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HomeMy WebLinkAbout018-2011-78-000 (2) i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600337 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: Kernon Bast TOWN OF HAMMOND 018-2011-78-000 CST BM Elev: 7~~1 BM Description: Section/Town/Range/Map No: 30.29.17.1093 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER f CAPACITY STATION BS HI FS ELEV. G~ Septic Benchmark It 0 ari ~ .•fte 9osing- -70 Alt. BMA q,V '1 101• b Aeration 'T Bldg. Sewer 4~9 '7 Holding St/Ht Inlet TANK SETBACK INFORMATION TANK TO 21L WELL BLDG. Vent Ai Intake ROAD DPt71et-- Septic Dt Bottom } Dosing Header/Man. Aeration Dist. Pipe 11o. I 7q. 7- Holding Bot. System k at'S• o Final Grade PUMP/SIPHON INFORMATION L5, Manufacturer Gli Demand St Cover ,p t`- GPM l Q Model Number (3k) r2s~' ?(f) ~y (y TDH Lift Friction LLess System Head TD Ft b 1, . V - lR- Forcemain Length Dia. ~1 Dist. to Well - SOIL ABSORPTION SYSTEM BEDITRENCH Width 6 Len th No. Of Trenches- PIT DI NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7C/ SETBACK SYSTEM TO P/L G7 BLDG WELL LAK TREAM LEACHING Manufacturer: C~ INFORMATION CHAMBER OR G Type Of System: t") T-75 UNIT Model Number C~ht,,Lb~ DISTRIBUTION SYSTEM Header/Manifold Distribution Ix Hole Size role Spacing Vent to Air Inta ' ( Pipe(s) - ill ~ K So Length Dia Length Dia Spacing SOIL C VER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 1xx Depth of Ixx Seeded/Sodded xx Mulched Bed/Trench Center , Bed/Trench Edges / Topsoil Yi5s' N- Yes -N ectiion #1: Inspection #2: COMMENTS: (Include rode discrepencies, persons present, etc.) 1IInsp0,A-1 Location: 780 154TH ST 61-1. J ~rl l~ ~l 1.) Alt BM Description = 2.) Bldg sewer length = ~Q - amount of cover i Plan revision Required? ❑ Yes ❑ No Use other side for additional information. go (~IU~ Date Insepct ' Sign lure Cert. No. SBD-6710 (R.3/97) oa County 1 40) R, Safety and Buildings Division 9 t 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) 9 2n Madison, WI 53707-7182 r ~ ~ ~ MAR U i 660 3 37 it y perm4+ ' 2RSRJONoWz"r State Transactio Number In accordance with SPS 383.21(2), Wis. Adm. Code, subm pF ,,z,.upnate governmental unit is required prior to obtaining a sanitary permit Note: Appb rorms 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 secon purposes in accordance with the Priv Law, s. 15. 1) m), Stn s. 7 L Application Information - Please Print All Information Property Owner's Name Parcel # 1 l i" 1 / Property Owner's Mailing Address Property Location O 9 41 . ' ©9 3 Govt Lot Cn3, rate Zip Coder Phone Number / ° 1- Section ~1 1, t circle 0*- T j_J~_ N; _ E ~r W II. Type of Building (check all that apply Lot `J 1 or Family Dwelling-Number of Bedroo Subdivision Name ❑ PubliclCommercial - Describe Use City of ❑ State tied - Describe Use CSMCNumber ❑ Village of 301 7 Lo. of Q. fit . C III. Type of Permit: (Check only one t on line A. Complete line B if applicable) A. System El Re Placement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) I El ❑ Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Permit Renewal ❑ Permit Revision B ~7 ~ Z '2 Issue 0 Before Expiration Owner G :G• IV Tvpe of POV1 TS System/Component/Device: (Check all that apply) Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-GTade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank D Other Dispersal Component (explain) ❑ Pretreatment Device (explain, 2Z.:5 V. Dis rsaUTr 'a ent Area Information: Design Flow (.pd) Design Soil Application ds Dispersal Area Required sf Dis fl ( Per-sal Area Proposed (sf) System El an n VL Tank Info Capacity in Total # of Man/ufacturm Gallons Gallons Units -9 r*A New Tanks Existing Tanks o m 1441 Septic or Holding Tank Dosing Chamber 9'.. r VII. Responsibility Statement- 1, the undersigned, a responsibility for installation of the PORT'S shown on the attached plans. Plumber's Name (Print) Pl ipAure MP/WRS Number Business Phone Number 7 4 ~ Phimber's Address (Street, Ci}),,State, Zip V ~ 7 r ounty/De artment Use Only Approved Permit Fee Date sue Issuing . t Signature $ gS. 06 ven Real Denial DL Couditi ..oas-for Digapproval ~ Irthf.t 3 J. 'i~i~,~es•:ai: crN r:xnt ~ Q~`!_rnc m~ sc P o, . ale per Pkn Pt'o tided by Iu, &A-A"A- w . 2. At Oe c re c IMS mlAit Lou' i a ele per appkr1W codtf I M;narn; ! ~l•r . I I Attach to complete plans for the system and submit to the County only oa paper aoY less than 8 r2 z 11 inches in sir SBD-6398(8 11/11) P Y t ~ System PLOT PLAN ADDRESS 948 LaBarge Road Hudson Wi 54016 PROJECT Kernon Bast COUNTY ST. CROIX NW 1/4S 30 /T 29 N/R 17 W TOWN Hammond NE 1/4 3/8/17 BEDROOM SYSTEM ELEVATION 983/98.1/97.9 3.5' below grade DATE XXX HOLDING TANK AT-GRADE CONVENTIONAL LIFT CONVENTIONAL DOSE TANK SIZE 1000 gallons LIFT TANK SIZE630 FIr MOUND - SEPTIC TANK SIZE 1125 # of ~et}i4rrhers 22'5 LOAD RATE •4 ABSORPTION AREA HOLDING TANK SIZE - BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 154th St. P oom ous~ 3 O Huffcutt Combo Tank s B-3 B-2 10' 5W 10' B.M.* 2% Slope 50' 70' Property Line -1 Vents 30' j (t 102' 101' 25' 211' Property Line Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 3/8/18 Owner: Kernon Bast Location: NE 1/4 NW 1/4 S 30 T29 N,R17W 780 154th St. Hammond System type: In-ground absorbtion system (conventional) Manuals Used: In-ground absorbtion system (version 2.0) Pressure Distribution Manual (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. ~r Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Sheet 8. Dose Tank Cross S ction 9. Pump Curve ` Signature License numb#226900 System PLOT PLAN ADDRESS 948 LaBarge Road Hudson Wi 54016 PROJECT Kernon Bast 29 N/R 17 W TOWN Hammond COUNTY ST. CROI NE 1/4 NW 1/4S 30 /T 3 3/8/17 BEDROOM _ SYSTEM ELEVATION 983/98.1/97.9 3.5' below grade DATE )OCX HOLDING TANK AT-GRADE CONVENTIONAL LIFT CONVENTIONAL DOSE TANK SIZE 1000 gallons LIFT TANK SIZE630 SEPTIC TANK SIZE !-'e-.ti 5 MOUND 1125 # of e4ambers 22' LOAD RATE •4 ABSORPTION AREA HOLDING TANK SIZE BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100° Filter Lifetime Filter ❑ BOREHOLE (DWELL *H.R.P. same as benchmark 154th St. I I F o 3 edroom House 30' Huffcutt Combo Tank 40' B-3 B-2 10' 50' 10' B.M.* 2% Slope 50' 0' Property Line -1 Vents 30 102' ,34~ W1k pra;r y 101' 25 211' Pro ert Line p O i O d cu a) C LL > '~2 N ~ W C7 x m m o U- O C~ cn C O O. - r d o M L w c~ .R. a ca a) N i.L L O O • L L C O Q Q ui LM * U N - . V • r L_ - w i C i a Li- M o Ccu ° W >0 N N N - O ci a o o \ ..N to Q m . O O > ~ U N ~ Z Q1 W W U` 75 I - to- O 70 42) L . . . . - o (D L- IR L cb w N GQ ~ w C~ to ~ N L O RCN POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner l ✓ r "-f Z2 Septic Tank Capacity C al ❑ NA Permit # Septic Tank Manufacturer ❑ NA 3ESIGN PARAMETERS Effluent Filter Manufacturer f Q ❑ NA Number of Bedrooms❑ NA Effluent Filter Model / ❑ NA Number of Public Facility Units WNA Pump Tank Capacity 3 0 at ❑ NA Estimated flow (average) al/day Pump Tank Manufacturer ❑ NA 1 Design flow (peak), (Estimated X 1.5) gal/day f' Pump Manufacturer ❑ NA Soil Application Rate aUda /ft2 Pump Model - 1J ❑ 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 (BOD5) 420 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODs) 530 mg/L -Grou nd ❑ I Ground (gravity) (pressurized) Total Suspended Solids (TSS) 530 mg/L NA 11 At-Grade ound Fecal Colifomt (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in dia. ❑ NA Other. ❑ NA Other. A Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent Other: ❑ NA IAINTENANCE SCHEDULE Service Event Service Frequency (Inspect condition of tank(s) At least once every: ? ❑ month(s) ears (Maximum 3 years) ❑ NA IIPump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA llnsPect dispersal oeil s ❑ month(s) At least once every: year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ear(s)s) ❑ NA nspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA year(s) 19ush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) ether. ❑ month(s) At least once every: NA ❑ year(s) ether. 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 wmbined 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 (X) or more of the tank volume, the entire contents of 1:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. 111 other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, land 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 ~Mthin 10 days of completion of any service event. Paine of START UP AND OPERATION products or other chemicals that For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting may impede the treatment process and/or damage the.dispersal cell(s). If high concentrations are detected have the contents of thO tank(s) rernoved by a septsge 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 normai 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 eftluenL To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to tt>ie 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 yehides over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of arty 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 POWT~: antibiotics; baby wipes; cigarette butts; -condoms; cotton swabs; degreasers; dental floss; diapers; disiinfeetants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting producN.s; 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 propetly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Cade:. • 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 property 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 filed with sail, 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: ,19~,A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm. The replacement area should be protected from disturbance and compaction and should not be infringed upon by requitled setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled 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 technologl/ 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 evaluaoon must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be instaliedl as a last resort to replace the failed POWTS. ❑ Mound and atV ade soil absorption systems may be rand Waicted 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 TANIf UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER E Name E 7> 1. Phone, Phone } SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone J - i I 7 C _ 1 Phone j ; _r5 Ct This doc urnent was dratted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(t) and 38IWI), (2) & (3), Wscnnsin Administrative Code. i' i j N ff • I : I P „~-T i _ 1~~±141 i it L~.L Li i IL p 00 p I I ' i I J I ~ I ~ ^ i S t, o S, Lu I I i Septic-Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer Pump Manufacturer Zr_ Tank Model Number Gas, v Pump Model Number S-=3 Total Tank Capacity Alarm Manufacturer Max. Bury Depth r" Alarm Model Number i ~ Switch Type ( I._. < Filter Manufacturer Total Dynamic Head (TDH) - Feet Filter Model Number levation Head EIL) Distal Pressure - Network Loss Minimum Pmnp performance Required Force Main Loss GPM! Ft TDH Total outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade sealed Watertight Securely Mounted With Lacking Device Weather-proof Junction Box - - Fitjished Grade - - 10 t ~ aa.. Vent Min. 12" Disconnect Above Grade Means With Vent Cap :rte . • i;:,<. Outlet Filter Inlet inlet Baffle - A t . . Switch Settings and Reserve Capacity Tank Volume = / GPI Weep ' B Hole Dimension, Inches Volume Gal. (reserve) At: IX. (alp) B 2 off Elevation C , .l (dose) C ` Ft Bottom < < (dead) D D > Elevation Total 4/ <a: • Ft T.In 2i i I; . a . s < + < + < < . < s <>< + r a < a <,<~ 'a: a'•' :i > > • ;•i > a ,i>i,i><>:'>: s >'aa•::+ ::i :a ;t;<; t,i s < a><,<>a,<~. : s~>+f : s > > 1 a > > > > a a a > > :<:><<<a a<a<aaa<:ea<<+<<+aaa<aa:::a>: a•aaaa _ . GENERAL INSTALLATION: The septic/dose tank is bedded and back filled m 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 as effective locking device adl and installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fist~gs, laid on stable soil to prevent settling or sagging.. The force maims sleeved with 47 Sch• 40 PVC to bridge the tank wi excavation and the .sleeve. is sealed. watertight. Electrical service complies #h NEC-300 and Comm 16-28. Page of 42105 U I :n TOTAL DYNAMIC HEAD/CAPACITY w HEADY CURVE PER MIND T E MODE L,B 555/57/59 EFFLUENT AND DEWATERiNG j 25 Model 53/55/57/59 20 6 rt. Meters j Gal. L trS. L \ 5 t .5 43 63 15 #51, 3.. 34- 29 ~ Q C 46 19 7 2 1 C Hecd 19.25 ft. (5.9m) o I \ 2 ~ar 5 - 3 15/16--6 5/32{ '/2 /2 NFT 0~ 1 U.S. GALLONS 30 40 50 3 5/16 LITERS 80 160 / 0 r e q l i FLCW PER MINUTE 009897 / 4 1/15 Variable level float switches available. Variable level long cycle systems available. Available with special cord lengths of 15', 25', 35' and 50'. I' ~JI Alarm systems available. L Duplex systems available. I 1 ~I r 1 3 3,/32 ' ~ SK858 Single Seal Control Selection Listings C Model Volts Phase Mode Amps Simplex Duplex CSA UL 1. Integral float operated mechanical switch no external control required. M53/55 & M57/59 115 1 Auto 9.7 1 - Y Y 2. Single piggyback-variable level float switch or double piggyback variable level N53/55 & N57/59 115 1 Non 9.7 2 36r-4-8,5 Y Y float switch. Refer to FM0477. BN53 115 1 Auto 9.7 Y Y 3. Mechanical alternator "M -Pak" 100072 or 100075. BE53/57 BN57 1 230 15 1 1 Auto 4 Auto 4.8 .7 1 i Y N Y~ 4. See FM0712 for correct model of Electrical Alternator. ' i, Y I D53/55 & D57/59 230 1 Auto 4.8 1 - -Y Y 5. Variable level control switch 10-0225 used as a control activator, with Electrical E53155 & E57/59 230 1 Non 4.8 2 -3,-r4 & 5 Y Y Alternator (3) or (4) float system. Single piggyback switch included. a caurioN For information on additional Zoeller products referto catalog on Piggyback Variable Level Float Switches, FM0477; .t F Electrical Altemator, FM0486; Mechanical Alternator, FM0495; Sump/Sewage Basins, FM0487; and Single Phase n e; e-, ' s e c a c v e r C: c Simplex Pump ControVAlarm Systems, FM0732. d .°e ~ ~"a•.O na, S J Y! For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. - MAIL TO. P.O. BOX 'S.217 f I Louisville, KY 40250 Manufacturers of. . Zo SHIP TO., 3649 Cane Run Road ~ i Louisville, KY 40211-1961 rLWITY PUMPS 9111CE lggg O - (502) 778-2731 1 (800) 928-PUMP - PUMP l0. _ _ _ http✓/www.zoelleccom FAX (501) 774-3624 0 Copyright 2002 Zoeller Co. All rights reserved. f QI LOT' 48 1 t LOT 47 I f 84,752 1.95 ASQE FT. i g 1.86 ACRES f 0 LOT 46 81,138 SC. FT. f 2.01 ACRES I I j : ~15' 87,527 SQ. FT. i I. a.i..... 1 I I f i , f _ - I way N89°45'02'E 723.42' _ - - _ - 33 _-~14L--- - 1 I i I I ' i LOT T9 LOT 78 i 8 8 S ' al _ $ LOT 80 8 2,00 ACRES CQ 2.00 N 2.00 ACRES 87,125 SO. FT. i w W 87,125 SQ. FT. r 87,125 SQ. FT. ; I i ' e15 • i i I sear - ` - EASEMENT 211.47 125,18 211.47 DRAINAGE M 21147 SB 45.05 33 33 N 9-45'02"E- 2877.36' I 11 I o I dC~4 9~ I d----- I el, o~ ~I - f 1 e5 :ETS ~ ST. CROIY COUNTY S P`I`IC", 'I ANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 0,A,ner/Buyer Kernon Bast Mailing Address948 LaBarge Rd., Hudson, W1 54016 Property Address _ (Verification required from Planning & Zoning Department for new construction.) _ CitylStateRoberts' WI Parcel Identification Number 018-2011-78-000 . _ _ LEGAL DESCRIPTION Property Location E i$ , N 'f4 , Sec. 30 T 29 N R _ W, Town of Hammond Subdivision Plat:Emerald Acres 1 st Addition Lot 78 Certified Survey Map Volume Page # Warranty Deed # (before 2007)Volume~_.~ Pale Spec house Uyesolo Lot lines identifiable Elyes0no 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 tite 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 §SI'S. 3$3.52(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 113 full of sludge. Iiwe, 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 ofNatural Resources. State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County planning, & ;Coning Department within 30 d ys of the three year expiration date. llwe certify that all statements on this for n are true to the best of myJour knowledge. Ilwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 3 9 18 SIGNATU E C)F 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 frorn the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. 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Please print all lot venaaflott. tev ed by pale Personal In/onnMton you provide may be used la sec dart' pu~~o~ I,'pM~ L~ nr)). a Z ProperlyOwrner CRQIX~%~ I 2 C kUv A St L4 S~. pFFi tt! v4 s 30 r 29 N R f7 teG Property Owners Mailing Address Lot # pluck W. Nanre or CSMff ST City Slate ZIP Code Plume Number ❑ City ❑ villaye (Eftown Nearest Road d I to i ( 7 ew construction Use: esidential / Number ut bedrocxns Ctx1e derived desiyn Ilow tale _~PS--_ GPD ❑ Replacement ❑ Public or commercial - Describe: j Parent inelerfal - Flood Plain elevation ii apirltc:able Game! ic mmerg comments Sy S~Q 6Y` I Q J, YQ'z t~ d ( _ . Q arrd eounernlations: / a t..N-C ( 5 r-4- t-C -to C" So-►ti S s Del-sr t~, Zeo~ Boing # ❑ Boiny -f t I [ pit Gnuund surface elev. it. UepUn to INnlliny factor _l In._ _ Sol Appfica lion Rate i (L Horizon UepUn Dominant Color Redox Description Texture Sbucaure Consisiwrce l3ounxlary RIMAS GPD/If In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sir. 'Elf#1 'Eff#2 J~ t I3 -.5;( 2 nn~G7 -1 __5 -3 ~,yM, Si C1 2ms5~L 3- f g z 5 O_ - c, '43 -j Q w - - Boring # ❑ Boring ~ FZ1 -7 Pit Ground surface elev. ~L4 y it. Dept Igniting lac i ~ - in. Sol Application Rate Horizon DepUr Daninard Color Redox Description Texture Buie Consistence Boundary Roots GPD/le in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sir. _ 'EII81 'Eff#2 I C?-I l~ 3 S( I Z rr-)--bc c~_ l v . FJ 4 la g 12 s o Ir Effluent 01 = 800> 30 < 220 ng/L mid TSS >30 < 150 rrrg/L ' E errt #2 BUU < 30 mg/L and TSS < 30 nrg/L CST Nana (Please Print) - - tune CST Nunber Address Date Evaluation Conducted Ielephorre Nurnber -5)~ -7!p4 i Page Z.-ul Property Owner Parcel ID N ✓ I Boling # ❑ Boring _ elev. it. Depth to Gnrilorg factor - in. It Ground surface a oi n 1 licatiar Rate Ilorizon Depth DOminantColor RedoxDescription Texture SUUdme Consistence Ouurnlary 'EI(1tGPDR'Eg#2 in. Munscd Qu. Sz. Cart- Cubr _ Gr. Sz. Sh. l o- 2 l ( sb~ _ 5 5 -ion -5 t Boring # Bwigg r-f7 U Pit Ground suface elev. it. Depth to limitiny taGur in. catlon Rate Florizar Depth Dominarrt Color Redox Description Texture Slrudme Cunsislerrce Buurrdary R-IS DIfF In. Mtmsell On. Sz. Cont- Cobr Gr. Sz. Sh. 'ERN2 ing N F1 Boling F Bor Ground surface elev. It. Depth to lirnitiny factor ❑ Pit _ Sol n icaGm Rate Horizon Depth Dominant Color Redox Description Texture Structure Goosislanre Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. S7- Sh. Effluent #1 = BODs> 30 < 220 rnglL and TSS >30 < 150 nrgfi- ' Elitlent N2 = BODS< 3U mgtL and TSS <30 nrglL The Vepactment of Commerce is an equal opportunity service provider and employer. I f yuu need assistance to access services or need material in am alternate fumiat, please contact the department at 608-266-3151 or'ITY 609-264-8777. SRD-pfO(R.0U01r1 I'AGe3 t)I_ ►.Orr~ ►.r.c~n►. ►>ia~:►i►►'ru~r~~:,~~ i~•►µ~►~a,<.;~ I~Z~.rr,lt(Z_I;t,ni.✓ NAME: s~~ - ?g _ ELEVATION: Bfvl I DESCRIPTION:-- i-P- O7~-( Pa Ive.-- - BM 2 CLEVA'I [ON: C'-~a - - BM 2 DESCRIPI'R N: C- SYSTEM ELF VA Fl t1: - -~d-- SYSI'GM'I'l'I'I::____i - ' d Vol, ~l 1 ~ v Dct:A Act SIGNATURE: , _ UAlF: --7-: /F ° !