~10 -1 t'- C-1 0 .6c, 7-51 /Ap 51 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 151: mg/L ` Effluent #2 = BOD A030 mg/L and TSS < 30 mg/L CST Name (Please Print) Signal ur CST Number Q 17 11 t Add s Date Evaluation Conducted Telephone Number a es~1 C) J> , -o)-dol-'7 65 -a3~3-y Il° j SBD-9330 (Rl 1/11) ve up t' Property Owner -40 epa e W41114 w Parcel ID Page C~ of _ Boring # ❑ Boring ` {q pit Ground surface elev. 00. 601 ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Soil Application Rate I Texture Structure onsistencg0oundary Roots GPD/ft in.Muunsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 a' v?$ Y~2 ply r y _ S 5 0-,5 -7 i a . Le _I Boring # ❑ Boring t ❑ pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence oundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color ! Gr. Sz. Sh. E ff#1 ff#2 s s E t I Boring # ® Boring ❑ Pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth I Dominant Color Pedox Description Texture =,,,,rh. nsistence oundary Roots GPD/ft in- Munsell Qu. Sz. Cont. Color „ ff#1 ff#2 1 8 i 3 I i t Effluent #1 = BOD , > 30 < 220 mg/L and T SS >30 < .150 ;gin/L " Effluent #2 = BiOD , < 30 mg/L and TSS < 30 mg/L The Dept. of safet} and Pioless;on d Sorg iccs is ~n cyu 0 },j~~,rt~uiitl ;cr~icc procidcr tui J employer. If y01-1 need assistance to access services or need material m an alt.t ~,at<~ 1 - itial- crn3iaet tic depm1ment at 508-266-3151 or JAY till -11 Relay. R1311-13 31111, 1 1 I'. Property Owner 'T4 Parcel ID # Page of F-31 Boring # ❑ Boring r Pit Ground surface elev. 00, 11a ft. Depth to limiting factor 1 in. 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 I o-t, Ib`~Q3/z 3 s5b~ m f OL ►v~ t_ c F ! . a 1i c T.J ❑ Boring ❑ Boring # ❑ pit Ground surface elev. Depth to limiting factor in. 17So_ilApplicatjon Rate Horizon Depth Dominant Color P.edox Description ! Texture Structure onsistence Boundary Roots _ GPD/ft in. Munsell Qu. Sz. Cont. Color ° Gr. Sz. Sh. ff#1 ff#2 i I i I f ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F-1 ❑ Pit Soil Application Rate Horizon Depth Dominant Color P,edox Description Texture Structure onsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color iI Gr. Sz. Sh. ff#1 ff#2 i ' I i t * Effluent #1 = BOD s > 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 508-266-3151 or TTY through Relay. SB D-5330 (R 1 V 1 1) f+wl wRV 1P~S 421tKY.rY M#.....aw ~ V. 5 .f 'via L y Q ~ y RAJ CL 46 n N , f 4-1 h _ - nom' J - ------ter--, Y u r- - I 4 ~ t r t. a v 2 _ - ` L 16. F-W P .4 - o ~i .t 4 m ~ , _ to >i - - - County Safety and Buildings Division 0 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) P S Madison, WI 53707-7162 ermit Application State Transaction Nu b In accordance with SPS 383.21(2), Wi~. ~e, submission of this form to the appropriate governmental unit is required prior to obtaining a ryWPB Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and RRMt- .onal SpB jw~Cl~erso information you provide may be used for secondary purposes in accordance with the 4*7,. - _ Stats. x^ lX 4 I.OA lication Informs n - 11 Information Property Owner's Na Parcel # , 3/ - ` ~.J ~h QQ / wu UU` cl~ ope~ty Owner's Mailing Address T/ r l Property Location ~J o ~C/ L~ / t V Govt. Lot ity, State Zip Code Phone Number y,/4, Section Lf le one) TON; R.EoW Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling - Number of Bedrooms 111'3) 3 / Subdivisi Name Block l G` ❑ Public/Commercial - Describe Use a~ ❑ City of El State Owned -Describe Use CSM Number Li Village of ~ E211 S] l c l S ( 7 XTown of 111. Type of Permit: (Check only /one box on line A. Complete line B i p icable) 90KL X, A. Ad ew System ❑ Replacement System ❑ Treatment/Holding T k eplacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued ❑ Change o Permit Transfer to New Before Expiration L 1 1 Owner l~ IV. Type of POWTS S stem/Corn onent/Dev ( a that apply) 77+- 14- 1 r Non-Pressurized in-Ground ❑ Pressurized In-G ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) • System Elevation V1. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U v 2 New Tanks Existing Tanks o N _ elk O 0. U V] ~n v] Lc. U` 0. Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumb r' Name (Print) Plumbe ' Signal e MP/MPRS Number Business Phone Number Plum)W (/'s Address O t, City, State, Zip Code) f~/~J f © / / ! V ~~Q Vlll. Court [De artment Use Only JV'3pproved ❑ d Permit Fee Date Issued Issumg ent Signature Owner G eason enial CV, V( IX. Conditions of Approval/Reasons for Disapproval 3 1_ SYSTEM OWNER: ~G 1. Septic tank, effluent filter and dispersal cell must be seryiced /-maintained as per management plan provided by plumber. 2. All setback system and submit to the County only on paper not less than 81/2 x 11 inches in size as per applicable code/ordinances. S13D-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE r Project Name. U &1_f Owner's Name: G0-0 d z~ Owner's Address: r tr-e r e)l Lega Description.- Township.- /-Z County. T Subdivision Name: Lot Number: Parcel ID Number. OA -/%,5 3 ,3 c) C, C~ 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 Fo- Page 5 Warranty Deed Page ° CSM or Plat Attachments: Soil Tes; & House Plans Designer/Plumber: ~19WLicense Number: o`?o?c~s 5 Date: Phone Number 7/S- ?U D ~ ~'S/~ Signature , l Designed pursuant z. the in gourd Soil Absorot;o, Paae " i } c i G ~jj Soil Absorption System Cross Section ,11-- 4" S&---.,:!e 40 Final Grade PVC Ve-, Pipe Wit, Ve-` cap ft Leaching Chamber 7c5, / ft _ System Elevation ft Soil Adsorption System Plan View ft Leaching < Vent Or Observation Pipe Chambers Trench 1 4" Dia. _i re^,_ Heade LeaCIlir'f~ unan:be,r Speci#icatiC Manufacturer And Model EISA Rating 0?0 sq per chamber Sci' aiication Rate ypd'so't _Z-A. ~ gpd Design F'c,-. s 7 Sc l Applicatio, Ra - / ° EISA = 3Z 5Z hambers _ 2 rci,._ --I-1-L__, cha^ /7X -3V 0 Page of - 48" (EFFECTIVE LENGTH) 11.2"y 1 ~r 13„ 1 ~I 8"INVERT `8'' INVERT. I 'j 11 5.3" INVERT - 1 r 12.7' INVERT f .Q ` 1 5:~- -9~ t _ Plus standard Chamber specifics a r~- ~rr 'I T 800.221 m Cl) r 2 m C ° n rn ~ / 0 Z < v v w m n z n r z / s ch m g -v Cj) 4 PIC, rn -4,z z ° c7 x 12 m Z N ~ Z a _ 129 r 1 10 0 a6Pd (SZ:DI) JanraS XVJCTqdp :dq iGa fir:OI lee Znc - ~ i E-- t ) - .a r t v O Cl_ J W r a Z. rt i ~r C1 Lc) L.U c cj / - y F co v LL- F- Lil f 7-7 '';LE IN~OHAFI IJON SYSTEM SPECIFICATIONS Owner Septic Tank Capacity p e--> gal ❑ NA Permit fr - Septic Tank Manufacturer 1 kkj__, - ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 1 C/~ fipNA Number of Bedrooms 3 ❑ NA Effluent Filter Model - Number of Public Facility Units 0 NA Pump Tank Capacity - M NA gal Estimated flow (average) gaUday ?urnc ank Manufacturer NA Design flow (peak;, (Estimated 1.5) 415-0 gal/day Pump Manufacturer NA Sol( Application Rate Y ? gal r •la "urrip Model iNA y~ft' Standard Influent/Effluent Quality Monthiy average' Pretreatment Unit Ak_NA hats, Oil & Grease (FOG) 530 m9' . ! SandfGravei Filter ❑ Peat r=iite- Biochemical Oxygen Demand (BOGS) 5220 m94- KNA Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) -150 im91L 0 Disinfection ❑ Other: ?retreated Effluent Quality Monthly average Dispersal Cellist ❑ NA Biochemical Oxygen Demand (BODG) i :'3C mg,".- n-Ground (gravity) :1 In-Ground (pressurized) Total Suspended Solids (T SS) <_30 mg;;. r,,:-, At-Grade ❑ Bound Fecal Coliform (geometric mean) <10' cfu i Oval ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size in d(a. G NA Oilier: ❑ NA --Other. :Jther. =N" ❑NA 3tFer: ~ i NA ''Values typical for domestic v, astev,,ate- and santic Zane; MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) ` At least once every: A 2'yearis)ls) (Maximum 3 years) ❑ NA ) =um out contents of tanks I p When combined sludge and scum equals one-:bird of tank volume ❑ ►yA Inspect dispersal cell(s) At least once every: u mo th(s) (Maximum 3 years) G NA Wyea (s, Clean effluent filter At least once eve-V 11 NA Yearjs inspect pump, pump controls & alarm At least once evew: ^ months,i yr NA years; ~Y ;Mush iaierals and pressure test At {east once every: L-' monthtsI NA _ ❑ year(s) ?than: month(si At least once every: ~ year(s) ❑ NA E ❑ NA ,'iAINTENANCE 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; P0V%1TS Inspector; P014'TS Maintainer; Sept age Servicing Operator, Tara inspections must include a visua: inspection: of the tank(s) to identify anv missing or broken hardware, identify any cracks or leat:s, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surfa;:n, he dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any por,di;"; co of affluent on the ground surface. The ponding of effluent an the ground surface may indicate a flailing condition and requires tipa Immediate notification of the local regulatory authority. 'i,{Vnen the combined accumulation of sludge and scum in any tank equals one-third (}~i 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 . i !Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, prmreatme:it emits, and any servicing at intervals of 512 months, shall, be pt?rfarmed by a certified POIhTS RSaintainer. T i ' rsprj'.'. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painti Page er of 2 that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected of the tank(s) removed by a septage servicing operator prior to use. ng products or other chemicals System start up shall not occur when soil conditions are frozen at the infiltrative surface. have the contents During power outages pump tanks may fill above normal highwater levels. When power is restored the excess discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or effluent. To avoid this situation have the contents of the umwastewater will be Power to the effluent P p tank removed by a Septage Servicing Operator surface prior to discharge restoring of pump or contact a Plumber or POWTS Maintainer to assist in manual) o eratin the restore normal levels within the pump tank. y p 4 pump controls Ya Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb 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 an or compact, the area POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diaper disinfectants; drain (sum d prolong the life of the P pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; med caions,; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT bNhen 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 soil, gravel or another inert solid material. CONTINGENCY PLAN filled with If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to replacement system: 9 code compliant ❑ A suitable replacement area has been evaluated and may be utilized for the location of a provide a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon required setbacks from existing and propose 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 by comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barrie systems must technology a holding tank may be installed as a last resort to replace the failed POWTS. T g advances in POWTS alua i be " ul-LeplacZ e ai e '~fZv!4Iz 17~~ ~D2 N> a o r0 ank Mound and at-grade soil absorption systems may ~N57"R Il C~"lD>~ E] be reconstructed removal of infiltrative surface. Reconstructions of such systems must comply withintheplace < c WARNIII > rules nlleffectt at that time the biomat at the SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT O ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. OXYGEN. DO NOT kDDITIONAL COMMENTS RESCUE OF A )WTS INSTALLER Name ~(POWTS MAINTAINER Name Phone Phone PTAGE SERVICING OPERATOR (PUMPER) 7Na me L OCAL REGULATORY AUTHORITY mm ne Name r _ J Phone ~Q = - - document was draftacl in nnmplinnae with ~:haptor Lnmm P3.22(2)(b)(t)id)&(f) and 83 540), (2r m..GGL~ ~ , & ( Wisconsin Adistrative Cocie. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer __Sc'_ e7--4.. Mailing Address '290 7-~ /~(Jf 1j_a - --c Property Address (Verification required from Planning & Zoning Department for new construction.) City/State IV Z,(~ 9"~ Parcel Identification Number LEGAL DESCRIPTION Property Location '/4 Sec. 1 T 3 D N R IS W, Town of Subdivision Plat: ~L t J- , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # f U 7& /76 (before 2007)Volume Page # Spec house Elves," OR Lot lines identifiabl~Ilyes❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance ofyour 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 §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 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 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number drooms -5 7> 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 deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) o fry 8y fk~ O O - O 0 I,A-ZC-mOb LSLamMLTmi9~e 9MTUa /ra ,o-A yo~,iL ~u.~e I AEE I _ ui/I I~,II ~ rI~,B r2p/I I~,II a - a S I e I 4- - a~[~nvn I m~'mvn I m W I ry Y m o3L~nvn I oaixwn ~ -d 4 I I I = a I I - -I - - i - L ~ A` -3 J II 3 0 - J s 8 m W ~ o JJ \l• 6 m ~ ~ ~ m ao m~ r0-ib ,0-,Li ~o-A x02[ r0-.A Mkg Y r I ~ I I I ~ ° I I L I I I r0-,ZI r0,il oea[ AD rl/f 01-f e i ~f/I I,t I 11" .o{,eb - - ~ Nd d F yLL' r~~ ~ LL h 6 NO v p N ¢O o ~ ~ 8 w ado = - 0 m a~ j= { Co w a wY O 3 N 17 = w > \ii\li\ p~~w3a~ o ~Wisransin Department of Commerce SOIL EVALUATION REPORT Page f of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code n 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. 2- 3 / - ~jQd P/ease print all information. Reviewed by , Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~i- L raA _ 0t Property Owner Property Location Govt. Lot W" ~/4 S T3 N R E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City late Zip Code P one,Number ❑ city ❑ Village To Nearest Road New Construction Use:, Residential ! Number of bedrooms -131 - - / Code derived design flow rate _ ~ l GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L ~ ~ t / ~C Flood Plain el ation if applicable General comments r and recommendations: Boring M Boring # ~ Pit Ground surface elev. Depth to limiting factor -L. 2 i in. Soil Application Rate - Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 -Eff#2 zh /X . 7 , G 91 1~) Boring # Boring L Pit Ground surface elev. _ ft. Depth to limiting factor --/,-/In. F9 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz._Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 z _ fn tVF.,.y 5 j:, C I rn i n F r ! Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 1 ' Effluent #2 = BOD < 30 mg'L and TSS < 30 mg/L CST Name (Please Plana) i ari cc~ CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Te!epi one Number 1008 192nd Ave, New Richmond, WI 5401 ~a 715-246-4516 Property Owner Parcel ID # Page of FT Boring # E] Boring f X Pit Ground surface elev. Depth to limiting factor 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. I 'Eff#1 'Eff#2 j'n ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil ~Rplication 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 ❑ Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor in. El 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 Effluent #1 = BODI > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.6/00) Soil Test Plot Plan Project Name Lakes and Hill Development Shaun d~ Address P.O. Box 10598 White Bear Lake Mn 55110 CST #226900 Lot 31 Subdivision Glen View Date 7/18/03 1 /4 NW 1/4S 19 T 30 N/11318 N/ Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation 95.1/94.6 *HRpSame as Benchmark Alt. BM Top of Survey Iron @ 96.6' Scale is I" = 40' unless otherwise noted Please Note: Tested area may not be suitable for desired building area. Check; system location before excavating. Please note: survey was not Area`bf soils not suitable for conventional system completed at time of testing, setbacks from lot lines may change. Installer must verify all lot lines and setbacks before installation. 5' o 3 -3 40' B-1 0 40' 101' 5% 00'A L 20' Slope B-2 D a 150 99, 41 B.M.: M' 114' Property Line ~!W N M IQ N N ~r LC) O 35 t 3S N 6c r a - N Z E-• J- 4___________________4 1 J Ze' M ' 1 / r7 /'Fr / ~ , a ON, ~FS CO C14 11 m m M, • m r m 8 DRAINAGE 1 1 ON /m p EASEMENT 1 N 130,15 1 / a` =•a .4 III / / / ^~tr tib I / hb / ,3 M I ~ / 6 1 .sue .L~~•esiy! //~~h~ ,l~s 2~ 36 si FOyt2 •rr•~ / j/ 're V)l sr; h° i F h O; tib~ I 9g 0,1 fF` J 1 •8c I 2F.N p i I •r i LJ ; _ k' cg g ~ J1 O• J Z ^Z HW O SU'~ W W Lj Z F- 0 JIRo a no STREET LLO Z U = L: o , ! s o O U- 0 LLJ ---------i f _,..I 25 S 9 'I F- ~ .J Ln = LL. Z Q ~QOO a d U v ^ Z U) } ? O Z F- r Z W W 3 Z LLJ Z) -T ~ ~-O F- LL. LL. U - Zm U- OO O ZX CC 00 ~w M W F- z; P N U ~aao 0 p LLJ _ IY O o W 2 N ¢ = 3 Z _ a~WOZ F- O z LL- O t- "rsEt- =WE~° LA V a QO = W F- W ,an a moa_ o ~ Q N Q LL a d < ZZ ow a) ~m 00 i~ rr a In o 441.48' I \ I ~ - ~ Ssa>g 71~ I `l 32 Jg J~ \ \ 29SS,-29-~J w A 74,625 S.F. i \ N ° u (1.71 ACRES) z z > 1 J, m 4 H 479.53- w o N ~ 31 22 [030.80] 106,697 S.F. I N (2.45 ACRES) I I i NG 133 Eg b4 3S. I - j a f j l 66 I NOD 29) 23 30 2 120,152 S.F. I o? SS)¢ (2.76 ACRES) I r 24 lb 29 sob \\h~ \ 123,231 S.F. (2.83 ACRES) i l rri V ?6 ~Y \ \ 2a F \ \ 25 ?.~g83~zs4,71 s Q PLATTED LANDS \ JR Sa / *WUM D. 26 ASPERSOPI tij~ \ h\~~ hp 7~j S-2564 -k