HomeMy WebLinkAbout030-1044-20-112 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 600273
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:
Michael Bidon TOWN OF SAINT JOSEPH 030-1044-20-112
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
IS 20.30.19.160E-10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
lV r r<
4Is W/ Dosing Alt. BM
Aeration t; .Ye4 Bldg. Sewer
Holding St/Ht Inlet ~(/(J
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
~
Septic Dt Bottom Vv, ~vZ
Dosing Header/ an. f) .per
Aeration Dist. Pipe p (Q ' J
Holding Bot. System 'j'
► 2 3 `t,2
PUMP/SIPHON INFORMATION Final b.g b.
emand St Cover Z T?>
Manufacturer D
GPM vat
Model Number ~j
System Head TDH Ft
I Y. -Friction Loss
TDF L' ^
Forcemain Len i Dia. 2 r Dist. to Well , ~L_ O
SOIL ABSORPTION SYSTEM ' ~t 1 = i n.-,)JeX'
BED/TRENCH Width t r Nj(4 en PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Vff%
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREIylr LEACHING Manufac re/7, rl' x
INFORMATION CHAMBER OR 17 /J7
Ty e Of System: va j UNIT Model 'Nu
M, L I/ y.
U ~t( DIV DISTRIBUTION SYSTEM 4, ~flM N r
Header/Manifold , Distribution x Hole Size Ix Ole Spacirfg Vent to A7lntake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER XA~Y~" X Pressure Systems Only xx Mound Or At-Grade Systems Only
-ion Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil es - o
COMMENTS: (1 iscrepencies, persons present, etc j Inspection #1: I f I/ Zb~ 7 Inspection #2:
Location: 1430 47111 ST
~y.
1 1
1.) Alt BM Description = i r / k 5 Z~
2. Bldg sewer length = / 2J l t en~~ Gb &RS
- amount of cover `1 x 2d = &2 'n A/--
Plan revision Required? ❑ Yes )IC No Zo 1 d / ~J
Use other side for additional information.
Date Insepcto Signature Cert. No.
SBD-6710 (R.3/97)
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ST. CROI_X COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TA-NT-K(S)
This is to certify that I have inspected the existinz septic and/or dose tank
presently serving the following residence:
(Street address) located
at: 1/4, 1/4, Section , Town N, Range ",W,
Town of St. Croix County Wisconsin.
T'nnn ;nspection_ I oerr_i y that I have fo?1n, the tank(s), to the beet of my
knowledge, will conform to the requirements of Co 84.25, and it (they)
appear(s) to bc fdDcLioning properly.
Most recent date of inspection or sew ice
Did flow back occur from absorption system? Yes No
(if no, skip next 11*ne.)
Approximate volume or length of tune: zallons minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
(T is d' lumber Signature) (Print Name)
(Title) (License Number) ?N9/1vllDRS
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer 1 R 113 Wisconsin
A r i strative Code)
Rev. 9/2008
s -7 - 39
County
Alk,
~^Fk q,~ 2~T22001 Safety and Buildings Division
t~A W. Washington Ave., P.O. BOX 7162 Permit Number (to be filled in by Co.}
z~3
PCOUMadi 1 CRO I4,o mmut4kN Z54DCFF1 WO
N 3AK0 State Transacts rtiNumber
Sanitary Permit Application j/i.
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 A dress (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 'a -2
1. Application Information - Please Print All In ation
Property Owner's Name Parcel #
Property Owner's Mailing Address Property Location a ,3 Q ~j o 0
0 1 7 N 5-17
Vv, c
City, State Zip Code Phone Number -J Section
S cucle one
1 7 T ~y N; R 1 E or
II. Type of Building (check all that apply) :Lot #
Subdivision Name
or 2 Family Dwelling - Number of Bedr o
`C-Ce- Bloc
❑ Public/Commercial -Describe Use ❑ City of
CSM Number El Village of -TOYS
j
❑ State red -Describe Use . (Town of
Z ~ tom- t.•J 1 ~ ~ It -7 P r,~ ,
III. Type of Permit: (C eck only one box n line A. Complete line B if applicable)
FB ❑ New System ~2eplacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and ate Ied
❑ Permit Renewal El Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New V
Before Expiration Owner Lva
IV. Type of POWTS System/Component/Device. Check all that apply)
ANon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ olding Tank ❑ Other Dispersal Component (explain) catment Device (explain)
V. Dis ersal/Trea ent Area Information:
Design Flow (gpd) Design Soil Application Rate pdsf) Dispersal Area Required (s ispersal Area Proposed (s:,, System Elevation `To - 3 >
-750 7 750 77. 5 ~~tL (.t A,J In IZ
r
VI. Tank Info Capacity in Total # of Manufacturer
o
Gallons Gallons Units n _
W U U N
New Tanks Existing Tanks / o ~ 1? `a ca
W ~~/7 v y w C7 a
Septic or Holding Tank f j~%
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume respousibility fog installation of the POW TS sho the attached plans.
Plumber's Name (Print) Plumber's Si ature ber Business Phone Number
F u G 2 ZyZ 715 H (-31-I5~
Plumber's Address (Street, City, State, Zip Code)
VIII. Coun '!De artment Use Only
Permit Fee Date slued Issuing nt Signature
pproved ❑ Disa $ zLe4o. 40 /t /7
Owne en Reason for Denial .77
IX. Con di eason5 for Disapproval 3) ~ ~LL f~ % 1. M tsrk; etfli, & Illbar iioll Y'~ 'i `6 `e
pen -so cep mnumt all be 1nlyic ~s ! rm rots`. qt r
as per ;7lan3gemen! plan ptc iiaed by plumbef. I ~S' ~CCe.'~ Odd !
Z ~A►itseEl~Ckrec,~iw~r,^antsmtr~toei.r-~TStit"e-i
is pff 1'IpCficrbh w6i / w.rdime nrm. 130 4
Attach to complete plans for the system and sub t to the County only on paper not less than S in x 11 inch siz
G~►tr.~e.- Tts t, ) , - Cy (V ('.11 .
SBD-6398 (R. 11/11) Pt~V 4.Z. -r~
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: N\\e+A I IC( 4_? 10c)f~,J
Owner's Name:
Owner's Address: I `"133 -7 7
+40Q LTC) t-3 iAJ 1
Legal Description: _ Zci I ,3d
Township:
County:
Subdivision Name: a5fV1 vm21- fl, Lot Number:
Parcel ID Number.` Lqy - .z.C) Z
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 i St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: E License Number. 2
X 23ZG1Z
Date: Phone Number 1 , c
Signatur °Q
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
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4°Sdieduk 40 Final Grade
PVC Vent Pipe
YY?th Vent Cep
Leeching
Chamber , 5 ft
ft
320 ahwafflo Aw"M me Yin
6 ft
7Orr Trenct► 9
C Observabon P"
' cu.
LTrench 2 Header
~atn~ to ttf f~►
Manufacturer And Model
EISA P4ft!g 2U sq fit per ember SoH Appficatfon Rate gpdisq fit
y 50 gpd Design Flow f Sol Appkedon Rift EISA = Clambers
I C4-"
2 rows of chambers each.
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner KWt~ 1 P"L L ~-3 10 tj I~j Tank Manufacturer: ❑ NA
Permit # j
O-.Septic ❑ Dose ❑ Holding Volume: (gal)
DESIGN PARAMETERS Tank Manufacturer: W. ❑ NA
Number of Bedrooms: ❑ NA eptic Dose ❑ Holding Volume:U (gal)
Number of Public Facility Units: EXNA ertical Distance Tank Bottom(s) to Service Pad: (ft)
Estimated (average) Flow (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft)
Design (peak) Flow = (estimated x 1.5): al/da Specific servicing mechanics must be provided if vertical is >15 feet or
_60 (g y) if horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: : & (gal/day/ft) Effluent Filter Manufacturer: j( I-V\TE1C ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model:
Fats, Oil & Grease (FOG) 5_30 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BOD5) 220 mg/L ❑ NA . ❑ NA
Total Suspended Solids (TSS) 5150 mg/L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer:
(BODs) >220 mg/L NA ❑ NA
(TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
❑ Disinfection ❑ Wetland
Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other:
(Bobs) 530 mg/L Soil Absorption System
(TSS) 530 mg/L ANA
Fecal Coliform (geometric mean) 510° ❑ In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
❑ At-Grade ❑ Mound
Maximum Effluent Particle Size in dia. Ll NA ❑ Drip-Line ❑ Other:
Other: Ef NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) hen combined sludge and scum equals one-third (X) of tank volume
❑ hen the high water alarm is activated
Inspect condition of tanks At least once every: ❑ month(s)
~3 year(s) {Maximum 3 years) El NA
Inspect dispersal cell(s) At least once every: El month(s)
3 -Ky (Maximum 3 years) ❑ NA
ear s
Clean effluent filter At least once every: Clan ar(sjs) El NA
Inspect pump, pump controls & alarm At least once every: El ymeonth(s) ❑ NA
3 ,Myear(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA
13 (year(s)
Other: ❑ month(s)
At least once every: El year(s) El NA
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 (f6) 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 5_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.
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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 foilowing 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 INSTALLER POWTS MAINTAINER
Name Name
Phone Z (S - 3'-~. Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name 5' 6a )e Phone Phone -7(6 jlrg$
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.
Dose Tank Cross Section And Plump Performance Specifications
Tank Manufacturer W( Minimum Pump Performance Required
Tank Model Number Ls GPM @ Ft TDH
Total Tank Capacity
Max. Bury Depth
Total Dynamic Head (TDH) -Feet
Pump Manufacturer Elevation Head
Pump Model Number
~S Distal Pressure
P6
Alarm Manufacturer Network Pressure Loss .TC°Z
Alarm Model Number Force Main Pressure Loss -7
Switch Type Total 31-79
Manhole Min. 4" Above Grade
With Locking Device
Vent Min. 12" Weather-proof
Above Grade Junction Box 1
With Cap
- - - - - - Finished Grade - - - - -
Depth of Cover Ft Disconnect
1 Means
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Outlet
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Inlet } `t Switch Settings and Reserve Capacity I I
y`} Tank Volume = GPI Y
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Dimension Inches Volume Gal. A
(reserve) A ~5 <'< Weep
(alarm) B 2
Ll -4 C> B L
} } Hole
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(dose) C Off Elev.
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r t> (dead) D Ft
Total
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GENERAL INSTALLATION: The 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 excavation and is sealed
watertight. Electrical service complies with NEC 300 and Comm 16.28 Wis. Adm. Code.
03/051gj Page of
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Toll Free 888-999-3290
Office 23 1-5 82-1020
Mailing Address
F
1455 Lexamar Drive, Boyne City, MI 49712 ax 2 -7324
Email s irnte imtech @ freeway. NET
Web www.aae-sinuecl, c0m
INSTALLATION & SERVICE INSTRUCTIONS
INSTALLATION:
When installing an STF-100, screw filter into discharge port of any pump that has a 2" National Pipe Thread.
Pumps with a smaller discharge port may be adapted to fit. When installing an STF-100A2 a tailpiece and male
adapter will need to be added to the inlet end of the filter to the desired height and a 2" union will need to be
added to the outlet end of the filter. Always install the filters in a position where they can be easily serviced.
**Always use caution when starting threads to avoid cross threading**. Plumb force main into the 2" sch 80
PVC union. **We recommend that the union remain together during gluing to insure that glue or cleaner does
not ruin O-ring or sealing surface**.
SERVICE:
Service of filter screen is dependent on usage as every system is unique. For most residential systems we
recommend inspecting the filter within the first year to determine the necessary service intervals for the filter. In
high volume systems we recommend inspection within the first 6 months to determine necessary service
intervals for the filter. Once the service interval is determined it should be consistent unless something changes
in the system. Always inspect the filter screen for any damage or corrosion and replace if necessary. If our
STF-101 service alarm switch has been installed and adjusted properly it will alarm when the filter requires
service. It should be serviced no less than when periodic pumping of the septic tank and pump chamber is
performed. Servicing will be more frequent if using any one of our optional filter socks (600 micron, 150-190
micron, and 100 micron). Check your local health department for septic system servicing recommendations.
If the screen becomes clogged before the periodic pumping requirements, a high level alarm or light will
indicate the need for service. If system is equipped with a "pump on light" that stays on longer than normal, this
also may indicate a need to service filter.
To service filter screen, unscrew the 4" cap. Pull filter screen from canister and wash out thoroughly in
appropriate location with proper protection. In some cases an additional filter screen allows quicker service
allowing the dirty filter to be washed later at the shop. Note that in cold conditions the filter cap may be difficult
to remove. Keep the filter in a warm area or pour warm water over the cap before removing. Once the filter is
installed in the tank it maintains a stable temperature and removing the cap will not be a problem.
If the system is equipped with our Service Alarm Switch, the filter screen does not need service until the
Service Alarm Switch activates a light or audio alarm. We still recommend that the filter be inspected once a
year for damage or corrosion.
NOTE: The total dynamic head loss of the system must be increased by 0.5 feet of head to overcome friction
loss through the filter.
SERVICE ALARM SWITCH
The alarm switch is available in three pressure ranges, low head, medium head, and high head. Installation
is simple, on SIMITECH FILTER systems, remove 1/4" plug from base of filter chamber and connect tube fitting.
Next, run the tube up into the tank riser and connect to service alarm switch. The alarm switch is fastened to
the side of the riser via the nylon strap provided. Run alarm wire to alarm box. The service alarm switch can be
wired with its own alarm or with the high water alarm.
Pressure adjustment is made by removing the end plug, and inserting the 7/32 allen. Clockwise increases
pressure. One turn equals approximately 3 PSI. The low head alarm switch comes factory preset at 8 PSI and
is completely field adjustable within it's range (3 to 24 PSI). We recommend the use of a ball valve when using
an alarm switch. Once you have installed the filter and alarm switch, the ball valve can be closed off to simulate
a plugged filter so that you can make sure the alarm switch is working correctly.
****TRY OUR LID/SCREEN REMOVAL WRENCH. Our wrench holds filter lid firmly and hooks
screen for easy removal and installation. Made of PVC plastic.
Installation Service Instructions. doc
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
D
OWNER/BUYER f`~j,rL ~~ln~,~>
r
ROUTE/BOX NUMBER Fire Number
CITY/STATE 5%, ✓L7SL?~/j ZIP,S
PROPERTY LOCATION: ~4? Section T 3ej N, R
Town of o7e,-, St. Croix County,
Subdivision, el 7-, Lot number-.,Z_.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on- site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. ti
0
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources, Certification form must be completed
and returned to.the St. Croix County "honing Office within 30 days
of the three year
expiration
date.
SIGNED
II
DATE
St. Croix County Zoning Office
P.O. Box 98•
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
D
LABOR EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 81 BUILDINGS
BOX 8 7989 HUMAN RELATIONS
P.O. BO PRIVATE SEWAGE SYSTEMS DIVISION
P.O.
MADISON,1Nl 63707' BUREAU OF PLUMBING
MCONVENTIONAL ❑ALTERNATIVE alate IM
.n I.D. Numbs:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound fit
NA OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Mike Bidon Rt. 1, St. Jo-6eph, W1 54082 a _T E,
BENCH MARK EP. m -nl 1-41 11 P01-0 DESCRIBE IF DIFFERENT FROM PLAN REF, PT. ELEV.' ST REF. PT. ELE V
NE SE, Section 20, T30N-R19W, Town 06 St.Jo,6eph,Lot#2, Stout Sub.
Namr of Plumber: MP/MPRSW No
Cnunly San,lary P.rmit NUTMI:
Danavin Schmitt 3205 St. Choix 83866
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIOUIDCAPACITY TANKINLETELEV. TANK OUT LET ELE V WARNING LAB LOCKING COVER
Z'A q5. 33 9 d 2 PROVIDED PROVIDED
YES ❑NO
G VE ❑YES NO
REDOIN'. NT DIA. VENT MAI I HR;H WA NUMBER OF,: Rono. PgoPE.rv WELL BUILDING. VENT TO FRESH
L1 ALARM PEET FROM C L/ LINE/ AIR INLET'
❑YES I~NO 1 C ❑YES ~NO NEAREST J s ~a?
DOSING CHAMBER:
MANUr ACTURER REDOING uOUID Cnpnl:nv PUMP MODEL PUMP.SR'lu)N MANUI Ar IUHf+I WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
YES ❑N0 ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMPANDCONT.DLSO ERATIONAL NUMBER OF - PROPERTY WELL BUILDIN(; V NTTOFRE H
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth Of plowing 1 I Nl,u, OIAMF rE H MAE f HIAI ANb MA HKIN4
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH Lf NG H NO Of UISTH PIPE SI'A(,INI. COVE11 N5111L I11A
^ THE NCHfB I aPITS LIQUID
DIMENSIONS, PIT DEPTH
V L DEPTH FILL DEPTH UISTI/ PIPE UISTN PIPE. DISTR. PIPE MATERIAL NO DfSIII NUMBER OF PROPERTY WELL BUILDING V NT TO FRESH
BE LOW PIPES aOVE COVER E I E V INI I 1 ELEV F NU PIPE S LINE
} Il n pp a
(p
7~/O i~.$7 7 2 FEET FROM AIRy~LET
41
NEAREST-► /0 y0 too 3 (0 3
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA.
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
IL COVER TEXTURE IN HMANI N I AIARk l IIS 1011SINVA T I(,N WE LLS
DEPTH OVER TRENCH BE D DEPTH OVf H IHENCH NEU OIPT"Of TOPSOIL MULCHED
SODUID ❑YES 5Fl UFI❑i NO ❑YES ❑NO
CENTER EDGES
❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH w1orH LENGTH NO OF LA TEHAL tSPAlHAV DEPTH Nf LOW PIPI FILL DEPTH ABOVE COVER
TRENCHES
DIMENSIONS
MANIFOLD PUM MANIr OLU DISTR PIPATERIAL NO DISH/ DISTR PIPE UI RIRUT ION PIPE MATERIALS MARKING
ELEVATION AN ELEV ELEV DIA ELEV PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING UHILLEU COHHECILY OVE. MATERIAL VERTICAL LIFT COR KESPOND$ TO APPROVED
PLANS
YES ❑YES ❑NO
COMMENTS: PERMANENT MARKERS- OBSERVATION WENS JNF BER OF PROPERTY WELL. BUILDING:
3 T FROM LINE
❑YES LINO ❑YES LINO REST
o ~
rn fi•~L ~ e-t tom, ~.c,
Sketch System on V
~ j in i county file for audit.
Reverse Side. \ JI
SIGNATU
TI LE
DILHR SOD 6710 (R. 01/82) ~ ~
Wis. Dept. of Safety and Professional Services SOIL EVALUATION REPORT
Division of Safety and Buildings Page of-
in accordance with SPS 385, Wis. Adm. Code
County C;
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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
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)).
--A I /,;6
Property Owner Property Location
c. Govt. Lot 1/4 1/4 S Q T U N R' ( E (or W
Property Owners Mailing Address Lot # Block # Subd. Name or SM#
I
C Is
City State Zip Code Phone Number ❑ City ❑ Villa
ge ®Town Nearest Road
❑ New Construction Use: ❑ Residential / Number of bedrooms
3 Code derived design flow rate GPD
F9 Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft
General comments
and recommendations: 4~m N ti' `1 r t '
F T] R9 Boring# ❑ Boring
pit ^ r r
Ground surface elev. ft. Depth to limiting factor : - ~ in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
s
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
a e
~-~y 3 to y
t1ev Boring Boring # ❑ Pit Ground surfacft. 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 #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print Signature CST Number
Address ' --Date Evaluation Conducted Telephone Number
CS
5 SBD-8330 (RI 1/11)
Property Owner Parcel ID # Page of
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor 1n Soil Application Rate
2
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
❑
❑ Boring # Boring
F] Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
2
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Boring
F-1 Boring # Ground surface elev. ft. Depth to limiting factor in.
ation Rate
❑ Pit Soil )GPD/ft
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Effluent #1 = BOD 5 > 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.
SR U-8330 (R 11/11)
CA C. Lj 16;
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