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HomeMy WebLinkAbout014-1041-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600335 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: Edwin Hall TOWN OF FOREST 014-1041-30-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 19.31.15.299 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution ix Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length 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 Mulched Bed/Trench Center Bed/Trench Edges Topsoil E] Yes E] No T ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2005 HWY 63 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑ No Use other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) r I County C \VJ L11:7 LL)) Safety and Buildings Division ST CROIX AIN 2Q1 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) iPS AN 12 2018 Ma'01bn, VA 53707-71 t K2 ~ (DO 33 j WGRSV7H6TK Sanitar}Permit Applicarnuff W State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental un+t 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 secondary j t purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. * ~F 1. Application Infor n - Please Print All Information Property Owner's Nam Parcel # 01 -1 EDWIN HALL 014-1041-30-000 Property Owner's Mailing Address Property Location 2005 HWY 63 Govt. Lot City, State Zip Code Phone Number SW V, SW V, section 19 DEER PARK WI circle one) II. Type of Building (check all that apply) Lot # T 31 N; R 1 E or WX [14 or 2 Family Dwelling -Number of Bedro 3 Subdivision Name TI CII CAIN`' Block # ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of ❑ State Owned -Describe Use 5 Ntvt l qk5 t~ EZ F1~5 Town of FORESET III. Type of Permit: (Check only on box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) y B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 4i `Q IV. Type of POWTS System/Component/Device: Check all that apply) E04on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ 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/Treatment Area Information: yc 17' VUO .tJep: Design Flow (gpd) Design Soi pplication Rate(gpdsf) Dispersal a Required (sf) Dispersal Area P posed (st) System Elevation 450 y 1 5 O 12 V36 94.5/94/93.5 VI. Tank Info Capacity in Total # of Manfacturer Gallons Gallons Units o b New Tanks Existing Tanks o cz, ~d / dW ~z , Septic or Holding Tank X 1000 1 WEISE X Dosing Chamber 600, WEISER X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number PAUL R KOEHLER225410 715-246-2660 Plumber's Address (Street, City, State, Zip Code) VIII. Catmty/ De artment Use Only Approved E2- 1 Permit Fee Date Issu d [ssum ent Signature S-Mr Given Reason For Denial V 7 3 / " IX. ConditIAN Y8 easons for.Disapproval 1 rk 6iYltfh.tilt4r cni 3) 61,k,54L an o/~ t° u,si,,et cell lust III be ic- s ` t ec OC L.4s per,-nar:ayemen' plan nrc, iae i by )IUn0e.. (gyp • 2. All sefberk rec,0i--,:'Pn,s tnlJst LU i:':_: rt, ire as per appilcnb1 coe,, l:rrt:? Ine='. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) 00 N O O it J 0 w J LL 0 2 a O -4 LL w M cr 0 Q ry w m Ln O q:r O ~ Q co 01 O) M Cl1 Ch Ch (3*1 Qt H rl 1. 00 00 O ' i Q Q r4 N M Z_ _Z Z_ U U W W W Q W W O O 0 CL (n co m m co co V) I L.j 1..1..1 00 O N w O W~ J a ~ w O m a w 3 z ~ 0 W~ c a I w Ij p oO10 ~ LL CA W 0 N ~ N Z Z m l Q t Z m o m t I~ W 0 m o 0 CC O W E J J o C 0 w W 0 ¢ 0 0 LL w ~ Z z rl m d W N Ln 3: V) o o~ 0 2 CC 0 a o m0 N M ° w i s o Z W a-1 N~ N LLI m Q1 W J fL S °'%1 3 Lr) 0 N g O c 3 ° 0 F- LA W cc R L 0 cr co d u1 0 w -1 0 t; d N 0 rn rn°~Ol rn m 0 E9 AVM H91H 0 , CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: EDWIN HALL Owner's Name: EDWIN HALL Owner's Address: 2005 HWY 63 DEER PARK WI Legal Description: SW1/4 SW1/4 S 19 T 31 R 15W Township: FORESET County: ST CROIX Subdivision Name: Lot Number: Parcel ID Number: 014-1041-30-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: PAUL R KOEHLER License Number: 225410 Date: 01/09/2018 Phone Number (715) 246-2660 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 N Ol 0 W O w 0- -j LL O o ?r a O w L!1 LL O ei w m Ln O V' O O Q~ cn (n Ch 4m m , m 00 01 ~ r-I .q l0 00 00 -1 Y Y N In N 0 \ oc cc rn 0) 0, ~ ~ ~ ~ C7 C7 l7 Z Z Z_ LLI u u u w W W Q W W O O O CL N co co m m co LU W~ ~II LL 01 0 00 N 1 LLI O W J LL W O > CC i in 1 z 3 w cr O w 0 ° m 3 ° N 0' m cc 1 3r ~ a ~ 01 W ° O N l7 o~ itu U LA Z LL Z LLJ Q Z m O m co N O r a J J ° p H a O w LL O p LL a 1W w u a w I z Z 1T-4 m P 3 3 3 Ln CL Ln o_\ o O O N O z o_` m O N M O ~J t/W O oq W Q N f e-1 W J m Q1 a 2 O 3 a N -L.U ' f f- Ln w CC at 71 in o O 0 0`1 o Iji ~ N VI Q1 01 Q7 01 01 O £9 AVM H91H SOIL ABSORPTION SYSTEM DETAIL I GRAVELLESS LEACHING UNIT Page_of Project Name: edwin hall 45 No. of Cells 9 Per Cell 3 ft Cell Width 45 Total No of 90 ft Cell Length 50 sq ft EISA Per Cell 3 ft Cell Spacing 2250 sq ft Total EISA Manufacturer Model Laying Len EISA Rating EZ1203H-5ft 5.0' 25.0 Infiltrator EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: infiltrator Gravelless Leaching Unit Model: ez1203h-10ft Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent Soil Backfiil 12 _Geotextile Fabric v d ft Infiltrative Surface 12 in Q A ft Limiting Factor - i in s Slotted and Anchored Vent! 8 _ Observation Pipe with Cap y- ■r...r.r.....r...-r..r--iii......r..eu....■r......■■.........r.r■r.r r.... PlumbeNDesigner Signature: Licenses: mp225410 Date: march 8th 2018 - c - - - - * '.r.-.. - - - - - - - - - - - - x U 00 O LQ U N N r- co M U L C) 11 U E N N N N U V' U QOj M N CR r 00 P j!~'~illl ~p /./M1'I'II ~jY l'"II III I'n\ Cl) - III III III III V P L' YQ + III I cli V ~ I li: ul=,.r.Y •,;,S.r.',.t co U III Ilvllll II III II~..I r- 0 Lo y II ~ I I I W I ~ I. I~~ I ~ I IIII I I I III VIII III I I I oil I I Y'~ s bI I d/ ~ ~ I II III IIII I , f ~I ~ I~I II II I ICI II ~ ~I~'/ ,u~~ll I ~ _ 1 ► ' ' u I:;IG,I~~~l~li lu, L_ IIII ~ F- GO U 04 06 I ~ I' W O A/ ¢ S cn Y . w a r{t- ~ - /fir Cl f w m / 2 cOJO /'/p~Gdvl,.. dlq Adl~~~~~1/~G ~l O 15- L_ C C z d tq J U O Q U3 C/3 0 uJ._ C/) w MO Lr) LL, o LL CID w Z co LLJ O ~ w LL. w ¢ LL ~ `e L1 U C/3 LU O eo Z o `n `n U J ~ rn w d U LLI ~U') Q u- d Z LO J O - ~ O O w U) C G C, " O Q LL O LL > H W O Q Q O Q Q O O O aa~UF- F- Septic-Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer wiener Pump Manufacturer goulds Tank Model Number 1000/600 Pump Model Number epo4 Total Tank Capacity 1,600.00 Alarm Manufacturer sj rombus Max. Bury Depth 8.00 Alarm Model Number ps patrol Switch Type float Filter Manufacturer of lock Total Dynamic Head (TDH) - Feet Filter Model Number 525 Elevation Head 5.00 Distal Pressure Network Loss Minimum Pump Performance Required Force Main Loss 50.00 GPM 5.00 Ft TDH Total 5.00 Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade Sealed Watertight 4,Securely Mounted With Locking Device Weather-proof 1 Junction Box F'nished Grade - . . ® Depth of Cover Vent Min. 12" Disconnect Above Grade Ft Means With Vent Cap a > Outlet Outlet Filter Inlet Inlet Baffle A , a> Switch Settings and Reserve Capacity < a Tank Volume = GPI <:< Weep < < Hole Dimension Inches Volume Gal. B r (reserve) A 18 301.68 (alarm) B 2 33.52 Off Elevation C (dose) C 7 117.32 Ft <,< t , < Bottom (dead) D g 150.84 <~< D Elevation Total 36 603.36 Ft t s< s s a t s t<<< a< t t s: t a e<< t t a a c s<< t s t<<<< a s a t t t< t<< t t t e t t t t< <'t GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 U Page of RGOULDS PUMPS Submersible Effluent Pump MODEL 3871 5 EP04 & EP05 Series APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermo- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for plastic enclosed design for heavy duty ball bearing con- following uses: lubrication and efficient improved performance. struction. • Effluent systems heat transfer. ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms superior strength and corrosion manual operation. Automatic Canadian Standards Heavy duty sump resistance. . Association • Water transfer models include Mechanical 0 Motor Housing: Cast iron for @Pus File # LR38549 • Dewatering Float Switch assembled and preset at the factory. efficient heat transfer, strength, and durability. Goulds Pumps is ISO 9001 Registered. SPECIFICATIONS FEATURES ■ Motor Cover: Thermoplastic • Solids handling capability: 0 EP04 Impeller: Thermo- cover with integral handle and 3/4" maximum. plastic semi-open design with float switch attachment points. • Capacities: up to 60 GPM. pump out vanes for mechanical 0 Power Cable: Severe duty • Total heads: up to 31 feet. rated oil and water resistant. • Discharge size: 11/2" NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: METERS FEET _ 1040 F (400 C) continuous 1 ° 1400 F (600 C) intermittent. • Fasteners: 300 series 9 30. -4--5 GPM stainless steel • Capable of running s ~-2.5 FT dry without damage to 25- - - - - components. °a 7- 6- 2°. Motor: • EP04 Single phase: 0.4 HP Z 5- 115 or 230 V, 60 Hz, 1550 0 15'- _ -_i - - RPM, built in overload with a a j i EPOS automatic reset. o • EP05 Single phase: 0.5 HP ~ 3 10'- - - EPOa T - - 115 V or 230V, 60 Hz, 1550 RPM, built in overload with 2 5 _ - automatic reset. - • Power cord: 10 foot 1 standard length, 16/3 lo SJTW with three prong ° 00 20 3o 40 50 GPM grounding plug. Optional 20 foot length, 16/3 SJTW with 0 2 4 6 8 10 12 rnVh three prong grounding plug CAPACITY (standard on EP05). Goulds Pumps © 2005 ITT Water Technology, Inc. ITT Industries Effective January, 2005 w 83871 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner EDWIN HALL Septic Tank Capacity 1000 gal ❑ NA Permit # Septic Tank Manufacturer WEISER ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer POLY LOCK ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units X E)(NA Pump Tank Capacity 600 gal ❑ NA Estimated flow (average) 300 gal/day Pump Tank Manufacturer WEISER ❑ NA Design flow (peak), (Estimated x 1.5) 450 al/day Pump Manufacturer GOULDS ❑ NA Soil Application Rate •4 al/da /fts Pump Model EP05 ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD6) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD6) S30 mg/L Q In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L CS NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5_10" cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ye in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve ❑ month(s) (Maximum 3 years) El NA s ~ year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA r(g) 1 (Maximum 3 Years) ❑ NA Inspect dispersal cell(s) At least once eve ❑ monthi s 13-year(g) Clean effluent filter At least once every: 1 ❑ month(s) ❑ NA 1 ~ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA s .®,year(s) Flush laterals and pressure test At least once eve ❑ month(s) NA every: ❑ year(s) ~ Other: At least once every: ❑ month(s) 2NA ❑ year(s) Other: [P-NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (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 5512 months, shall be performed by a certified POWTS Maintainer, A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of 7/ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(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 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 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 fines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T a o ing ank aluat ^ / be ' e ai e . ?kD~4m rrs✓ VIDoe- JJ$1'/ CahtS'muc- l D ❑ 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> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name f E Name ,f.: Phone , 2( 4 Phone s Z _ 1`L e*7 SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY SEPTAGE Name Name AJT"I 2DAlt~cJ Phone 7~ _ /Uz Phone 41 (pICD 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. ST. CROIX COUNTY ' ~tl~~~ SEPTIC TANK MAINTENANCE AGREEMENT AND FEB 16 2018 OWNERSHIP CERTIFICATION FORM EDWIN HALL st Croix county Owner/Buyer C r ,.~,v 1?evelo~ment Mailing Address 2005 HWY 63 Property Address 2005 HWY 63 (Verification required from Planning & Zoning Department for new construction.) City/State DEER PARK Parcel Identification Number 014-1 041 -30-000 LEGAL DESCRIPTION Property Location 1/4, sW sW ,4 , Sec. 19'T31 N R 15 W, Town of FORESET Subdivision Plat: , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑yes[Dno Lot lines identifiable El yesE]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 §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 statemen 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 a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 09 2018 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) 4 ~ t ~J t -7 L=1 It ' Wis. Dept. of Safety and`Professional S OIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings oeiesZo1 in accordance with SIPS 385, Wis. Adm. Code County ST CROIX Attach complete site plan on paper not less thoR 81/3;)11'iinches in size. Plan must include, but not limited to: vertical and horizont6tre€erznc2'~oint (BM), direction and Parcel I.D. 0 4-10,11-30-000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. NNE A,;,,f" Revie d by Date Please print 69 E Y p Personal information you provide may be USE R6XoeP (m)). Property Owner -ocation EDWIN HALL Govt. Lot SW 1/4 1/4 S /9T 31 R 15E (or) W ■ Property Owner's Mailing Address Lot # Block # Subd. Name or SM# 2005 HWY 63 City State Zip Code Phone Number E]City Village [Drown Nearest Road DEER PARK WI ( FOREST 200TH ST ) New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD El Replacement rl Public or commercial - Describe: Parent material SILT LOAM Flood Plain elevation if applicable °d ft. General comments JEWET SOILS. RECOMMEND A AT GRADE SYSTEM AT A . LOADING RATE. and recommendations: 1 11 Boring ~Z Boring # 72 Q Pit Ground surface elev. 9 S ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * 01 * ff#2 A 0-10 7.5YR3/2 SIL 2MSBK MVFR G 2 .6 .8 B 10-40 7.5YR4/6 MS 0 ML G I VF .7 1.6 C 40-72 7.5YR SCL 3MABK MVFI GW .4 .6 FT] Boring # Boring 9 4 84 Q Pit Ground surface elev. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *N2 A 0-8 7.5YR3/2 SICL 2MABK MFI GW 3F .4 .6 B 8-54 7.5YR4/3 SIC 2MABK MFI GW 1VF .6 C 54-84 5YR3/4 SL 0M MVFI GW .2 .6 * Effluent #1 = BOD > 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) gnat es CST Number Address Date Evaluation Conducted Telephone Number ~I w Jc~r L ~Or.:.~c~ ~S ao / SBD-8330 (RI 1/11) Property Owner Parcel ID # Page J],- of F Boring # Boring 9~4 50 pit Ground surface elev. " ft. Depth to limiting factor in. Application 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 0-8 7.5YR 3/1 LS 1 VF13K MVFR C 2F .6 1.0 C1 8-50 7.5YR4/6 SL 0M MVFI G .2 .6 C2 50-76 5YR5/6 C2P5YR5/8 C 0M MVFI G .0 .0 ❑ Boring # ~ Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ` ff#2 Baring E Boring # Ground surface elev. ft. Depth to limiting factor in. ® Pit 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 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. 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