HomeMy WebLinkAbout018-1096-03-000 (2)
:'A sconsir Cepacment or Cannn`"0° PRIVATE SEWAGE SYSTEM tsmry St. Croix
Safety anc Be 1 -.g D,', "T
INSPECTION REPORT Saniay Permit No
GENERAL INFORMATION (ATTACK TO PCRFAIT) 605168
Ste:C Plon ID No
PcrsOr'al i"lor^'abon .fe2 p'.1. Ile rear De use0'e'seGOr'de'y D11;uses F"ivacp I_a''/: 5 't, C4 !1l;mj]
Per-~t HCicer=, Nare f: V.Ilage Iownsnlp Pa:-el Tax No
Darren & Vikki Grass TOWN OF HAMMOND 018-1096-03-000
CS 1361 L ev. IIse HM Llev. BM Desn,iplion JLC:I L'9+lown74ange Map Np.
09.29.17.778
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACI IY STATION BS HI FS FLFV
Septic Henchmark
~X(STij~ ~u( ~ UOd >.!oy (oLLe (r), C,()
Dosing At. BIx1
~c. C fs-tcr 7~Xj /nicl
L4 9k"U
Aeration ate, (",-V 13109 Sewer "
Ivd - /
Holding St-'H: Inlet
7, C? 7(fl.6~
lfHt Outlet
TANK SETBACK INFORMATION S
TANKTO Pit, WELL BLDG. Venl:c Air intake ROAD Of Inlet
Sep: .c D! Bottom q,
7/00' l~•.~J -
Desr, HeadedMan. ~D
Aeretton Dist. Pipe 7e. L4 v
Holder; - Boll. System
Final Grade
PUMP/SIPHON INFORMATION a-
1
Manvactu'cr Demand St Cover
GPM f tr 14,1 G• r (O /Q?. 1?e
Model Number -1-
2 _6611L
k 73
TDH Litt Friction Loss System Head TDy7 Ft
F5 .k1 7 1 Z T 7-72
Fcrcemrn Len th Dra. his:. to Nei
7941 I 71ur," -T~ 'a
~S2
SOIL ABSORPTION SYSTEM
BEWTRENCH Vidin _en;Cr No Dr 'e"ves PITEIMENSIONS N7T9' Insl > Dias Lowc Cep:h
DIMENSIONS +T' o r 3
SETBACK SYSTEP41 TO Pfl. C BLDG WELL LAK !STREAM LEACHING M 'u'C --"pp
INFORMATION tD f Sy, err. CHAMBER OR - ~wtt Il-'r`-~,~
..C«t!i 1 L_n y i loon UNIT I:ocelNu-
DISTRIBUTION SYSTEM ~5{ y ~~j Cl~ L Vft
Heace"r Man Inid Dlsl'il;A, r, x Hale Sve - x Fe e Spacir3 :"[:C Air Infakc
~I
y ' Pioe!si
.er;th ~ C a Le^;~h ~ Dra Gparlrq
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
DcVtt, crs Ceol•O':er _ xx!7eplh nl _ ~x Seede7+SCdded xxNtulched-
Cuc;TrcncCc: to ? 6edTe-rn EC;es - IoDRarl - -
/ Y" No Yes No
COMMENTS: tinc.I.de code disc,epercies. pe,sens present, etc.) Inspection #1 Inspection 92
Location: 1fj'!A TH ST 0.--
1 ) Alt BFA Descriptor -
2.) Bldg sewer length -
- amcw of cove, _
Plan revision Required; _ Yes -J No I
Use other side for additional rformaton . _
Date I DsepcOfs S;nature .:xt NG
560-;7'r, ~,R >e i
L~ Sakty aril Bu"l Dl St rroix
/s `s' 201 W W35hr19tOr1 Ave, P_0- BOX 7162 S.anlta~ 14*mt \unbn Iw is f it e l o has C-0) Madlson. W 53707-7162 / V
JLr of ( 2 C, ~5
tae Tr \t.nlxa
- Sartitary Pl t Applica
I n a xvvdt w N.th PS iS i}\N..t - .,y.x. p(Iht Mxm M the aArv,vtxr LV.ettalafail late
rs ny.tvgd Pxx b RYmrt \..tc \RJrwKn Rhm lix saahnva.d b Pnyctl %4hr,, 1.1 .htr.Yrnt than matting aldr l
Idr rkpa~a 01 . rnltl _ a`iPrl~voal 1.-n as IiYVOaI m(a>eabnl ~w ptm a1C mT lr u tvatrt
putaxsmaYiv.ka~z•Nnh Ur Ptaa~ IAN., I~tlp lfml. Ctaa, _ _ '
L A lirston forectuat6a - P Prot An 1oremsfisa 1086 174th St. _
Prul O%Mt \qne I Paf.til a
Darren & V*Ju Grass - 018-1096.034)00 - 1
N..petu 0a,m-c\Wh2•\S1te+, P.aryYn lcwa•xan V~
1086174th Street tA.t Lot
(ln st>,.- rgl..k Phi Nuoil NE . NW 9
l
- 17 r..rd:.arc ~
11 T 0t1 - T 29_ S. R I _
Pe toR (Acct a9 that apph I 1 n s
II«~Immh lh.dlnN \,mtAf, 0r l4.ru..m 3 3 %Uhl^~`0no /
Idni A Pheasant Ridge
P.tt.Itll'..t~.et.Ll dkYYttar L Y
❑ Ctn ar
u Stale O ned rreYYex I w CSN \1ndler U ~-ttlaY of
, r5 CL ti ,awn w I(ate aX.f - - -
Ilt. 1}pr of remit- -
- -
1 ❑ Oafaev 1k~G-am a, Lmtmg ..,+m
II, Q~~7 \ S'v Ttratmagil4.fvg tat 1 OM,
K. ❑ IN a l ❑ Pomv Rl ...4171w ❑ Pemn Ttamre In ti. I Pc. was Pcrma Nuni avid ILrc t-. d
1 f.cc I -.n.:.. i a+~ 429937 6111/03
- -
_ ,a• t/Dec-ire: (bale A that a
\..s l`re,vm~ed In (:nom 0 ❑ Atdaa.k ❑ %k.ut > _'J m .4s.utaNe and ❑ K.ud ` 1 m .•i ,.aaelie x,~l ryry 1 -
(1
14JSmg [s* 0 (Y!rr i hycr.-.l t ..nr~...~v I cslJanl ❑ Peaeaoea 1?nve l4pdav.! 45 on I I of
rv4117\rea larermal
I to'~l Fl-, IprJ I)n \1,Iw.t. pp.icP Ihy.e~ii A. R .(1 Dupavl Arcs P (Jl Jl a
450 .5 900 900 97.4-44 96.4
i
j AT lmk l.r. • q~., r..,l : NatudYmY
f (ialMns <iadhxN I:nai ZaWeA-100 - _ _ = 1' •
4s Tai, Fx.msg Task, _ - = 8 0
Ayer.,!\1fer. last 1000 1000 1 tttfkLt X
1l.att (1>mbaa 1 750 750 will X
Ill Respeawbirrh %tatetati - L eb. aaLr ~.nrd, R, yr ve.pa..W tor toteaat:. .r dw rawl'Il w de vatackrd p4vd
Pr.mhi', M1ava tRan/l \rP\IPR\ Yuairr lAemaea Phase V.anhv
Keith Knudtson 648443 651-470-1737
927 150th St. Roberts V1(, 54023
VtJLL nh Ak rtment 1 K Ooh -
Parmn F« ~ Ibx cv ly, 5
.rn Rc3u-: In Ikvul I I ~ ~ / 0 I
17L (~OtdMD116 1001lWfill u for Dta,ppoaal
1. Sept tank, e fly - o!e- nl 'l r µ U
un,He. cAl toil re 'S -rtF.rrs• Iw C.rCI a
ass per ,nar agem ! plan uo by piu nbe<. s Z
2. As oeti reeurer.'mm ri w: Intl ir.(i J CA- °Y
ar ~ ipFlialbM taM. / .r4ina~lctr.
~►e+. do
\w.r w arpkt~ rfaa. for atr gees aad vk~t r tk ('.a~1..J.. pope r ie. d a el %111
SB0.63981R 11- I I1
ST. CROIX COU NTY ZONING OFFWE.
(TRTIVICATION STATEMENT
FOR UTILIZATION OF EXIS'T'ING SEPTIC TANK(S)
This is to ceriiA that 1 have inspected the existing septic and or dose tank
presently sevim<, the followinL residence:
(Street address) I b 2 L(t V 7 ul - Iz;yk- located
at: NT,, ~Jtv ' a. Section Town N. Ranee 14 W.
I own of . St. Croix County Wisconsin.
t pon inspection. I certify that I have found the t<ank(s)_ to the best of m \
knowledge. ~yill conform to the requirements of SPS. 3K4.25. and it (they)
appear(s) to be functioning properh.
Most recent date of inspection or service
Did flow back occur from absorption systern'. Yes No (if no. skip next line.)
Approximate volume or length of time: gallons minutes
Lank Capacity
Consn•UCtion: Prefab Concrete _ Steel - Othcr
Manufacturer (if known
A°e of] ank (if kn(wn): Permit nu ther (tf kn n)
( Licensed PlUnlber Sienature) (Print Name)
G 5`9/x.3
(TitleI (License Number) MP!NIPRS
(Du
Form w be compleled by licensed plumber ( Dept of Safety and Professional
Services C'hapier 105 and s. 145.0(1, Wisconsin Statutes) or licensed disposer
(NR 1 I) Wisconsin Administrative Code)
Rev. 2 201
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name Grass sewer
Owners Name: Darrcn Grass
Owners Address: 1086 174th St.
Rohcrts. i.
Legal Description: NE 114 NW 1/4 S 21) T 29N R 17W
Township Ilattunond
County: St.Croix
Subdivision Name: Pheasant Ridgc
Lot Number
Parcel ID Number: 018-1096-13-000
Page 1 Index and Utle
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Fitter 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. Keith Knudlson License Number 648443
Date 08/25/2018 Phone Number (651) 470-1737
Signature
Designed pursuant to the In-Ground Sal Absorption Component Manual for POWTS Version 2 0 SNn-10705-P (N.01/01)
.
Page 1
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5411 Absorption &ntem Crow Section
100.50 ft
100.40 ft
4' Schedule 40 Firfal Grade
PVC Vent Pipe 97.00
VNOhVent Cap ft
Chamber ► 97.40 It
Y System Elevation
3.00 ft 5.00 ft It
Soil Absorption Swtern Plan View
ft
3;00 it
{
ft Leaching - Trench 1
Chambers
UNIMMiMMEWHENWEBW K\ 4' Dia.
Trench 2 Header
Vent Or Observation Pipe
Trench 3
Leachina Chamber SpeciRcadom - -
Manufacturer And Model
EISA Rating 20.00 _ sq ft per chamber Soil Application Rate 511gpd/sq ft
450.125 gpd Design Flow 0.50 Soil Application Rate _ 20.00 EISA = 15.00 Chambers
3 rows of 15-00 chambers each.
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ) of 2
FILE INFORMATION SYSTEM SPECIRCATIONS
FCP:11 ner D arren Grass Septic Tank Capacity 1000 gal ❑ NA
ii C Septic Tank Manufacturer Huffcut ❑ NA
DESIGN PARAMETERS Fffluent Filter Manufacturer Zabel C NA
Number of Bedrooms 3 ❑ NA Fffluent Filter Model A-100 ❑ NA
Number of Public Facility Units E.t NA Pump Tank Capacity 750 gal ❑ NA
Estimated flow (average) 300 gal/day Pump Tank Manufacturer Wieser ❑ NA
Design flow (peak), (Estimated x 1.5) 450 gal/day Pump Manufacturer Goulds ❑ NA
Soil Application Rate gal/day/tt2 Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average' Pretreatment Una ❑ NA
Fats, Oil & Grease (FOG) 530 mgft C Sand/Gravel Filter ❑ Peat Filter
Biochamical Oxygen Demand (ROD,) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection O Other:
Pretreated Effluent Quality Monthly average Dispersal Corls) 17 NA
Biochemical Oxygen Demand (BOD,) Sf0 -1311- ❑ In-Ground Igravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ AtGrade ❑ Mound
Fecal Coliform Igeomotric mean) St 0` cfu/100m1 ❑ Drip-Line _ ❑ Other: _
Maximum Effluent Particle Size Y. in dia. ❑ NA Other. ❑ NA
Oilwr~ ❑ NA Other: ❑ NA
`Values typical for domestic wastewater and septic tank effluent.° ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ Vearls) c) (Maximum 3 years) L7 NA
Pump out contents of tmklsl When combined sludge and scum equals one-third (Y,) of tank volume ❑ NA
Inspect dispersal cell(sl At least once every: ❑ ear(s) sl (Maximum 3 years) C NA
Clean effluent filter At least once every: I t -oo(h)s) ❑ NA
❑ year(s)
El month( 't ❑ NA
Inspect pump, pump controls & alarm At least once every: ''year(s) sl
Flush laterals and pressure test At least once every: ❑ month(si ❑ NA
❑ year(s)
Uther: I At least once every: C month(si (7) NA
C Year(s)
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, Septege Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing ur broken hardware, identify any cracks or IeaKS,
measure the vnlume of combined sludge and scorn and to check for any back up or pondinp 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 pending
of effluent on the ground surface. the pending of affluent on the ground surface may indicate a fairing 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 (Y,) or more of the tank volume, the entire
contents of the tank shall be removed by a Supiaye 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 fitters, mr:rhanical or pressurized components, pretreatment
units, and any servicing at intervals of _<12 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 v o•
START UP AND OPERATION
For new construction, prior to use of the POV%7S check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process andior damage the dispersal cellls). If high concentrations are detected have the contents
of the tenkls) 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 pwnp tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cellls) in one large dose, overloading the cellls) 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 feat down slope of any mound or at grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the porformance and prolong the Irfe of the
POWTS: antibiotics; baby wipes; cigamtte butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pumpl 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
Inupurly 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 pas 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
It the POWTS tails and cannut 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
cornply 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 tailed POWTS.
tatit a o ing Lank
alua r
rudy_be e a. '~'fZ D+11 fj !7>a ;`pre. n/t~ Corvs'f7zt1~~ a
❑ Mound and at-grade soil absorption systems may be rec.unstructed 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
POW IS INSTALLER POWTS MAINTAINER
Name - Name
Phone Phone -
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ~T. C6zb t)U pI ZOAII,k'l
Phone ;21S-.t-~ .7~ Phone -JIS- i fO0 U
Thir. nocrment was dratted in compliance wen chapter Comm 83.22(2)(b)(1)(d)&(fl and 83.541 71, (2) & (3). Wiuoncin Admirtistrative Cods!
t
Pg. 8 of 10
Dose Tank Component Cross Section
Approved Manhole Covers With Warning labels
and Locking Device / 4" Min. Above Final Grade
\ Weather Proof 300 Junction Box
Electric per NEC C 300 & SPS.
4" Sch. 40 Vent / 316.012 WAC
> or = to 12" t
Above Final Grade
Disco
Alternate Outlet (oration
W/Approved 4" Sleeve
Inlet Force Main Dunn. - 2 "
Weep Hole or Anti Siphon Device
Note: Pump switch and alarm to be A
wired to separate circuits
B Pump Off Elcv.
C
Tank Mfr. Wieser Concrete 750 gal. D
Dose Tank Ekv. ~
Vertical Difference Between Pump Off and Distribution Pipe - Z~.l
Minimum Required Supply Pressure
d- FT. of Farce Main x 258 Friction Factor/ 100FT-
Min. Dose 71.00 gal. Total Dynamic Head _ I Zt `f
Max Dose 120 gal.
Number of Doses 5.7 Per Day GaL Per Day/ #of Doses A.
Volume of Backilow,
Total Dose Volume /~Gal.
Pump Tank capacity 750.36 Gallons Dimensions Indies Gallons
Pump Tank Volume 20.28 Galtlnch A 21,00 425.88 '
B 7. 4036
Pump Mfr. Goulds C D /c 9
Pump Model EP04 D
Minimum Discharge Rate = _
Alarm Mfr- SJ-E_ Rhombus Total- 37 750.36
Alarm Model Tank Alert I
Bed Tank per SPS 383A5(5)
Anchor Tank as necessary to negate buoyant forces per SPS. 383.43(8)(8).
( GOULDS PUMPS Submersible
Effluent Pump
A 11
E P04 & E P05
Series
APPLICATIONS _ • Fulh submernrd in higa ■ EPOS Impeller: Thermo- ■ Bearings: Upper dird over
Specifi;aliy ucigned for the gaidc to bine oil for plash: enclosed design for heavy duty ball bearing cog
f0lloveing uses: lubrication and efficien- i:nuroved performance. strucuon.
• Effluem systems hca: uan,!cr ■ Casing and base: Ruggea
• Homes thermoplastic design provides AGENCY LISTING
Available for automatic and -
• Farms superior strengtt. and corrosion -
Heavy awry sump manual operation. Automatic resistance. Cenndwn standards
• p
• YJater transfer models include Mechanical S 1' • ksoonUOn
F loat Switch assembled and 0 Motor Housing: Cast iror. for File x tRae549
• De'vaatering
preset at the factor). effiden,, hea:lrarsfe[ strength
and durability. Goulds Pumps is 609001 Registered.
SPECIFICATIONS _ FEATURES ■MotorCover:Thermoplastic
• Solids handiing capability. - - cover wrt, integra; handle and
maximum. ■ EP04 Impeller: Thermr•- float switj, attacbmem paints.
• Capacities: up to 60 GPb"., plasic semi-open design power Cable: Severe drRv
• Total head;: up to 31 feet Pumo ova vanes for mechani:al rated oil and water resistant.
• Discharge size: i : ,.i" NPT sealpmtettion.
• Mechanical seal: carbon.
rotaryicerdnx stationary:
ITU"A-1,J elestumen.
•Temparature: MTPS r_tl - -
104° F 1401 Q wntinuom 10 _
140° F (60' QI intermittent +
• Fasteners: 300 Series 9 30 -sum
stainless steel.
• Capable of running a'--_z, Fl
dry without damage tc 15 - -
comronents.
Motor:
• EP04 Siagic prase 04 HP, 51
1' 5 or 23o 1, 60 k-, 1550 -
o is-
RPM, bail: in oved:ad wish I
EPOi
aink reset. °
• EV05 CS Sialc phase: 0.5 His
a - +c_. - - - - -
1' 5 V o- 230%, 60112 1550 -?e 7 LP04
RNA. buih in oveduad with
automatic react. -
• ?owe, con, ; 10 foot
standard leu9th,163 _
S1TtM1' w# mree prong roc i c %c 4mc su GPM
grounding plug Optiunal 20
too:lengm, 169 SALti'vnih c a 4 ; - r,c mtrn
three prong grounding plug
(standard or EP051. CAPA:r'
Goulds Pumps
-•::.,,,,-t, ITT Industries
NUN IH LINE OF I
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68,396 SO. FT. 72. 000 so. FT. 2. 10 ACRES
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P
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LOT ACRES
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Fr. N LOT 24 00. 7,.367 SO. Fr.
1.89 A a F 1. R LOT 25
73,459
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2 "a , 4~ oh
110 1 N ll
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ST. CROIX COI `NTl j
SEPTIC TANK MAINTENANCE AGREENIFNT - ` ! J
AND SEP ] 3 2018
ON% \F RSlill' CERTIFICATION FORM
St Ga;c :clInt„nry
Owrter ETnser Darren or Vikki Grass comet n; of„
Mailing Addrr.: 1086 174th St.
Property Adthvm same
i \ criti.au,n r Vui" from Planning & /onin, Department for ne,%
Cit% State Hammond Wi. Parcel Identification Number 018-1096asant R-03-000
LEGAL DESCRIPI ION
Pro n. Location NE NW 'S". , . 9 1 29 \ R 17 `N. Tow n of Hammond
~ . _
Subdivision Plat: Pheasant Ridge t_rx = 3
Certified Suncy Map # Volume . Page 4
Warranty Deed # (tieforc 2007)Voluaw Page #
Spec house 0yesd Lot lines identifiable e' )esono
SVSTENI NLAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of sour septic system could result in its premature failure to handle wastes. Proper
maintermaocZ consists of pumping out the septic tank eve" three years or sooner. if needed, b% a licensed pumper. W hat you pm into
the system can affect the fmw-tion of the septic tank as a treatment stage in the waste disposal system Outier maintenance
responsibilities are specified in §SPS. 93.524 1) and in Chapter 12 - St. Croix County Sanitam Ordiluncv.
The property owner agrees to submit to SL Croix County Planning & Zoning Department a certification form. signed by the
owner and by a master plumIK;. jomrmme}man plumber, restricted plumber or a licensed pumper seriR ing that (1) the on-sitc
wastewater disposal system is in proper operating condition and or after inspection and pumping (if oecessa) L the septic tad is
less than 11 full of slrrdee .
I we, the undersigned have read the above requirements and agree to maintain the prisate sewage disposal system with the
smWar& get fixth, herein, as get by the Depattnment of Safety And Professional Sere iccs and the Department of Natural Rcsour-cs.
State o( Wisconsin- Certification string that your septic system has been maintained must be compkted and IClurned to the SL Crom
County Phnoing & Zeming Department within 30 das s of the three % eat expiration date
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Vwr certify that all statement, .n this form arc true to the best of my: iur knmwledge. Lwx: am are the owner(s) of the
property described abos e. b.. anue nt a warranty deed recorded in Register of Deeds Ofliice.
NumW of bednroms 3
0u ;DS dell
SIGVA I'~f kqf OF APPI_ICANT(SI DATE
"•,\nx information that is misrepresented ma) result in the samwta permit being revoked by the Planning & Zoning Department-
Include with this application a recorded warranty deed from the Register of Deeds Office and a cop) of the certified surrey map if
reference is made in the "arrant-, deed.
(RED'. OV12)
csT aol~-I8y
Wisconsin Decartment of Safety and Professional Servitors 916
-
Division of Industry Services SOIL E ORT p3352
Page 1 of 3
0 L - - in accordance with SPS 385, Wis. Adm. Code Keith Stoner CST
Attach complete site plan on paper not less than 8'G x 11 Inches in size. Plan must County
include. but not limited to vertical and horizontal reference point (HM), direction and St. Croix
percent slope. scale or dimensions, north arrow, and localron and distance to nearest road. Parcel I.
- 018- 98- -00(1
Please print all information. Revi By Date
Prasonal mhlrmation you provide may he used lot su¢xlrWary purposes (Pnvay t aw. s 15 04 (1) (m))
Property Owner Property I ocation
Darren & Vikki Grass Govt. Lot E1/4, W , S9. T29N, R17
Property Owners Mailing Address I.of w Block p Subd. Nam r CSM#
1086 174th Street 3 Pheasant Ridge
C:dy Stale Zip Code Phone Number City Village Town Nearest Road
Hammond WI 54015 Hammond Same
New Construction Use: Residential I Number of bedrooms 3 Code derived design flow rate 450 GIRD
Replacement Public or commercial - Describe- Z f-PC'
Parent material Sandy Loam Till/Sandy Outwash rlood plain elevation, if applicable NA ft.
General comments Propose 3 S x 62' dispersal cells using a.5 SAR. Center tho upslope cell over the 10040' contour w/a S.E. M 97.40 , center cell
and recommendations. over the 99.40' contour w/a S.E. of 96 40, center down slope cell over the 98.40' contour S.E. of 95 40'
Bonny A Borng
a Pit Ground surface elev. 99.03 ft. Depth to limiting factor >115 in- Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure 'Consislen Boundary Roots GPD/1t'
in. Munsell Ou. Sz. Conn. Color ! Gr. Sz. Sh. •rff#I •t nrz
1 0-6 10YR2/2 sit 2msbk mvfr cs 3f-m 0.6 0.8
2 6-12 10YR3/3 sit 2f-msbk mfr gs 2f-m 0.6 0.8
3 12-26 10YR4/4 sicl 2msbk mfr gs 11 0.4 0.6
4 26-45 7.5YR4/6 Is Osg ml gs if 0.7 I 1.6
5 145-115 7.5YR4/6+5/6 1 sr Is Osg ml 0.7 1.6
Will
❑ Boring k Boring
Pit Ground surface elev. 100.48 It. Depth to limiting factor >94 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consisted Boundary Roots GPDrft'
in. Munsell Ou. Sz. Cool. Color Gr S7 Sh. •Erflft •E a41
1 0-9 t0YR2/2 - sit 2msbk mvfr cs 3f m 0.6 0.8
2 9-22 10YR4/4 - sic] 2msbk mfr gs 2f-m 0.4 0.6
3 22-28 7.5YR4/6 - Is Osg ml gs if 0.7 1.6
4 28-94 7.5YR4/6+5/6 sr Is Osg ml 0.7 1.6
Effluent #1 = BOD 5> 30 < 220 mgA- and TSS >30 < 150 mgA.Effluent #2 = BODs 130 mg/l. and TSS <_30 mg/L
CSI Name (Please Pnnt) Signature: 7 - CST Number
Keith Stoner 224059
a= -
Address Keith Stoner CST i Date 1-..valuation Conducted Telephone Number
23220 Wood Creek Rd Siren. WI 54872 8/112018 715-566-0900
tall 11;.(1411! .11)
Property Owner Darren & Ykki Grass Parcel ID i 018-1096-03-000 Page 2 of 3
Boring
F Bonng H Pit Ground surface elev. 98.10 N. Depth to limiting factor >8S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in Munsell au. Sz. Conf Color Gr Sz. Sh 'Fff#f 'Fffx2
1 0-6 10YR2/2 - sil 2msbk rnvfr CS 3f-m 0.6 0.8
2 6-15 10YR4/4 - Sid 2rnst* mfr gs 2f-m 0.4 0.6
3 15-19 10YR4/6 - sl 2f-msbk rnfr gs if 0.6 1.0
4 19-34 7.SYR4/6 - Is 0sg ml gs if 0.7 1.6
5 34-85 7.5YR4/6 + 5/6 \ sr Is Osg ml 0.7 1.6
l
q ft i
Boring 30 .
Boring * Pit Ground surface elev. Y If Depth to limiting factor in -
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
in. Munsell Qu. Sz Cent Color Gr. Sz. Sh. 'EHtlf •E142
Boring
Boring # hit Ground surface elev. R Depth to limiting factor in. t
Soil Appliwhon Rate
Horizon Depth Dominant Color Redox Description I Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Ou. Sz. Cent Color Gr. Sz. Sh- 'En#f -u1u2
I
Effluent M1 = BODs> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD. < 30 ffKA and TSS < 30 mg/L
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