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HomeMy WebLinkAbout026-1013-70-120 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 605007 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Michael Knudtson TOWN OF RICHMOND 026-1013-70-120 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 14 11 ~ .6 M 1 04.30.18.48E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV. Septic Benchmark Wieser' 3 /Z50 I.55 163. /a6 I df- s Alt. BM ra-,-, Jt.~. 9's 16/• 5 r^• re Aeration Bldg. Sewer Z e v, 24 Holding St/Ht Inlet s, q7. TANK SETBACK INFORMATION St/Ht Outlet G•Z 5`7• TANK TO P/L' A WELL BLDG. Vent to r Inta a ROAD Dt Inlet 4 O aA. Dt Bottom Septic Z-7 /Z41 Dosing Header/Man. 4 yw C. 7 Aeration - Dist. Pipe 4. 9 Holding Bot. System 7.77 75• 7q CW- PUMP/SIPHON INFORMATION Final Grade Z .4 160 Manufacturer Demand St Cover a _ GPM i^j ~tti. 7g 161.5 Model Numberl- TDH Li Friction L ss Syste ad TD Ft Forcemain ia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of P~ Inside Dia. Liquid Depth DIMENSIONS 3 /60 .3 11'Lr~c.~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: cZ w INFORMATION CHAMBER OR G Typ Of System: f_ IV A UNIT Model Number: +tiv e.~`p b /V DISTRIBUTION SYSTEM /6 ~./6 0 = 30 ~Q Header/Manifold 'I Distribution IGO Ill Ix Hole Size ix Hole Spacing Vert t~ Intake Pipe(s) Length Dia Length , Dia Spacing SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only Depth of xx Seeded/Sodded xx Mulched Depth Over Depth Over -TT Bed/Trench Center / C Bed/Trench Edges psoil Yes E] No Yes E] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection # Location: 1128 174TH AVE 1.) Alt Description = , C 2.) Bldg g sewer length = - amount of cover = Z~ 3Q qatue ro 9-7 ~ ///Plan revision Required? ❑ Yes No 77 f -1 , ld Use other side for additional informs o n. Date 4 Insepctor' ignCert. No. v SBD-6710 (R.3/97) r D County Safety and Buildings Division St Croix 6 ' 4 1 20~$ 201 W. Washington Ave., P.O. Box 7162 MAY WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Madison St. Croix County ►Developmen anitary Permit Appli!ca on State T`ar'sa~i°RFNumber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this to t ~Jl-1' 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 ses in accordance with the Privacy Law, s. 15.04(1)(m , Stats. 1. Application Informatio lease Print All Information 'krl 174th ave New Richmond Property Owner's Name Parcel # Michael Knudtson 026-1013-70-120 Property Owner's Mailing Address Property Location r 3c; 2570 Mayfair Ave Govt. Lot City, State Zip Code Phone Number NW $W Section 4 White Bear Lake MN 551100 30 1611lrcleone) II. Type of Building (check all that apply) Lot # T _N; R EorW 1 or 2 Family Dwelling - Number of Bedrooms 4 3 Subdivision Name Qk W Block # ❑ Public/Commercial - Describe Use ❑ City of Jam ` CSM Number ❑ Village of Richmond Val El State Owned - Describe Use 4 N =/&C A w_ 11 Town of _3 &t6 III. Type of Permit: (Check only on box on line A. Complete line B i p licable)~ A. Iu cNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner C2- E/~, IV. Type of POWTS S stem/Com onent/Device: Check all that apply) 7- p~ ,KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank 7F Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Tre went Area Information: UA40"' 7' Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed ( System Elevation Q 600 .4 1500 1500 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units c 0 y u New Tanks Existing Tanks Polylock 525 p L a U v) rA u C7 w Septic or Holding Tank 1 2~ 0/W ~ ~ Jb ` Weiser XX Dosing Chamber {S~® VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's-Signatures MP/MPRS Number Business Phone Number Countryside Plumbing l r 664713 715-246-2660 Plumber's Address (Street, City, State, Zip Code) 321 Wisconsin Drive, New Richmond VIII. _Cwnty /De artment Use Onl A roved Pemmt Fee Date ssued Issuing ent Signatur )pp S 66 :Reason for De al -/t IX. ConditV4. asops for isapproval 1 tai k, ezAtJbvlt~'ip 126Gf ai1~}iarxsu crif ~mtst r. Its Pit ter ~p Pkn pl'or tided ; 4! $ Z e r.~ 2 M=tiles tti t1mu►lx r . Attach to complete plans for the system and submit to the Co!Yty only on paper not less than S 1/2 x 11 inches in size SBD-6398 (R. lI/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Michel Knutson Owner's Name: Michel Knutson Owner's Address: 2570 Mayfair Ave White Bear Lake MN 551100 Legal Description: NW 1/4, SW, Sec 4, T30N R18W Township: Richmond County: St. Criox Subdivision Name: Lot Number: Parcel ID Number: 026-1013-70-120 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: Countryside Plumbing License Number: 664713 Date: 05/11/2018 Phone Number (715) 246-2660 Signature ter ~ltia :na~.Jt~,s . r Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 S,Q F 3NIl HIND wOild 1S H1ZTT ■ ■ I a s v ■ c O d ' d w. a O t O Y ■ h C ~ ■ V C W > ■ C E I ` i Gl Y A 0 /Y71 PA D N V~1 O a° a v a o r^, ■ Y N 10 ~ u L, C ~ I N Q O • t14 • N N u E co N 2 - v _T a 3 ° O f i 1 ~ 0 o awoy posodojd m o ° ■ ~D ■ N Z O a W LJ u 0 2 U U < N Q to d ■ a 03 c ° o ■ ~ N ei > C E CL + 1 Q O O m a0 C p _N d O CD N CO E O CO O ,i N ■ ~a a a o . r CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Michel Knutson Owner's Name: Michel Knutson Owner's Address: 2570 Mayfair Ave White Bear Lake MN 551100 Legal Description: NW 1/4, SW, Sec 4, T30N RI 8W Township: Richmond County: St. Criox Subdivision Name: Lot Number: Parcel ID Number: 026-1013-70-120 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: Countryside Plumbing License Number: 664713 Date: 05/11/2018 Phone Number (715) 246-2660 Signature s~3Y►v'tf3 f Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.01Qb 7: 0 1p, alL :~.i +`itRt!t'~ ~;~te^~•ti.a age K~~eci4sn ItR .5; M '3NIl NUND WO H3 1S H1Zii ■ a I s c ~ v e d O I v w v o Y rl oo N C ~ ■ 0 m V. Q > ' O 2 t0 N QC ■ 01 u a ■ c - I LJ i ~ 41 M 0 N H ■ ■ q ~ I o ~ a d n r^, ■ NQ Y C N I M V L cl _Y O N E O ■ H u m m E co w O a I N 2- 0 a O ■ ■ O I ■ o ~ cli o awoy pasodoad I m z o Ln z N I Y 0 C CL W a J 2 u j O a+ _ a - a CL t0 O N u E a in to N O O I + O 00 i O d O C3 N O ~ -1 co m o] -1 to ■ a a 0 SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page L of 1 Project Name: 3 No. of Cells 10 Per Coll 3 ft Cell Width Total No of 30 100 It Cell Length 50 sq ft EISA Per Cell 3 ft Cell Spacing 1500 sq ft Total EISA i Manufacturer Model Lai Length EISA Rating Infiltrator EZ12031-1-5ft 5.0' 25.0 EZ1203H-101t 1wr 50.0 Gravelless Leaching Unit Manufacturer: INFILTRATOR Gravelless Leaching Unit Model: EZ1203H-10FT. Finished Grade 1096ft Typical Cross Section m- Observation Pipe with approved cap or vent Soil Backfill 12 In ._,;::::•r:::`.;:i:i:::a<.;: -Geotextile Fabric ~k_ft Infiltrative Surface 12 in E.. Limiting Factor ~ i In Slotted and Anchored Vent! i Observation Pipe with Cap •.....■■.rr..rr..rr~..riii...r....■■..■r.r.. r.. r....r.....u ....r.......■ Plumber/Designer Signature: License 225410 Date: MAY 11 TH 2018 i I MInc. Innovations in Precast Drainage Zabel PL-525 Effluent Filter & Wastewater Products A Division of Polylok Inc. PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: 1/16" Filtration Slots f • Rated for 10,000 GPD (gallons per day). Alarm Switch ~ 10 000 GPD (Optional) • 525 linear feet of 1/16" filtration. _ • Accepts 4" and 6" SCHD 40 pipe. Extensi n Handle • Built in gas deflector. • Automatic shut-off ball when filter is removed. Rated for • Alarm accessibility. E 10,000 GPD • Accepts PVC extension handle. PL-525 Installation: 4f k 525 Ideal for residential and commercial waste flows up to of 1 Linear Ft. 10,000 gallons per day (GPD). of 1/16` Filtration Slots i 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" 3. Glue the filter housing to the 4" or 6" outlet pipe. If i SCHD 40 pipe the filter is not centered under the access opening use a k Polylok Extend & Lok or piece of pipe to center filter. I i 4. Insert the PL-525 filter into its housing. Certified to 5. Replace and secure the septic tank cover. NSF/ANSI Standard 46 PL-525 Maintenance: i The PL-525 Effluent Filters will operate efficiently for I - several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, E the owner will be notified by an alarm when the filter Gas Deflector needs servicing. Servicing should be done by a certified septic tank pumper or installer. A omatic Shut-Off Ball 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. j 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all, solids fall back into septic tank. l 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. ; Outdoor ilt Alarm Extend & LoksM Polylok, Zabel & & Best filters accept Easily installs 7. Replace and secure septic tank cover. the SmartFilterO switch and alarm. into existing tanks. 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W w w Q o II > s 5 W O l l rl X cv F- I I w N Q w W ~ Z Q W cl: Q „98 CD2J 1036 SV Y z a POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of '2- FILE INFORMATION SYSTEM SPECIFICATIONS Owner Michel Knutson Septic Tank Capacity 1250 gal ❑ NA Permit f Septic Tank Manufacturer Weiser ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Polylock 525 ❑ NA Number of Bedrooms 4 ❑ NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units NA Pump Tank Capacity gal aNA Estimated flow (average) 600 gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) 858 al/day Pump Manufacturer NA Soil Application Rate 4 allda /ftZ Pump Modell NA Standard influent/Effluent Quality Monthly average` Pretreatment Unit )9 NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD6) 5220 mg/L 9; NA ❑ Mechanical Aeration ❑ Wetiand Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOO.) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L )2S NA ❑ At-Grade ❑ Mound Fe 1 r rf.. ..t e1 n4 f„lnn_1 ❑ D. L: C r, . ca o : "g° - -1 N- vin c,. Maximum Effluent Particle Size Ys in dia. )p NA Other: ❑ NA Other: NA Other: ❑ NA }Values typical tar domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: 3 year(s) El month( l (Maximum 3 years) ❑ NA ❑ Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) 3 ❑ year(g) (Maximum 3 years) ❑ NA Clean effluent filter At least once eve 13 month(s) 13 NA every: 1.1 13 year(s) Inspect pump., pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ monthts) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) 13 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 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 (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 512 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 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 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. T alua ' a o mg Cank be' a a.a flzogi8TIC FDZ'A' /'&-J Cfll~IS77zCISlDnJ ❑ 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 Countryside Plumbing & Heating Name Countryside Plumbing and Heating Phone 715-246-2660 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Powers Name s---, G ( 0 U L L~f N 2 jAI Phone 715-246-5738 Phone -7 40- tv 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. ,ER Page 3 of 3 ; . me-&#644,c l ~n a f. Brian Parnell Address / _ ,~v 4r 4 e CST 231314 .erv ; e l,.h ~ 6y1" S5~/7 Date_ 5/- 2 7-49 Benchmark 1 T6P 2 &C /DD, v Benchmark 2 r Soil Boring Suitable Area 1 40' Scale 0 e 2 - +F4:: F I0 ' I 0 TT-r S I -T L4-4- 77 ST. CROIX COUNTY SEPTIC TANK MAIN rENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM owner/Buyer Michel Knutson kAaili Mdress 2570 Mayfair Ave White Bear Lake MN 551100 Property Add 1128 174th ave _ (Verification required ftm Planning - AVmg Department for new construction.) city~ta New Richmond Parcel Ide tification Number 026-1013-70-120 LEGAL DESCREMON Location NW , SW sec. 4 . T 30 N R 18 w, Town of Richmond Subdivision Plat: , Lot # 3 Certified Survey Map # Volume , Page # Warranty Deed # (before 2007)Vohune . Page # Spec house Dyes Mko Lot lines identifiable Oyes❑no SYSTEM MAINTENANCE AND OWNER CERTQ CATION Improper use and maintenance ofyour 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 phardw 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 septle tank is less than 113 fag 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, heroin, as set by the Department of Safety And Professional Services and the Deparime t 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 wi 30 days of the three year expiration date. I/we certify that all statements on s form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a deed recorded in Register of Deeds Office. Numbrjr otbodroams T- - 512/ 18 IGNA OF~1P.IG (S} DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. zr 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 decd. (REV. 04/12) i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Michel Knutson Septic Tank Capacity 1250 al ❑ NA Permit # Septic Tank Manufacturer Weiser ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Polylock 525 ❑ NA Number of Bedrooms 4 ❑ NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units I:R NA Pump Tank Capacity al QNA Estimated flow (average) 600 gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) $5$ gal/day Pump Manufacturer NA Soil Application Rate 4 al/da /fts Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit )M NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODE) 5220 mg/L 03 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 (BODE) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L )M NA ❑ At-Grade ❑ Mound Fecal Coiiform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. )Q 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 every: 3 ❑ month(s) year(s) (Maximum 3 years) ❑ NA ❑ Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 11 month(s) ❑ year(s) (Ma)imum 3 Years) 13 NA Clean effluent filter At least once every: ❑ month(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm At least once eve ❑ month(s) ry' ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ 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 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 512 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. SHCE - 670.30 s 56U4:25 - 1,2. X18 t `3' 9.14 FRO" f-o IVD /~o1ir p ~ LOT I mam w !F DI&VE (7-YF M PG. 51 _ 8 VA" EAsr ulve- or I-off' i SHE N IX4 OF SW IX4 ~ M 139*58"2Z* E 450.00' 1~ Sep 77C Os 33-08 416.9 2 w • Lor 8 2 E 44:9.38' 416.92" 0 33.06 100" BLDG I C> TRACK t:3 C%j L K30 -Zow ° - E 89*56 22 - " E. 449.96 R 891-E 44'x.95 PE . 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Plan must include, but not limited b: ~d hmizortal refivence point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ao . Please print all information. ! bate Personal 6darmefion you pmt away be used for saeoudary purposes (Privacy Law. s. 15.04 (1) (m)l 7 ✓ Property Owner Property Location % c f Q e l A-/j cc f-ro .1 Govt Lot U) 19 5119 S T N R 10' S (or)© Property Owner's Mading Address 4i C` v e Lot # Block # Subd. Name or(SW //a 3- / 7Y city State Zip Code Plane Number ❑ City ❑ Village ®Tovvn Nearest Road ~Il. R,Cc 11t47I lit 5YOt7 ( ) Rlfchmo,7~ yf-'tau New Construction _ Ose_ 91 Residential i Number of bedrooms Code derived design flow rate D GPD ❑ Replacement ❑ Public or commercial - Describe. Parent material Cf C' (4L Flood Plain eieva if applicable N4 it General comments and recommendations: Bor" # ❑ sores F11 ® Pit Ground surface elev. M/ 6 ft Depth to tirrrtbM factor 9 in_ Sod Appk2fion Rate Horizon Depth Dominant Color Redox Desa"on Texture Stricture ;onssWice Boundary Roots GPD/ft 2 in. Mansell Qu. S7- Cont Color Gr. Sz. Sh 1 11#2 I 0-7 /0 /-X Ut 1114 L l/h l- AV4.1 G cv m Y 0. Z 7-15 MSbk MloF C C- 11n O'6 /5--2s 7,501f YI /VA msl fnjl~ c 64- 0, 6 6.8 Y 2s- 5'y S sV6 M4 S~ M7 k IWI C ef- l Or C/ 0,7 S Yy srR l 4 j jnS6k .Fr 0, y o. 12- Boring Boring # Boring - ~oJ © Pit Ground surface elev. Y' fL Depth to riming fay in. Z~ Sod Application Rate Horizon Depth Dominant Color Redox Description Texture _ Structure ruse Boundary Roots GPD/ft Z in. Mansell Qu. Sz. Cont Cow Gr. SZ Sh. 01 ff#2 1 0-7 /DYR 3/ /V~ L my c~- ZA 0, C/ 0, 6 Z 7-16 10M % /t//4 G ams6/C 12741 w Z m D, 6 D,8 3 l6-2y -7,rye`'/ SiZ ;2 n?j-A , cw /ryr o1 6 6, ? Effluent #1 = BOD > 30 1220 mg& arc TSS >30 < 150 mg& ' EMuett #2 = BOD < 30 nVL and TSS < 30 nVL CST Name (Please Prtt»t) ~ Signature CST Number I l 2 3 131 Address Date Evan Conducted Telephone Number e .Son, e riey-- 7/37- Z (17 3 ?,03 SBD-83-20 (RI 1/11) o Z Property Owner i ~ e / 1 /I Gc j'S' ~C Pare fD # O26- /0/-?- 76-/2a Page of 3 3 # ❑ ElodM > s pit Ground surface elev. ~ ` g ft Depth to krrfrlg factor / 9~ in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure :;on~ce Boundary Rotes GPD/ft ' in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. ` ff#2 0-6 /©A mU4,-- C w t o. 4/ 6. 2 6- /5- O % G carder I9~74, C,(,_ 2 rz Q. 6 ©~8 .7 1t-,Z3 7,srR V, M4 511z 2P7rA 1v~. c / rn o, d o1 g y z3- q8 ~'YR % S /msdk - , y 0,-7 Boring # ❑ Boring ❑ ❑ Pit Ground surface elev. fl. Depth to kniling factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure undary Roots GPD/ft 2 in. Munseell Qu. Sz. Cont. Color Gr. Sz Sh. ❑ Boring ° Boring ❑ Pit Grand surface elev. R. Depth to lirniting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture SMx*xe aonsistence Boundary Roots GPD/ft 2 in. Murnsell Qu. Sz. Corp Color Gr. Sz. Sh. ` ff#i = ft#2 = Effluent #1= BOD 5 > 30:5 220 nV& and TSS >30 < 150 mgA- ' Effluent #2 = BOD 5 30 mg& and TSS < 30 ffKA 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 departmern at 608-266-3151 or TTY through Relay. SBD433o(Ri I/I I) Property owner / /1 i /C e / l /1 Gc f s o~C Parcel tD # O 2G - /0/-?- M- /Z d Page Z of 3 F Boring* ❑ Bay 5 2 Pit Ground surface elev. • g ft_ Depth to TaN&V faces / ?If irti Sod Appfication Rate Horizon Depth Dominant Color Redox Description Texture Structure :G~ce Boundary Roots GPDift ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sts 0-6 n7c w 6, ~ 3 ~s- z3 7.sYR .S/`,z r~s rn c w rn 0, 0, g L( Z3- 79 EY9 % A S IMS~k IV~A' - - d, y D. F-I ❑ Pit Ground surface elev. ft Depth to knifing factor in. Sos ' ucabon state Horizon Depth Dominant Color Redox Description Texture Structure Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. * ff#2 i I Boring # ❑ Boren ~~j] ❑ pit G"mW surface elev. tt. Depth to kniti sg fac for in. Sod lication Rate Horizon Depth Dominant Color Redox Dion Texture Structure onsistence Boundary Roots GPD/ft in. Munsell OLL Sz. Cont_ Color Gr. Sz. SK -tW2 * IItluent #1= BOD , > 30:5 22D mg& and TSS >30 < 150 mg/L * Effluent 92 = BOD 5 < 30 mg/L and TSS < 3o mg/1. 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. SBD4330 (R31ni 1) OWNER Page 3 of 3 Name Brian Parnell Address 112,?- IZ~~ 4' & e CST 231314 /~~cv / !rC -e &,,T Date Benchmark 1 2;2 vc l a /iL• App'v A b ® Benchmark 2 fiO~P 2 _ Soil Boring T~ Suitable Area F = 40' Scale -j-~ 1_ I I- 1 I I ~ o ► i I I i ! ! 1 P ce 2 I l I t I ! 1 I I 11 i; I I f, 71f r--I I( -i~~~ I I I I ~ 1 I! i I I 1 ; ! I I l i l l i! f j i fjll !I - 13 f I i ~ I i t i l i I -T-;-- { D t I- # i t I~ I I I ( I I ~ ! f~~ ~ a l ! I I i I ! ! ! I{ i l l ~ I, j l s T_ I~ I I I I I I ! ! I I ! S _ ( ! 31 ! I ! I ~ I ( ! { I { aL. I - T-T { i I