HomeMy WebLinkAbout020-1044-80-025
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605062
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:
Deanne Miller TOWN OF HUDSON 020-1044-80-025
CST BM Elev: Insp. BM Elev: Description: Section/Town/Range/Map No:
/66 -7 3 *N 1 6.5T 19.29.19.177H-10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE '0,1 CAPACITY STATION BS HI FS ELEV.
Septic n 3 Benchmark
Q-sew.. F.' ILr•. . 9 iol. 9
Dosing Alt. BM
1666 : t L,, o. S. 31 q(o . co t .10'
Bldg. Sewer
F•r 144'. P~ o fzr 5Z5 7r3 • !
Holding St/Ht Inlet
'31, -72
TANK SETBACK INFORMATION St/Ht outlet -v4 c?, 2. f i
TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt Inlet
5.74 9Z•o`
Septic 7 Z is /fir 2- t - Dt Bottom 13 • .
Dosing ` Zs 33 / Header/Man. 5-3z. a` • cp 33
Aeration / Dist. Pipe I
s.3 9f, •(03 /
Holding Bot. System J
G. b 9 S. 3
PUMP/SIPHON INFORMATION Final Grade
3. 35 . (p
Manufacturer O J 0 GPM Demand St Coverer Jim ` 3 711:0-
1~' ( 7
Model Number 6f qb- 110,
.
TDH Li Frictio o System Hej4 TD t
1r
Forcemain Len th DDist. to Well
I a' r2 ,
a ~
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth
DIMENSIONS //Q Z rre r _ A
SETBACK SYSTEM TO P/L BLDG i WEELLLW/J LAKE/STREAM LEACHING Manufacturer~L
INFORMATION CHAMBER OR
Type ystem: Cv UNIT Model Number:
0 4Je~►® /6 3~ 7
DISTRIBUTION SYSTEM L*JIl *-a
Header/Manifol / Distribution x Hole Size Ix Hole Spacing Voizi,
Pipe(s)
LDia 4 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 3• Z~ Bed/Trench Edges Tops o' ` Yes ❑ No es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 878 CANTERBURY CT
1.) Alt BM Description= 2.) Bldg sewer length =
- amount of cover = ; „„d J,- 5 C,
it
p
CA
Plan revision Required? ❑ Yes No •7 q~ /d / Q^Q C
Use other side for additional information. L G (Q V V J
Cert. No.
SBD-6710 (R.3/97) Date Insepct Sign; "OF
~n GOULDS PUMPS Submersible
Effluent Pump
MODEL 3871
AO. 4 & EP05
EP0
l M
- Series
APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower
Specifically designed for the gra de turbine oil for tic enclosed design for heavy duty ball bearing
lubrication and efficient improved performance. constriction.
following uses:
• Effluent systems heat.transfer. ■ Casing and Base: Rugged
• Homes Available for automatic and thermoplastic design provides AGENCY LISTING
• Farms manual operation. Auto- superior strength and corrosion Canadian standards Awodaftn
• Heavy duty sump matic models include resistance. Co- Fk # 1.1108549
• Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron
• Dewatering assembled and preset at the for efficient heat transfer, °oti P"'"~ tso Soot Reglsttyed.
factory. strength, and durability.
SPECIFICATIONS ■ Motor Cover: Thermoplastic
FEATURES cover with integral handle and
• Solids handling capability: float switch attachment points.
3/a' maximum. ■ EP04 Impeller: Thermoplas- ■ Power Cable: Severe duty
• Capacities: up to 60 GPM. tic semi-open design with rated oil and water resistant.
• Total heads: up to 31 feet. pump out vanes for mechanical
• Discharge size: 11/2" NPT. seal protection.
• Mechanical seal: carbon-
rotary/ceramic-stationary,
BUNA-N elastomers.
• Temperature:
104OF (400C) continuous
METERS .FEET _ _ - - ` -
140°F (6000 intermittent.
- - .
• Fasteners: 300 series 10
stainless steel.
y
s
• Capable of running 30i
dry without damage to 8 - - - - - - - - *2.5 rr f
components. 25
7-
Motor: • EP04 Single phase: 0.4 HP, u 6 20 - - v I
115 or 230 V, 60 Hz, 1550 a _ J-- '
RPM, built in overload with o s
automatic reset. r
q - - I- EP05 -
• EP05 Single phase: 0.5 HP, c - I
115 V or 230V, 60 Hz, 1550 3 10 ' - i- -
RPM, built in overload with Poo
` I - I -
automatic reset. z - -
• Power cons: 10 foot 5
standard length, 16/3 i - _ ---T-_-- -I!_--_------I1
S1TW with three prong
grounding plug. Optional 20 ° °o o zo ao a so GPM
foot length, 16/3 S1TW with
three prong grounding plug
(standard on EP05). 0 2 4 6 8 10 12 milh
CAPACITY
Goulds Pumps
® 2003 Goulds Pumps
Effective July, 2003 ITT Industries
83871
Septic-Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer _ Wieser Pump Manufachu+er goulds
Tank Model Number 1000 Pump Model Number epo4
Total Tank Capacity 1,000.00 Alarm Manufacturer sj rombus
Max. Bury Depth 8.00 Alarm Model Number
Switch Type
Filter Manufacturer 2!y jock Total Dynamic Head MR) - Feet
Filter Model Number 525 Elevation Head
8.00
Distal Pressure
Network Loss L. _
_ Minimum Pump Performance Required i Force Main Loss
45.00 GPM 8.00 Ft TDH~ Total .00
p 6 co
Outlet Manhole Min. 4" Above Grade With `
Locking Device. Inlet Manhole /00 / ole Min. 4" Above Grade
< 6" Below Grade Sealed Watertight Securely Mounted With Locking Device
Weather-proof x►
Finished Grad Juncor~B~
3.3 /b
t
1 Depth of /
Cover Vent
Abentove Min. 12 Grade " Disconnect
Ft
With Vent Cap Means
J
outlet
Outlet Filter
Inlet Inlet Baffle
<
ayc c
Switch Settings and Reserve Capacity
s
A 4 1/413
a <
Tank Volume = GPI Weep
Dimension Inches Vol me
u G- al. { B Holy
0s` (reserve) A 20 556.00 E
(alarm) B 2 56.00 4:; Off Elevation C
40,
Ft
(dose) C 5 139.00
Bottom
(dead) D 9 250.00 4 4
D Elevation
Total
Ft INSTALLATION: The septic/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 materiel, 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 tank
excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 1628 WAC.
02105 LJ Page of
~~rti t C-q
^+c ` County
l Safety and Buildings Division St Croix
' $ ,to,$ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
P Madison, WI 53707-7162
{ Sr, ~N
All
'y rev ' State Transaction Number
a~~s en-nit Applica
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this font. •trart+ htal u~t
is required prior to obtaining a sanitary permit. Note: Application+fonns 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
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats.
1. Application Information - Please P ' All Information 878 Canterbury Court
Property Owner's Name , Parcel #
Deanne Miller -1044-80-025
Property Owner's Mailing Address Property Location ` a ci I . l 17 f~
878 Canterbury Court Govt. Lot 1
City, State Zip Code Phone Number SW y, N E Section 19
evcle one)
Hudson W1 54016
11. Type of Building (check all that apply) T 29 N; R 1 ~or W
X I or 2 Family Dwelling - Number of Bedrooms 5 #1 ) Subdivision Name
Vim' j Block #
❑ Public/Commercial - Describe Use c
❑ City of
❑ State Owned - Describe Use / CSM Number ❑ Village of
I~2'G..,°.J rtti 1.c 171 .Y~ITown Of Hudson
Ce& ill. Type o heck o y one box on line A. Complete line B if applicable)
A
XNew System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner 155~z r
IV. /Com onent/Device: Check all that apply) Non-Pressurized In-Ground Q' Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in.
of suitable soil
mg an Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Trea ent Area Information:
Design Flow (gpd Design Soil Application te(gpdsf) Dispersal Area Required (s Dispersal Area posed (sf) System Elevation
750 .7 1072 1 0 I 95
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks o
PolyLock 525 % w a
Septic or Holding Tank 1000/600 1600 1 Wieser X
Dosing Chamber le y
1
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
iness Phone Number
Plumber's Name (Print) Plumber's Signatur MP/MPRS Number 7s715-246-2660
Countryside Plumbing & Heating 664713 Plumber's Address (Street, City, State, Zip Code)
321 Wisconsin Drive New Richmond WI 54017
VIII. _County/ epartment Use Only
Approved ❑ Permit Fee Date I ued Issuing ent Signatur
0-0wae0iven Reason for Denial
IX. Condit easons for Disapproval /
1 .Saptilark etflum Mte and
'Ol ipet;'ai cell ryust all be s>it C;1, S nt rrec ) ~1aM.C
gs per;TW.3getnen! plan pro /ide-i by pluinbe:. /
2. At illlft ret JWnems mtr3t tN 1 :d~lit lt'.E : f
s W o"kifth cal' J .M;1lN 1GaE. ; ~~i .a r ti~ Ito .A-•,. k. 'IA,
Attach to complete plans for the system and submit to the County ly on paper not less than 8 1/2 x 11 inches in size
L•L L,,\,\ y tnt.,v* it 1 ~CJ7 ~T;
SBD-6398 (R. 11/11) /~L /'t~rM,~ ~`<'.c
Large oak tree
- BENCH MARK ONE GREEN
Pit 1 Bench mark 2
METAL POST WITH PINK
1 SH
I
TREE 100.00
I
BENCH MARK 2 GREEN
METAL POST WITH PINK
Drive tree RIBBON BASE OF LARGE
1
OAK TREE. 100.7
way
I
Pit 2 FROM BENCH MARK TWO
PIT 1 IS 213DG SW
1 1
I 18" asli tr E! ELEVTION IS 98.3
1
I 1
Proposed
S
IS 1/ VL
Q c'i~li mark f vv vv PIT 2 IS 17 '1 1 n C!'V f~ L❑CELL .J
I
1 Home ELEVTION IS 98.5
bedroom
PIT 3 IS 181 S
I 1
Q
j 0000, Proposed well ELEVTION IS 97.35
Wieser 1000-600 ga n 0 PARCIAL ID OF PROERTY IS
septic tank . 020-1044-80-025.
'0 it 3
Polylock 525 filter . System elevation 95 .00
I
1
1 I 1
I
I 1 I 1
1 I 1
1 1
1 I
f, 7
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Derrick const. / Jonathan & Deanne Miller
Owner's Name: Jonathan & Deanne Miller
Owner's Address: 878 Canterbury court
Hudson WI 54016
Legal Description: SW 1/4, NE 1 /4 sec 19 T29; R 19 W
Township: Hudson
County: St Croix
Subdivision Name:
Lot Number: 1
Parcel ID Number: 261-1044-80-025
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 P & H License Number: 664713
Date: 06/22/2018 Phone Number (715) 246-2660
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POwrS Version 2.0 SBD-10705-P (N.01/01).
Page 1
Large oak tree
Pit -1 Benchmark BENCH MARK ONE GREEN
N METAL POST WITH PINK
RIBBON BASE OF ASH
,
TREE 100.00
BENCH MARK 2 GREEN
Drive tree METAL POST WITH PINK
RIBBON BASE OF LARGE
,
way OAK TREE. 100.7
Pit 2
O FROM BENCH MARK TWO
PIT 1 IS 213DG SW
,
18" ash t '
ELEVTION IS 98.3
Bench mark 0.00 Proposed
I PIT 2 IS 171 DEGREE S
I Home
j ELEVTION IS 98.5
j / bedroom
PIT 3 IS 181 S
Proposed well ELEVTION IS 97.35
Wieser 1000-600 ga n O
' PARCIAL ID OF PROERTY IS
septic tank .
it 3 020-1044-80-025.
Polylock 525 filter . ;
I
System elevation 95 .00
,
,
,
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page_of
Project Name: Derrick Const. / Jonathan & Deanne Miller
_I, No. of Cells Per Cell
ft Cell Width
~~fJ\ Total No of
11D ft Cell Length y- sq ft EISA Per Cell
3 ft Cell Spacing- m sq ft Total EISA
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
Gravelless Leaching Unit Manufacturer: 33 t'r4'bY
Gravelless Leaching Unit Model: 17 Y1 18'
Typical Cross Section
Finished Grade~ft
Observation Pipe with
approved cap or vent
<:< >:::<>:<>:<>:.:<>:;:
Soil Backfill
30 in
Geotextile Fabric
.>i ii :•i u'ii:•i`•i i•i ii Si i':<':•i is>i'x'>:':%: ■
. i >i`c'ii :i zi : ~l:i !'i•i ri':;':i :C>i >i ~ i
42 ft Infiltrative Surface
12 in daL
Limiting Factor
in Slotted and Anchored Vent/
Observation Pipe with Cap
Plumber/Designer Signature: Countryside Plumbing and Heating
License 664713 Date: 06/22/2018
IV I
MOX 'AL
PZ)L Ar-
Inc. 7 Effluent
Innovations in Precast, Drainage Zabel PL-525 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
Alarm Switch
- Rated for 10,000 GPD (gallons per day). 10,000 GPD (optional)
• 525 linear feet of 1/16" filtration.
Acc
Accepts 4" and 6" SCHD 40 t e. Accepts 1" PVC
•
p p Extension Handle
• Built in gas deflector.
• Automatic shut-off ball when filter is removed.
- Alarm accessibility. Rated for
3 10,000 GPD
- Accepts PVC extension handle.
PL-525 Installation:
Ideal for residential and commercial waste flows up to 525 Linear Ft.
it-
of 1/16"
10,000 gallons per day (GPD). Filtration Slots
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 SCHD 40 pipe
the filter is not centered under the access opening use a
Polylok Extend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
Certified to
5. Replace and secure the septic tank cover. NSF/ANSI Standard 46
Pt.-525 Maintenance:
The PL-525 Effluent Filters will operate efficiently for
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" r.
years. If the installed filter contains an optional alarm,
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. Automatic
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.
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. `
6. Insert the filter cartridge back into the housing making
sure the filter is properly aligned and completely inserted. Poolylokutd, Outdoor
Zabel & Best Bestt filters Alarm accept Extend Easily & L installs
alls
7. Replace and secure septic tank cover. the SmartFilter® switch and alarm. into existing tanks.
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Jonathan & Deanne Miller Septic Tank Capacity gal ❑ NA
Permit # Septic Tank Manufacturer Wieser ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Poly Lock ❑ NA
Number of Bedrooms 5 ❑ NA Effluent Filter Model 525 ❑ NA
Number of Public Facility Units ANA Pump Tank Capacity gal XNA
Estimated flow (average) 750 al/day Pump Tank Manufacturer j~ NA
Design flow (peak), (Estimated x 1.5) 1125 al/day Pump Manufacturer (KNA
Soil Application Rate .7 gal/day/ft' Pump Model RNA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit RNA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (B0D6) 5220 mg/L X 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 (B0D6) 530 mg/L Xln-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L X NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) <10' cfu/1 00mI ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Ye in dia. ;ANA Other: ~ NA
Other: XNA Other:
XNA
*Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every' 13 month(s)
year(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
Xyear(s)
Inspect pump, pump controls & alarm At least once every' 12 month(s)
❑ year(s) 1~3:NA
Flush laterals and pressure test At least once every: ❑ month(s) NA
❑ year(s) X
Other: At least once every: ❑ year(s) 1XNA
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.
Page Z of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
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.
r p~ T
IA"///,~1 aluati
31 a o mg~ank
be ' e ai e f fLD14115 TES 9: 1~1~ 4'5 5T9UC-710
❑ 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 C. O V_ Name K
Phone I Z Phone _ b_ 2
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name ® r sG Name f t g (0 VdL\Z 2011j1 Phone 7 S- Phone
Z-L 102.S I
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.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Jonathan & Deanne Miller
Mailing Address 878 Canterbury Court, Hudson, WI
Propcrty Addres 878 Canterbury Court
(Verification required from Planning & Zoning Department for new construction.)
City/State _Hudson, WI Parcel Identification Number 261-1044-80-025
LEGAL DESCRIPTION
Property Location.S 11/ '/4 ,ry ll~r '/4 , Sec. f 9 , T Z N R 19 W, Town of
Subdivision Plat: , Lot #
Certified Survey Map # Lot 1 , Volume 20 , Page # 5171
Warranty Deed # (before 2007)Volume Za , Page
Spec house Qyes[; ho Lot lines identifiable Wes❑no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
I
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 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 within 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 am/are the owner(s) of the
property described above, b f a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 5
SIGNATURE 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. 04/12)
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Wis. Dept. of Safety and Professional PRI
ervices gL EVIALUATION REPORT Page of
Division of Safety and Buildings ` ~UN 2 5 L~
in accordance with SPS 385, is. Adm. Code
County ST CROIX
Attach complete site plan on paper not less than 8 j 11. yr g jrt si e. Plan must
include, but not limited to: vertical and';horizontM0bfjte' ,direction and Parcel I. . 20- 044-80-025
percent slope, scale or dimensions, north`-arrovv, and lobation arxi $stance to nearest road.
~a by Dat
Please print all informatio Revied
o.
Personal information you provide may be used for secondary purpos s iv ac a , 1 4 (m)).
Property -Owner Property Location
® a
J
r (1 L, y r!./ R'Iiyl~; Govt. Lot SW 1/4 E1/4 S 19 ' 29N R 19E (or) W
Propert n s Min Addr ss Lot # Block # Subd. Name CS%V
h~~i.. 3 1
Cit State Zip Code Phone Number ity Village own Nearest Road
4'~1" 4YI -5,001 ( ) HUDSON BRAER ROAD
a New Construction Use Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement ❑ Public or commercial - Describe:
Parent material OUTWASH Flood Plain elevation if applicable NA ft.
General comments CONVENTIAL.7 LOADING RATE.
and recommendations: X-
1 Boring # 11 Boring
Ground surface elev. 98.3 120+
0 pit ft. Depth to limiting factor in.
Soil Application Rate
z
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
A 0-4 10YR3/2 LS 1FSG MVFR GW 2M .7
B 6-18 7.5YR3/4 LS 1FSG MVFR GW 2F 7
C 18-69 7.5YR5/6 SG OMG ML C .7
C1 69-120 7.5yr5/4 SG OMG ML C .7
2 Boring # Boring 98.5 120+
❑ Q 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
A 0-4 10YR3/2 LS 1 FSG MVFR GW 2M .7
B 4-32 7.5YR3/4 LS 1 FSG MVFR GW 2F .7
C 32-60 7.5YR 5/6 SG OMG ML C .7
CI 60-120 7.5YR5/4 SG OMG ML C .7
oil
* Effluent #1 = BOD 5 > 30:< 220 mg/L an TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Paul R Koehler MP225410
Address Date Evaluation Conducted Telephone Number
321 Wisconsin Drive New Richmond Wi May 31st 715-246-2660
SBD-8330 (RI 1/11)
• i
2 3
Property Owner Parcel ID # Page of
a Boring # ® Boring 97.35 120+
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
A 0-6 10YR3/2 LS 1FSG MVFR GW 1M .7
B 4-32 7.5YR3/4 LS 1FSG MVFR GW 1F
.7
C 32-84 7.5YR5/6 SG OMG ML C .7
CI 84 -120 7.5YR5/4 SG OMG ML C .7
COT
❑ 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
❑ 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
* Effluent #1 = BOD 5 > 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.
SBD-8330rest (RI 1/11)
• s
Large oak tree
- BENCH MARK ONE GREEN
Pit 1 Bench mark 2
I METAL POST WITH PINK
RIBBON BASE OF ASH
TREE 100.00
I
BENCH MARK 2 GREEN
j
METAL POST WITH PINK
j RIBBON BASE OF LARGE
OAK TREE. 100.7
I
I FROM BENCH MARK TWO
~ O Pit 2
j PIT 1 IS 213DG SW
18" ash tree ELEVTION IS 98.3
I
Bench mark 1100.00 PIT 2 IS 171 DEGREE S
' I
ELEVTION IS 98.5
I '
' I PIT 3 IS 181 S
I ELEVTION IS 97.35
I
PARCIAL ID OF PROERTY IS
020-1044-80-025.
~it 3
I '
Lo 7'
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ J _
PROPERTY ADDRESS: LEGEND
878 CANTERBURY COURT I, Ty R. Dodge, Wisconsin Professional Land
HUDSON CWI 54017 ANTERBURY Surveyor, hereby certify that this Stake-out X =WOOD LATH OR PIN FLAG SET
Plan was prepared by me or under my direct WOOD HUB SET AT 10'
supervision and is correct to the best of my =OFFSET, U OFFSET, 0' ON
RECOMMENDED BUILDING ELEVATIONS- knowledge and belief. BUILDING EXTENSION
TOP OF FOUNDATION (TOF) 766.66
GARAGE FLOOR (GF) 766.33 C-- • FOUND 3/4" IRON BAR PER CSM
WALKOUT LEVEL` (WO) 758.00 T.O.H.- TOP OF WOOD HUB ELEVATION
`MINIMIMUM BASEMENT FLOOR km T.O.P.- TOP OF IRON PIPE ELEVATION
ELEVATION PER MBFE DECLARATIONS- `gC011111 _ SETBACK LINE:
867.5 50' FRONT 100' BAER DRIVE
O
i~ TYFL * 10' SIDE MIN, 25' TOTAL
DODW 25' REAR
$-244 - UTILITY EASEMENT
CLEAR u~4 X100.0 EXISTING SPOT ELEVATION
ELEVATIONS SHOWN ARE 1?}. f_'•..~~~ X000-0) PROPOSED ELEVATION
NAVD 1988 DATUM. NORTH
SCALE: 06/18/18
0 40 80
i
i
I \ ~ I
'X64-
763.7
106.28'
I r T.O.B.- 764.1 763.4
6
1~0
60d p /
~F sod
2700 SF 3.0 \ I
4 ~ 762-3--
T. - Q T. .H.- 762.23 ! 90
{ 762.6 6 p
a o.
X 763.2 -
GPI
X7 1 m
Jg~ I M
°o N I'I
~o q
I ~ _ I
in o _ 62 I '
rl~
00
nl I 162
\ 0
4;D.H.- 761.02
M i r
- L - -J T.O.B.- 755.7
I - a
760- >
J
LOT 1 5.8
1.10ACRE5 - / /
4,8036 SF N -
020-1044-80-025 roi 750 °o /
750 - . - j N
i
750
DRAINAGE EASEMENT'
cr-
746
J'
193.58` ~i
R-988
/ L 3.2
i
PMECT: carom sm Q1Xi DRANK BY: TRD
DERRICK CUSTOM HOMES (JON MILLER) ~~.,hmha M,...., ~„1 CNEGKED BY:
o LOT 1, C.S.M. VOL. 20 PAGE 5171 ~~.n54751 nMe DATE 06,14/18
Tel 715-=-M Td 725-3111-5z"
715-M2-54K f. 715AEI-= DWG Fl1E: @61121
SEC 19, 291V,19W, TO\'/P, OS HUDSO" I, ST CROIX COiJ V-Y, '.V!SCOf aVl oo~.meo..muq,WO wuna.w,owuq.- REF FllF
HOUSE STAKEOUT PLAN Auth•Consulting/associates S&N Land Surveying
I JOB NUMBER: 6G61_121 REN90NADETP1D NAME. DATE7B