HomeMy WebLinkAbout034-1014-50-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605008
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 3083752
Permit Holder's Name: City Village Township Parcel Tax No:
Mark & Tara Price TOWN OF SPRINGFIELD 034-1014-50-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
eVG C le= 07.29.15.101 A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (I ARICA- Benchmark 160•0
Dosing Alt. BN<L,* 1 -1
L
Ao;atien Bldg. ewer
LJI Jt= . 1ED
Holding St/Ht Inlet
SUHt O
TANK SETBACK INFORMATION -
TANK TO P/L WELL BLD Vent to Air Intake ROAD Dt I let
G
Septic 7 t~ i vI Dt Bottom F-4 -5 0,6
/ a45'
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final PUMP/ SIPHON INFORMATION Grade
Manufacturer Q~ Demand St Cover 01 30
GPMM/ ,
Model Number .Q 3
[Forcemain DH Lift . Friction L s System Head TD Ft
U,R' leg0 3 its * t(,Lo
Length L8/' Dia. Dist. to Well
t
SOIL ABSORPTION SYSTEM
BED/TRENCH Width I Length No. An niches PIT DIMEN No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS iao tA).k i -
SETBACK SYSTEM TO P/L BLDG WELL LAKE REAM LEACHING Manufacturer: J8
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length ~ Dia acing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over t Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
11 Yes C; No E] Yes [I, No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~~f d~ Inspection #2:
Location: 2733 110TH AVE fL
1.) Alt BM Description =
2.) Bldg sewer length = MIA
- amount of cover =
Plan revision Required? ] Yes F] No I I
Use other side for additional information.
Cert.
(R.3/97) Date or's Signature No.
SAN -Du I e
[Fri;
ra D
u~l~D
i
- n us ervtces Division County
Q 1400 Washington Ave ST. ~q o%K
O O P.O. Box 7162 -1
Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
,oix County Os~g
-Pvoelepmerlt
State Transaction Number
Sanitary Permit Application 368 3 -752-
fit accordance with SPS 383? 1(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (ifdifferent than mailing address)
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
urposes in accordance with the Privacy Law, s. 15.04(1)(m), Stars. 7-7,53 xU ^~L_
ion
1. Application Information -Please Print All InfTD
Property Owner's Name Pa
rcel R
035! /C/y-So-coo
1AQK 4 640<4
Property Owner's Mailing Address Property Location
6-7,R9. .poi
a 733 Govt. Lot
City, State Zip Code Phone Number
/VE IVW Section 7
circle one
GZJ_AJ1JcoG Lirr ~S 457:Y6 /3 T o?9 N, R l V
11. Type of Building (check all that apply) Lot a
I or 2 Family Dwelling- Number of Bedrooms Subdivision Frame
Block
❑ Public/Commercial - Describe Use 8-Eity of
CSM Number Q' YlInge of
❑ State Owned- Describe Use /
9 Town of S~~/~1 L F/fL0
(Q ~ ~OtJJL ~
Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) N J 1►
_ A.
❑ New System Replacement System ❑ TreatmentfHolding Tank Replacement Only ❑ Other Modification to Existing Syst~ e. am
i
B. ❑ Permit Rcncwai ❑ Ycrmit Revision ❑ Change of Plumber El Ptmrit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
fV. ? e of POWTS System/Component/Device: (Check all that apply) Y% f%T6 tool
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade V Mound > 24 in_ of suitable soil ❑ Mound < 24 in. ofsuitable soil /
❑ Holding Tank ❑ Odrer Dispersal Component (explain)_ PretrraUnent Device (explain)
V. Dis ersat/Treat nt Area Information: a
Design Flow (g pd) Design Sail Application te( pdcf] Dispersal Area Required I Dispersal Area Pr sed (sf) S tion G'6n/ravM
Goo o Goa /sue 1 Goo vw) 98..7`a pL•S`
VI. Tank Info Capacity in Total n of Manufacturer
Gallons Gallons Units i y o
New Tanks Existing Tank; y
! ~ It~l~Cp i = U rn ~ yr v. t7 c.
Septic or Neiding+m k
_ 4700 - /.7ao / ~J/ES~-a GR E rE ~
Dosing Chamber
}
NTII. Responsibility Statement- I, the undersigned, assume respo ibility for ' to titan of the PONN'TS shown on the attached plans.
Plumber's Name (Print) //a Plumber' Si re MPS Number Business Phone Number
L 'A K6 177 y/5'_9__ i716 9G2- Y~sS
Plumber's Address (Street, City. State, Zip Code)
i
. d, ~eX /d ~a LfvX Sy7d0
VIII, County/Department Use Only
i--- Permit Fee Date sued Issuing Age ignature
Approved rsanproved S S f~l ` +
(lV tab S L 5 ~8
c'e R,:ason Ibr Denial
v
i l?k. Condt 1 -w' z ~'oF ts.tpgrovat
tihp8t•^:ri Ceti must a0 ! WE t111 •s.tt L . /
es per man3gemetV plan pi-O riders W piuimbe;. exJ
2. At ie(bW* rliG,l,lW:teM must tie r.'eB:Rti 11'61 /
so per yffacws cod! l adinall 4 t,_,
a-a
,roach to complete plans for the ssstcm and submit to the County only L: ITS than 8 in 't it inches in Sim
r
a ~)-6398 (R. 0,W1 4)
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vv ;~T%rF DIVISION OF INDUSTRY SERVICES
~~TO 3824 CREEKSIDE LN
HOLMEN WI 54636-9466
Contact Through Relay
http://dsps.wi.gov/programs/industry-services
www.wisconsin.gov
~o _/roti`
~ssroNPti Scott Walker, Governor
Laura Gutierrez, Secretary
April 05, 2018
CUST ID No. 224199 ATTN: POWTS Inspector
KENT HOKE ZONING OFFICE
H&H PLUMBING LLC ST CROIX COUNTY SPIA
PO BOX 10 1101 CARMICHAEL RD
COLFAX WI 54730 HUDSON WI 54016-7708
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 04/05/2020
SITE: Identification Numbers
Mark & Tara Price Transaction ID No. 3083752
2733 110TH Ave Site ID No. 847888
Town of Springfield Please refer to both identification numbers,
St Croix County above, in all correspondence with the agency.
NE1/4, NWI/4, S7, T29N, R15W
FOR:
Description: Four Bedroom EZFIow Mound System \ Sloping site
Object Type: POWTS Component Manual Regulated Object ID No.: 1755243
Maintenance required; Replacement system; 600 GPD Flow rate; 16 in Soil minimum depth to limiting factor
from original grade; System(s): EZflow Mound Component Manual, (R. 7/12), Pressure Distribution Component
Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code CONDITIOP
requirements. APPRO)
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, DEPT OF SAF
stats.
PROFESSIONAL
The following conditions shall be met during construction or installation and prior to occupancy or use: C)IJIION OF INDUS
Reminders
• A sanitary permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be mad ith "
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required.
• The existing POWTS shall be abandoned per SPS 383.33, Wis. Adm. Code.
• The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or
soil compaction is prohibited in this area.
• A copy of the approved plans specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department which may include local inspectors.
KENT HOKE Page 2 4/5/2018
Owner Responsibilities
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS
occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follow the contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 250.00
Fee Received $ 250.00
6~wst--r \ Bal ance Due $ 0.00
Gerard M Swim
POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633
(608)789-7892, Mon - Fri, 7:15 a.m. - 4:00 p.m.
jerry.swim@wi.gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Mon-fri, 8:00 A.M. - 4:30 P.M.
H&h Plumbing LLC
Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with
"SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered
and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed
by SPS Chapters 360-366.
KENT HOKE Page 2 4/5/2018
Owner Responsibilities
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this approval.
• The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS
occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follow the contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 250.00
Fee Received $ 250.00
Balance Due $ 0.00
Gerard M Swim
POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633
(608)789-7892, Mon - Fri, 7:15 a.m. - 4:00 p.m.
j erry. swim@wi.gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Mon-fri, 8:00 A.M. - 4:30 P.M.
H&h Plumbing LLC
Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly
Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with
"SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to
the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered
and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed
by SPS Chapters 360-366.
Page I of 9
riv to nsite Wastewater Treatment System=3,E-(-"E-Ne0
Index and Title Sheet
Prf) ect Name: 44K f Y4l1q
~ i°4,e4 A
Owner's Name:
Owner's Address:
_ ~ L E~t..1oo0 ~i r1', C.JI SYa/3
Legal Description: ZVE. /14J, 7, o? 9 N, /S 41
Municipality: Town, age, Cif of ~P.civt f/EAd
County: .Sr. ZA0/X
DALLY
Lot Number: - Block Number: CSM Number/Fn
Subdivision Name: ETY AND
- SERVICES
Parcel I.D. Number: Q 3 y- /0lll- 5a - 000
SERVICES
TRY Page 1 ~~106X '`3-C6 SiS~EET'
Page 2 d"tor ~t,va
Page 3 ~itoss SEc rio.J elxw-) U/E-w of / "U'a
Page 4 Z,4 r6il.4Z LAY.-r--Page J'~EPra ~i~uy~° ~idA.~sQec Gitols ~iEeri.J
Page 6 ~~yMP `'~E/CFO/1MA.JGE ~u.tuE
Page 7 1o 4) rS Ow vE•a's /yiydu e /'~i~~./t E~,rEJr ~tg~✓
Page 8
Page 9 /~'/t TE.~ /wJfo.
Name of Designer: _ //4'a s-- 114 License Number: day/ 99
Signature: Date: 3-.?.l -ao/8
Designed pursuant to the following POWTS Component Manual and DSPS 381-385:
//Ez Ftory //ou ~a E6M~0 J 7' /1a~u~~ - tlEa. 84,6 ?4o7
`"/ZESS4kE ~lSr~eiburiea ~aM,o. /J~~.
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Page S of 9
COMBINATIOL SE~TiC/®OSc °a ~eNK CROSS-SECTION
(DRAWING NOT TO SCALE)
MANHOLE RISER & COVER
FINAL GRADE (per SPS 384.25(7) & (8). approved
f (slope ground surface away from lacking device. & warning label; Extend
f/ manhole(s) for proper drainage) manhole riser as necessary.}
4' Min. Sch. 40 PVC Tank Vent
ELECTRICAL located 12" above grade or 24"
4" PAin. Sch. 40 PVC Tank Vent !UNCTION BOX above Regional Flood Elevation
j BUILDING SEWER located 12" above grade or 24
comply with SPS 316
(per SPS 382.30(11)) above Regional Flood Elevation ( and NEC 300}
i
FORCE
j _ MAIN
I~12" i,4- OPTIONS
I s 6" cover I>18"
l r ' ~I
23" min.
I rAANHO~E ~ ~ "I ~•--Force
8OTT0610F INLET (invert a ev2tion)~ ~3" it Hole ! 1 _ - Weep ill: i.• T~-. l -
(vraste:zaler level)
~ r~/V "~~viv Rrcpeny uateG
9{ - - ~,r. ^~~a C . • , ren not uxd
V /Q ~n/C O N: D Alarm Float
rr I t fT'o8.?,7-/1/B c
On Float
1 r Fi c rE•r, r
Approved Effluent Filter B r
_ e ¢eLET PIFE <;5 padide Size Off Roar
(lec m Iratre) Required On Outlet _
Elev. _
!I: a - ~.1 d
MAXIMUM BURY DEPTH OF 96"
4NWIUM OF 3" OF SUITABLE g BEDDING DINmay be G 13 required p TANK & 33(
GPD
T nil ftflRnuYaCt!Iie : J1EfE4 Daily Wastewater Flow (DWF): Gdo
Septic/pump Size: 1,?oo/80 o gallons Number of daily doses: S 5- -~O
;i=rm Manufacturer: S ,7 E. Q/fc.vau 5 Force main volume: /So z : _ /43 gallft = a Y. S gal
iAcdel Number: P~A.JK /OLEa r!
Actual dose volume: 133 y gal - gal = /a gal
e (total dose volume - volume of force main)
c 1115%7 P IT;!;) i r nufacturer: Zi rnE L'ii'f ,j r DOSE TANK CAPACITIES:
,Aodel Number: 9E~t/ G/M Reserve above alarm ~0 in = Yys gal (D)
Alarm float above on float d in = 5~1 gal (C)
Minimum Discharge Rate: 3 5! 3Z GPM
On/Off float measurement in = /.3.3, y gal (B)
to = 177. 9 gal (A)
`Juriical lift (pump off to lateral invert)........--.. 6.7 ft Off above tank bottom
S~)stem head (distal pressure S x 1.3 ft): 3.3 ft
/SO t Force main x o?• S1100 friction factor 3.8 ft DOSE TANK DIMENSIONS' 94 to
- f° Length l~5! in Width tdth
-
..r °r
-It°c. +•i^'tton oss .
in Gallonslinch a1.4.?
EFFLUENT PUMPS
e~~.~af9
BEN SERIES - 4/10 HP
15 VOLT PLUG
115 VOLT PLUG B
B
9EN-CIA-SFS 9[N-CIA-Rf
Ili volt PLUG
I
C
9EN-CIM
9EN-CIA-S FS 10.76' 10.54" 8.07"
27.33 cm 2654 cm 20.49 cm
9EN-CIA-RF 9.15" 9.6" 6.8"
23.24 cm 24.38 cm 17.27 cm
9EN-CIM ' 9.15" 9.6" - - - 6.8--
23.24 cm 24.38 cm ; 7717 cm
- - - -
7M SC 100 ISO Z00 250 300 Coyer ( Epoxy-coated cast iron
'Thermopl tic
9 Motor Housing I Epoxy-coated cast iron
impeller Material Thermoplastic ela_stomer
Impeller Type No locn g
Volute Epoxy coated cast iron
6 Motor Shaft Steel
Nitrile with carbon and ceramic
X1 Mechanical Shaft Seal ;faces
Fasteners Stainless steel
{ Upper sintered sleeve and lower
_I Bearings
_
- t--- 3 Oil bearing
i o,.r
Power Cord
CAPAOTY - GPM
0 Franklin Electric HoUre:1.800.7017894 I www.lRilegwnL[Om
Page 7 of 9
POWTS OWNER'S MANUAL AND MANAGEMEN'T' PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner - ~ e t ~i4iGR PiIiGE Septic Tank Capacity /?00 gal D _NA
Permit - Septic Tank Manufacturer /ESEti ~o Oct O NAB
DESIGN PARAMETERS Effluent Filter Manufacturer EnIG0 O NA,
Number oi'Bedrooms (I00 gpdrbedroom) { y Effluent Filter Model ,r,-ogaa- / G O NA
Number of Commercial Units y Pump Tank Capacity 966 _ gal D NA
Estimated flow (average) ( Od gal/day Pump Tank Manufacturer { LJ/ESE~t. O NAj
1 Design flow (DWF) = estimated x 1.6 Goo gal/day Pump Manufacturer i L/Tr[E 1-,14aT D NA'r
j Soil Application Rate { /.Q gal/dayift2 Pump Model { 9EN G/~! O NA
Pretreatment Unit (0 NA)
Influent/Effluent Quality (O NA) Monthly Average C3 Sand/Gravel Filter O PeatFiltcr
Fats. Oil & Grease (FOG) 530 m&L O Mechanical Aeration O Weiland
Biochemical Oxygen Demand (BODO 220 mg/L p Disinfection D Other:
Total Suspended Solids (TSS) < 150 mg/L Manufacturer: tModel:
Soil Absorption Component (O NA)
Pretreated Effluent Quality (M NA) Monthly Avcrage
Biochemical Oxygen Demand (BOD;} 530 mJL O In-ground (gravity) D In-ground(pressurized) I
Total Suspended Solids (TSS) <30 mg/L D At-grade ®Mound
- O Drip-line O Other:
Fecal Coliform (geometric mean) < 10 cfu/i00mL
Vertical Distance `Dank Bottom to Service Pad: _ ll
r
Maximum Effluent Particle Size US inch diameter Horizontal Distance Tank(s) to Service Pad: ft
Dispersal Linit Mfg./Model Number_ ® NA
Calculations:
Soil Dispersal End Cap (Dispersal Unit EISA)
DWF - Application Rate = Area Required - EISA or (Trench Width) = Units or Total Length ofTrench(s)
DESIGN CRITERIA
O "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publication 9.6 (SSWMP l lanual)
D "1CC Flowytech Mound Component Manual" Version 1.2
Fiowy Mound Component Manual" Version 8/20/2007
O SBD - 10854-P (R. f /12) "At-Grade Component Manual Using Pressure Distribution" Version 2.0
D SBD- 10705-P (N.01 `01)"ln Ground Soil Absorption Component Manual' Version 2.0
0 SBD - 10691-P N.01/01) "Mound Component Manual" Version 2.0
Cl SBD - 10657-P (R.6/99) "Drip-line Effluent Disposal Component Manual"
SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0
D Other:
MAINTENANCE MONI'T'ORING SCHEDULE - MAINTENANCE AND MANAGEMENT _
Service Event Service Frequency
PumPiInspect dispersal cell(s), clean niter Pump/ inspect At least once every: R 13 months ® 3 years O Other:
Inspect pump & pump controls; alarm, pretreatment unit At least once every: O months 9 3 ears O NA
At least once every: O months 3 years O NA
Flush I and pressure test laterals
START UP AND OPERATION: For new construction, prior to using 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 scptage servicing operator prior to use. Sy=stem start up shall not0ccur when soil conditions are frozen
at the infiltrative surface.
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and
quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving appliances and
fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units,
other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not
include laundry waste. showers. dishwater. etc.
This system is designed to handle domestic strength wastewater; however, the disposal of food based greases, oils, vegetable/ fruit peels.
seeds. banes, and food solids, such as those produced by a garbage disposal should be minimized. Toilettissue is the only paper that should
be discharged into the system. Other non-biodegradable items, such as baby wipes, tampons, sanitary napkins condoms, cigarette buns.
dental floss, and cotton swabs, should not enter the system. Chemicals, such as petroleum products, paint, disinfectants, pesticides.
antibiotics, solvents, etc., should not be flushed into the system because they can seriously damage your PQW"1S and contaminate your
i 1
1
a CROIX COUNT1-
S1P'TIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
O\vi-icr/Buyer Q,~ 4 TarGL c a-, A~
Mailing Address
Property Address ?2J Cz U h ~~r.),od 1 l lll5&13
(Verification required from Planning & Zoning Department for new cons uction.)
Ci CviSt tte ~ehVVIX~G~ C/ _ Parcel Identification Number
LEGAL DESCRIPTION (~l
Property Location NE /4 , Ilinl 'f4 . Sec. 7 Th N R )5 NNE Town of- P<l~
Subdivision Plat: Lot #
Certified Survey Map # Volume Page 4
",,~'arranty Deed # (before 2007)Volume . Page -
Spec house DyesQio Lot lines identifiable ❑ yes[Ino
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 svstem can affect the function of the septic tank as a treatment stage in the waste disposal system- Owner maintenance
responsibilities are specified in SSPS. 38352(() 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 b_v the
owner aitd by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operatim__= condition and/or (2) after inspection and pumpinh! (if necessary), the septic tank is
ess than 1 /3 full of sludge.
t/we. the Undersigned have read the above requirernerus and agree to mail-Jain the private sewage disposal system With
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 S[. Cron:
county Planning & Zoning Department within 30 days of the three year expii°ation date.
I/we certify that all statements on t . orm are true to the best of mylour knowledge. I/we and/are the Owller('s) of" the
property described above, by virrtut of a rranty deed recorded in Register of Deeds Ofiic
Nttttiber n edr ms `'t
SIT ATURE OF APPLICANT(S) DATE
`Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning,Deparmnent.
Include with this application a recorded \van-anty deed from the Register of Deeds Office and a copy- of the certified survey mars i
reference is made in the warranty deed.
(REV. 04/12)
C RECEIVED
Wisconsin Department of Comrrja 10 2014 SOIL EVALUATION REPORT Page of 3
Division of Safety and Building
ti I'. CfZOIX qQ6MEgnce with Comm 85, Wis. Adm. Code
: QMWNMY LHVEL OPMENT. County 7- O
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. 000
percent slopa scale or dimensions, north arrow_ and location and distance to nearest road. v `7r
eviewed Date
Please print all information.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). :Z~
Property Owner Property Location
p ' 1/4 /l~w Ia' /1/4 S 7 T ..r N R / 5' E or
Govt. Lot ~ / (
Property Owner's Mailing Address Lot # Block # Subd . Name or CSM#
M/7-6A bdv"A
City State Zip Code Phone Number ❑ City F ❑ Village [Town Nearest Road
6e r7 ox) 0d 2~ t ~~~~/3 75G~ " ~y5 3 S r r e f'r i cl I/(-) fh Ace,.
GPD
on Use: ❑ Residential / Number of bedrooms Code derived design flow rate
Replacement ❑ Public or commercial - Describe: ft
a a a n,- C~ S e) S)c? Flood Plain elevation if applicable
General comments s a S~C 41 (-,e-
and nnrenncommendations: LL-
Da
LLV~ J( /7 llt;92~1
1 Boring
Boring #
E] pit Ground surface elev. -96, ft. Depth to limiting factor in.
Soil Apelication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •E GPD Eff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ( cJ
/ C y L S b tC U `t r C iJ D' C~ a
~ bYr2~ _ SQL w~ .b , ~ - L
//R~ 7 -7 Y K C _
`f
-ctrGLLvI C - -e~-
❑ Boring 7 /7
❑ Boring #
❑ pit Ground surface elev. ft. Depth to limiting factor - in. oil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rooj!*Eff#1 GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. r 'Eff#2 -r
LL7 (0-1k
oy~'' 3 7.sy t c .1).C b- l~ t 6
~
7.sYtz 7 s
~It
Effluent #1 = BOD > 30 5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Plea nt) Signaturz - CST Number
Vl ✓l1 ~e ee St)G~ ~
Address Date Evaluation Conducted Telephone Number
A)76~y (7/-5) 77~)
4
Co U Page cam, of
Property Owner 1 ' IL l u Ul C r Parcel ID # G 3 y° SL~ Boring # Boring
❑ pit Ground surface elev.? S_ ft. Depth to limiting factor _ in.
F31 Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots t Eff#1 GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
/ 3 - L 2 s b k /vlu c
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s72 } oy - u
8 10'I2 f3 7
C:3 75Yif 5 SCL c s
-2,,
❑ Boring # Boring ft. Depth to limiting factor in.
pit Ground surface elev. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots tE~GPD/ffEff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Boring Depth to limiting factor in.
Boring # Ground surface elev. ft• ❑ Pit Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
Gr. Sz. Sh. `Eff#1 `Eff#2
I in. Munsell Qu. Sz. Cont. Color
{
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BODS < 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.
S9D-8330 (k.b/UQ)
PropeayOwner rG ~tC3~~S I { ~flT t Parcel €D# 03'1-6:22-56) Page a of
3 Boring # rr_1 Boring
t_.J pit Ground surface elev. S7 Ft. Depth to limiting factor _/!~2_ in.
Sail Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDrW
in. Munsel€ Qu. Sz- Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2
L 2s btc IuU t~ 8
2- AL
t 1 8 10,!a 70k it b L rr l.<J if G- c~
T~ Boring fJ Boring
❑ pit Ground surface elev. tt Depth to timiUng factor in. Soil icafion Rate
T! lorizon Depin Dominant Color Redox Description Texture Sin. Munsell Qu. Sz. Cant. Color' Gr. Sz. Sh. 'Etf#1 'Eff#Z
f
r
t
Bcong it
aoring
€ Pir Ground surface elev. _ ft. Depth to limiting factor in.
Soil licafion mate
Horizon Depth Dominant Color Redox Description Toxture Sfruch)re Consistence Boundary Roots GPf]1ifi
I in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. f "ERfft 'Eff#2
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s
1
Effluent = SODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS 30 mg L and TSS E 30 m91L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 603-266-3151 or TTY 608-2648777.
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