HomeMy WebLinkAbout030-2125-70-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 600340
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:
Pavel & Elena Miligoulo TOWN OF SAINT JOSEPH 030-2125-70-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
8 1 G5T 25.30.20.1021
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER 41,`.s CAPACITY STATION BS HI FS ELEV.
Septic r Z Benchmark g ~5
1 J ` Alt. BM r IW JQti. :1. 5 /40
Aeration Bldg. Sewer
5,a5 9/1 7, 7
Holding St/Ht Inlet • &5
TANK SETBACK INFORMATION SUHt Outlet 7,4
TANK TO P WELL BLDG. e Air take ROAD Dt Inlet
~OcJ ~ IIM
Septic d ' ~Z Dt Bottom
Dosing Header/Man. ~yZ x~7
Aeration Dist. Pipe 7
Holding Bot. System G, ,gyp /
I `O `7
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM 3'
Model Number
TDH Lift Friction Loss System 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 3 Z (.Q~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Typ Of System11 CHAMIBER OR Mod umber: ~l I1 d
~auWeuJl~o~o~
DISTRIBUTION SYSTEM =.sZ
Header/Manifold Distribution J ix Hole Size x Hole Spacing Vent to it Intak
t~ Pipe(s) Q
Length S Dia I Length Dia Spacing
SOIL COVER I x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over Depth of xx Seeded/So ed xx Mu ched
xx
Bed/Trench Center Zg Bed/Trench Edges Topsoil s ❑ No es ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1353 BIRCH PARK RD t r_ / 6 d
1.) Alt BM Description = ` ; ( L.,
2.) Bldg sewer length = IT,
-amount of cover = /49 Plan revision Required? ❑ Yes ~ / _ 3 S
Use other side for additional information. Ll~ ` V L
Date Insep Xrgn re Cert. No.
SBD-6710 (R.3/97)
.-0
" lndus Servi es Division ❑ty
t 1400 Washington Ave ~;t C,
E r P.O. Box 7162 Sanitary Permit Number (to be filled in by Oer~
PS Madison, WI 53707-71 06
Sanitary Perffi t Applic ' 4SGNV-,G State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission Jate governmental unit
is required prior to obtaining a sanitary permit. Note: Application. _owned POWTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Services. Personal info _.,on you provide may be used for secondar J ~A V-1-VI
u oses in accordance with the Privacy Law, s. 15.04 l) m), Stats. t/`' ►r I ~V~ t
1. Application Information - Please Print All Informati
Property Owner's Name Parcel #
~V ~'~;1Gt L C'
Property Owner's Mailing Address Property Location! 30 ad 0Z
Govt. Lot J City, State Zip Code Phone Number /a, Section 2-1,-
J
(circle on
T N; R2_D E o
IL Type of Buildin (check all that apply) Lot
1 or 2 Family Dwelling -Number of Bedrooms I Subdivision Name
n~
Ok eA OJSe_ Block fti P~ Y-l'
❑ Public/Commercial - Describe Use l
❑ City of
❑ State Owned - Describe Use CSM Number Village of
AT.- of C_,:~ \ V-1t c-~ps•e-
2 bit-4- Ce-At) ,..j ~o -l- Ito
C er T
111. Type of Permit: (Check o ly one box on line A. Complete line B if applicable)
< y El Replacement System El Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
t~Wew S stem
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that a 1
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank Other Dispersal Component (explain) ❑ Pretre t Device (explain)
V. Dispersal/Treat nt Area Information:
Design Flow (gpd) Design Soil Application Ra (gpdsf) Dispersal Area Required r ea Proposed (sf) System Elevation
V1. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o °
New Tanks Existing Tanks P o a p
a U in ~ ~ ~ C7 P,
Septic or Holding Tank l t l arc,
1~
Dosing Chamber 6_0(_01(11
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's S'ature r M P mber Business Phone Number
_7 71
Plumber's Address (Street, City, State, Zip Code)
VIII. ount /De artment Use Only
Approved =Zp Permit Fee Date slued Issuin gent Signature
Reason for Denial
IX. Condls~ fiteasons for Disapproval
Septt~: ark, aft-cm like- i,'mi
Urip2t:!Eo Cl'fl -USt dU be t (G!S < ltc; - i
2 ! u,iaerl bV Nlumbei.
~s p+er; an.~gemen:plan p
. `A# * ri6c ttsents rnwt ue r. rte ir.E
as per PKRmbl1 cty.,,- / crdiran or.1,
Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inches in size
SBD-6398 (R. 08/14)
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Wis. Dept. of Safety and Professional Services SOI~ EVALUATION REPORT Page of
Division of Safety and Buildings;. J~nl 1 2 ZM
r1'`accordance with SP 385, Wis. Adm. Code
Attach complete site plan on lI4aper nopess;ttaiar~~W~2t>Y 11 inch s in size. Plan must County .
include, but not limited to: vert~Cal~p4t 4gptgt~ emft (BM), direction and Parcel I.D. ,
percent slope, scale or dimensiees rror[h arrow, and location an tan to res d. U7 ca nj. Please print all information. Revie d by Date
Personal information you provide may be used for secondary purposes (p ~3 /
Property Owner Property Location
Govt. Lot 1/4 1/4 S T N R E (orW }
Property Owner' Mailing Address Lot # Block # Subd. Name or CS #
City State Zip Code Phone Number
❑ City ❑ Village ®Town Nearest Road 13 ~
( )
IT 101
® New Construction Use: ® Residential / Number of bedrooms `J Code derived design flow rate ; yt GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments
and recommendations:
1.
F T1 Pj Boring # Boring
~ p ~ •
pit Ground surface elev. ft. Depth to limiting facto 2-0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2
-2 PA ~ bK.
s
C_ ~'(4.) IUD rye C
F2 1 6 Boring # ❑ Boring
Pit Ground surface elev. ft. Depth to limiting factor r in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
y
d
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * E uent # BOD 5 < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Address
ate Evaluation Conducted V Telephone Number
.S 61
SBD-8330 (RI 1/11)
Property Owner T~v L. Parcel ID # J " y Paged of
Boring # F1 Boring
F-31 C U
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 / ff#2
F] Boring
Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Effluent #1 = BOD , > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
S B D-8330 (R 1 1/ 1 1)
Property Owner Parcel ID # Page of
Boring # Boring r V y
i~ Pit Ground surface elev. i i ft. Depth to limiting `factor ;r in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
❑
Boring # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
Effluent #1 = BOD , > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD , < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-,151 or TTY through Relay.
SBD-8330 (R11/1 I)
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: [-1_E Imo` N i ICS l L
Owner's Name:
Owner's Address: ' 5, I i~C'tR K N
Legal Description: 1/Z vt,' i~41
S ?t is Z Z 6°'I-~
Township: `j -
~ LS{ t' H
.ounty:
>ubdivision Name: Q k-
_ot Number: / -7
'arcel ID Number.' I5
I
i
Page 1 Index and fide
Page 2 Plot Plan
Page 3 - System Sizing A CrQSS-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
esigneNPlumber: JL' F I._ C'
License Number }~l<,S'
ate: Phone Number y C,
5--
ignature
;signed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD -10705-P (N.01f01).
Page 1
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A toy"
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~ Final Gra
4~ 4Q ~ S
Pvc Vent Pipe
Unit vem cap
-
Leaching
Chamber
-
f ft
tI A n Ilan
Tranch
Vat Or Observollm P" Leac" C
4' 69ie.
Trench 2 H
ism how
Mass And Mo" _1 i~ t- C i-~~ I-~~C j ~ V ►-C ~ 9
EISA Raft -2-0 sci ft per chamber Soil Agftation Rate g q ft
gpd Design Flow f 7 Sol n Rift : ~ EISA Chambers
2 roves of chambers each.
Rage of
Or PA ff- low
0P"5251P "-25 FILTER
UZOMS
EWS
SPL40 FEATURES F
Y s
s Rated for 1Q,W0 GPD
_ Lbum Fed of I11i
PL-M W5
Madon
PL W6 Pam of °
t; . 4 and B° SCM. 40 A
*Accepts PLAM5 PPL425
~ in Gas r
everai yews under n aa1 condftions bare Autwlatc gwt.(W Bel v*m FEW is Removed
rhV~ it be
ted y to or at Most everY * Al=m Amass t.Y
t yeam gt contakis an a to OWWVA be noated by an arum wl~t Me P O~~
be done bya
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raer~e.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner L -4 U LF,VlA a1 O / ~ r 1L ~ Tank Manufacturer: V~;(C_~E ❑ NA
Permit # TH (.j V
Septic ❑ Dose ❑ Holding Volume: (gal)
DESIGN PARAMETERS Tank Manufacturer: ❑ NA
Number of Bedrooms: ❑ NA ❑ Septic Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: XNA Vertical Distance Tank Bottom(s) to Service Pad: J' (ft)
Estimated (average) Flow : (gai/day) Horizontal Distance Tank(s) to Service Pad: { 5(i (ft)
Design (peak) Flow = {estimated x 1.5): t_ Specific servicing mechanics must be provided if vertical is >15 feet or
50 (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: , (gal/day/ft) Effluent Filter Manufacturer: L. i F Tl N\C
❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: I
Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: Z L F_ Ll cE
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA
Total Suspended Solids (TSS) 5150 mg/L A Pump Model: l\; y S
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer:
(BOD5) >220 mg/L XNAjq
(TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
Pretreated Effluent Monthly average e El Disinfection El Wetland
Y 9 ❑ Sand/Gravel Filter ❑ Other:
(GODS) 5_30 mg/L Soil Absorption System
(TSS) s30 mg/L NA
Fecal Coliform (geometric mean) x104 In-Ground (gravity) El In-Ground (pressure) F] NA
Maximum Effluent Particle Size in dia. El NA ❑ At-Grade El Mound
❑ Drip-Line ❑ Other:
Other: ❑ NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) [jQWhen combined sludge and scum equals one-third (3) of tank volume
When the high water alarm is activated
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Inspect dispersal cell(s) At least once everY ❑ month(s)
3 1 year(s) (Maximum 3 years) El NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
L9 year(s)
Inspect pump, pump controls & alarm At least once every: 3 1 month(s) El NA
ar(s)
Flush laterals and pressure test At least once every: ❑ month(s) ;kNA
❑ year(s)
Other: ❑ month(s)
At least once every: ❑ year(s) A
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
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 a check for any back up or ponding of effluent on the ground surface. The soil
absorption system 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 treatment tank equals one-third (X) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 5_12 months shall be
9 performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
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START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are
detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment
tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat
scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge.
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 s. Comm 83.33, Wisconsin Administrative Code.
• All piping to tanks, pits and other soil absorption systems 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 (pumper).
• 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 the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil 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.
❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
*_.J~ SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER _ POWTS MAINTAINER
Name (7F-
f- FC_ x Name
Phone t lS _ L 4q I 3--t See--' Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name G y
Phone Phone
71-15
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer ► M' um Pump Performance Required
_ LP
Tank Model Number L, ' GPM @ Ft TDH
Total Tank Capacity
Max. Bury Depth
Total Dynamic Head (TDH) - Feet
Pump Manufacturer Z Elevation Head
Pump Model Number j\i 1:S• Distal Pressure
Alarm Manufacturer 4 t(j M,&` s Network Pressure Loss
Alarm Model Number P_T RL° ZZ KForce Main Pressure Loss j
Switch Type Total
Manhole Min. 4" Above Grade
With Locking Device
Vent Min. 12" Weather-proof
Above Grade --0.
Junction Box
With Cap
- - - Finished Grade
T
Depth of Cover Ft Disconnect
1 Means
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Inlet Switch Settings and Reserve Capacity
sr> Tank Volume = GPI
{
't' Dimension Inches Volume Gal. A
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(alarm) B 2 B Weep
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S S i L t t t{ S{ S S C S S i S S t{ i{< L< L S t t t{{ t<< S i t t{ S S trt S S, t
GENERAL INSTALLATION: The dose tank is bedded and back filled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the
manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have
an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved
material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or
sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the excavation and is sealed
watertight. Electrical service complies with NEC 300 and Comm 16.28 Wis. Adm. Code.
03/05lgj Page of
Site Search - Zoeller Pump Company Page 3 of 3
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MODEL 151/152/153
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GALLONS
LITERS 0 40 80 120 160 200 240 280 320 360
FLOW PER MINUTE 014508
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SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICA'T'ION FORM
owirer/Buyer Pavel & Elena Miligoulo
Mailing Address3316 York Bay, Woodbury, MN 55125
Property Address 1353 Birch Park Rd.
(Verification required from Planning & Zoning Department for new construction.)
City/State Houlton, Wl Parcel Identification Number 030-2125-70-000
LEGAL DESCRIPTION
Property Location 40 v, , 160 '/4 , Sec. ? , T 3O "N R20 W, Town of Saint Joseph
SubdivisionPlat:Birch Park Lot# 17
Certified Survey Map # Volume Page #
Warranty Deed (before 2007)Volume Page #
Spec house Dyes C❑no Lot lines identifiable Eiyesnno
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 Comity 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 (I) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department witlrin 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge, I/we an-dare the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Nuinber of bedroom
S ATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in tire sanitary permit being revoked by the Planning & Zoning Department.
i
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)
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St. Croix
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. Q
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Reviewed _ ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location ■
Quest Development, Inc. Govt. Lot E 1/2 1/4 SW 1/4 S 25 T 30 N R 20 EE (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
Suite 150 10700 Old County Road 15 17 Birch Park
City State Zip Code Phone Number ❑City Village ■ Town Nearest Road
Plymouth MN 55441 7 3-595-9512 County Road E
New Construction LlseE] Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD
Replacement F] Public or commercial - Describe:
Parent material i ,oess over out wash sands Flood Plain elevation if applicable
General comments
and re mmendations: This it is suitable for an on-site conventional below grade sys
c3
12.5
FFIBoring # Boring l
F-1 Pit Ground surface elev. 98.48 ft. Depth to limiting factor >98 in.tiori Ra
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots' GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *.Eff#1 2
1 0-7 10yr3/3 is 1 mgr mvfr cs 2~ -1 :3= 1.2
2 7-98 7.5 r5/4 s Osg ml - - .7 1.2
. 72 Boring # 1-1 Boring 99.07 >110
Q Pit Ground surface elev. ft. Depth to limiting factor in.
Soil 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
1 0-7 10yr4/4 Is Imgr mvfr cs 2f .7 1.2
2 7-13 1Oyr3/2 Is Imgr mvfr cs if .7 1.2
3 13-29 10yr3/I sil 2mskb mfr cs - .5 .8
4 29-56 l Oyr4/4 sil I mskb mfi cs - .2 .3
5 56-110 7.5yr5/8 s Osg ml - - .7 1.2
* Effluent #1 = BODS > 30 < 220 mg/L and SS >30 < 150 mg/L LEffWent < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signa CST Number
227387
Thomas C Nelson -
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, WI 715-246-2454
Property Owner Quest Development.Inc Parcel ID # Page 2 of 3
Boring
FTI Boring # 0 Pit Ground surface elev. 99.59 ft. Depth to limiting factor >115 in Soil 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
l 0-16 1Oyr3/2 - sil 2msbk mfr cs 2f .5 .8
2 16-68 10 r4/4 - sil 1 msbk mfi cs - .2 .3
3 68-115 7.5yr5/4 - s Osg ml - - .7 1.2
❑ Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f `
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil A lication 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
* Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
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