HomeMy WebLinkAbout032-1060-70-300
,v5ccnsin Departmeel of comirii PRIVATE SEWAGE SYSTEM (.wmtr St. Croix
Safety ann Hit, ding Deader
INSPECTION REPORT tar, tar, Permu No
GENERAL INFORMATION :ATTACH TO PERPdITI Stile Plan ID No 605039
,;mal mtnnat un yc.. prat fle oc used far Senomaary our,uscs ?•i•: acy La I, s. s ea ! I!:,n)l
e-ini I Hellerk Name t; IT Village T.wrf ip Parcel Tax No Allen & Katherine Lesnau TOWN OF SOMERSET 032-1060-70-300
CST RM Llo-, I ircp. uM L'C 13M n, ~pvra SaaionTOwmftange:Map No.
23.31.19.306E
TANK INFORMATION ELEVATION DATA
TYPE MANUI-ACTURER CAPACITY STATION HS HI FS ELEV.
Sep' c
d. ^ Bi•nchmalk
Lt le
Dosing t r r Alt.l
Aesahon bldg. Sewer ~
7 0 O nk
Holding i SUHt Inlet
- -
TANK SETBACK INFORMATION Sl Outlet 60 10)~ 50
TANK TO P1I- WELL BLDG Veal to A Irlakc ROAD DI Inlet
I ~
i
Seofic 1 Dt Bottom - - - -
Dosing Headevftlar
Arratu'n Dist. Pipe
77,,
Lqa
Hold ng Bot System 7,Y) 11 -
PUMP/SIPHON INFORMATION rina. Grade
l`):
P,4arufachPe' Demand St Cover
31
tAa ael Nl.ri>(r
1 UI1 I iN - iclicr Lo System Head TDH Ft
For.:emai•I t e•tgth D sl to tN'el
SOIL ABSORPTION SYSTEM
BEDITRENCH :'uitltr t eratn No Of Tre--hes,~ PIT IMS NC.pI Pitt, Ins le Da I ~q.nn Oe, to
DIMENSIONS
SETBACK SYlill TO loL BLDG ,-JELL IAKE:STREANI LEACHING DJ.;n..faClurr• '
INFORMATION CHAMBER OR
r:e CI System: Al 1 UNIT lki Nit
-r
C
DISTRIBUTION SYSTEM 9-9 I G kx'_1
Heace '11 .111 frln List it_bor x I:u. e Size x Hole Spacng V n: tui I Irlake Pep ~i
~•n,0 Z `J' C a Lit.-J-11 Ula Snaci-.9_ - I
v
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Deul., OYef L VJt 0:er .x IL-1II y`I IXSCe UGvt;
4~ -L'JcdISGdCCU - xx l.! I
~HedrTrenrh feeler 3 q IBenTrena^Frget Tct:soil
1 Yes No Vcs No
COMMENTS: :,Include code discrepenues, cersons present. etc i Inspection 41 Inspect or #2.
Location: 69b 2WTH AVEE~
t'AU ENT Description= 'Ti
-t_
2 ; Bldg sewer myth
-amount of cover= Qf
Plar revision Required? Yes No
Use other side for additional information. _ 140
I
Date hsepctcr9 SignaLce Cure No.
fv all b i s
- -
v vxti i} _ Counb
stry Services Division
I S _ 0e aBs Xing', Ave ( Sanitary Permit Numbcr (tu be filledin b) Co.)
PS 4 2018 m. lson,wt -07= sz ~pl7J~63~
Sal I w' l'e•F it'll i ~atlOTl~ - ° m slay: Tran~ctirnt Numbcr -
In accordance, with SPS 3S3.21(2) t1'is. Allot Cod sabmision ol'Ihis font to the approlmate government p war
is r.pired prior to olvaining a s. mu tv lwonit. Note: Application forms for slate-owned POWTS are sdumiad to
Pro ml Adtlresx Recent than mailig ..add...
the Depannmrll of Satctp and ProfLmsianal Sen r . Personal inliomammn you provide ma) be used for sfeor~ t,)
ptnrposcsin:uyoldmnc. wnh lh<Pncacc Lea's 11.114(1)(m).Slals,
_I. kppilcation Information- Pleau Print .Ml Informatio
Propenv(Amer' Nam Invel if
Property Ovvnei s \laihng. Waress Property Location 1 3, ~j_ 1q, 3vb
Govt Ult _-tea
('itv Slate 1zip Cwt. 1'hm~ wNmtdt.r L'•. riti 'i, Section
IL Type of Building (check all that apph) )Al 4
1 ore Famih Uw flint Somber uC l3etlrvMnLS _ Subdivision Namc •
I i
46
❑ PublicrCommerebd Deunbo Usz C"/l-
❑ t C3 City of
~DJ'SC"-
Slate Owned - Describe Use J - - - Cl Villagc of
~iS\ t / 1 CSM Number
_ -17
Z All -CC 1.1_L (ZZ ~ 7.2 v wnlo2 T'ovvn of
III. TVpe of permit: (Check _out% bne bu>, an line_ A_. Complete line B if applicable)
Nem Svxtam^ ❑ Replacement system 1 Q heatmmVHalding I':mk Replan"'."Only ❑Odnr,llndifiuition to l?cistirtg S}•Aem (cvplaut)
B. ❑ Permit Rcaenal [-31 Permit Rev Isom i ('bangs of Permit "1'r nsfer to Sew U l tiravimte Permit Numbsr and Dale Issued
Itefr~re Expiration Plumber caner Tit Fr'( -
TV Cylx of POIVTS S\slenl/Component/Dcyice(Check all that apply) _1- a,; ,Je, 4
0 Non 1 mssmiz d In-Ground Q Presstr,ced ho-0,noud ❑ da-Grade ❑ .hound a4 ,m of suiwhk aoil ❑ Mound DI at. of suitable soil /DG
Q oldmg Tank Olhs Disp.rsil Component (explain) QlYdre:nm nl Device (eplain) n J S
V. Dlspersal/Treatmen ren Information:
ly / pers.at Area Proposed (s Sv lent Klvvalion
Desn n F loo I(, J) Ucs~l Snil lpplicaltuu Dnsparsal Ar a R quhcd (s IA
/ Rat (BP'Ivt) _l i f✓ ~ c ~ / - / - -
VI. Tank Info _ - C'aryrirc in
Gallons Told of
\I 1mmr .L t v
Gallons l. nuts
,'Tanks Leering l:•ruv
Septic or Holding hank -.5-t El 1 Q_, f ❑
Doling Chamber 10 .1❑
VII Res o tbtlity Statement- 1• the undersigned assmur resportcihthyfgyi4duHit ion f Ire POWTS shorn on the attached plans. _
Phnnbv stsanm( ml),~ Plumber Str~nn~rusr-- / \IP:\)IRS Vmubcr lliwn~ev Phone Vmnba )
Pltmnbn s lddmss(Stra.C City State. Jp CoJ)
VIIL County/De artment Use Only
p~"Ss~. ppros' Permit F v Ila1e Issnin root Sigoalur
4pp roved
ty to Givrn Reason Denial 1S _T 1~''0 `C115
IX C.ondi o . P. IOi14'\f{{F Disapproval 3\
t~+Txer:a. cell rust dl ¢~s~'.1cas ' r, •r_ g JJ ' r 1}} o
Os per Tfrayemen! plzn pro /iae^ U. ,e.,.111:10-
2 N rtlNerk re15cJret.. a RUA w r..a,rt. I: c
w per #;;kpbN Cori,: I udinanoct.
- :\Itach to romnlHe nlwo for Ibr vtelem and svbmii W Ilrr Cwwh wily.. paper gal lm U.8 at a II Indrn iu tlu
1 i
i
~"~~i~<•gss+ ti~~E f'
r
~ X
i,
1
!11
i
i
cow +
_y
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: - - -
I
Owners Narne:
Owner's Address: r
Legal Description: -
Township:
County: -
Subdivision Name:
Lot Number. r - _
Parcel ID Number. -
Page 1 - Index and Idle
Page 2 Plot Plan
Page 3 System Siang & Cross-Section
Page 4 Filter Specs
Page b Maintenance Information
Page 6 Management Plan
Page 7 SL Croix Gty Septic Tank Maintenance Form
Page 8 Warranty Deed
page g GSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber - License Number.
Dare: Phone Number _
Signature
i
uesigre pursuant to um In-Ground Sal Absorption CompaOnt Manual for POWTS Vc iwr ZA SOD 10705 P (N.OINt}
Pane 1
14
_ -=i';.?~r .mac>'"~~J,~ - ✓'~loT
~ carN~.,,;r~
If I
It
~~~fCfr> -
A
~y
Soil Absorption System Cross Section
ft
4' Schedule 40 Final Grade
PVC Vert Pipe
Wrrth Vent cap
j
Leaching
Chamber
- ♦ SYstem Bevation
ft ft
Soil Absorption System Plan View
tt
>~l
ft Vent Or Observation Pipe t-eaching Lrench 17
rye Chambers =
4~
~L~III~II>lei'III~II~~IIIIIILI~IIIDL(~1(~«I~_I1~'1]I~ ~ . ~
' Dia.
l C12 1 Header
Leaching Chamber Specifications 1
Manufacturer And Model
F_ISA Rating_ _ sq ftper chamber Soil Application Rate gpd/s9 ' ft
L gpd Design Flow ~L_ Soil Application Rate " EISA =
Chambers
2 rows of - - chambers each.
Page of
r \
PL-525 EFFLUENT FILTER ( I
Polylok, Inc is pleased to add its -
new commercial filter to its existing
line of quality effluent filters.The
PL-525 is rated for over 10,000 GPD Alaml Accepts PVC
(gallons per dayi making it one of accessibility extension handle
the largest commercial filters in its
class. It has 525 linear feet of 1.16 a-,
filtration slots. Like the Polylok
PL-122, the new Poly lok PL-525 has 3 ''u
an automatic shut off ball installed 525 linear feet
with every filter. When the filter is of 1116r- ,
filtration slots Rated for over
removed for cleaning, the ball will
r to,ooo GPD
float up and temporarily shut off
the system so the effluent won't
k
leave the tank. No other filter on y
the market can make that claim! Accepts 4- & 6- _
SCHD. 40 Pipe
o7L'~J~G`^ 4\Isc "•.`2`.:~e cue C@:
The PL-525 Effluent Filter should `
operate efficiently for several years
under normal conditions before
requiring cleaning. It is recom-
mended that the filter be cleaned
=very time the tank is pumped or
at least every three years. If the
installed filter contains an optional j ^y
alarm, the owner will be notified
by an alarm when the filter needs r Gas deflector
00t
servicing. Servicing should be UW I
~-,ewe+'k«' (
done by a certified septic tank ? s-'" P Automatic shutoff I
ball when finer
pumper or installer,
( is removed i
1. Locate the outlet of the u.".-f'atea~ 6,c15,4a6
septic tank. 11 5,371,640 j'
2. Remove tank cover and pump
tank if necessary. ~2 J Installation: 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
filter is removed. Ideal for residential and com- 2. Remove the tank cover and
4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
5. Hose off filter over the septic 4' or 6' outlet pipe. If the
tank. Make sure all solids fall filter is not centered under the
back into septic tank. access opening use a Polylok
6. Insert the filter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the fitter is properly aligned and 4. Insert the PL-525 filter into
completely inserted, its housing.
7. Replace septic tank cover. 5. Replace the septic tank cover.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORM TION„ SYSTEM SPECIFICATIONS
( :,n--r
<v ;~-XJ• . r - Tan<Rian..E;r•turcr: )i'ir-- r1' I I NA
fX1 S:•,; c L i Dcse n Heldlllg Volume:` j cal)
DESIGN PARAMETERS Tank Pvian:afadurec G1 NA
Number u.` Bedrooms: -1 NA ❑ Septic 11 Dose ❑ Holding Vclume: (ee0
Number Of Pill, is Facility Units NA Vertical Distance Tank Bottom(s) to Service Pad: ift)
Es-inixeci (average) Flow: alal:aap.; f lorizontal Distarce Tank(s) to Service Pad: (rtj
.ipcu ic, son;ic'ng rreehaaics must be provided if vealicatis >15 feel cr
DeS2pl (Peak) flav- (bSh naiad x 1 c
. ~C•-~' (gaUdnyj it huntrnfal is -150 feel. SDeci'a ins" Ours /to be providetl on b.
In S'lu Soil Aoplicatun Ratc: (gntr;fay;fi') E`Oueut fiver WnufactUrer, l -
❑ NA
ti'andard (Dorlestic) Infh.e )L E-fluent Monthly averngo Eff uwe ' Filtcr Nlodei: 2
-a1;, Oil & Grease (Hl:;) s301ry:L Punp Manufar-surer
3icchemical Oxygen Dc-,and (R.^.r;_) <_220 r;Pl 1-1 KA &NA
Tc'a1 SubDellded Sord> (TI SS; -:150 mglL I'un:p Paodel'
H'.c_ n Strength lrflt:ell'.'EfflJen: Paonthly average R citroatmenl Unit
(FOG) > 'lo noiL f,tan,!`aCtllfer:
(BOD,) %2211 mgr. to NA y(J NA
_ (TSS) _>750 mgrL ❑MA.::h:arical Aeration ❑Poat 1-11ter
- - I I Ll"i:lfncl oil ❑ +Netland
I'munated Effluent Montcly average ❑;,and;'a:avel Fite I..I Cthec
(10D,) -30 mg:_ So_' Absorp-.on System
(TSS) -:30 rna.9. [ Nit
Fatal Co~ironn (geom..=.t^r. riear) <10 l>{l In-Gruuru (gravity) ❑ Ir-Oround (preesuro) ❑ NA
C Drp ne I I L4a~nd
W7aximum Effl~.:e^t Particle Sze la .in din I I NA F) Drp Li Line ~ cnh=+-
U!hel: I-i NA Orre-
LINA
MAINTENANCE SCHEDULE
Service Event Service Frequency
I'um p O,A ccnteuls of tank(s) 7s'hen mrrb.•1cd sludge and scum r.:jua. , onCrthirC ! ; 5f 6scl: volu,r:e
I ❑ 6^Jr:r. 1 the high :eater alarm is actuate-)
In +e;torationcftank(s) A•least onceevery y = ❑1of1fi•"j (Maximum 3 years) fiNP.
yea(;)
Inspect dispe'sel cell(s) ~AC least once eve; ❑'+'r'rih(s)
y RI (Maximum 3 years) F1 NA
yeaWs)
Clean effluent filter Al :east on:. cvM: a dl (x) I I NA
J l~f Yc one)
Inspe t pump uu•np controls & warm At least once a'ee•y. I I men+h's) NA
_ _ I )~c rsl
Hush laterals and pressure test
_At lads once edery. J nonU-ra) - N!i
❑ ) irf5j -
Qther:
At least OCCe I NA
Other
❑ NA
MAINTENANCE INSTRUCTIONS
Irspec ons or tank:; mci . m ats' iI;A , r :1stc lls ,;1:.I Lc r .:dc 11,' 111 .Ii ..CUaI oV'e;Ilj cm :it tic 'c Io,vinr licenses O C@CifCaPons
61aster I'Iumher ful5sler i'lumorr Res't'ic:ed :Srnve', PC':".-TS Inspe::tcr, P04:1TS fa1cic'a.nei Or Sepraye S^rvicing Operator (Fumfie; .
Tack inspeUiuns must include a visual inSpecton of the tank(s) to identify any missing er broken hard Ware, ider:Vy any cracks or lnz: s
measure fire volume of combined sludge and sc,in and a ci:nck for ;:ny back up or pending Of efflunnt on the crOUnd surface. The boo
absorption syscrm shal be visually inspected to check the effluent ,evels in thn observaton pipes and to check for any ponding of efflce;:
on the ground surface. The pending cf effluent on the grol,nd surfa:x tray indicate a failing condiLon and requires the, ;mn-l
notiti0m[ion of the local r00L.19t0ry authority.
V-1hon the combined no:umulatiun of sludee anti scum in any tmn-miert tank equals one third or more of the tank VOlnC;e, the emir-
contents of the tank shal bo removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 1
Wisconsin AdminislrAlve Ccdo.
All other services, including but not limited to Coe servicirg of effluent falters, meoharioal or pressurized conq:onenis, pnaratment units,
and any sonticing at intervals of <12 months, stall be perfcrned by a r:ewied PO%VTS l0aintainer.
A service report shall be provided to the local regulatory authenty ,vit' )n 30 days of comp'6'ion of any service event
Gb:,.-pG~ rTZ; e~S)
'all" of -
START UP AND OPERATION
for rear construction, pica to rise of the POtNIS chest treatment tam(s) fur the presence of painting products, solvents n other
chemic:a.ss or sediment tha' may irpede the boatmen' process andrnr damage the soil absoriet oil system If high concentrators am
detecteJ have the contort:: of the tank(,,) removed by a Septage Servicing Operator (pumper) prtxto use.
Pump lanks may fi I above r.crmal high-emter Ire:cts price to start.;p or due to pun'1p failure;, Start up or restoration of po-nr under these
conditions is not re;;ommerd(,d. as the excess waste'aater+will bat discharged 'o the sod absotpt on system in one large dose causing an
overlaid that may resift in the backup or swface d schargo of e°Oua-.t and dam: ge to the system. To avoid this situation have tae
contorts of the pump tank re'noved by it Sep:ace Sr.rviciny operator 0t.mf =r) piton to restoring power to the Pump Pr contact a Plumber
or PONIES fvlaintainci to assist in manuall,,•' oporatirg the pill p controls until nu:rual effi.nnt levels arc restored mdthin the pump tank.
System star up shall rrt occur when soil C01161ioca arc frozen at the infiltrative surace.
Uo not drive ::r park vehicles over tanks or the soil absorption system Do not dnve or park over. or olherarise disturb or compact. t^0
area with- Iii feel down slope of any mound or at-grade snrl absorption area
Reduchor, o: ofirination of the fcllo'wing frori thn wastewater sPeam may mprcve the per'orniarrce and prolong the life of the treatment
tanks one suit absorption system: acids. anttioccs, baby +wipes: cigarette hulls. corxloms, cotton swabs, degreasers, dental foss,
dinners. disinfcctnn's. fa's, fouodntim drain (sump pump) discharge, `suit and 'vegctali e pa:~lings gasoline, greases, herbicides, meat
scraps, med-nations, oils. painting products, pesticides, sanitary napkins.. solvents. tampons. anti •arater softener LLne discharge.
ABANDONMENT
When tile. PObV I S fails andror is permanently taken cut of srre'ir^. ihu `o!:u~ro ng steps shall bc. taken to insure that the sysl•nm is propel ry
and sa'eiy abandoned in compliance •vmth s. Cunm' 83 33, Wisconsin Adminisinatnre Code:
• All piping to ta•rks, pits and oilier soil abscrp! on systems stall be disuornected and the abandoned pipe openings scaled.
• Tire eo rcnts of all. tanks and pits shaii on rcenOved and properly disposed cf by a Septage Scimciny Operator (pump^r;.
• After pumping, all tanks and pits shal he excavated and removed or their covers remc'ved nd the void space Find •arith sci'.
travel ci another inert solid waterri
CONTINGENCY PLAN
:f the P(1b^JIS falls and atnnot the repaired lire fo'le.vang measures have teen, cr roust be taken. to provido a cede cAmptint
repacemenl sysrom:
Ed A suit;;tie replacement area has been evatated acct may be u`i izc:f for the location of a replacement soil absorption sys;Orn.
lee ie0:'acemen' area shnuld be pietectOd `rem dIStUIbanre and caapaciiu'1 and she-11 net he. infrinued uprl by rawiree
setbacks fern existing and propused structure, iot'incs arc :yells. Faii.irc to protest the replacement area vrill result in the reed
fora new soil are site evaluat on to establish a scrtat; e replacement area. Replacement systems most comply veitil the rules in
effect at the time of Pieir remit ISSUanee.
l7 A sjitable replacement area is not a' <a lable due to setback anchor soil limitations. It 'he soil absorption system cannot be
rehaLilitatcd and barring advances Jr POb'U fS technology, a holding lank may be instated as a last resort
the site has not heen evalcatcd to identify a surtaole rep acemen' area. Upon failure o`. the P04,11-S it soil and site evaluation
roust be porfomaed to lou?tc. a suitable replacement area. If no replacement area is available. a holding tank may be installed as a
las'resert to replace the talloc POWTS
❑ frieund and al -grade so I absorption Sys'erns !nay hn ranrSturcted in prince td[01Nrg removal of the biomat at the infrltratbe
surace. Reconstr,;d ens cf s.n:h. ;;ystems must comp.y :vi:h lhr rules r effect at tfia: t me.
WARNING
TREATMENT TANKS. PUMP TANKS. AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
J` RESULT. ESCAPE. OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWIS MAINTAINER
;r~ '-0~anie
N::me-1 777 77
f'hcnc - r , Phor'e
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Nance ?lame;
"hi'.; cocu°lont '.vvv dr aftCd Cry the s,a fs of :tie !'neon Lake. htan:udi:: an•:d '"'iID_:.irira. Cc:mDr PO+-,vTS regulatory ageroies in ocrnphanee vrilh .ecimcir
urr.m A322P2 u I'(n):°.{f .r :1. ..541 11 .i)&r,+i, vhrashA,INI n.1'111
START UP AND OPERATION
Fo- :ieov consinrclicn, u'. or is u :::f fhe. !',t, • ,r. ;*n::nt ,c nC',.:.I tr: n ;uci.-.c -mr1 c.a, snlvens or other
uhemica.s or sediment tha', may irnn l-., fhn trca[mcrt nrnec:ss ar!din- d~.rrage th:- soil nb snrp.tv)7 system If righ ecncenirabons are
Jczcctcc have the contents cf the ta-kisr rf T:,)V-c try a Septage Servrcinc Operao: ~pjmper:i prier to us=.
i+grnp tan:;s may fill above nonial high•ua:er levels- prior to slaiwc or d-, to pump fai:ures. Start jp or restoration of power t.r;der base
coroitions is no, recommended, as Rte ex ess %vastedaater will be disccaaieec to the soil abscrpton system in one large dose caasinc an
overload that Inay resub in fhe cn:^".rp nr surface 6:scharge of effluent and damage IT,, the system. Tc avuid this sikadx have the
;.nnterts of the pump tan rernoved by a Septegc Se vicine Opcrnto• (numpa-) prior tc n:stonric per:r; ;o tnc pamn o• coma- a Plumber
o- P,"'-i !Ari;ntaine' zc, assist i.n manual y operaihr; the pump controls until nofma effluent !evels are restorec within the pjmp tank.
System start up steal no; o=w when so:i amd7cns arc. tro-cr at -*Inc.- iniltrmrvc surface-.
Dc not drvc or park vehicles ova, tanxs or the soi absorption s;i slem Do r:ot dive or park over. or other•.;:se disturb o- compact, the
area vitl^ir. 15 fee: dow, slope o` any rrounc c- at-g-ad^ s n, absorptier area
R:r^u:aror o• c.iminatior of the fol!ow;:g n'orn the w•astewlte- stearn may rnDrove hie performance and prolong the life of the treatment
I~.r4s and sC'I absorpton systerir: acids, antibict,cs, baoy vapes, cicare5e bu::s, condoms. cotton swabs, degreasers dental loss
d zpcr=, d:sintr:^tan-s, fats, fccndaticn drain 'SU:np pumpi d:scfrarae, fruit avid vegetable pealings, gasoline greases, herbicides, meat
credioalicns, oils, pnri: ig prodw-s nesticides, sanitary napkins. solvents [ampnns. 2nC carer soflene brine discharge
ABANDONMENT
,VJ en the !'IYA' I S faits endue is pcrma^c:^~tly taken cut o` service the follo,.ving steps shall be taker to insure that lire system is properly
and sa`cly abandoned in comp lance vvth s Comm E•3.33, V-Asconsin Acirnints-ratve Code*
• AI' piping to tanks. pits and other soi absorption systems snaf be c:sam-acted anc tie aoardonitil pipe ornenings sealed,
• ! he contents of all tacks and pis shall oe removed and properly disposer of by a Septage Se•via:ty Operator (pumpe-).
• After pumping, all tanks and pits shall be excavatec and removed o: t-eir covers removed and the void space fillec with soil. -
gravel cr another inec scid natena..
CONTINGENCY PLAN
If Pie PC'`A;TS fals any cannot Tie m:nairro the following measures have boon, nr gist be. taker, to provide a code compliant
rcn':acement svst:;mv
A. suitabis replacement yea has peen evalt.atec and may be util:__>ed for the lo::a::on of a remacement soi absorptier sy>frm.
re -DaCernont area S-cold be protectec hoer ds:u:ba:^ce ald ::o:n.+action and sho.,id nx ,e infrin;gec upon by recwrec
=c-hscks f•om exsiiny and propese9 S:n;cture, lo' line- enc. welts Fa lure r,: p-otect the replacement area wit result in the nand
r'+r a nevv soil and site rvaluanon tc estaolish a s.:iteb~e -eplacement aft:a. Replacement systems 'tuwst winply with the rules 7
^~i.^t at the time of :her parmit issuance.
I ; s.rtable •epiacerne:r area is no: a:aitaole dne tC setbacK anal+or soil Irmrtahocs. It the soli abso-nor' system cannot l.c.
rehabilitate) and barrir:c acvarces it POVs' I S technoiogy, in noz!no tank may be installer as a last reser
1_I The site: has not beer evaluated to idenljy a sizable: replacx-mert ar.=,a Loon fail.ire of the PCYA' I S a soi and site e+n'',:a-i:-,
must be pergrmed to locate a suitable repiacxrrert area. If no replacement area is avai:able a holding :ark.•nay be instal ed a~ a
las: re.o-l to replace the ti PO'd•.?S.
Mcsrd and a•-grade sit absorption syat_r rr:ay _,e aeons-Acted r pta-e `olbe.Vn, r -'t'..va! r:f [ _ Cj n':a,
surface. Reconst_ct (in_ X sic:: a;ys':•n ro::at nnm;,iy •>nith 717 ruin'; in ^9c :t ar that -!rr::,
WARNING
4~ TREATMENT TANKS. PUMP TANKS. AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
~ 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
Nrr-~.-~' / Name
r'ncne - - -'hOnn
SEPTAGE SERVICING OPERATOR (PUMPERi LOCAL REGULATORY AUTHORITY
-ric
I r % r w:wnU:i '.vat fl a`':::: b tin, tn. ~,'rJp _di:. • ..'!U... :!'d ~ i C.:q i5t r.. n-It.If ;lit:'a_ lu Bt: Ilai Wl L. e: t _.,._•-i:
~_:r rn f.J "ur i t r , .._.54.; t',. : :-•.c , -_ir kohnlm r a ;:oCr. _
ST. C'ROIX ('01 NTT
SIT I IC I ANK MAIN I I N:'\N(T AORHAII AI
AND
T (AVNI<RSIIIIt CI.R'I II ICA I'ION I-ORM
O\vncriRuycr lrl/ l
Mailing Address 7 /Z(( ;JLGt.1AOC 1cr l `%3l dY c~^c S-t1S
ZU~TH Ay- _r
Property :Address v2
(Verilication requunf Irom Planning S %oning I)eparintent r;~r new cunslnletion.l
Cil,, State i.; P;uca Idcnlilication Nnlnhet 1~:r` j' yam- jC
I.I'.CAL DESCRIPTIO\
I'ruftcrty' Location , Sec,; I _ ? N R 1't','Iown o1'
Subdivision ]'Ill: of
Certified Surs cy Map # _Y3G f ~ 7 VOlulne _Lz Pare J_;
Warranh Deed # (before 20b7)V01umc . Page 11
Spec hole<v ❑yc,i0 Lot lines idcnlifiub!cno
SYS FNI MAIN'rENANCE AND OWNER CER'I'IEICATION
Improper use and nminlen;mcc. 0t y0ul <epli;: ,cstcnl coul;i rc>ult :n its premature tail'aic to handle wastes- Prep;:r
VIA! Iren:vuc. eousisls of pumping out the seplic tail: every three gears .a ooncl. it needed, by a licensed pumper. WIril you pill into
lit, s<s""ll C:alt atIeet the function Of tile scpuc lan.l as a Irramtenl stave in the wa,w disposal system. Owner mainlcnan:c
I'es:•nll>Iin 111.128 ate speclfictl Ill $SPS. lu i?t 11 and in cimptcr 12 -tit. (ribs County Samtat\ Ordinance
I he prup2rty ow'ne i agues to 01,11111 to St. ( roix (ounly Pl:mnOw I,.. /oning Uepartnlenl :I evilification Ibnu, I^ned Ly the
owa::r and h) a ma;lcr plumber, iowrivymar plumber, teslriclcd plumberur a licensed pumper cu-ify ire That I i the .,n-s.Ir
wa:ICwat2r disposal system is in propel' operatin, condition and .r(-,) aliar inspcclion and pumpill• i it vc,ss:n) l. :he sepEe tank is
Ic„ than lit full ofsludec.
I!\ac, the under;i'ned have read the above requirements and agree to maintain the private saw-agc disposal sy,icat wish the
andards set forth, herein, as set by file OcImmili nl of Safety :And PrOtc,sional Scivices and the f elimmicnt of Natural huouree,,
sr :e o 1kVisconim. Cerfilir;won slatinr. 11111 you' septic %\stcnt has been maintained must be completed and remmcxl to the St Croix
t'imw) Hamlin- & /oning Mparuncutt within 30 bays of the Ihtec year expiration date.
Ilwc rtify that all suucmenls on 1 11 t a 1 arc true to the b co of nrydnur know'Icdgo I/wr am are the ow'ner(s1 of the
pl.q,rrn descnhcd about by girl/ue/ofa x' manly lied recorded Ili Register of Deeds Office.
Nun11yer ( bcdr ems j 7
it I
"SIG, 1'I l1RL OP APPLICANT(S) DATE
`%r y in torn I a I inn that is II I isle presenled may result in the sanitary permit hcmg revoked by the: PIaOrlin 2 S Zoning I )cpanment.
Ind hldr "ill It application a recorded warranty decd from 0u- Ite,tisfer of Deeds 011ice and a copy ol'the certified survey map if
refcrcnee is mule in the ,varranlu decd.
(REV. 03112)
Wisconsin Department o5lndustry,- SOIL AND SITE EVALUATION REPORT Page~of _
Labor and Human Rela6are
.Ajvlsion of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
c-ot.Nr" ,
Attach complete site plan on paper not less than 8 1 2 x t 1 rncho +PT11?91 Ian must include. but
LTG Y
not limited to vertical and horizontal reference point (BMJ: direction Afldh_/,Ipt e, scale r' - PA~R:;I:L I 0 x -7
dimensioned, north arrow, and location and distance dfi,nearest road ' I/ Z - /4'
APPLICANT INFORMATION-PLEASE PRINT"ALL INFORMATION OU (o `W D DA-
VER: / PROPER, _OCATION e- -7v- _3so
PR021 OW L
GOVT 10T "Q.S s I 5>~ .N." ~tj E;o l~
PROPI OWNERS MAIL NG ADDRESS CT a P.IOC;K s S,1BD NAME OR CSM ~
^i O 4)9!53
.~i
Ct-STATE ZIP CODE Pl-ON=NLMBER - CITY ❑VILLAGE O%Vf NFARF TROAD _
t 7 2e New Construction Use [Xj Residential ! Number of bedrooms S I Addition to existing building
f [ Replacement [ [ Public or commercial describe
Code derived daily flow p gpd Recommended design loading rate - bed gpd'N2 , trench. gpdif12
Absorption area required bed. 112 z-Z i trench. ft2 Maximum design loading rate 7 bed, gpd.fl2__, f trench. gpd,Yt2
Recommended infiltration surface elevation(s) ft (as referred to sisite)plan ten k)
Pireirt aterialn!site//considerations ~L(~ y vac _t r>>«chm
P anent material p~ ~(.„r,~/ „ Flood plain a vation, if applicable L
-_an
S - Suitable for system CONVFN' ENAI MOUND IN-9L"_ND DRESSURE AT GRAD SYSTEM N FILL HOLD NG TANK
Unsuitable fors stem ES Liu Ib1 S Liu A'S ❑ U ®S ❑ U ❑ S O u LI S Wu
SOIL DESCRIPTION REPORT (I"P -rV
Dc ing # Horizon Depth Dominant Color M0tt1&S Texture Structure Consistence Boundary' Roots GPDrft
in. M,uunsell QU. S7. Cont. Color Gr. Sz. Sh. Bed Trends.
and
J
fl
Dr-GIh,to
f
Prrnrg
`Ulbr• rr
Remarks:
"/a4 g
rled. ~ 7
ft,
I ailing
factor - -
~L 6 I i
Remarks:
CST Name-Please P•irt _ drone. _ -
AAC rPSS ~ _
Scr tnqDate. / CSTNumber
-
- -l -J _ - A/
PROPERTY OWNER SOIL DESCRIPTION REPORT pdge_-~) of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence B!u" Roots GpD?ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed 'TmrxJ
UTZ
Ground
elew
5 fl.
Depth to l
lini6na - - - -
factor
Remarks:
Boring #
A ;/t
7 : r3
/ 112
%G /G SCE/~_ 8
Ground
elev.
Depth to
lirriting
factor
L
Remarks:
Boring # /
71
yE -
Ground
elev
i
Depth to -
limiting
factor
Remarks
Boring #
i
Ground -
elev.
it.
-
Depth to - -
limiting
factor -
Remarks
SBD-8330(R Of, 1;21
PROPERfYOWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D.1 .5
Depth Dominant Color volts Structure GPD.rft
Boring # Horizon Texture C(InsstenCO Boucbry Roots
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T"
r
& ra ~ ate. I
/ I
Ground :s - 1Fli( l`~ j 7'
- -
elev.
2M ft
Depth to
GmiFrg _
factor
L-j
Remarks:
Boring # /
r G _ /GSt'~l
ell- /z
Ground
elev.
lG/ k ft. - - - - - - - -
Depth to - - - -
limiting
factor _ i-_---
>9 I i
Remarks:
Boring # - -
Ground
elev T
yf ft - ° - t - -
I
Depth to
limiting
factor
Remarks:
Borin9 #
I l ~ '
4a °
Q
Ground -
elev.
I
Depth l0 - - - - - .f
linuting
factor - - - -
Remarks: _
SBD 6330111 n5Ri2)
c- •
f 7
.r
IG',L
-7t 31'
3
>s
~ Uas
s~i'