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HomeMy WebLinkAbout030-2131-12-000 V.4sccns!n Depanmert of Commer!.. PRIVATE SEWAGE SYSTEM -ou try St. Croix Salely ane Bw di^.g Division INSPECTION REPORT Sarn!ary Perms NC (ATTACH 10 PERMIT] 605191 GENERAL INFORMATION stare aIa- 10 'k, Perscra nf,,,wic you pmoice mar be -sec tot secc-Awy pwposes IPir:ary La.c, S.1iC4 )1:IM)I Petmi! PC de`S Nallle City Village Tovish p Patrice: Tax Ne Eric & Jillian Olson TOWN OF SAINT JOSEPH 030-2131-12-000 CST Hh' fleu 1 1 I-so Bbl E cv. BIv1 Descr pt+c. Soul orr To.-.n RargelMap No 23.30.20.1066 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION Bs HI FS ELEV Septic Benchmark Dos-ng At: BM Aeration Bldg. Sewer HoWing SUH: Inlet S7Ht Odle: TANK SETBACK INFORMATION TANK TO 1, -:ELL BLDG. Vent to A I I`lako ROAD Ct In at Sep: C D: Ho!lor DcSirg HeacerAlan. Aeration Dist. Pipe Ho'-Ing Got. System Final Grade PUMP/SIPHON INFORMATION Ma n.lfa--.urer Demand St Cover :;Ptd ldodel Nimbe' IDII Lift Fncbon Loss System Head TDH F7, Forcemain -ength Dia Csl to:'sic SOIL ABSORPTION SYSTEM BED:TRENCH Lengl- Nc CI frenches PIT DIMENSIONS No Of Piss I-sic c Dia Liquid Dcp:h DIMENSIONS SETBACK SYSTEM TO P~L BLDG 's^. ELL I AKE.'STREAM LEACHING 'a-u'us:u cr INFORMATION CHAMBER OR Type Of Sys'lcn! UNIT Mcde Ndni DISTRIBUTION SYSTEM HeadeNtvla!nloW C Sir .hul m x Hole Site x Pole Spacing Vert tc An FtW Pi aye-(Sl Lerylh _ C.a Le,Dia S6Uvi^a SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only CoF,iP Over Dearr Oyer xx tteplr of ax Seetletl+Sodduc xe A'W;.-ec ecd+l Larch fen:er Hee!Tien& Edges 7opsc l l Via _ Nu W.5 Nn COMMENTS: tlnclude code discrepences, persons Ptesei:, etc;. inspection #1 Inspection #2 Location: 154 HERITAGE TRL 1.) Alt BM Description 2 ) Bldg sewer length = - amount of cover = Plan revls on Requeedl Yes _ J No I - - Use other side for add tional iWormalion. 1. - - - - Date msepo!ors Sigratu-e Cart No 5BD-6? 10 :R. Y07: 1 {J~j Y1/ O~ ARTN`y, i~ ~(l~ tl t. ~lrv fKp of ntmY II//~_ e_ ty r 1 ~:4Z ';4CL InduslrySErviceseDivision 5I 12tHk 97 'p~ ( 1400 E Washington Ave SP P.O. Box 7162 Sanitary Permit Number (to be filled in by Co-) `W\ ` S. I ? P 17 2018 hdarlison,VJl 53 07-7162 y 'k^sspnny ~_~l Sanitw.3x-T'L nit Appllc, ) Sratc Transactiup umbea in accordance with SPS - 43 lull Wis. Adm. Code. submission of Ibis form to the appropriate govemmcnfal unit N is required prior to obtaining asanaray permit. Note: Applicalon ;Jrms f f - mined to - " - the Dcpanment of Satsty and Professional ScrvlcaS. PeIS011al int. l6natinn vaa prorldC May be used icr second, Project Address (if different than mailing address) purposes in accordant, with the Privacy Law. s. I i.0,1(D,m!, Suls. - -T - I S I t(C,~IIESL)C i i-'~L 1. Application InfnrmaUn -t Icasc Print: Info ration Property Ow-ricr s Name t r l l 142/ te- p ueel s ERIC 0CSr,tj 30-~ 13j 1z-CGL')L) property Owner's Mailing Address Property Locationo23. 30. A 0. 10 rt L i I q S ~'t o PJl✓.-.~ I~ - C~ I IZ _ Go 1 Lot Ci^~ Stare zip Codes ©'7 Phone Number p rJl l S V. Section LU -2C, (crrelc~e) ~IDUTUfJ v1.F~ SL-ACX;'L_(JI-2`1C1-DHB~)T vi~, , N ee. i Type of Building (check all Thal apply) Lot.. _a {~~J or-' h'amilily Dwelling - Number of Be.ironms IZ- Subdivision Nano ❑ Public:bommcrcial - Describe Use Blctk" _-.--t-c-, C, LE 0 w7( r_ - El State Owned Describe Use Pit. ('fly of - - - - C's\I Number ❑ village of 1 Z p'isa~ GellS w Z e nI one box on line:l. Complete line ~fa,vn <t S`T _~CJ~1'~i III. T Ch ck L---- y - ) 1 - e B if applicablcl_ INCw System EJ Replace.^.icnt Svsrcm ❑ 1'rcatmenNHelding'I ank Rcplacomcnt Only ❑ Other Modification to Existing System (explain) Il ❑ Permit Renewal ❑ permit Revision ❑ Change nl ❑ permit "fmnsfer to New f List Previous Permit Number mid Date Issued Bcri.rc Expiration Plunihr. Owncr 'N-Typt o - stem Component! Devoe' (Cheek all that apply) ',nn . ressur !zed ht Ground Pressunr d In-Gm nJ ❑ At-(irate ❑ Mound mod _?d ut..fsuifab!e soil El ~l0und <'4 to of suitable soil 1Sn1r- L)y - ".it omponcnt(cxflaull ❑1, v DNicr(cxplain) Dis l:rsal. 1 realm 1 Ana Information: f-1 t~SA_1~s7. Desien Plow (gp' Design Soil Application I Dispersal A e ImJ (xQ Uepcnal Area Propos (<f) Svstcm Elevation 6 1 Raided sl) Z. C 1 'tank Info Capacity ~y~ O V C Gallons 'COtal ri of Q r a U f°t b :uluYd![ o - V. [iallons I!niLS mcr V. v S New 'I Utks L'zrnutg'faaks -R v, u J Septic or Holding Tank I Zl.JL~ 1TCC~ I ~.r1J(1 E_ ' ❑ ❑ ❑ ❑ Dc nIK C'ba:ntia: 1L, l ] O- CJ II Responsibility Statement- 1, llte undersigned, assume responsibility for f allation of the POMTS showu on the attached plans. Plumbers Name (Prim) Plu Si tic r M( S'um~cr Business Phone Number F r- _1,- Et^X ('r• 7.32.12 ~1S ll~1t-~`ISB Plumbers Address (Sheet, Cry Slate. Zip Cade) N III uty!Deparln{cnl F se Only lpprore.: - ply Pcnnit Ecc Da Issue Issmn ,cot Sipn e ore Ra m [s r I lrnicl S Y~J ' 60 1 `7 1 ,X11 . n Q ~/~n+~o _ 1\ Condi1il 7A~ki{~I rHealie- for Disapproval 1. bepl.. a ,rk. K*E .r, son or ~J /vD 1 U- .,`1l2'-. cry - tell Le v _ 3sper.nar3gemel plen Je ~r_p roe:. 2. A11 tsr!ba-k reeut° .ass mu t Lu r e • ,r J M per PpFtla>ble r. >r.1: rr><ir z _ T _ KSS 1^^_SL~ JQ15~ 4D YJC.. Attach o, coinpletr. plans for the syftrm and roit rn r C'onoty onh• on paper out Irss than N L1 s 71 inches ia. SBD-6398 (R0311) j i , ~ ',rA iLl~. t'~~ till .5~.✓ ~~i ~iJ G S~fL ~-~~i~lll, l I CONVENTIONAL COMPONENT DESIGN Residentiai Application INDEX AND TITLE PAGE Project Name ~J IL ! LSC;ti~ Owners Name: Owner's Address `f S TAI I j f . (_'C~('~ lS Legal Description. _SCt r1 E V1 , zC, > Y. I rownship _TG SFr h :ounty: Srt LE:D 1 subdivision Name SE I I IZS C ~E-I~ -ot Number, 1 Z 'arcel ID Number. ~l 2) _s 1 - 1 Z-- Paoe 1 Index and title Paae 2 Plot Plan Page 3 Svstem Sizing & Cross-Section Page I Fitter Specs Page 5 Maintenance Information Page u Management Plan Page i St Croix Cty SeDtlc Tank Maintenance Form Page 8 Warranty Deed Page 5 CSM or Plac Attachments: Soil Test & Mouse Plans esigner/Plumber: -:1 F-1-- rc;x _ License Number IVl f LZ j Z L1 Z ate: Phone Number 71~ ~I91 - 3 `I 5 ignature y signed pursuant to the In-5rouno Soli AbsorDtron Component Manua; for PON,?S Version 2.0 SBD-10705-P !N.01101j. Page 1 Lt t IL -4 fL.G~Q (A&:I, % S I N1i'KS 1-Za7`11- -t ; P v ilu r'F~,~'~c S<L% iAkjIC i I.1 M* 4tti1~ZK I Gt' r L t1 eJt <; I~\Cf ~I~`YF ELL- L GC / G Sc-it_ 1wKIIU( i; x •T ~Y AbogroGon 1 ft 4°8dmdul40 t Bede PVC vent Pipe 5 wm, vent cep 4~ , tt ChW ipip -.No. `f~yfpt 8yetern Sbvailon ~3 R ~ IM Absolgtkm AM= Pkn Trench 1 - ~n Mert Or Obeervalm Pkm ctmtm TTWwh 2 Header M.rp,face,rar and Modal J-I.i r ~ 17~ N L 1:' fit' % i L' IL I EIBA Re ft Z CJ sq it per ctrorttbsr sw App icom Refs'_ gpolaq ft Cc,C'C ' qpd Dn%n Flow +Sd AppkWbn Rate + Z U EISA c A itj Clwllbets 2 rows od Z , Z Z- chambers each. Peps of INSTALLATIOt, 1"Tr[UCTMUS , & PL.-M51PL-r6Z5 >rILTER :R9WW= 1. 1 &qD,L.W FEA►3UM 8 BENEF" Featam & =K s Retied IN 10,000 GM 'Y •,G a PL-b25 = 5!~ Lk>eS Feet of 4MB' F~aifOn FI4MIon PL-825 = M t In w Feet of 113Z' s- "f PLC oAoauptie 4' and 8' sow. 40 Pb° rL.B'l516Q613rer~t Ftlter ehoiAri opards eidarsY • BUYI in Coe Daltecbr sverai yearn under nonnni oonditm bakwo eAuWm 6c Shul~M Bel when FOW Is Removed rWcw *ig. it k rsoonwwwad that the Mar be rod ffmmy time the wk is pumped or at knot eMY oAiarro AoomWAW I yeam if the irokMnd fter oordains an op%OW ACCe{1is PVC F bn a. the goner ws be no66ed by an skim when the a roods asrvking• Savidna should be dons by a sod sspw %w* pumper or km*dWr ;OMMBWM PROM= - wrrr Pdouft "C Ma y. t r ' z 1 - I 6AMN1 fAlC° 1tL~r>edsb Gaam eri wCove m Pdyldc +d 31.+oYo pP~ecsb~laaktfd* uxw errr+n _ WwdComwelft a f skMikdon Maid ~nhePQw~O~didrw MSMM sDvao,-A o Oowwora"Pas bft open t snilne iat- mrfsawan forb9ft s>Pf~ roaraa~+~ arc Fftra dArg4 grow °Bi°~ Ear:ttiatbcofPbiyloka,~itourwpb~ea~ w.f" POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: V-0 ICS6 R ❑ N Permit # ;Septic Cl Dose ❑ Holding Volume: Z(]O (g: DESIGN PARAMETERS Tank Manufacturer: fjN Number of Bedrooms- ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: WE e' (f Number of Public Facility Units. ❑ NA Vertical Distance Tank Bottom(s) to Service Pad: Estimated (average) Flow CIO (gal(day) Horizontal Distance Tank(s) to Service Pad: j 0 If Design (peaks Flow = (estimated x 1.5): C , alltla SPeciLC servicing mechanics must be provided if vertical is >15 fear n _ o tg y) if horizontal is >150 feel. Specifc instructions to be provided on back In Situ Sal Application Rate: (gat'dayRr") Effluent Finer Manufacturer: Ll F6TJ NV' ❑ N, Standard (Domestic) Influent/Effluent Momhty average Effluent Filter Model: Fats, Oct & Grease (FOG) s30 mg.'L Pump Manufacturer: +r Biochemical Oxygen Demand (BODr) x220 mg/L ❑ NA RN, N, Total Suspended Solids (TSS) _150 mg/L Pump Model: 'S High Strength Influerb Effluent Monthly average Pretreatment Unit (FOG) >30 mgA Manufacturer: (BOD.) >220 m 1L NA F.1 ITS_)_ >150 mg.-I. Mechanical ion Aeration ❑ Peal WFilter eiland a-1,11 Pretreated Effluent Monthly average [I Sand1G!av ❑ arid/Grav ❑ el F liter ❑ Other: tnec _ (BOD,) s30 mglL Soil Absorption System (TSS) s30 mg+L PkNA Fecal Colgorm (geometric mean) '10' In-Ground (gravity) ❑ In-Ground (prossure) El Ni Maximum Effluent Particle See ;Q in di a. ❑ NA Grade ❑ Mound ❑ Dririp-Line ❑ Other. ❑ Other (71 NI MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume When the high water alarm is activated Inspect condition of tank(s) ~ At least once eve ❑ monthW - ry'_ __.3 ❑ year(s) (Maximum 3 years) El Nf Inspect dispersal cell(s) At least once every: I ❑ yooms(s) (Maximum 3 years) ❑ NF Clean effluent filter At least once every ❑ momhfs? ❑ N< - _ - 1 ❑ year(s) Inspect pump. pump controls & warm At least once every: ❑ month(s) - ❑ ❑ year(s) Flush laterals and pressure lest At least once every: ❑ murnh(s) - ❑ ❑ year(s) Other: At least once every: ❑ month(s) - _NP ❑ Year(s) omen: - l ❑ NP MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certification Master Plumber, Master Plumber Rest,icted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper Tank inspections must include a visual inspection of the tank(s) to identity any missing or broken hardNare, identify any cracks or leak measure the volume of combned sludge and scum and a check for any back up or ponding of effluent on the ground surface. The st absorption system shall be visually inspected to check the effluent levels in the observation pipes and to deck for any pending of efftuer on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and requires the irnmedial notification of the local regulatory autixxity. When the combined accumulation of sludge and scum in any treatment tank equals one-third ('h) or more of the tank volume, the entr contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 11: Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment unit: and any servicing at intervals of <12 months, shall be performed by a oerbned POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02:0! 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Jo/pue sl!e1 S1MOd O41 ua4M 1N3WNOONVSV -afumps!p auuq lauagos lalem pue 'suoduel 's1uaAlos 'stjlXdeu Aipl!ues 'seppgsad 'spnpold buqu!ed 'silo 'suogeolPaw 'sderos /w 'sopa!glaq 'seseal6 'aupse6 's6wlead olgela6aA Pue 1914 'oBimps!p (dwnd duets) u!wp uogepunot 'slet 'sluepalu!s!p 's iade!p ;OU leluap 'siosealrap, 'sgems WWO 'swopum 'sgnq agale6p 'sad!m Ageq 'sOgagque 'sppe :IualsAs uogdlosge Ips pue sluel 3ugea.q agl to egI ayl 6uoloid pue oouuwlotlad 941 anoldwl Aew weans lalemalsem aql woal 6uvnopot ayl to uogeu!w!le to uo!pnpaa Tarp uo!tdlosge !ps apel6-lp to punow Aue )o adols umop laat % u!yl!m ease I 'pedwm jo glnlsip asvlvallo Jo 'leAO Ted to eAup lou oO -walsAs uogdiosge 1!os ayl io sXuel lano sap!laA )tied Jo 9AUP IOU Oct aoepns angelligu! 041 le u9zal We suoq!Pum pos u94m lnooo lou pegs do Leis walsf,S Muel dwnd ayl u!4l!m patolsai ale slanal luanWa lewou ;gun s1w1uoo dwnd aU1 6ugejado Allenuew ui ls!sse 01 lau!elu!eyy S1N50d to lwnld a pelum to dwnd aw of lamod 6uuolsal of )oud (ladwnd) jclelad0 6uioweS a6eldaS a Aq Panoua. )fuel dwnd egl1o s)'ualum 1 aneq urgen)!s sutl pone oI 'IualsAs ayl of a6euisp pup tuanp;a to a6muos!p a•.,eyns io dmpeq a p ui gnsai Aew WL11 peoliano 6u!sneo asop o63el auo u1 malsAs uogdiosge pos all of Pa6myos!p act qya ielemalsem ssaOxa aql se 'papuaulwooal lou si suo!ppum ayl lapun lamod )o uogelolsel jo do lie1S sain;Iel dwnd of anp jo dnllels of joud s!anal l9lemg6ly Ieuuou anoge IIy Aew s ruel dwnd asn of joud (ladwnd) jolalad0 6up!nlas a6eldaS a Aq PanouJal (s)jUel 8L fl to slueluOO eyl ane4 papolap 3 suogequwum g6lq 11 *WISAs u011dlosge pos agl e6ewep lo/pue sseooxl lualuleall ayl apedwl Aew 1e41 luaw!pas io sleowwri 110 10 sluanlOS 'spnpoud 6u!pl!ed to aouasaid all lot (s)Iluel luauueOA HOalO S1MOd 041 10 9sn 01 .loud 'uorpn-gsum mou lod NOUVM3dO ONV do lavls -w-aid Page _ of START UP AND OPERATION For new construction, prior to use of the PO6VrTS check treatment tank(s) fa the presence of painting products, solvents or off chemicals or sediment that may impede the treatment process andior damage the soi, absorption system. If high concentrations a detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper] prior to use. Pump tanks may fill above normal highwater levels prio. to startup or due to pump failures- Start up or restoration of power under the conditions is not recommended, as the excess wastewater w411 be discharged to the soil absorption system in one large dose causing overload trial may result it the backup or surface discharge of o luen' and damage to he system. To avoid this situation have t contents o` the pump tank removec oy a Septage Servidng Operator (pUmoer) prio to, estoring power to the pump or =*act a Plumt or PO'vVTS Maintainer to assist in manually ooerahng the pump controls until norma eflluen: levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative so. face. Dg not drive or park vehicles over tanks or the soil absorption system. Do not drive or park ever, or otherwise disturb or compact, t ei ee within 15 fee; down slope of any mound o- at-grade soi, absorph3r area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatme tanks aria soil absorption system' acids antibiotics, baby Wipes, cigarette butts, condoms. cotton swabs, degreasers, dental floc diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, nit scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, arid water softener brine discharge. ABANDONMENT When the POWTS fails andlor is permanently taken out of service the following steps shall be taken to insure that the system is prope and safety abandoned in compliance with s. Comm 63.33. Wisconsin Administrative Code: • At: piping to tanks, pit and other soil absorlobor systems snail be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shat' oe rernaved and properly disposed of oy a Sept age Servicing Operator (pumper • After pumping. all tanks and piss shay. be excavated and removed or their covers removed and the void space idled with s: gavel or ano!ner m., enlid matcA-. CONTINGENCY PLAN If the i'OLArTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code complia replacement system. A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption syste The replacement area should be protected irom dislulbanue and compaction and should not be infringed upon by regwr setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement arGn will result in the ne for a new soil and site evaluation to establ!sh a suitaole. replacement area. Replacement systems must comply wittn the rules effect at the time of their permit issuance. A suitable replacement area is not avai'able due to setback andror soil limitatiors. If the soil absorption system cannot rehaoi:itated and barring advances in POVoTS technoicoy, a nold:nc tank may be installed as a last resort The site has not been evaluated tc identify a suitable replacamernt area. Upon failure of the POWTS a soil and site evaluati must be perforill to locate a suitable replacement area If no replacement area is avaaabie a holding tank may be installed at last resort to replace the failed POir%TS. U Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infittrati surfac_. Reconstructions of such systans rnust comply with tor: -Jos!-, effect at teat time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR MCI J SUFFICIENT OXYGEN TO SUSTAIN LIFE NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MA' RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER [N~J-me F Name one j' L - -315 r' Prone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~.I. --C-KC'j~ T~ 7 (✓(\/I Phone Phone This d=jifient was draftoo by the stalls of the Green Lake, Marquette and Wa ishara .^.nun•y "O\ArTS ragutaw., agenaet in complipncG wle, so-bc Ceram 8322(Z)(b)(1)(d)&(f) and 83.54(l),(2) & (3), Ktiseonsin Adminbtrative •Codc. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownedl3uyer o K biL:5c N r Mailing Address H45 t~IbNE7E i uJ O , vv ii _5'1 C6'c Property Addresl J``~ ~~E 1~ 1 T I\ E I K L. t (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRIPTION 4/ _ Property Location ►b/ '/d , s E , Sec. 2L' . T W N R z-L'W, Town of - I _JGSEVH Subdivision Plat: S£ I~ LE KfS C L1= f j Lot . Certified Survey Map # Volume, Page n Warranty Deed (before 2007)Volume . Page Spec house } es _ no Lot lines identifiable . es - no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance ot'your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic uutk ever) 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 §Comm. 83.52(1) and in Chapter 12 - St. Croix Count% Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a ccnification 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage dispoW system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of W is orsin. Certification stating that your septic system has been maintained most he completed and returned to the St. Croix County Planning & -Zoning Department within 30 days of the three year expiration date. I/we certity that all statements fmi form aretrue to the best of my/our knotdcdge. Uwe am/arcthe owner(s) of the property described above, by virtuty deed recorded in Register of Deeds Office. ,7ber of bedrooms SIG RE OF PLICANT(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. owgNAGE r EASEMENT I LOT j 10 1 3.001 ACAS H.W.L"908.0 130.711 SQ. FT. 1 ~ L B.O.+90lf.0 t 5.0 H.W.L=608.0 aeya+ww~croPOF rncw ' . O'~ x/ 11 jF PWE fa&VATMN-40" I a000 AMES ! I 30.491 so. FT. 1 fASEMENTI t LOT 12 I \ 3.000 ACRES I 130,090 60. Fr. f L-e.o.-906.0 \ H.WL=903.0 I \ J 1 I cQ !OT S I D"NAOE I \ ~s \ EASBAEW t I. A. 1 \ 130,892 SCE. Fr. H.W.L.;ft903.0 ~a ~ 1 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County _ Attach complete site plan on paper not less than 8 12 x 11 inches in size. Plan must (1 O include, but not limited to: vertical and horizontal reference point (BM). direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Review by Date Please print all information. Personal information you prorde may be used for secondary purposes (Privacy Law, s. 15.040)(m)). 63 Property Owner Property Location ,'Zp , C o r r 4ciie H~ YES Govt. Lot 1!4 114 S T f N R_ E (ol) W Property Owners Mailing Addreds Lot # Block # Subd. Name or CSM# r (P-72 S} IIL ~ r jJ~yC~ 12 Se ~Y/ers 6/e City State Zip Code Now Number [D City o vilWye fj] Town Nearest Road New Construction Use: [3 Residential / Number of bedrooms Code derived design flow rate GPD E] Replacement ❑ Public or commercial - Describe: _ Parent material L 4~ Flood Plain elevation if applicable ft. General comments . and recommendations. Boring# El Boring ❑ . - 11 /~~j ®pit Ground surface elev. L ft Depth to limiting factor ~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 O-)O r z - ZYl ta1~C ' LS 5 3 2 ya )o "sjj, Up-1.54r- 4/<o SILI hk n r cS - y 4 S v cj , Boring # Boring C Pit Ground surface elev. \ I` fl. Depth to limiting (actor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'EH#1 'Eff#2 ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >3D 150 mg/L ' Effluent #2 = GODS < 30 mgfL and TSS < 30 mgfL CST Name (Ple a Print) / Signature / CST Number Addr ss Date Evaluation Conducted Telephone NumHe 2u SI . Scn er~+ Iul 54c,25 f i y a Property 04ner i i W' :1 q , t Parcel ID If r' J Page of -7 Boring# ❑ Baing Q pit Ground surface elev. ft. Depth to liodtinn factor I in. Haizm Depth DorrJnant Cdnr Redox 1>PSCriptiort Ycxhrre Soil Application it., Structure Corsislcnce Bourxlary Roots GPD711' - In. Munsell Co. Sz. C "t Color _ 'EftHt 'Flip. ii it tll ❑ Boring If ❑ Boring ❑ pit Gaxmd surface elev. 8. r)epth to limiting factor," _ in. _ Snit AppGathnn Re' Ilcaizon Depth Dominant Cnim Redox [Ascription texture _Suudnre Ca•sistence Boundary Roots GP_ivlll In. Munsetl Co. Sz. Cont. Color Gr. Sz. Sh. 'EffH1 •I:IIN2 Boring H ❑ Boring F-1 - - ❑ pit - Ground surface elov. ft Depth to limiting factor _ in. Soil Horizon Application Rol. Depth Dominant Color Redox Description Texture Structure Consisience Boundary Roots _G_P_ D!IP in. Munsen Du. Sz. Cont. Cola Gr. Sz. Sh. 'E1191 'EINQ - ' Effluent #1 = BDD,> 311 < 220 twin and TSS >30 < 150 m D.1. • F"Irlucnl 112 - 1!C1D, r!n nip'Ir and 7 SS <30 nulil. The Department of Commerce is an ecptal opportunity' service provider and employer. If you neecl assislance to access services t,I need material in an alternate format, please contact the department 411608-206-3151 of TUT 608-264-8777. san mo I0. oxM1 Prooeny (honer I Parcel lD # Page of ~ Boring # ❑ Boring r- - - 1~-,11 l L'? pit GratnA surface elev. --i ' 1.1i H. [kplh to limiong (-actor , , in. - 'coil AppDlII, Horvnn RDeplh min ant Cntnr Rodnz t>escripixr Teznrte Suuarue Carsrstancc Rourxfary Rost. CpU/Itr Monsell o]u. Sz- Cnni. Coior Gr. Sz. Sir. •rlf#1 *HIH. i E Baring # ❑ Boring ❑ Pit nnr and surface elev. ft. DcPth to fimWng facInr in. r - cnil ApPliCaUnn fF.: I lorir0n I Dbpui Dominant Coto, Redox Desarpilan 7ex11ae Shumuc (:.rsislcuu: ! oonaaiy Rao:e Gi'Dfil_ I In. Munsell On. Sz- ConL Color Gr. Sz. Sh. Enxt ffih? ❑ Boring # ❑ Baring ❑ PC Gnxmrl surface elev. IL Depth to limiting facto--. in. Soil Amm tinn I:al Horton Ckepth Dominant Color' Redox Ll--wpfion I exlure Structure Cortsislena, bounnary Boor, GPDrhr in. 6!unsell Ou. Sz. CnnL Cc!or Gr. Sz. Sh. 'FII#t •r.IIH2 - ' Eflijent #t - BIM, > 3n c ??g nK A and TSS >'lG 15^ mn.~. =Muent T? = BCtD~ < 38 mg'1, urn:! TS S <;10 rt:9't- Tlu D I)artmrnt of COtnmrrce is an equal opportunity service r nvider and employer. If you nee-it assislancr, to access service< nr need material in an allemate format, please contact du department at 608-_60-3151 or 'M' 6118-?64-87?7. San ofo lP. mnxp 4 ~ . PAGES OF 5 NINuL6if rJ4 J.4'1'#1 z -I.L(iAI DC 'RIYT74~I vw ~CA1.E:I h/C? - BM 1 1:1,[:VA'I,ION /~rl C 13M I 1)Ii1CRIY1'ION of ~wcF BNI 2 FLEVATION •'O BNI 2 DIiiCRIVI'ION~ n I{ SYS 1'P.bI IJANATIOK~ SY1TM'1'YPfi %'r (r cr ~ro r•c CONTOUR ELEVATION A) (J i C' eti • SIGNATURE - -n~ Cs~ aDls -III ,r;~i~ Dept r1r ,arelyarn: P'~_ it I~'f~C 5011- EVALUATION REPORT Page i r,r 5 D'•sision o` Sa'ely and Build`li+gs - , - - - njaTC.14We oith,SP' 385, 'N S. Adm. Code _ ~~P ! County Attech uongrlele Silo ;).Nn than b 1i2 X 11 InrhCS n size. Plan mint - - :nclude, but not limited to. r nl r h<v r14~ ~1 rf?~. w,r,p pq nt ;Rt r1 d.re:;Lon and Parcel I D 1 , ;:ercenl slope, scale nr (firl "TON" T ),;4 I s:rps.v;~t and d stance to rearost road. w Q - ~ ~ - { O C~- C-) Pf6ago~printall information. 1 Rrvi :cd by 3. 30 ad.)0 Duo For:uni.lnf"R3.L n,.::r q'v rll fy lL.-~.-'... 1; .rdT•r 1:..::='fi'- 1, 0 r^'I:. /8 Propery0'.v'icr ee y oca'.on p 1 N~ T L' R Q G T~~ Govt. Lot g k V45 r v/ 2to T_~o N R 2--) r iorj yJ Properly O'wner's P,tailing Adcress Let x Block # SLb 1. N• o or CSPd4 P1 N~' CI'; _L-i7 12 SF7"t~f 2~ GLEN CAy State Z,p Ciode ?yore Nurnec- ❑ City ❑villa e ATov:n Noarnct Road I l 0L4 l +vN WI S'Io82 i 7' t' N 1 .1 N Nt l q c L ® New Construction Use. ® Rosidomal I Nuht:or of bedrooms Code de-iveo design fiove rate tIJ 0 vPD ❑ Replacement ❑ Public or commercial - Descr.bo: Pa•erl nalerial Flood Plain elevation if oppll:.ablc ft. General :.ommonts and •ecommendalicns: 2U I Bosng Boring F ® ❑ Pit G•c.uxf sudace e;ev. 9. Depth to limiting factor_ in. Soil A:; Nb::at on Rate Horizon Deplh Dorninan! Color Redox Doscr pticr. 7cx1,ce Stnlaure onslslenee Eounday Roos GAD `t iII Alurscll Oa. Sz Co'I cnlor Gr. 5z. 87. 1 -`52 C?rn~;~t_ _ = m;b~ 2~ _C v'r 75• r. ye, - rr,sb+_ 1 S >C 4; ova Rorina Borrg 7 10 FTI ® El Pit Gound surface elev. Depth to limii:np `actor in. - - SOII A lolicetion ate Horizon Depth Dominant Color Rodox Deaaiplian Texture Structure ;oisistence ouncfary Roots GPD41 in. Munsell Od. Sz. Cent. Cnlrr Gr. Sz. Sh. ff41 R42 -6 75 R3/L MsbK r'I c' Za C, Ly"SinI: ti i - .L~ ro- 10 31 7, 5. 2 5 4 ti G Ntin tt f 1' - 1t .1i ,Z Effluent 41 = BOD > 30 220 m_,'L and TSS >3n SG mgI ue -I ;J2 = 80Q!r1? :n,:L and TSS < 30 cut I CST Namc (Please Piin11 1 , 0n=h,re r t >T Numher Address ' W:a .•al,;ation conducted I ele-!xme N.imher I2j I+i4 (C'q I'1 S~ 1.1 `~,Clcl zy,.r~-. 11,'11%. Prcccrtq Owner L R I l \J CIS n N Parcel ID 3~ _ Z 13 - I Z - J 4l c, Page Z of -J ® Bor ngC Rorng -I ❑ Pit Grourd iurface ee:, 711 . I:errUi to Lit ia•r:: factor 7 y J in. Soil Ap 9ication Hale I iori:on Do .2,11) Domi-an: Color Re iox Gescripv on lexture Slc.wixe Jorsistence ounCar. Rohs i;Pilifl ' in. f:!u-sell ),I Si. Con: Color Gr: Sz. Sh. ff#1 *7-4 ti 5 vr 3 v S. ?Mbk 5 t y~ ! zrYrsbl~ N F1 Bonnq F] Boring ❑ pit n-mirrl surfeo(! elev. tt. Ccpth to linitil, f.,clnr in. Soil .4p ,I.ralion Rave Herizon Depth Dornmant Color Rcdt Dcscrip:icr~ Texture Svcture c•ulslmce ouni Hoots GPD.ft in. P.lunsell Qu. 7,nt ;nlor t; ."it) «d, 1fl'2. RCin F-1 Hc'i'i ❑ Pit Ground su?a::e elev fl. Br:pth to factor in. Soil n I'c: tier Rase Honxor. Depth Dcminart Colcr Recox Cescript on lexture S7ucture 'cnsstenee oundwy Rows GPD1ft in. I:'unsel l 0 Cnn:. C!; nr @- S~. Sh_ • --rpf 1 f(J: ~>30 a220mplnn-TSS%30 <15C rra'L 'cfflucntk2-B01) <:V: rr lL -z TSS_30 m9l lhz Dep[ 0f Safety and Professittnal ticn ices is as cyual epporlurily set vice provider and employer. If you fixed assistance ur access sm ices or need meeriul in an altemate• lunnat. contact the cepartm:nt al 60S-266-31 51 of TIT through Relay. 8[l_ 9:1 aTntr. FropelN OvrnF• Panel !U " Z . j • p C Fa~~ o` Boring Bo-ing ❑ b ® J " _ G ~ ❑ Pd Ground sur"a i cl^✓. rt. ..Dept- t Lrri ..c farlar in. c:'. v_:,ILa=orb Holzer Dcpth IDen:inant Cale Reoex De m"Io'; -es:.ce~ Slr.:ctrc :Desistence oun ary Room 3°D+, i i•i. 011nsr.I1 GL. Sz. Colt. Color 0 ( F-I - r C dULI"(] Son^; r' L Fd -2: u, ~ SJ r,'_CC UL' 9. h Lie,: 1'i 1D 1. nili•i,; (a:aor in. Sc;l A~Dliar_~n R_te n._- nlnr u ~ ^ti 26, ttn7 ^'eCery I RC'!:: ~r n in P.kt_s..ll Ou S .h ff:' ``,2 I I i I ~ i Born; r rrLJ F,1 ~a ^e,aA SU-J%: CICi. GeJP ' 121 rnila~ fnrlur ir.. Pi `S:~il „pli-a0on Rste ❑ r1Dr.zO- Depl~ Domm m .al ldv. -Jfr.,lc; Gpprc n. P,7uasoi Q~VS:z. Cant GDlc.r 3r. . Sh. ",a Sf:,t L_ - i t #1 = BOC r % K 220 mail and l SS %30 < 15i' mfr.. ' Eclucn: r2 = 30D 30 m vl- a•-- sS = s:i rq,+l - The Den: of Swcva and Fruiussr.?nal SCn'1 Cs is an ryuai epponuint'V service !N-Wider and ernplcn'cr. qcu nr:d sssistaace 7e a:;;ess s. n a of n>_.1 n,ztc re X. ar a::crtatc format :.tnta fur rparunr.ut a, Ug 2F. ? I51 or T-1' :hrou_*h 3rlay. SB= ii"sG,T,I:!IIi low CR► r.- 3~- Zf 31-12-00~ SS 083 a 911 N 1 q r 5 O Q- ~ ''=1d~ ~ r a N ~y m GREEN STP.KG ® A~~' 6 nti 98,E \ o S Lk) Lo-T' S TA LV NOR120r4TAL. F5M X= B►~=1 poi YLI vE~~ ► C- p l o~n Ti ? o~7 1?u:D Lmc nova STAKC FLP7 51?G- ~ _J -2 , vii (J U1 1 ~ L ~ ~ ~ r- ~ - a C ~T) J ~ J "Q o 9S i, l h N ~s Z --~1`-~ ~ E r.'_ < P n a f i 1 i ScTT it p Z' SOON* J o 1n - Sb SSZ r,. N S_ o ~ 4Q I r ~ ~!1 ~ •yy»,RLF f 40 .r. ~e°' 1 ~ tii.. S it V rv ~ r CO - wW7