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HomeMy WebLinkAbout022-1080-50-003 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) SAN-2018-048 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: Steve & Donna Licht TOWN OF KINNICKINNIC 022-1080-50-003 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 28.28.18.4381 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 SETBAC INFORMATION TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt M 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 x 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 xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ No Yes No COMMENTS: (Include code di crepencies, persons esent etc. B Ins a tion #1: nspection #2: Location: 1110 PINE RIDGE DR 1.) Alt BM Description = 2.) Bldg sewer length - amou t of cover obs r 5 0 ~-b L Plan revision Re wired? Yes o Use other side for additional information. Date Insepct Signatu Cert. No. SBD-6710 (R.3/97) 5/) - )c 18 - 0 ~q 9 v~tiy County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN ~Gp In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 P (715)386-4680 Fax(715)386-4686 Attach complete plans for the system on paper not less than 8-1 /2 x 11 inches in size. County Sanitary Permit # _G eck iLL.Pws previous application 5f~~1 _ Za►B--a~f S• 1. Application Information - Please Print all Information Location: Property Owner Name IVA/ G ~ 1 /4 /vej 1/4, Sec 1 e, V Q_" Doti f'l!~ T Z-g N, , R E (or a " Property Owner's Mailing Address Lot Number Block Number 61 e 2 City, State Zip Code Phone Numer Subdivision Name or CSM Number pert ~~t I( ~ 5--qcj -z z I Z - ` qO -71 L Village grown of ! ,IV 1 or 2 Family Dwelling - No. of Bedrooms: II Type of Building: (check one) Lumler(s) ❑ Public/Commercial (describe use): /I I ❑ State-owned Road eck only one box on line A. Check box on line B if applicable) f 9_ C 5 MA be,-A) 2 ❑ Reconnection 3.❑Non-plumbing 4. ❑ Rejuvenation II. TyF~J~R~ Sanitation ; Permit Number Date Issued B ) _State Sanitary Permit was previously issued Q.3 IV. Type of POWT System: (Check at apply) Non-pressurized In-ground ❑ Mound 24 in, suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment ea Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation U 3 -16,5-0 .sue VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non- umbing sanitation system. Plumber's Name (print) Plum ignra e (no sffmps): MP/MPRS No. Business Phone Number 101 Plumber's Address (Street, City, State, p Code) VIII. County Use Only ❑ Disapproved Sanitary Permit Fee Dat Issued Issui gent 7Sign5(NJ Approved Owner n IniUa arse 7!) 0 rmination IX. Con V tions of Approval/Reasons for Disapproval: L (f-A ~i b2s~wee,~..i L a oJ~-~e~V /~et►~ i is i-b I Rev: 8/05 ST CROIX COUNTY REPAIR SEPTIC TANK OUTLET PIPE REPLACEMENT FOR A THREE BEDROOM RESIDENCE Owner's Name Steven Litch 1110 Pine Ridge Drive River Falls, WI 54022 Located in the NW 1/4 of the NW 1/4 of Section 28, T28N, R18W. TOWN OF KINNICKINNIC ST CROIX COUNTY WI Parcel # 022-1080-50-003 Lot # 3 CSM 397708 V5/1487 INDEX Page 1 Index & Title Page 2 Asbuilt Elevations & repair scope Page 3 Septic tank certification Page 4 Septic tank maintenance agreement Page 5 Z Warranty deed Page' 6-1 CSM Page `7r1 Manual and Management plan Attachments: Permit file, adjacent property Soil test Prepared By Michael Rodewald 285 County Road SS River Falls WI, 54022 715-821-6229 MPRS 931384 Signature r 11 9er k TP yes ~i% l~ ir-.4-,e wrc.'~f 7h -r n/G Seg.. _ ;.~__`LGc a S-_- /s t3YC3 (S ~ ` ~3 ✓~i ..___.S t _ _~L~!!i'IKIf' TLF'~ _ Ae- I- k,7 ~x;sk .4f, t A- e lop V~ 7t a ~ ,9.5 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -5-M-& Lz}1T TOWNSHIP K~NR! ~xxtl%1,C SEC. T N-R W ADDRESS A-T ST. CROIX COUNTY, WISCONSIN i SUBDIVISION Am,?.,,, LOT LOT SIZE Igo. 1 of b•7~ PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM WELL 0 l"IOUS~ 6 S , o. II ~ 1 i31~ 7 , ! 4 ~'twt;~ ;v awl ioo , csd TTCM! Rcvao C xvq~~ N INDICATE ~ORTH ARROW BENCHMARK: Describe the vertical reference point used ;(:T3GYZ`C` ~AaG of ~LT_ y Elevation of vertical reference point: 100,01 Proposed slope at site: z,°fa SEPTIC TANK: Manufacturer: WSESGYt.- Liquid Capacity: 1LW GwciaN 1 Number of rings used: 2. Tank manhole cover elevation: q8.!S Tank Inlet Elevation: g5.4VI Tank Outlet Elevation: `14AS' Number of feet from nearest Road: Front,O Side 0 Rear, O 8 3-Q~~ feet From nearest property line Front,OSide,ORear,© feet Number of feet from: well building: 1-7',7 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SRF RFVFRSF STT1F 1 DFPAkTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.lS:-SQX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ' NW4,NWa,S28,T28N-R18W iU CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number (If assign etll Town, of Kinnickinnic ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Liberty Road NAME OF PERMIT HOLDERS JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Steve Licht Cou ty "TT" Apt. 7, Roberts, WT 54023 a~• - g 7 HE',. MARK (Permanent reference pant) DESCRIBE IF DIFFERENT FHOM P AN. PT. ELEV.: CST REF. PT. ELE V.. Name of Plumber: MP/M RSW No. County Sanitary Permit Number. Thom-s H. Cody 6 93 St. Croix 96039 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED'. 1 \C Sc~~ act r SCI RA qq e'5'Y ES ENO DYES 159NO FRESH BEDDING: IJV ~'IVENT pIA.. VENT MAT L.. fGH WATER NlJMBER OF . ROAD: `aoE ERTY WELL : BUILDING: IVENT R INLET. C, LA M FEET FROM 01 C ES 10 _r' YES >-4^0 NEAREST S3 _1 DOSING CHAMBER: MANUFACTURER ~IIEDDING'. ILIGUIDCAPACI TY PUMP MODEL. PUMP/SIPHON M ANUFACiUREH WARNING LABEL LOCKINGCOVEfl PROVIDED- PROVIDED: DYES ENO EYES LINO DYES ENO RESH 1PUM,A D CONTROLS OPERATIONAL NUMBER OF LINE PRNIOPERTY WELL BUILDNG AIR INLET GALLONS PER CYCLE: (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) _ DYES UNo NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at t edepth of Plowing PvarH DIAMETER MATERIAL AND MARKING -FORCE or excavation. (If soil can be rolled into a wire, construct on shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: JINSIDE CIA #PITS uoU- LENGT NO OF DISTR PIPE SPACING COVER DEPTH: $EDtTRENCH WIDTH V~ -y TRENCHES "l,0~ } MATERIAL! PIT DIMENSIONS lJ TO_ GRAVEL DEPTH FILL DEPTH DISTR. IPF DISTR PIPE DISTR. PIPE MATERIAL: NO. DI R. NUMBER OIF PROPERTY WELL. BUILDING: VENT FR ESH PIPES LINE. AIR INLET . 8ELOW PIPES ABOVE COVER Et EV INLET ELEV. END FEET FROM lD t 4.4D Q4f3~ a~ _ 4 NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope heck 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- eets the criteria for medium sand. TIONS MEASURED. DYES ENO SOIL COVER TE %TURE PERMANENT MARKERS OBSERVATION WELLS DYES NO DYES ENO SEEDED MULCHED DEPTH OVER TRENCH;BEO DEPTH OVER TR ENCHBEU DE TH OF TOPSOIL. SODDED CENTFR EDGES DYES LINO DYES ENO DYES NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER jNO1OF TRENCHES LATERALSPACING: GRAVEL DEPTH BELOW PIPF BED/TRENCH, WIDTH LENGTH DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.:.-. ELEV.: CIA, ELEV. PIPES: DI A.: 13 ,ELEVATION AN DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CO RECTLY DOVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS. I DYES ENO ❑ ES NO PROPERTY WELL: BUILDING: IV' LINE' COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. FEET F RROM FEET F O EYES ENO DYES ENO NEAREST LA J, A- 7 1 Iiu~ 44 37 D ELI Retain in county file for audit. Sketch System on Reverse Side. nTLE IGN TURF. Zoning Administrator DILHR SBD 6710 (R. 01/82) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 19-of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity gal ❑ NA Permit # Septic Tank Manufacturer 1-C../ ;r5 P,-Z ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ANA Number of Bedrooms ❑ NA Effluent Filter Model NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal o1NA Estimated flow (average) gal/day Pump Tank Manufacturer 2'~A Design flow (peak), (Estimated x 1.5) 1~~C-Ur gal/day Pump Manufacturer E NA Soil Application Rate gal/day/ftz Pump Model -E 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 (BODS) <_220 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 -fi6ln-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size %e in dia. 42<A Other: ❑ NA Other: 0 NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 ears) ❑ NA Inspect condition of tank(s) At least once every: `a .i,7-year(s) y Pump out contents of tank(s) When combined sludge and scum equals one-third (%3) of tank volume ❑ NA At least once ever 13 m ) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) , Y: year(g) (s) Clean effluent filter At least once every: El month(s) -ANA ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) OVA ❑ year(s) ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) C%-,NA Other: At least once every: 11 month(s) ❑ NA ❑ year(s) Other: ❑ 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 identity 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 (Y.) 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 <_12 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. START UP AND OPERATION Page T of 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 safety 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: 99ce A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback andior soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. Iv~ T aluati a o ding~ank bei a aie TfE~ IJ,~ ~h/5`-g(JcnD ❑ 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' A POWTS MAINTAINER Name ✓t r ~se 96-p 'J' 41) Name ye, Phone ~7 (S_ ~ Phone '715 - Z - ~ZC "i SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name fQ S T(v Name ST. ~l~ l OU /N ZDII~~~ Phone f _ L 5~ ~C'.Z Phone '7 / S- 3 e (O- (0 fcD 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. 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 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 property and safely abandoned in compliance with chapter Comm 63.33, 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 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 filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or,must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 1 ' r~ T v N aluati a Ming tank be i e ane t~2D{-liBTf~~ t'-D21.1✓ C~t~157'KCI~I[) ❑ 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 - rt"A-- POWTS MAINTAINER Name 14 tke- ~P J'T LG> Name /r k Phone ! 07- Z5-- oe)0 Phone -LL- *57- &/ZC' > SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name l2 S S~ CV Name S~ ~ ( N ( -QlJII Phone Phone This document was drafted in compliance with chapter Comm E3.22(2)(b)(1)Id)&(fl and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) Zz-/080---56-Ca- This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street addre1414, 16 ewe Q. u e l located at: (lr '/4, Section 2-8 , Town 18 N. Range W, Town of /<tA j , ~ kj N j, , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service ~ y Did flow back occur from absorption system? Yes No .k (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: e-1)6 6 Construction: Prefab Concrete Steel Other Manufacturer (if known): ett- Age of Tank (if known): /9g 7 Permit number (if known) l .3 q 1111e- A1,j- t ~,icens d Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS kl (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Steven M. Donna J. Licht Mailing Address 1110 Pine Ridge D. Property Address S a rn e (Verification required from Planning & Zoning Department for new construction.) rr~~ City/State River" Fads Parcel Identification Number 02G-1080-50-003 REGAL DESCRIPTION Property Location NW '/a NW /4 Sec. 28, T 28 N R 1 W,Town of Kinnickinnic Subdivision Plat:The Pines , Lot # 3 ~ C -7 ~ Certified Survey Map # 7d 8 , Volume , Page # 1487 /-1 Warranty Deed # 427760 (before 2007)Volume 784 Page #249 Spec house Dyes Elio 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 frill 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 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 warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNATURE OF APPLICANT(S) DATE '';'~*Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. M*~ 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) D YNT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUS)DUS>TR ~'RY, DIVISION LABOR AW P.O. BOX 7969 PERCOLATION TESTS (115) MADISON W 53707 HUMAN RELATIONS (H63.0911) & Chapter 145.045) LOC ION; SEC ION: TOWNSHI MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISIO NNAME: Tag N/R i$E (1 v--, 7~1 tak.l NIJ IC, 3 - CsM v~L S 1(4 Y? COUNTY: WNER U ER'S NAME: MAILING ADDRESS: C"Tl! ~•I-~' J°ru-r *F 7 s~~z3 ST-GZUix LlC>3~RZ S K)1. USE DATES OBSERVATIONS MADE NO. BE COM RCIALDESCRIPTION: fIc~7 IP D `~6CAT TESTS: Residence PIZ ~.elNew ❑Replace I i RATING: S- Site suitable for system U= Site unsuitable for system CONVE NT L: MOUND: NS ESSURE: YS (~41JTf~MJr ~ -f N H0LDINGZ ~f :RECOMMENDED SYSTEM: (optional) ®S El U ®S ❑U QJU V( ❑S Z~ `x ~l d' CO~y G)1`l? Ou/4L BET-) If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the tom, under s.H63.09(5)(b), indicate: C ~-1~SS Z Floodplain indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL - P H T R UNDWATER-P*iW1E9 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 1 ELEVATION OBSERVED S HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B NoUE '"Q~.sI o-8b bnI;s7S;7.z`Q>, ~s B- 3 It °19.11 > Q •-3 o it 3 g- s t B- a•b' 98.6 > 8.6' o•-~' It O JUN 291967, r ' PERCOLATION TESTS WICE T DEPTH- WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MI NUMBER INKS- AFTERSWELLING INTERVAL-MIN. PERIOD 1 R D PE ~T'I-• i L p- 1 S.~ ~ 1 3.0 CS S u 9 S• < 3 .3 P- S . P-- P- P- _ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 013 lTI f'u It R.-25Z LA-0- ( IJT FNc,E 91 }~I,AIf.~FI S-Z) 'IS SYSTEM ELEVATION ZL- q3. SO' ; - - -I - I -r r- r T ~ r i _ -7 0 I ~ ~ I~ I Y'7 f~ ZI - ~1~7 N S i II y G , _ i - T- i 11 I i I I i -T 3e ~ t - 31, r I U1 'q l rt b~ a"rM:l Bv1~Jl1N P I P S S - - - - - aV , • Cl .1 - -t- - - ~1.N5.7' ~t..9~.i'scrt~ 1"=Va' sEG ~ 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: f-~ZT'4vN~ L. 6 -z>s -e'7 ADDRESS: L,+ ap x 2 CERTIFICATION NUMBER: PHONE NUMBER (optional): L_L_Swo w s c G--)6 /3-y2S-0)1- CST SIGIG A~ os - ' DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DI LHR-SBD-6395 (R. 02/82) - OVER -