HomeMy WebLinkAbout032-2105-80-000
vUernrsm L'epa~tmo~totCannnr'tli PRIVATE SEWAGE SYSTEM ccurly St. Croix
;afery ..=.nr. Su Id rg Divison
INSPECTION REPORT `an t;r; Pe•mit No
605093
GENERAL INFORMATION (ATTACI I TO PERMIT) Stale Plan ID No
I'ersn-a rrO , -i, - . -u Fraewe mn ha Igr SGCOmUaiy pwposuS JP,, S; L rn o l` 74 'drr1:1
Pees He "e' N:,^ 'e Crv Vil age Tasnsh p PatceI-ax No.
Allen & Kellie Wittstock TOWN OF SOMERSET 032-2105-80-000
1ST ftM1l -Ie r;p. BRA L C: BM Uvici vtiE Sernor.TO,en+RargwDAap No
/d3 9 Ct,,~.~ l Jer {c 28&33.31.19.993
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION HS III FS ELEV
Septic Benchmark
s 16W 16,11.. Cow 3.8 I /a7.7 /d3. Q S
Dosing of ;^75 3Z~ All BM rill, e6 3.4 /63,9
A6Wpe11 6" t~ Bldg Sewer I~
n O 6
Holding StiHt Inlet
TANK SETBACK INFORMATION St-Ht Outlet
TANK TO PrL R,%NF ROLDO Flip AROAD
M BeirrIffl-
T ~ SePUC 41 Z 306 0J4-- 8 s3 99 z
p320 3 I Headcr.Man
t~ 3 9. s . l9
Aeration '5 D st Pgxe 11,571 QB p
Holding Bel System /dl p/7. ~6f I
PUMP/SIPHON INFORMATION Fnal G,ade • -3 /dz • Cl0
Macufa:a.lrr Demand St Cover~~
GPM s 3. /a3.9
Mode: Nurrher
TDH Jim Fn-,,.!ion Luss System Head TDH Ft i
Foleenlam Long'. Dir.. IC Well
SOIL ABSORPTION SYSTEM
DeD!TRENCH ."uictr _enptn No.Of-,errhes PIT IM4 ENSIGNS No ()'PIS 'M10Dn: Lqu r7 cepl•)
DIMENSIONS 3 % z 7%n _
SETBACK SYSTE I0 TO PrL BLDG :"WELL LAKF:SIHFAM LEACHING P,L;n,.f::clule`. r
INFORMATION c CHAMDER OK
IYpe''H _iyglcnl /I //S~ /7 -3j?' UNIT D,IpdEl mtel
DISTRIBUTION SYSTEM SE ZZ 1'Z.Z 9` 4 d-..k,
II h:. a: dt~n^n'o / DiSn DU'Ifn x lcdc>m Hale spacinq rlvaV.E
Lcngp• (00 :)a I<n ,ln Ua Sparing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Deot-.O r 7cp'hC:u xx')rpthn• xnSCU:1ctlSucdca rxM,I:nna
Bedl If •l, Be<. Tren. Ftlres No Yc, No
COMMENTS: Induce code diserepenc,es. persons -resent etc.. Inspection Al / Inspection p2.
Location: qqt '90TH A'VC rI GL,,, IOGIi O 3ZQ
;1 All BM Description - 61~ 6L" 2.? Bldg sewer length _
- amount of cover 11 J -T pal an 320
Plan revision Required? Yes o Qg I o
Use other side for additional infcrmation. O a -~0
Date hsepct 's P-11 Cert. No.
SOD-6713:14 .3a? i
- l (_ou
~C'tr Industry Services Division
o1v
- -
' 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.)
P-O. Box 7162
IUL ?I_ Madison, WI 53707--7162
- - - State Transactim Number
,Sanitary Permit APplicatio 1~, L l
In accordance with SPS 333._1(2) Wk Adm Cod:. sulnnisaon of Ilds tarot to the a unit
is required prior to obtaining a vnaan' pe nit Now ApphLoaion forms for srateocm.xl PO\\r17S are submitted to Pn>)eel \ddress (if c411'ererLL ihan uwiling address)
are Dcpanmeni orsafety and Professional Sent- Personal information you proridc may be used fir scoandary
purposes in acvord.wv hill, the Prisac; taw. s. I i f14(1)(m)_ Stair.
1. Ar licalien lnfotma[ioo-P_lcase Pliol Aillnformatitm - - -
I'mperty(hrner'sNamt / Ymoelp
property Chester s Nf Dili" Address property Locators y 'J : I
Orn-L 1.01
Phow Numha r ~t-•. h~'~y_`'i Section
Cds Slat. Zip Code
IL Tvpc of Building (check all that apply) 1 n~
ILJ 1 or? Famrl Ucsellion -Number of l3nlrooms Subfnrtlerl ham.-
❑ PubliciCommercial Dcscnbe U.e
❑ Crty of ,
❑Statc(haned-nescribe use - ❑ village or
CSN `iombtr
Q T. of 1--,
1-
III. T_Vpe of Permiittt_-A((Chetkkl(oniv one box an li=ne A_ Complete fine B if applicable) V~-
❑ Nei s,%-A n T HepMc -meta Syaem ❑ Tr,,b,,nt/Hulding Tart: Replaeegoers! Onlr U Other UodiGoGon to F_cisting SlA-oi :-cylain)
13. ❑ Permit Renewal ❑ Permit Revision [ ] Clung. of U Pamtt T aruJr to New• It Previous P r"al Number and ate )ssfted
Heforc Expiration plumber Uwne
IV_. Djit: of POWTS Syste_IlJ_Com[6ortent/DeVica (Check at) that apph•)
ln-Cnouad C] Prrssun<.J In hound ❑ al-hark ❑ lduuod _ 2d in of.uitable soil ❑ \,om.l< 2d in. of ariwbl. swl
Holding I'anA OUter Dispersal Cnmponrnl (.splam) ❑ Prareatmeot Device (cslslain)
_ LtL# rV1Y1rl~Y_.~
_ V DispcrsaUCrcatmen Arm Information.
Design Flow (gl,d) Lk:si,n Sal .lpplluation Uispers.d Vv He<ryit:d (sl) Ur p -rs-rl .9rs Proposed (sl) Svsten l;leration
VI. Tank Info Capa.inm t c
G Ilons
'Taal of 2
hlanulS.wreT = ° V 4--
LE Septic or Holding Tank _ . a
VIE Responsibility Statement I, the undersippel, x wmr responsibility for installation ofthe_POLVIS shotm on the attached plans.
Ylumbtr'ulam (fr(inl) ` P1umAT.$yaTiire J \IPI\It)tS 'smnlxi I3uvn +s Phone \uni/b..i
l1on,b i s -Nddress (Street- City. Stale. Zip Co&) _
VIII County/Department Use Only
lpprvv,d Dtsappr9sed- Pe``r1m1it ~yF{~ yR~e Iss`eed Issui / SiPfaw e
IX. Conditions of ApprovaUReasons for Disapproval 3) Qan A l
SYa1 EP1 Cj'A'NF lie T ~9,
1 Septic tank offuenl fI1Fi 1 r I
dls crs:d ( ell mu3t he r~l rd i_n al^(~ irr,::
as rur rtt3nnyc:nenl plait ,r ~,:'i~ tort h;, pldmGec
w rt
s3stem and submit to the Couoly mrh ao paper no lea Waa S Vt s l l inches in shw
ell ~l tr(elrp or
,s petav{I,a
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: -
Owner's Name: I/ z-
Owner's Address:
Legal Description:
Township:
County.
f 25C L -F
Subdivision Name: < =
Lot Number-
Parcel ID Number- .mil/%
Page i Index and title
Page 2 Plot Plan
Page 3 stem Smri9 & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 SL Croix Cty Septic Tank Maintenance Form
Page 6 Warranty Deed _
Page 9 GSM or Plat
Attachments: Soil Test & douse Plans
J
()esignerrPtumber License Number:
Date: J c' Phone Number
Signature jl 2
oeskjrwd plf w roe InCm nd sta aesoq*m Cwwa f Yarwd W POWrs versbrr 20 ,%Uu 1oms-p (molnn),
Pate t
l
1
r
- r-
- /i
a;
04 Z~ /I
7 - -
Soil Absorption Svstem f,--- Section
r ft
4' Schedule 40 Final Grade
PVC Vent Pipe
VJth vent cap ft
♦ -
Leaching ~
Chamber
ft System f7evation
- ft
L
Soil Absorption SVStem Plan View
tt
ft Vent Or Observation Pipe I eachmg L Trench 1
Chambers
I
j ~
4' Dia.
Trench 2 Header
I~ Leaching Chamber Specifications
Manufacturer And Model i ,
EISA Rabng._~%/: sq ft per chamber Soil Application Rate
gpd/sq ft
gpd Design Flow Soil Application Rate EISA
=
a . Chambers
L --_-2 rows of _4, _chambers each___ - -
Page-- of
PL-525 EFFLUENT FILTER
Polylok, Inc is pleased to add its
new commercial filter to its existing ii
line of quality effluent filters. The
PL-525 is rated for over 10,000 GPD = Alarm Accepts pvc
(gallons per day) making it one of amessibBity extension handle
the largest commercial filters in its _ r
class. It has 525 linear feet of 1116 `
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has
an automatic shut off ball installed 525 linear feet t F
with every filter. When the filter is of 1116' Rated for over v
removed for cleaning, the ball will Pdtration slots
float up and temporarily shut off ! ~ r 10,000 GPD h
the system so the effl uant won't `
leave the tank No other filter on
the market can make that claim? j Accepts 4" & 6"
SCHD.40 Pipe
PL-525 4 ;nlt-enariee: r
The PL-525 Effluent Fitter should G
operate efficiently for several years
under normal conditions before a
requiring cleaning. It is recom-
mended that the filter be cleaned {
every time the tank is pumped or i \ e
at least every three years. If the a s r , r
installed filter contains an optional a I gg
`
alarm, the owner will be notified ! W
by an alarm when the filter needs
servicing. Servicing should be Gas defled«
done by a certified septic tank -Automatic shut-off
pumper or installer- s r ball when fat"
7 i--
1. Locate the outlet of the gg U.S. Patent Nor 6815,486 is removed
F
E
septic tank. S 5,srt,640
2. Remove tank cover and pump
tank if necessary. DL-52-5 =t stallatfi 'r.: 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 131-525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
4
tank. Make sure all solids fall ' or 6' outlet pipe. If the
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 filter is property aligned and 4. Insert the PL-525 filter into
completely inserted. its housing.
3. Replace septic tank cover. r 5. Replace the septic tank cover.
a'~
ST. CROIX COUNTY
SEPTIC TANK MAINTAINANCE AGREEMENT
AND
OWNERSHIP CERTIFICATE FORM
Ovmer/B'rYtr_ 1 i;~
,sue ~
Property Address- 19A'~/f/JE
(VsErat;m tagsved ham Flaming Department for sew amrrtesim)
City/State.;_~„~.-_'-' Ms,4L Parcel Identification Number_a, 2 -_2o - ,'?0 - Zw
;%h 2
LEGAL DESCRIPTION
Property Location''/., /j(/ 'A S/ee J TY[N-R_dW, Town of ~)Arnl~rf~
Subdivision --~,sc;;_ 1~s I.dp 4
Certified Survey Map#_. , Volume Page
Warranty DeedN _(e~~ to volume ~ 881 -page L'S
Spec house _ yes _ X no W lines identifiable yes _w
SYSTEM MAINTENANCE
Improper use and maintmance of yotir septic system could result its prernattne failure to handle wastes.
Proper nuintetunce 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 atfed the ftmaion of the septic tank as a treatment stage in the waste
disposal system.
llie property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the
owner and by a masteaplumber, 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 113 full of sludge
Uwe. the undersigned have, read the afnveroquirertents and agree to maintain the private sewage disposal system with
the standards set forth, herein, as set by th Department of Commerce and use 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. Zoning (ice within 10 days of the three year expiration date
SIG 'RE F PLICAW L ~J DATE
#of proposed bedrooms s L
OWNER CERTIFICATION
1(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 th.5property described above, by virtue of a warranty deed recorded in Register of
te.
;IG v F A. r - DATE
Any idarmahoo that r rlncrapramted may ronik w the aaNary perm[ being revolted by the 7mme Depatmaai sea
« include web this applicium a ranged watratry deed @om the Itegder of Deeds office
a copy of the owtdwd on-my cop dcdaeoo u made nthe w>vrry deed.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ~►h~t itRVt eIGSS%L (bns,~ uC
Mailing Address Po SM,r X66 Svc s~# , r
Property Address <//i / "f~ 1
(Verification required from harming Department for new censtmction)
City/State t~ / L+ l 5 Parcel Identification Number
LEGAL DESCRIPTION
Location Sec. ~ T"" N-R1W, Town of ~ "YV.irf5~e~
Property ~
Subdivision (-'z& j Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # 17 7 . Volume (911 Page # Spec house Dyes ❑ no Lot lines identifiable 9 (ryes O no
SYSI M MAAUMMANCE
Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maiaoersnce
consists of pumping out the septic tank every throe years or sooner, if needed by a lioersed pumper. What you pt into the system
can affect the function of the septic tank as a treatment sage in the waste disposal system
The property owner agrees to submit to St Croix Zoning Department a certification form, signed by the owner and by a
maswphmober, journeyman plumber, reshimodplumber or a liceasedpumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition andlor (2) after inspection and pumping (if necessary), the septic rink is leas than 1/3 frill of sludge.
Uwe, 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification
sating that your septic system has been maintained must be completed and retrued to the St Croix County Zoning Office within days of the three year expiration date.
S ;,,.a Op eb,,, .,}I DATE
OWNER CERTIFICATION
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 Wdescnabboyco tue of awarranty dad recorded in Register of Deeds Office.
61 o
SIGDATE
•••••s nt.••••••
Any imformatior that is mis-represented may result is the sanitary permit being revoked by the Zoning
Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of_
FILL= INFORMATION SYSTEM SPECIFICATIONS
O':mef
Tank Manufacturer. ❑ NA
Pei [lilt #
Septic ❑ Dose I I I loltling Volume, .T - (gal)
DESIGN PARAMETERS Tank Manufacturer. iaC LI NA
Number of Bedrooms: _ 11 NA Septic ❑ Dose I I f folding Volume: (gal)
Number of Public facility Units. j4 NA Vertical Distance Tank Bottom(s) to Service Pad: 00
(gavday) Horizontal Distance Tank(s) to Service I'ad: (Iq
Estimated (average) now
Uesi n - Specific sewfang rnechank,s must be provided if vertical is >15 feet or
g (peak) Plow (estimated x 75) ^ (.tauday) it hodirxrtal is:-150 feet. SpecffK instructions to be provident on back.
In Situ Soil Application Rate: (gaVday/fl') fffluent Filter Manufacturx rF- _ ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: i.1 _ .
Fats. Oil & Grease (FOG) <30 rng4. Pump Manufacturer:
Biochemical Oxygen Demand (ROD,) :120 mg/I_ ❑ NA NA
Total Suspended Solids (TSS) <150 mgll. Pump Model:
Hgh Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/I_ Manufacturer
(ROD,) >220 mg/L NA LI Mechanical Aeration ❑ Peal Filter NA
(7 Ss) >150 mg/L ❑ ❑ Welland
I'retreated Effluent Monthly average Disinfection
❑ Sand/Gravel fitter ❑ Other
(OOO;) 30 mg/L Soil Absorption System
(TSS) <30 mgfi G') NA
Fecal Coliform (geomriric mean) <Iw 0 In Ground (gravity) ❑ In Ground (pressure) ❑ NA
❑ At-Grade ❑ Mound
Maximum Effluent Particle Size in dia. I I NA ❑ Ddp I ine ❑ Other.
Other: Other.
f1NA ❑NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) R) When combined sludge arid scum equals one-third (Y) of lank volume
_ I I When the high water alarm is activated
Inspect condition of tank(s) Al least once every: ❑ Month(,')
- ❑ year(s) (Maximum 3 years) ❑ NA
Inspect dispersal c oll(s) At least once eve
- - ry: ~ ycy(,) (Maximum 3 years) I J NA
Clean effluent fitter At least once every: ❑,rnonu'(s) I 1 NA
Inspect pump, pump controls & alarm Al least once every. ❑ 010111'(')
NA
El yea:(s)
Flush laterals and pressure test At least once every: F1 oioo11t(') ❑ NA
❑ year(s)
Othcv: Al least once every: ❑ month(s) ❑ NA
❑ year(s)
Other:
IINA
MAINTENANCE INSTRUCTIONS
Inspections of tanks arid soil absorption systems shall he made by in individual carrying one of the following licenses or cellifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POVVI S Maintainer or Septage Serv:cmg Operator (pumper).
Tank inspections roust include a visual inspection of the lank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge arid scum and a check for any back up or pending of effluent on the ground surface. The soil
absorption system shall be visually inspected to check the effluent levels in the observation pipes arid to check for any pending of effluent
on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory authorty.
When the combined accumulation of sludge and scum in any treatment tank equals one-third (1§) or more of the tank volume, the entire
contents of the lank 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 X12 months, shall be performed by a certified P04VI5 Maintainer.
A service report sf be provided to the to <if regulatory authority wtnin 30 days of completion of any service event.
GMw-nos (04105)
rage ~ nt.--
START UP AND OPERATION
For new construction, prior to use of the POWTS ehec:k 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 nonnal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is riot 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 pcunp tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or POWI S 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 sal 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 writer softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanwitly taken oul of skfvica the following stops shall be taken to insure that the system is properly
and safely abandoned in compliance math s- Comm 63.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil abscrpton systems shall be disconnected and the abandoned pipe openings sealed.
• 1 he 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 aril removed or their covers removed and the void space filled with soil,
oravel or another ine-t solid material.
CONTINGENCY PLAN
If the POWI5 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 dislulbance and compaction and should not be infringed upon by required
setbacks frcxn 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 c ornply 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 baring advances in POWfS technology, a holding tank may be installed as a last resent.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POW I'S a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a
last resort to replace the failed POW IS
11 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
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.
v
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER
F a'nName
one P- [hone _
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
This document was drafted by the staffs of the Green lake, Marquelte and Waushara County POWTS regulatory agencies in crroptianre with sections
C.=m 83.22(2)(b)(1)(d)&(f) and 83.54(1).(2)& (3), Wisconsin Administrative code.
r Safety and Buildings Division Co unyY~ /
plisconsin 201 W. Washingbn Ave Jam".
` = Madison, WI 537 - 71" Saniyry rt Number (b filled in by Co.)
Department of Commerce (n266-311
gs
stn:
Sanitary Pe lica on ` .
fn accord will Comm 83.21. Wis. Adm. Cods, personal r 'on you it,
may be used for secondary purposes Privacy taw, sl5."I xm) project Addrep (if drIbirent than .dg address)
I. Application Information- Pleas Print All Information / / fV1% t<-A4j
Propcny Owra's Namryr ~ PmctJ g .ot ~ BIw W/-
ll ~',fr ff//enJ. Jr,i! ~e Gstn~,~~ F
93
Property Owner's M mg Address / . 2J4 ed
Property I.parian
1>~-'A. Q/11L'A. Semionr~' 33
City. $We Zip Cade Pho-e Numbs f uek
of Buildia ;r N; R.2 Vr)
ype g (check all that apply) v, X 5 h'
'lor2 Family [hvelling-Number ofBedrooms`~__ J~ Subdivision Name -ES)dittanbsl
PubliuYbmmerciet - Describe Use L,1' i~ -
~Stateowned - Dexnbe U. ❑Cny_❑VdlsgeEffowaship of
r
III. Type of Perm6: (Chak only cue boa on line A. Complete Bee B if applicable) Q3.2 ~ ,a) O S %,3
O O
A. New Svstoo _ ;v Replaccrnem Systan C TreamwnttHolding Tank Replaceoleu only r] Other Mad mbW to Existng System
B. Pcrtnit Renewal 1 ❑ Permit Revision ❑ Change of Q Parma; Transfer to New Use previous Perin; Number and Date Issued
Uefare Expinu,on~ plumber owner /L <nl '!I o3 -~~(~,PI~~
Iv. Type of P0W'fS System: (Cheek ill that apply) TT JJ`"'
X'Nan -Pressunnsi la-Ground ❑ Mond > 2A in. of =nabk soil ❑ Mound 124 m- ofsuitable sol- - '11-MfwWa --Sngie$y,~prd Fihv ❑
Constructed Wetland ❑ Pressurized InGround ❑ Holding Tank O Peat Filter C Aerobic Tttahnmt Unit
❑ RmrculaWg Sand Filter ❑
Rocirculring Symlrepe Medea Fdtu _ IRaUii ben Drip une (-I Grave:-1 Pipe 7 otlb ( n)
Dis MAVrreatment Arm Info matiou: - - 2
Cosign Flow (gpd) Design Son Application spersal Area Required ( - uperad Area liopond (id) System Elevation
977
III V , Tack Info Capacity in Total Nmnbcr Manufacturer Prefab Site
Sted Fiber Plastic
Gallom Cnllmns of Units Concrete Constructed Glass
N. t as s
Tr1a i Tacks
&pucor HaWnan Tank _ //a!kJ / _ f
A U.
?wag Chamber
VII. Respomibility Statement- 1, the andersigae4 s mm responsibility for installation of the POWTSahosre oa the stenciled plans
Plum crane (Prim} plum 's Si TMPIMPRS Number &narns Plwrne NUmhre
Plumber's Address (Street. Ciry, State- Zip Code)
V'I1L Couo /De rtment use 4.1hatir
,y. Appruva f U Disapproved Smitaty Pbmu Fx -eludes Grorudwate Dam I-cd Agent Si®rmue o Strrnps)
• sw r
- Suearge Fa) ~ r
~ oww - G_rveo`Nmeaa,Dand _ VLF
1X. Conditions ~_prov_ fsr8btpystnal - SYSTEM OWNER: S~ Q~e~ 'eun Q~ F•S
I Septic tank, effluent filter and I Q ft ' /
dispersal cell must all be sorviced / maintained NBC
Cl-
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code/ordinances.
Arses m pkft pas (s Ma Cavry rob) sar ii~.raas m e w asr Im raaa U/Z a 11 imbe, Y a ae
SBD-6398 (R. 01/03)
Nlswnsin DePnmefd of Comnwrce PRIVATE SEWAGE SYSTEM Cou lly St. Croix
Sa!o{y a~.1 BUi,eing Diviegn
INSPECTION REPORT SaWary P0",I No
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan D No 488185 0
P,sonal information you provide may oe used for secondary purposes (Pnvi cy Law. s.15 04 (I Mm
Permit Holder's Name City Village X Township Parcel Tax No:
W ittstock, Allen
I Somerset, Town of 032-2105-BO-000
CST BM Elev Insp BM Elev BM Descnpiton: SodlonrruwniRargerMap No
rOU e-r) (06.&) CST 6, Ate- NE corµ4-,: 33.31.19.993
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
W ¢G.t /opp 11.3 lll$o ioc.co
Dosing Alt. BM -Tbr ob
ISr n;r Co r. j"w I,~ pj C7 o.tr14 /IO.GG
Aeration Bldg. Sewer
q.97 /o r. 33
Holding PL- SZ.~ -G4\'1'Jw SUHt Intel
1 l'44f'9.8G
TANK SETBACK INFORMATION Sti'Hl Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dl Inlet
Septic 87 ~Qr `y51 S e` 8U, Dt Bottom
.A l r
Dosing Headeriman.
!Z•le 98.65'
Aeration Dist. Pipe . r_S 6wo
Holding Bot. System N_o 97.3
ATE ea. rwZ Final Grade
PUMP/SIPHON IN RIIIi $ S 102-e,
Manufa urer Demand St Cover
GPM 1ST 7•'5?S /0 3 .ST
Model Numoer Lo r «y C►.s. W
~s. sr
TDH Lift Friction s System Head TDH Ft
i For am Length Dia. to well
SOIL ABSORPTION SYSTEM
BEDRRENCH Width I "in No Of Tmnches PIT DIMENSIONS No Of Pils Inside Dia. Liquid Depth
1 DIMENSIONS
SETBACK SYSTEM TO P!L BLDG WELL LAKErSTREAM LEACHING Macture n~
INFORMATION CHAMBER OR :ocl-#+w St
Type Of System UNIT
<wsv4+u'4: pl. S'1 1 1 (05 NG 1. H~ ~a ~rC 3L
DISTRIBUTION SYSTEM pt, cho. - t 2uti
1HeaderM4anibld Oistnoution x Hole Sirn Ix Hob Spetlrg Vent to Air Intake
if PiMrisl hJS
Lenglh~ ___Dia T' Length, DiSpacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over I U Depth o! za Soodod/Sodded xs Mulched
9e46reeewconler q , I BediTrench Edges topsdl Yes No F~11 Yes U No
COMMENTS: (Include code discrepencies, persons Dresent, etc.) Inspection #1: Inspection #2:_
Is(w I
Location: 441 150th Avenue Somerset, WI 54025 (NE V4 NW 114 33 T31N R19W) Grade Estates Lot 8 n Parcel No: 33.31.19.993
1.) Alt BM Description = Top ~ fs" Tarr f.OU- •1- To e 04 aA.pr- `Q- ISt-, C6f N-W
2.)84g sewer length = 45 t
- amount of cover = t
8 g ~ ~ {v0 vrvA~
Plan revision RogdreV r] Yes No 1D OG 1
Ilse othef side for additional infonnahon.
Can
SBC87!o (R.3fg'; Dete Oisopcfor's Sigrwture . No
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Wisconsin Deparunem of Commerce -SOIL AND SITE EVALUATION
DivlsioRof Safety and buildings T , Pap of
.
Bureau of Integrated Services h ncevyith s. ILHR 83.09, Wis. Adm. Code
Attach compete site plan on paper not ^ 8 in *6 . must County include, but not limited to: vertical (BM), and
percent slope. scale or dimensbru, ~loc lion and disler~v - nearest road. P
_ J, I
APPLICANT INFORMATION - ~ar Reviewed - - Oeb
PMaorml iMOrmetion you provide may be .15-04 (1) (m)).
Property 3 Z\ Property Locatiorr- L(1
F Govt Lai - 7K 114,S T - N.R leot'W
Oveler's Mailing Address Lot t Subd. hipme or CSMr
Ste ZIP Code Phone Number s 11 City_ ❑ VI" ~ ® Town Nearest Rand
Jy/
New Construction Use: ® Residential / Number of bedrooms Addition to winning buldirg _
Replacement ❑ Public or commercial - Des cAbe:
Code dented daily flow GIZ--_ god Recommended design loading rate ~ bed, gpd'f'~_2_. trrrh, WW
Absorption area required g-bed, NZ_ _benrcll, ft 2 Maximum design loading rate 1-Z_bed, gpd* , . bench, Wd*
Recommended Infilbaticn surface elevation(s) X97 7 n (as referred to site plan benchmark)
Additional deeigrdshe considerations
Parent material .,a._ Flood plain elevstlon. If applicable R
IS = Suitable for system Convantlonel Mound In-Ground Pressure AT-Grade System in FA Holdbg Tank
U = Unsuitable for system 9S ❑ u ®s ❑ u ®s ❑ u ®s ❑ u ❑ s m u ❑ s ® u
SOIL DESCRIPTION REPORT
Bring # Horizon Depth Dominant Color Mantles Texture structure Consistence Boundary Roofs GPDAP
E3 in. Munsell Ou. Sz. Conl Color Gr. Sz. Sh. Bed , Trench
L_ ZLL
Ground
elev. 3,
LfL _
Depth to
limiting
factor
>.lin.
Remarks:
Boring # M d
/
Grow '4L`~ , a✓._ iZ
elev. -
tt.
Depth to - - ,
limiting
factor
_in. Remarks:
CST Ne Signature Taleptione No.
Andreas - pate CST Number
tip fr l~ - c ~ -V/
PROPERTY OWNER,L/ SOIL DESCRIPTION REPORT 'Page -_2
PARCEL I.D.e /
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots aepM2
gyn. in. Munsell Oa. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
-.e 167 ~f
Ground
/elev.-y'
/~rt.
Depth to
limiting
factor
Remarks:
Boring #
2-s CZ
Ground
elev-
Depth to
limiting
factor
?>,v
Remarks:
Horzon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots
in. Munselt Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
all
Ground > -
etev. - ;
Depth to
Ilmitlng
factor
Remarks:
Boring #
*40
Lad
Ground _
Merv.
h.
Depth to -
IlMting
factor
--in' Remarks:
SBD-&930 (R. O7/98)
PROPERTY OWN SOIL DES RIPTION REPORT Page,-,2 cil---~Y -
PARCEL I.D.e
Boring # Horizon Depth DorMnent Color Mottles Texture Structure Consisterm Boundary Roots z
® In. Munsell ou. Sz. Cart. Cola Or. Sz. Sh. Bed . Trench
S.
9
Ground V4
elev. .
Depth to -
8rrtitnp T 97. 9i w
factor - -
Remarks:
Boring
® / _ 5 f! c
j/- Tel
3 +
Ground
elev.
6.
Depth to -
OnVdng .sue .
facto
Remarks:
Horizon Depth Do"nanl Color Mottles Texture Structure CAnslele" Boundary Roots P
In. Munsell Ou. Sz. Cont. Color Or. Sz. Sh. Bed . Trench
Boring # JUL
® 1Crs
Grand - _
elev.
- s -
Depth to
lm*hg
factor
?In' Remarks:
Boring #
13
Ground
elev.
tt
Dept, to
Iirn"
Motor
-~n' Remarks: -
SBD8330 (R. 07198) -
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wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County : St. Croix
SAWy end euildvg 0, ision
INSPECTION REPORT Sanitary Pemnit No
430147 0
GENERA INFORMATION (ATTACH TO PERMIT) Slate Plan ID No
Personal info n ahoo you pfcvee nay used for secondary purposes (Privacy Law. s 15 04 (1)(010
Permit Holder's Nain 54,r, _ GN Village X Township Parrnl Taz NO-
American Classic 1:40M" Somerset Township 032-2105-80-000
CST SM Elev 1 -1 BM Description. Scho 'RenigwWup NoM .
33.31.19.993
TANKINF ATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. sewer
Holding SIMI Inlet
TANK SETBACK INFORMATI SVHtO t
TANK TO P/L W ELL G. Vonl to Air trdake ROAD DI I t
Septic Bottom
Dosing Header/Man.
Aeration ist. PI I
Holding B0W#%fZL%
F
PUMP/SIPHON INFORMATION inal de
Manufacturer in and ver
G ! 11111111 Model Number
TDH Lift Fncffim ! nss System Head TDH t
Forsemain Length Dia. Dist. to v)
SOIL ABSORPTION SYSTEM
B DIMENSIONS Width Length No Of Trenches PI DIMENSIONS No Of Pits Inside Dia Lieuid Ceplh
DIMENSIONS
SETBACK SYSTEM TO 11P/L BLDG WELL LAKEI EAM LEACHING Manuhwlorer
INFORMATION Typo Of Syslom. CHAMBER OR r UNIT .brfel Numcer'
DISTRIBUTION SYSTEM
I Head"MMandold Dislri n x Neb S¢e x Hoe SDanng Vent to .4r intake
Pipe
Lennih, Da L. r_ _ _ Dia Span na
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst Onty
Depth Over Depth over xx Depth of u Seed ded xx Mulched
Bodarmdr Center BedrTrench Edges Topsal Yes No Yes No
COMMENTS: Audit ode disuepencies, persons present, etc.) Inspection ut_-_/_/_ , Inspection a'2:-/
Location: 441 1901h Ave Somerset, WI 54025 (NE 114 NW 114 33 T31N R19W) Gracie Estates Lot 8 Parcel No: 33.31.19.993
1.) Alt BM Description =
2.) Htdg sewer length =
amount of over =
Plan revision Required? Yes I No -
Use other side for additional information.
Date In"Dolo s Signature Cen. No.
SBU871e (R.3911,
Safety and Buildings Division County
i
Visconsin 201 W. Washington Ave., P.O. Box 7082 Madism m 53707 - 7082 Sanitary Perem (to be hood to by CoJ
De ertment of Commerce (608)261.6546 J /1/ 1`
nL
Sanitary Permit Application State Man LD. Num
In accord with Comm 83.2 1. Wis. Adm. Coda personal information you provide _
my be used for secondary purimes Pnvatey Law, %I 5.0/(1)(m) Project Address (it r0ermt Wrr mining address)
1. Application Information - Please Print All Infarmatoa ,
Propwty a Name - ;Pucd tat a neck
7
Dwmtt's 'ling fliddireSs --^77'.7~ t Prapaty Location $ • 113
[t o _ 3
Sstion,
City, Swe
Zip Code phone Number x
z Ix
H. Type of Buildlag (cluck all t apply) V -
a bdi Nuns CSh1-tlsmber
I or2 Fsmily Dwelling - Number of - Su
D Publr.Commcacud - Describe U~^yve a (/K u BQ ' "
D State Owned - Describe Use (Sry_DV iltayy, QTowndsip of
III. Type of Permla (Cbeck only oae boa a A. Complete line 8 if applicable)
A- New, Syvan D Replacement S
ystms TrumwuMOldiog Took Replattmanl O Other Modification to Existing System
is. ❑ Ponmit Renewal D Permit Revision ge otermto New IJst Pamir ben lssBefore Expin ion er
I V. Type of PONM S stem: Cheek all that a 1 _ _
❑
Nan -Pressurized lo-Ground D Mound > 2e m. of scalable soil Mound m. of WILabl it ❑ de Pass Sand Filter
Comumoted Waled ❑ Pr ,w d In u.mnd D Holdiog Tank tes U Tr ❑ ircuWing Sand Filter ❑
Recinadatimg Synltimc Media Filter _hin Clamber p Lan I Cnaycl Pr ) _ _
V. Dis aVrreatmeat Area 1 ormation: 2 74
Desigm Flow (gpd) Design Soil Apphcaowt Rare(yp&f) Dispe Area Rt (if) spersal Proposd (sf) System Fk /
.L ~ s/ .C 1-2 _ t/ v
VI. Tank Info Capacity in local Num Manse Zf&b Si Stocl fib« Plastic
Gallons Gallon of w/~f i _ 0 Concrtt Glaas
New E.Wog >j 1. -
Tanb TrJV - 7 _
Septic «NOUiag T:aa _ - 7
>W-
Amebic Trtatam Uaa
VII. Res o ility Statement- 1, the u nigned, as a resposslbllny for IwWlatloa of the PO\ shown as the attached plaoa
Plum me ( melon' S t MPIMPRS Numbes Busu+css Phasic Number
P umber's Ad4ttss (Sven, Ciry, S " ip Gde/) / , /
VIII ` oun ID rtse Only Xd01 vM Sanitary Permit Far (Includes Groat~wter Da issued uing A8 Signatum ps) r
Surcharge Fee) e7 / 0 0
aVRusons for Dia pprovaC~lf3.hacG>~ rn ~orn i,.• d3. ~3
AnarheppharpWn(«Ik Cwary wMt ayWw.•r aarW this Mtaalae
SBD-6398 (R. 08/02)
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