HomeMy WebLinkAbout018-1090-49-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
600366
GENERAL INFORMATION (ATTACH TO PERMIT) 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:
Thomas & Tanya Graham TOWN OF HAMMOND 018-1090-49-000
CST BM Elev: Insp. BM Elev: BM Description: ~ Section/Town/Range/Map No:
166,3-7 1 l Ca j4..., 16.29.17.714
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM C-, OW 12,3 /46,30
Aeration / Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Cie) Dt Bottom
Dosing 266 3 Header/Man. 7,15 • 3Z
Aeration Dist. Pipe 0/1 'S
401 ?Z •-+-7
1-7
Holding Bot. System Z } 7
Final Grade Y
PUMP/SIPHON INFORMATION .:s cir. 37
Manufacturer Demand St Cover
GPM Z• -6
Model Number
a~u2. Z y 3• *-r 7
TDH Lift . tion Loss System TDH Ft DA- /,3 "ll 3.5- 7
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trend PIT DIMENSIONS No. Of Pit` Inside Di` . Liquid Depth
DIMENSIONS 3 {0 -l 1 few
SETBACK SYSTEM TO t P/L cJBLDG WEElL'LI~U LAKE/STREAM LEACHING Manufacturer
INFORMATION Type Of Syste CHAMBER OR A
G z14 /63 /37 . 1 A J UNIT Model Nu _ r: `
r NT
DISTRIBUTION SYSTEM 15,~ 4-
Header/Manifold ( Distribution x Hole Siz x Hole Spacing Vent JA~ir Intike
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 Z Bed[Trench Edges Topsoil
Yes No E-1, Yes E] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
y~
Location: 967 176TH ST LDc4. cr
1.) Alt BM Description = IIN~~4~
c
2.) Bldg sewer length = / VCAJQ~ 1 ^-;4 ~t
- amount of cover = 1 Al
Plan revision Required? ❑ Yes No 5 -5 If %
Use other side for additional information. /
SBD-671 0 (R.3/97) Date Insepctor's gnature Cert. No.
County
Safety and Buildings Division
K 201 W. Washington Ave,, P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
O Madison, Wl 53707-7162
00 3 (40
Sanitary Permit Applic I State Transaction Number
in accordance with SPS 383.21(2), Wis. Adm Code, submission of this form to the appropriate governmental unit / h
is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if differen~r?4-7 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. /
Jpkt
L Application Information - Please Print All oration
Parcel #
Propery Owner's Name Of`~ I
Property tO er s Mailing Address I Property Location ] . 11
-71 Ll
l"l T 1 Govt Lot
~ ~ ) 1
City, ~tAte Zip Code Phone Number t' t j Section
i-
irc on
II. ype of Building (check all that apply) Lot #
Subdivision Name
C~3D I I
2 Family Dwelling-Number of Bcdroo
,
~a1c.Gme Block# c.. arc i
El Pubiic/Cotnmercial - Describe Use ❑ City of
CSM Number ❑ Village of
❑ State Owned -Describe Us _
3 Xz.; of 117-1
III. Type of Permit: (Check ly one b x on line A. Complete line B. if applicable) p~Q~ X
A. .r .
Q l~ew System acement System ❑ Treatment/Holding Tank Replacement Only C7 Other edification to Existing System (explain)
Lis Prev us Permit Number and Date Issued '0V
B- ❑ Permit Renewal ❑ Permit Revision El Change of Plumber 11 Permit Transfer to New f
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that apply)
'F34Qn-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank er ispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersai/Treat ent Area Information: 1 ' sZ
Des- Flow (gpd) Design Soil Application R dsf) Dispersal Area Required (s 13 ~A a~Pro~posedr(s/f) System Elevation~ ,}57 ®/f
eq.
VL Tank Info Capacity in Total # of an Y
Gallons GaIIOIIS Units ~itf I D °
New Tanks Existing Tank v"V F • o m
- a. U cn v cc
i
Septic or Holding Tank
Dosing Chamber j
VII. Responsibility Statement- I, undersigned, assume risibility for installation of the POWTS shown on the attached plans.
Plumber' ame (Print) Plumb Knatuk (MP/MPRS Number Business Phone Number,
Plumbers Address (Street, City, State, Zip Code
. "Ill
YE4
ountv/De artment Use Only -I
ppmved ❑ Disapprove Permit Fee Date sued Issuin grit sip
ygS• Ze /8'
❑ en Reason for Denial
DL Coudi p easong,~or D'~approva]
1..S k ~tfN,cnt l a~rn4
rk,
U41Mt::ti Cull t'sttii dl) be. Ri_ ~C?S 1'~ ~R '4~
as per :"ar,39~. plan pto lidert by plumber. p
2. A ~+elb''! mitt tic r.K~irt.it'.r!
as per sppikxlbh C4A! / r(f:11aArV?.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1 ill inches in site
SBD-6398 (R. 11/11)
System PLOT PLAN
PROJECT Thomas Graham ADDRESS 967 176th St. Hammond Wi 54015
SW 1/4 NE 1/4S 16 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 91.0/90.8/90.6 4' below qrade DATE 4/18/18 BEDROOM 3
CONVENTIONAL X)(X CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 911 # of chambers 45
BENCHMARK V.R.P. Top of ST Manhole ASSUME ELEVATION 100.37' Filter Zabel A-100Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
440' Property Line
s~QIG _ 11A" = 1 ni
3% Slope
B-1
3-3' x 62' cells with >3' spacing
Vents 275'
Vent B-2
>6„ Quick4 Standard
of Cover Leaching Chamber 60 B-3
with 20.0 ft2 of Area
~55.6ftA2/pair of end caps
4' Long 12 Val
Grade at System Elevation
34"
140'
B.M.
60' 25' ST 0-01 Existing 3
0 Bedroom House
All piping shall be ASTM SDR 30/34, within
10' of tank, piping shall be ASTM F891
476' Property Line
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 4/18/18
Owner:Thomas Graham
Location: SW1/4 NE1/4 S 16 T29N,R17W 967 176th St. Hammond
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
r:
3. Chamber Cross Section
4-6. Maintanance and Conti ency Plan
7. Existing Septic tank for
Signature
License number #22690
v
System PLOT PLAN
PROJECT Thomas Graham ADDRESS 967 176th St. Hammond Wi 54015
SW 1/4 NE 1/4S 16 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 91.0/90.8/90.6 4' below grade 4/18/18 3
DATE BEDROOM
CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK
1000 gallons LIFT TANK SIZE DOSE TANK SIZE
MOUND SEPTIC TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 911 # of chambers 45
BENCHMARK V.R.P. Top of ST Manhole ASSUME ELEVATION 100.37' Filter Zabel A-100Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
440' Property Line
Scale = 1/4" = 10'
3% Slope
B-1
3-3' x 62' cells with >3' spacing
Vents 275'
B-2
Lent
>6„ ick4 Standard
of Cover aching Chamber 60
' B-3
h 20.0 ft2 of Area
ft^2/pair of end caps
4' LonVal
34" Grade at System Elevation
140'
r B.M.
ST 60' 25' ST
Existing 3
Bedroom House
All piping shall be ASTM SDR 30/34, within
10' of tank, piping shall be ASTM F891
476' Property Line
Cross Section of Quick 4 Standard Leaching Chamber
Typical cross section for 2 of 3 cells
Quick 4 Standard
Leaching Chamber with
20.0 ft2 of Area per
Chamber 5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 95.0'
Vent A CI
rade Vent
4' 4" 4'
,A ~-'30/34 Septic Tank
4' Long 1 5' 4' Long V, Grade at System Elevation
34" Grade at System Elevation 34"
I
Spacing 5'
3-3' X 62' Cells
Observation tubeNent
Same on other end To be located on end of Cells
A
B
System elevations: C
A-91.0'
B-90.8'
C-90.6'
18 chambers per cell
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
)ESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms O NA Effluent Filter Model ❑ NA
Number of Public Facility Units 6NA Pump Tank Capacity al NA
j Estimated flow (average) ? al/day Pump Tank Manufacturer NA
i Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA
Soil Application Rate Model NA
Pump
aUda /fe
i Standard Influent/Effluent Quality Monthly average's Pretreatment Unit NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 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 ❑ In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/LNA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other:
iMaximum Effluent Particle Size Ya in dia. NA Other. ❑ NA
(A Other: ❑
"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: earts(s) (Maximum 3 years) ❑ NA
(.Pump out contents of tank(s) When combined sludge and scum equals one-third (Ya) of tank volume ❑ NA
linspect dispersal cell(s) At least once every: 0 month(s) (Maximum 3 years) ❑ NA
ear(s)
Clean effluent filter At least once every: ear(s)s) ❑ NA
I nspect pump, pump controls & alarm At least once every: ❑ month(s) NA
❑ year(s)
I:lush laterals and pressure test At least once every: ❑ month(s) NA
❑ year(s)
ether. At least once every: ❑ month(s) NA
❑ year(s)
ether.
11 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: aster
[Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must
iinclude a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the vol a 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
I-egulaitory authority.
When the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of
j:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
I0,11 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.
i:k service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
Page of
START UP AND OPERATION Products Or Other chemicals t*t
For new construction, prior to use of the POWTS check treatment tank{s} for the presence of painting are detected have the contents of thi;
the treatment process and/or damage the dispersal cell(s). If high concentrations
may impede
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. power is restored the excess ~ will ble
During power outages pump tanks may frill above normal highwater levels. When p is backup or surface d of effluent.
rig operator prior to restoring Power l tide
discharged to the dispersal ell(s) in one Large dose, overloading the cell(s) and may result in
To avoid this situation have the contents of the pump tank removed by a Septage O the pump contor to restore normal levels
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating
within the pump tank. disturb or compact, the area within
Do not drive or park hicimanover tanks and d or at-grade soil absorption area not drive or park over, or otherv+~
15 feet down slope any improve the perforrnanc~ and prolong the ~ of the pOWT~:
Reduction or elimination of the foiice+ing from the wastewater stream may ~l diapers; disvifectants; fat,; foundation drain
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; medications; oil; painting f our P~~~
(sump pump) water, fruit and vegetable peelings; gasotirre; grease; herbicides; meat scraps;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT shall betaken to insure that the system is propefilY
When the POWTS fails and/or is permanently taken out of service the following steps
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:.
• Air 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 fined with soil,
gravel or another inert solid material.
CONTINGENCY PLAN code compGnt
If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm•
should not be infringed upon by requioed
The replacement area should be protected from disturbance and compaction and ~ the replacement area will result in the need
setbacks from en site and proposed structure, lot lines and wells. cement lam to Replacement systems must comply with the nite$ in
for a new soil and d site evaluation to establish a suitable replacement
at that time. advances in POWTS technologlt a
suitable replacement area is not available due to setback and/or soil limitations. Barring
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 son 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. removal of the bionrat at the infiltrative
❑ Mound and at-grade soil absorption systems may be reconstructed in place following
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 ANWOR INSUFFICIENT OXYGEN. DO NOT
RCUM TANCES. DEATH MAY CULT. RESCUE O~ A
ENTER A SEPTIC, PUMP OR OTHER TREATMENT AY E TANK UNDER ANY DIFFICULT
O IMPOSSIBLE.
R CI
PERSON FROM THE INTERIOR OF A TAN
ADDITIONAL COMMENTS
t
POWTS INSTALLER POWTS MAINTAINER
c,
v
Name Nam
e_-~ . ~ 7 ~ I
t.,
I - Phone
Phone
SEPTAGE SERVICING OPERATOR PUM R LOCAL REGULATORY AUTHORITY
Name
Phone
Administrative Code.
This doerrment was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383..54(1), (2) & (3), W►sc onsin
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
`'his is to certify that I have inspected the septic tank presently
serving the residence located at:
Section T N, R W, Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced:
`id flow back occur from absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time:
gallons minutes
'apacity: G
Construction: Prefab Concrete Steel 0 her
Manufacturer: (If known):
Age /on k (If known)
( ) (Name) Please print
C l
(Title} (License Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding sting septic tank
condition, I certify that the tank to the bes my knowledge will
conform to the requirements of ILHR 83, Wis m. Code (except for
inspection opening er outlet baffle).
ti.
Nam
Signature MP/MPRS~%f,'`~
STD CROIX COUNTY
SEPTIC TANK MAINTENANCE t',GREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address °?i~. JJ
{
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State _ Parcel Identification Nur aber /0'V
LEGAL DESCRIPTION
Property LocatioD5'~t r/y , /'✓l_ '/a Sec. , T _N R~ W, own of ~ I rwL rL
/
Subdivision ` Lit
b f , YY
j I C-/ 1119
Certified Survey Map , Volume _ , Page # _ -
Warranty Deed # Volume Page #
Spec house ye no Lot lines identifiab yes } 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, ii' 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 wasl:e disposal system Owner maintenance
responsibilities are specified in §Comm. 83.52(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.
1/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 Commerce 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.
1/we certify that all statements o this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
grope scribed above, by virtue of a rranty deed recorded in Register of Deeds Office.
N er of b rooms
i1 SIGNAI`URE 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. 08/05)
T----,NORTH QUARTER CORNER
v' SECTION 16 - FOUND
ALUMINUM MONUMENT NOTE: ALL BUILDINGS
IN PROXIMITY WITH OF
A HAVE A FINISHED FL O(
ELEVATION NOT LESS '
ABOVE THE HIGH WATEI
m
- UNPL ATTED LANDS
n1
J A .
1 ~
a DRAINAGE AREA N89® 15' 4,5"E 650. 00'
120. 00' 440. 00' 90.(
FALLS ON-/ DRAINAGE AREA
NORTHISOUTH
FENCE LINE HM[~ 101.1
100-YR ~
LOT 19
N LOT 49
N 2. 48 A S a
108, 160 SO. FT.
o~
s144
L OT 50
LOT 48 w ti° 3. 14 ACRE;
136,692 SO.
2.43 ACRES
105,871 SO. FT.
.2
R1
L OT 18 vs ® M~•Z~
e
, e
588.2'5° 24°E 243.68" 1i 12
e < i
e ~
? w p J~• ee •
O
g ie
o LOT 47 e~
cn
' 3.62 ACRES
Safety and Buildings division- County -
201 W. Washington Ave., P.O. Box 7162 > & f -v 1
Visconsin Madison, WI 53707 - 7162 Site Address
Department of Commerce &7 1-7&
SmAtau Permit Apphcahon Sanitary Permit Number
2
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 40
may be used for secondary Purposes Privacy Law, s15. 1 m ❑ Check if Revision 3
1. Application Information - Please Prh d Ali Information State Plan I.D. Number /
Prope Owner's Name Parcel Number
g W IZI&M-suvi
Property Owner's Mailift Address Property Location 7 /
1v 81) a lJ
City, State Zip Code pone ~Iatnbe2 I.ot Block Number
j` r it ; t Subdivision Name CSM Number
H. Type of Building (check all that apply) 2 ' 0 T l i), ity
gh or 2 Family Dwelling - Number of Bedrooms ✓ X f illage-
OC)UNry ownship
Public/Commercial -Describe Use rDT
I
❑ State Owned o~ Nearest Rook
-7z) "5
M. Type of Permit: (Check only one box on line A (numbering w:henie-for use). Complete line B if applicable)
A. 1 jo New ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use
stem Tank Only System
B. ❑ Check. if Sanitary Female Previously Issued Permit Number Dace Issued
IV. Type of Permit: (Check all that apply)(munbering scheme is for internal use)
44 Non -Pressurized In-Ground ✓ 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In-Ground 4111 Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
❑ '
45 ❑ At-Grade 46 11 Aerobic Treatment Unit 49 ❑ Recirculamig 30 Other
' LaW
V. ent Area Information:
eaten K
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required sed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation
4 11 'L-7 Iva d
SD 5-75'- Il Z - 0 t: 9r,bt-
VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New pristine
Tanks Tanta
ant
Dosing Chamber O~
pesos.
VII. Responsibility Statement- I, the assume fa lnataBation of the POW15 shown ou the W.& M
i P7r-, 's Name (Print) a Sigmmpue MP/MI%S Number Business Phone Number
.id L Z,Z-
Plumber's Address (Street, City. State, )
e-" 02 -70 f *7 IN6
/DUse Onkr
Permit Fee includes Groundwater Date Issued Signature (No Stamps)
ved Sanitary
Surcharge Fee)
Frov2
iven Initial Adverse - l 1 L1 n
tad
M Car"ons of ApprovaUReasam for INsapproval
1. Effluent filter to be installed and maintained per manufacturer's recommendations.
2. Floodplain mapping = Zone "C"
3. All setbacks to, system and residential structure must meet applicable code requirements.
4. Well setbacks to be maintained per NR 811 & 812.
Attaei eaesplete plw (m the County a*) tier the i as paper not I= dm 8M x U iwhm h dw
5~~,~~`~' ~+L`~.~3 p'rb~/iiti)~ 1Y~ •'''r~t~ tN.taR(~GGe G`.rkinc..ye ci,rcc~ .
;SBD-6398;(RS ej.~'r•;r~~: 1-,t -
Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
raisin
nd Building Division Sanitary Permit No:
INSPECTION REPORT 399465
GENERAL NFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal informabun 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:
Robinson Jeffrey Hammond Township 018-1090-49-000
CST BM Elev: Insp. BM Elev: BM Description:
0/ 0 ' T vtaJ 30o ~aS+ lod-l:.w
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic Benchmark
2,W (p2.4too-0
Dosing Alt. BM I clog l/ fZ(
- r 3.0
Aeration Idg. Sewer .D S
Holding St/Ht Inlet
.3 Y..
S
St/Ht Outlet
Q . q
TANK SETBACK INFORMATION 44 -2
TANK TO P/L WELL BLDG. Vent to Air In ke ROAD Dt Inlet
Septic f / I---- Dt Bottom
Dosing G f_ Header/Man.
Aeration J Dist. Pipe
Holding Bot ,System /
~L tl.~ 0 -
Final Grade
PUMP/SIPHON INFORMATION 1S
Manufacturer and St C er
GP 2-4 -z-~b-~A Y ,3
Model umber
i
i
DH Lift Friction ss System Head TD Ft
Fo ngth Dist. to Well
SOIL ABSORPTION SYSTEM `k- BEDrrRENCH Width / Length it No. Of Trenches PR DIM S No. Of Pits Inside Die. Liquid Depth
DIMENSIONS 3 S.
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING yt~ctu "r /'r
INFORMATION Typ?p System: f HAMBER OR G m~Jh T7
DISTRIBUTION SYSTEM 2nd ~il:Lr. °I
Header/Manifpld Distribution If x Hole Size Ix Hole Spacing 'UVen!~b Air in
r Pipe( s) G
Length Dia_[J {L_ Length Dia pC~ D 1 '
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded Mulched
BedlTrench Center Bed/Trench Edges Topsoil Yes No Yes [W No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:__~ /_q-2-- Inspection #2: / /
Location: 967 176th Hammond, WI 54015 (SW 1/4 NE 1/416 T29N R17W) Pheasant Hills 1st addn. Pafjl~o: 1 217.714
~p eyed Srw~Tm•.7~' /S/~y~,~~'~
1.) Alt BM Description = y 6
Corr
2.) Bldg sewer length
- amount of cover
Plan revision Required? Yes ® No
Use other side for additional information.
Date Insepctor's Sig ture Cert. No.
SBD-6710 (R3197)
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of
Division of Safely and Buildings
in accordance with Cam 85, WIS. Adm. Code county -5 Yo
Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Man must
include but not Umited to: vertical and horizontal reference point (BM), dkection and Parcel I.D.
'~UV
Percent slope. wale or dimensions, north arrow, and location and distance to nearest road 010I a'
Please print all infWnavop.. Reviewed by , I Data Personal irdorr WhOn you provide may be used for ae00ndary PmPOSM(Pdvacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Q t Q n S G Govt. Lot S c V 1/4 j- 1/4 S /(j T N R/ E (or)Q
Property Owner's Mailing Address Lot #p Block # Subd. Name or CSM#
(t U Q~~ Li7ry
City State Zip Code Phone Number ❑ Ctty ❑ Village O Town Nearest Road
C~; New Constriction Use: Residential / Number of bedr=M 3 - Y Cade derived design flow rate O O GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material 7111 Flood Plain elevation if a I V ft.
General comments Sys{{M f I C L) , 70 ~10
and recommendations. JUL 0 2 2002
ST- C"N'OIX COUNTY
ZONI
Fl Bari # ❑ Boring
pi( Ground surface elev. O ft Depth to limiting factor O In.
Sa'1 Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsefl Qu. Sz. Cant Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Z i~ l~ lie, ,5 - ms kill
F Borkv# ° Baft
❑ pit Ground surface elev. n Depth to limiting factor in. Soo Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in_ Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Z Ip~ / S~ Zm Yn P s - S
e II.
' Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOOS < 30 mg/t. and TSS < 30 mg&
CST Name (Please Print) - - tore CST Number
Et S~ 2
Address / Date Evaluation Conducted Telephone Number
iIS- zy;;?
i
I
II
Property Owner (oh 61 SC h Parcel ID # paw of
° Boring
F-51 surface elev. S 3C~ ft Depth to Ifmilins factor ICC~ in. Sofl Application Rate
® pit Ground
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Etf#2
-~Z 1CZ S, ~u r c S 1 s
Z ► Z n / - ~L zrnS6~ ~s l v S;
3o-i l0 In O m l - -
❑ Boring # ° Boring
❑ Pit Ground surface elev. ft. Depth to Smiting factor in. Sob Application Rate
Horizon Depth Domeiard Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Minsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Etf#2
i
it
i
F-1 Bourg # ° ❑ Pit 9
Gn~und surface elev. R Depth to ferdf&ig factor in.
Soil Application Rate
Horizon Depth Dortnrant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Etf#1 'Eft#2
I
I
i
Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < 150 rng - ' Effluent #2 = BODS < 30 mg/L and TSS < 30 nv&
I
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material m an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SII6E370 M071M
r
PAGE-3 OF,3
4,S J(o T Z~,N,R, / E(or)i
N"MEh ' s n OT# LEGAL DESCRIPTION y
I
SCALE: I"=
o
BM I ELEVATION /(X1.
BM I DFSCRIPTION_AZ/ / /61" a- ~ r-e f fi
BM 2 ELEVATION O
SPC
BM 2 DESCRIPTION a' 1 n C o Lc -c
SYSTEM ELEVATION / 6/" /
SYSTEM TYPE ~ ~/-e j, R'OI Gl~
CONTOUR ELEVATION IS . S c 1 ~f y, -S
i
I
l
Z
S NATURE DATE
T.L. Sinz Plumbing Inc.
E5609 708th Ave. Phone: (715) 235-2644
Menomonie, WI 54751 Fax: (715) 235-2592
s f o,S rv? www.tlsinipILIMhIIIg.C()M
(e d 0 Q v►~(~ LA-riE dogrA
1t1~ L►~ u~o Wt N SSo~ 3
r14W.
DoT q9
oY II
~inS~Allu~ Mti ii
X21 ~ ~ x 68 zS ~ 'X
~yil3 2
~i
~ OV
4
q1i 58"icf- V\
~ ~ ~ - loo
X1-0 E
NM L I vl 8 Co ~f a ~ ~vu~.? u~
D 3 R£0 Ifvr~WT1" love
gl~ ` L S`~ tQo' 1C17 r,~ 7.x/Z-
A-100
iJVYi L 10 wood ZA-- 1t 1~rlte.C