HomeMy WebLinkAbout026-1161-25-000
coe''ty St. Croix
'J71xc•slC .-lrpaHr_r.: c`CC-'-w='= PRIVATE SEWAGE SYSTEM
sa`cfj arldurdlr.; Cvisir.n
INSPECTION REPORT sanl:ary per-t NC
605175
GENERAL INFORMATION (ATTA0I 10 PF RMIT) state plan ID No
peIiUna nr C'ma'ir. you p'o'ilbe may be b5L•d 'r,' £eCerda'y nurnCieS'n'ivacy Law s 1514 :1 t'^
Permit t•c ic, s Name ply V Ilage Tm%r%-,p Parcel Tax NO'.
Richard & Debra Sundby TOWN OF RICHMOND 026-1161-25-000
C$' 3V Flev I, B10 F P-.- Bid Dc -cnuliun. Slim- rTuvit Range Map INC
15.30.18.1248
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTL T WACITY STAT.ON BS Hi FS /LLLLE~V.
Septic I C5 t 1~ 0 (A I Bencrrara X55 I we ,5
m tti~
/ S V Alt BM J
AEiaftoo Bldg. Sewer 3.y 9~, 0'7
H' Inlet yr / l ! CI -
Outlet -I I2 r - JIfJ
14
S • 3 RS. ZS
TANK SETBACK INFORMATION C{
IANK TO PiL vJELL BLDG. VerltoArlrl Ae ROAD Dt Inlet
Seotlc D: BoCom
Dosing L HcaderP ~I/~
iZ.2
=Holdrg Dist. Pipe C
Bot. System
tH Its
U l
PUMPISIPHON INFORMATION Final Grade
(O 8s
lulanu(actLrcr Cmantl SI Covc~•
4-(;(L „ n -7 ,3(~ I LJ
I I L ? i 6
GPM
.9odel Number • JZ- .
TDH L. It FrictiCr Lass - . ystem Head TDH Ft (j~'
SOIL ABSORPTION SYSTEM fi
V 2 PIT DIp/~yt$IONS NC, Of ^ds In: de Dia L1ub Cc(
BED:TRENCH 'I~IUr I Len@Ix No OI TrencFes
DIMENSIONS Ix1 _ / /
SETBACK SYSIEtvt IO P+L HL DG V.i LAKE+STREAI`l EACHING `.fanutacauer n
INFORMATION CHAMBER OR ' 11~
T•i .e O` S'vstcrn , / UNIT l.1-ic IN
u^ .
DISTRIBUTION SYSTEM 50L F h V bJ
C4 (1p,100 'a-evI 11~q
HeaccY`dar raly' DiSCit-tr~r X -Nie m x hole spac ng V t to air nta•: -
Lc'1ptP. Din L~"Ig'i' Did $GACirg
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems
ue:rtr, O'er ~l Jtll C,,'f I:-.t"F ii( .rPE:tF.~ JL'a V'etI ]:x "1 1117
B'dr newt ::en:e• I } 3ea~Tmr&Edgus I~~ Yet No
COMMENTS: II✓non.ae::odedisreloercles...lpersons ores`ont.etci inspection>Yt Inspectlon42.
Location: 1543126THSI *WGa k( (1 tMi'le
I } Alt BM Description znhP o-1
l- Lt~G.L Sand ~ g~GtVf ~ ~ y lx (4l ~ . C~ t ,yil G~. (aA)(~ J
2 Bldg sewer eng.h = Q~ I (Il`T" All,
- amoLnt Of t:OVe' =Z U ( V J
?LIZ of cow (P latt; d(S( w~rnl~,
Plan revision Ro dd ~CYes _ No /~jVr
V ',U\t4` j c~ l U rCCSS~ Ste!
Use other sole for additional I 'or anon. )
1 -1~ paL f cbr s Sgn fur Cert. No
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aP _I ~•I 2~~0 I ()Box '62 S.w.t uy Prim: NuUcl lill<il in by l'o.Y
75
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5atuitaiV`irerllf)t .Arrlicat)o
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'.,o l 1 a'r 11 t d , pcrW." -.nior 1 side n')}' he used 6e'econAaty
'.i of I u 'a'. tit tI I 1 t
\ppfia ilia, Inlolnlati m Please P ring MI InfUl lnlll - J
I'll 11 I L::. \111 I _ ~ Pat. 9 r.
t t ' I„~'r i a I I:. liu~. 4:9:h ~ t_ _ _ PI p ny I,Aaaen
I
C II ? `ICG T Ztp (",xic Phonc Nun,h„ S,ep tr
-All j /Z
' ~ I'uae nnU
II Type of RuJdnh (check all that apply) l"-' - -
` :t. Suh..ts ot. Lamc
ka ? I.Un s t Inc \U L I :f R_:Ira:nts LL ~ f J , ~ /
) ~ I u +1i.3'on m I - Ila J if. r I6;
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Sa.c r rvu :1 - U x itbc 1. o:. _
f f ~ Tc en ~ ~Ni1/G
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III 1 ypr o u nut ( 'heck only one bile nn line 1 C'oulpleu fill, It it applicable) X
\ { \:,'S;:ucm I U I.T t. 't.m tl IJI. l v.nktp u,.::11"1 Only t~ Uttu ht>.ii teal)m to Fei stn )ua. Iiczplainl
1. arknu:,t.'1',rm lls'unthcr an Ud. IzsuA
IS ~I I'an Ili :d' 1'II- her UI'un it.[ rant, cl to Ncuv
li G.n L I n P I - Oancr ~3 i
1 1 Ss sluu Cmnpnnuu D,vtcc: (Check all 16 a apply? /v~y 5
Th T1 pe Sti4
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IJic l m: - aTn p l t o 1, men. ws{Hatn).__- - ❑Pr.taauvem D""' tq ,.m6
n _
\ Dis mr>al, 1 reauo •nt %rea Informant'
u u t l ••v _p< Daa- n \ \X11/,..: ti t. E.atci• _ 'Is0 Diapclvl \t R auirJ -f 4l U sp ,,,I Ate I n/r wd l \ • cm 7.1., •~:m 1
L 1/ ~
\l. lank Info ( I I Oyu Tal:d ul' \lat.Uli,wrtr _
Una,
Li.1 ..ill: ` I I
\'ll. 11espnltalliIity Statement- I, the und, srvnrA, a sunla rneptnlsihilily file installation u1 it., MAN I'S,haan nn the aoa i d plvn_.
t mt'<\ w. ~'n tl._~ I'L:ui . \t`yntv.: I h1I"\t \ \ur.h~J lle P Namhaa
I I s:A Cd I. t Ypl ,I •I
\ 111 Count Depart client l se Onis _ - -
I rn:I uc Ualc I ucJ h,umc :v S:gnaturc _
~is
IX. C'nnJi18Mb71fHIQ4YN@itcasnrn far Disapproval 31 - 3tld
J
1 Sapl.. tark
cetl erUt t '11 lilfe be , n1 S
sper.,,a' a_ -er pt&n r talee
2 All RMna:k re es. ♦ 1 ~G,.(n<+.~2,
wn -,jT npn1 t ' -r.t. n.' ~1 6d-ew
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Soil AbsorpSw %-,-Wm Cross'Ssctlon
.27,S' R
- 4' Sdedde 40 FnEi Grade
PVC Ved F'q, r ,
Wlb Vat Cap , .5 ff
Leatibg
Churrd r
~ SYS-ton Beratiai .
/ ft
it
soil AbsorvSon SvsfBrn Plan View
R
i~
R
Lux, ing
Vent Or ( rrahon l._! yeti ` ' I
Ch;
pipe
11111lliLLlillll~(1111111111111~ \
4' De.
LTrench~ Hoader
I ~ - - .-eadruw C-Era,nber ~eaficaSortS - - - -
Mntract. And MWet
J/ OSA nE&I9sq ft per chamber so, App&cation Rate -L-L7_ 4
pd/9y ft
gpd Design Flow APp6ragon Rafe r
EISA _1- Chambers
- - - - - z rows of _ dsambem east
Page - of
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q ZG18 , ~
Vkooism ac 1'lI unt cf Safety a•Id P•otgssbn~ SCNICPs Pogo _L. of
BI sicn(l lc d,t ysc-,ions
'S-64t IEV LUATION REPORI
- ~Li arcordatico •wAh SPS 385. Wr; Adm. Cade County
Attach complete Mo pla•I an paper not less than a 1;2 x 11 ~rchos Ir. size. Plan coos; include G 1p~
but not limited to •verlicaI Ar•.d I' onzurtoI roterenre enin: IHf:Ii dnuoLcn aid Ferrer! s ope• Parcel 11),
scale or d n1c•lsions. north arrow and location anc distanre in nearest road.
Please print all information. Revie•. Ly Dale Q
Pasoool "'I'n maJon you crcvrJu maybe used k:" secondary uci p uses 'Pnvy La,' s. 15.04t1)Im ii. ZT
lroceLmy O.•mer Prnpe'tI Laralue
Go 1. Lot r ! z V R F !:)r) VV
Properly Ownor's I1aill Ig Address l or M JlockiJ ~ucJ Nome or C:Sf•.18 .i -
z&v
Carr Sale Zi code Pt-ore Number ❑ cr' ❑ V Ilage kC] ovn Neares: Road
;9i _.t 1111--tat ii[[++//Jt] r ~ I _~~-iI. yi. ,.];V. I ~-r.~ ' >
Nev ® Re,idOnha!'Numberotbedro?ma C.& doe design Hon Ia b_Z- GPD
' Consuvetion se
❑ RenhComent ❑ PI bl,~: or couvocr ial - Describe- / L
'
Parc nt ma enal - Fk cd P.an eViation if arphaaccy![,Q
Ccnara cbmmPrIs and fecelrncrdorons' ~ >1. - / - / /
~j]( Pu Ground surface elevh. Depth to limiting fa: tor/ ( - In.
Sa.l Appl. catio'i -ate
I I <izon Ceidil Dom I ant Color Redax Derr option Texture Slnx;lure Cnrs,ster A: Boundary Reo:s GPDtFt'
In I•AUr bell Ou. Az Cort Colrr Gr Sz. Sh_ Eff#I 'Pt1:12
_
Orrin ❑ Bering
9' Q m Ground surface elor4. Depth to Hinting factc'/ / if
_ Sort Applicator- R_3:e
IIoI'iZon Depth Dominant Color Redox Dcr;(. on Texture Strd lure Ccnsismence Bourcary Roots Cl`WFC -
In rlanaull Qu Az Cca: Color Or Sz sh. FHN1 I - _1fC2
E: a II 41 - DOD 30 220 m9 d- and I S ^5_Riga LftluOnt N2 - HOD. ? 3,3 220 n J!L aid FSS 1 310 i 5O nIy!L
5
CSTJ me (f,,(aa rP'Print~ S ynara e CST Nun br I'
Adj'oss' ~J Dato Loaluatior Conducted Telephone Number
SBD-8330 (RNIM
- bt,ing N ❑ Rorinr~ _
❑ Pit Guw:c surface elr,v Depth to hur, irr, factor,-, i i.
Soil ApPlea: r Ra;e
Lferizai ~ Ueplh Lle'n,rant Color Rcdox Description 1 Texture Sl l Consislrnce I Dou:::ary I Reels GPDfFt'
h. f•.Wnset (Ai A7. Cent. Color .Gr Sz. Sir.
*102
❑ 6oriny
F Boring # ❑ Pit Grourd surface elev. _ 11. Doplh to linifing factor - In.
1 Soil Application Rai-
I IOwen Depth Domirart Coicr Radax Urs::np;icn Texture Stru<AUre 16onsislcr::e Boundary I R:rois upwi-t'
In. C^.urseli (J.i Al (;nt. Colo' Gr Si. Sh. 1 •Fffpl •Eff#2
Holing a ❑ Poll
❑ Pit Grc:.ind su'faee elev. _ t. Dop:h :o limiting facto' in-
Soil Apphcalicn Rete
Horizon Dept•i Dominant Cnlor Recox Descriei'Or. Tcxlua: Sirtict.vc t;onsstence Dowidary Roots GPD:Ft'
In. N1.19,oill 01- A2. Cant. Colo, Gr S> Sh.
'Effg1 •F"2
flluentfrl-p.(-i, :•3 22U rng Ldre i',-....-1"i0 mpfl 'Cf11jc:,US fed,i-3p _ZOn:grl aMTSs-?'W-IS'j,,igL
-l ' F>Onnf.
Ground so -e aov/f.S fl. Depth to limilinc fac(or1L/-L in.
Sotl_4J u.a:rn Rate
H ncu t- -Depth Dnninant Color F dox Descrf:Ainr Texture v ru tu,e- Carisislence Boundary .Rfnts G-:)•r _
Ic, ILin ell 31 A. Gen- COior GI o ah. -
6odng h ~ 3oFty
ceound Suda6e cloy- _ It. Dep:n :o Irmitinj fantor
Soil Appfic:ahar- Raze
-
-~en2111 7tpti Uarnrt a.c Color Re7Cx Dcs npucm f 'eutura ?tvGture Coi iaturce 6ounddry Roots GPD+=t'
In tiun;.el Uu Ar. Cont. olo' Gr `z. Sn. Eft- 'Eff#7-
-
Borg « ❑ Bormg -
❑ Pi- Grcjrid sjrlw~ elev. _ f•.. Depth. to lint ng faces- ir.
Rate
H:xizon Dep;n Darn. cant Color Retim Joscmpliur 'lexlure Strt erE -onsistence DOUICaro Roots GPTFe
Ir. Idarucll Q .l Az CCnL Colo: 3r ° Sh 'Crf«1 'FfY'2
4^=n]_ 30- ?imp. cr%7 _ o_ -i p+ Ettl,, t::L r andTSSr- ffiIC',nw
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110 605 i75
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t P our r 1 I I r '.:d r rs.. ~I t t vrrti:m j rrev:Je a he used tar i:a
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1 \pph •:rllun Information l lemur prim All lnfnl tm I* Yif3
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11 Pype of Building (check all that apply)
S~bdr rc nn Vurr
I 14:nr t Ilin,• \r n,I; : Rra rrcnns `
it .%:C~~
I uGc"G.: or ~eml-U:xibc Cco LL l~
~IVDY1Iw ~T' ❑Ciry
flat:. G•.vv •J 11...:: ii,c I:u _ ~~J~~-
z-;flk-
IIL'1'ype. al il: Wilvek only one box in line Complete line 11 if :q)plic Me) _
N.. f a.r:a ❑ 3 prticmen Sysa:m . u-Cwr.t 1.114, e, l atd.. p '.xycn; t1:J~ 1~I C O:he• \IodiC -rr r to i:>:ir'.ing Ssgicm iexnlai:0
l{ I j I`-.-tr Lc P cviou, Pcttnit \umi,cnt J D.h: rcra:d
`crtm .:::I i~l'<.nun 3s ♦ s <lr ~.••'s rnr':-. I nacr to VCw ~.••~/'y17U.~~~~~ ~~'C~a~~
IS t,rcl u t _ 1~ iaa
1\ II I (m onull Du u<. I( heck I IIt .t)
r Lrr a Iu I. lwA r....n <,I lr tro:: r..I 1 A %1, l 1 i .ct Ir-0.u sod U Voucd -14 n of s.i:Wc ,,;I
IfalJi^.c l::ng O'be: D s .sal T75 C' 1 P' '..It
\ Ih pu cal A- It \ICn Information; I Is•.v t t I;t d I)r..t n it p'Le' ti -•n hu6(f1f
Acts V. t R _gnircc jai Nipara .5 u t r pusd i> tipsle ) Elceauon /
U
'r I'acurcr
t, e - C40
V'I. Tank Into I C 1I r it% n, M.
( ill rs (.all r. Gait. 'J P _
srrr..~r ❑4r~ 1- ~ 'C - / ! ~ V,<: is _ _ ~ ~ N.. ` v _
%1I. Rcqumsiblhl) stal meat- I.Ihc and r iLn d. as urns rrsptiyls 1 thq Im' fast ilia tion of the I tR\TS chmsn of the alraslad plans
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\111 note U<parrmrnl Ihs Only
t' ufl pa- Llafr 1ssu w4 1 _vn• cent Mau c
`~g5 g IS - _
: Lr. set t -Ihr~-n -
IN. Cundi( tr ~t4~j1 Z+ason, for Disapproval
.46petttar rxll Moat all be s°.~_IC?s_,>er,
M'pM .ptMWq- p=in poc, 2. M eeb~l7k-N~iMaerKS fnuat persnt, sr lr t ,j
GGW~~//
to Per ?m [ hl r .r,y M NIY.6l. _
\t t :coq e 11 n• hn tl .,t. r:onl cr b-r: I:u nnty all}' 11n paper nn ca Uraa s ll inchelot, r ,
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CONVENTIONAL COMPONENT DESIGN
Residential AppfKmbon
INDEX AND TIME PAGE
Project Name;
Owners Name_ 5- 1 l ; : (2_
Owner's Address /'i~a~
Legal Desarphon- ! ~ =
Township:
i
County.
- `
Subdivision Name:
Lot Number=
Parcel ID Number.
Page 1 Index arid btle
Page 2 Plot Plan
Page 3 system §k!T9 & Cross-Secfmn
Page q Fdter Specs
Page 5 Mautrenance Information v
Page 6 Management Wan
Page 7 St Crok Cty Septic Tank Mainkmance Form
Page 8 Warranty Deed
Page g _ CSM or Plat
Attachments Sol Test & House Plans
Designer/Plumber. lie Number.
- - .
Date: Phone Number
Signature
ply puamtn tl~e Ind StA Msapaoe CamO~ ~ for POIIIriS versiw, 20 sm-~b705-P paow,~
Pace 1
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M
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lQ ~
I ~ I
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U
Sol Absorv8on % st m Cross section
ft
4' Sdwdule 40 Fulal Grade
PVC Vert POP
VAffi Vert t:.ap
Leading ~
Chamber
Systwn EJerabm
g ft
Sol Absorption Slrstern Plan View
it
ft Vert Or 06ser4a5on Pipe Chambers Trerrch~ -
- aJ .:.Jos
1~IIIlIDIID~1[~Il(~II1~~ . .
4 Dui
Crendr 2] Header
Leaching Chamber SnecHiicarbons
r
Manufacbuw And Model ! . J
MSA Ratatg, sq ft per chamber Soil AppGCation Rafe ;
gpd/sy ft
_ 9pd Design Flow = Soil App6ration Rate
EISA Chambers
2 tows of Chambers each
rage of
o Filters
PL-525 EFFL UENT RUER (a C:
Polylok, Inc is pleased to add its - - T
new commercial filter to its existing €
line of quality effluent filters. The
PL-525 is rated for over 10,000 GPO 4 porn,
Accepts _
(gallons per day) making it one of accessibility <`~; 6ane8e F
extaftsilm
r
the largest commercial filters in its
class. It has 525 linear feet of 7;10 t
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has 1 t `
an automatic shut off ball installed sas rmearrwt
with every lifter. When the filter is - of ute- _ r
removed for clearing, the ball will rdtration dots hated f" over
float up and temporarily shut off
the system so the effluent won't
leave the tank. No other fifter on P
the madwt carr make that charm! a 4CCepts 4- •0-
SWD_40Pipe~a.± f
f
PL 525 Man (?three:
The PL-525 Effluent Filter should e
operate efficiently for several years !
under normal conditions before
requiring cleaning- It is recom-
mended that the filter be cleaned
avery time the tank is pumped or ` i
at least every three years. If thei i
installed filter contains an optional p
alarm, the owner will be notified
by an afar m when the filter needs -
servicing- Servicing should be Gasddlector
done by a certified septic tank r . ! Automatic shut-off
pumper or installer." ball v&eo Wer
1. Locate the outlet of the 3 us. Pmea Noe sats,.ma is removed
septic tank. s srt.sao
2. Remove tank cover and pump s~ - - _
tank if necessary. PL-525 Installation: 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
fitter is removed. Ideal for residential and com- 2. Remove the tank cover and
4- Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off fitter over the septic 10.000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Wake sure all solids fall 4 or 6 outlet pipe. If the
back into septic tank. filter is not centered under the
access opening use a Polylok
6. Insert the fitter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the filter is properly aligned and 4 Insert the PL-525 fitter into
completely inserted. its housing.
7. Raplarm septic tank cover. 5. Replace the septic tank cover.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ct_
FII.F INFORMATION SYSTEM SPECIFICATIONS
Fil-Wrl"I'l'it ~TankManutaaurnJN1
ft~ P.1 Septic. LJ Dose I I l loldinc 'ro,irm' aal
DESIGN PARAMETERS Tank Manufacturer.
Number of 13edrooms_ I I NA
❑ Scptic i I Dose G Holding Vnlgnte: (gaP,
Number of I_hiblic Facif!ty Units Id NA Vorticai Uistarroe lank Bottom(si I,- Scxvioe Pad: (h)
Fslimaled aveim e' Row : - aUda ' Horizontal Distance Tank(s) to :;.nMc e Pad: (fill
.1^Slyn (p[:ak) FIOW = (estimate:;i x 1.5): / . Specific. servicing mechanics must be r raided if veiliral i<. =•15 teat or
- _ ,i✓-C (gavday) if horizontal is a150 lent. SpetAr. instwc:iom Ie he provaed or. back
In Slu Soil Application Rate: (gaudayfie) Effluent Filter t.Aanufachrer
- ❑ NA
Standard (Domestic) Infuen:/Etfluent Monlhfy average - Ffiiumt Filler,10odr'i
Faki, 04t. Grouse (r0.^,) s30'm9h _ PUMP M. nutachirrr
Utmhemical Oxygen Ucmand fR00s) ' >220 m91L I. I NA !-~j' NA
_ Total Suspended Scdds (rSSI _1bU ny1L Pump Mode;:
I Ii,7i; S'frength Influent/Efhunnt Monfr.'y average Protrcabnent 1-hill
(FOG) '-30 mg/L Mamlfaclurer:
(UOD%) = 910 mgH ® NA I I Mechanical Aerafinn f~ Peat FJlel '~-N'A
(TSS) i50 mg/L
- L Disinfection ❑ Wetland
!'retreated Effluen'. Monthy average LJ Sand/Grayc9 finer O Olhe-
rsoD.t s0 mar. -
(rsS) :10 mg1L
i neat Coli:r>m: (gecmelric meant <-r11' j ' Irrt;round (graviy) 0 In-Ground (pressure) IJ NP.
F1 f ! P.I-ca:ado F) DVIC7,
Maximum I-ffluetd Parbcir. f;ize in din, )-I NA
Uriµ-_ma F) 1 Ulhe:
Olhec Other.
I J ls•. I~ Np,
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out corimnfs of tank(s) When combined sludge and scum one third (A) of farlk voWrne
I I When thn high water alarm is acbvate+
Inspect condition of tauk(s) At least untie ev . uwnlt s, _ - u NA
'Y- J. p n,„rf -1 (Maximum 3 yr:ars)
Inspect dapr..>.al cell(s) At least once ovf' mnrtt.i:.; (Maximum 3 years) f7 NP,
Clean effluent filter - At least once evey. h(`' ❑ NA
~yaar(s}
Inspe : pump, pump wnlrolS & alarm I At least once every: G mon(hi - - g.
t _ Y a 1
sf laterals and pressure test I At least once every: ❑ me rite(.-.).. _ - - - - - NA
I yrarO
Jlli r _ - ❑mnnth(.j _ _ _
At fomst one. every: r I I W,
❑ nfG
MAINTENANCE INSTRUCTIONS
In Perfuns of u7itks aI:U soil absorption systems shall to-rnudc h-y an ardimduai cn"ing o:)e of the fWlcv;ina liar s ur cu; bfr:~iio;a
Master Plumber, Hasler I'fumbrr mestnctsrf Sower. POW-18 Inspe:aor, POWI-S Maintainer or Srgragr. Servxxig Opsator (pumpel'l.
i ank irrpecions must in,,^.fude a visual insuecaiun of the tank(s) fo idmfify any rnzmnq or bmken hardware.. Id^nfify any'carks or leaks,
measure the volume of wrn.ri led sludge and scurn and a check for any back up a pending of effluent on the ground surface. The soi'
absorption qs cm shall be visually im;p-ded to check the offluent levels to the obsei va6un piprs and to chea< to, any pending of efiben:
on the ground surace.. The pending of effluent on Vie ground surface may indicate a failing condition and requires the iaimedmtc
notihr-rbon of the local rNi-i'aturv authority.
When the wmbined acarn:u!atlon of sludge and r.,am in any treatment tank equais nor.-third (f) ui more of fhe tank volatile, the entire
contents of the tank shall b' remove by a Septace Sewicin i Operator (pumper) and disposed of In accordance mth rhapter NR 'I
d,
Wiswnsin Administrative Code.
Ali otter servi,.P.s, including brit not limited to the sevi::ine of cfflUenl filters, mechaniw; or o:essunzed components, pretreatment units,
and airy servidng at inta.vals of _12 months, shall tie perormod by a c:e:hfied POWfS Maintains.
A semioc reuod s!lal, he provided to the local regu;atory autiwrity within 30 day/c of,'im, otion or any, service event.
cMw-cos (ozms;
Page of-
START UP AND OPERATION
For new construction, prior to use of the POWTS check 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) retrieved by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recornmerided, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an
overload that may result in [tie backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or PONIES 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 trozcn at the infiltrative surface.
Do riot drive or park vehicles over tanks or the roil absorption systern. Do not ddvr, or park over, or otherwise disturb or compact, the
area within 15 toot down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following froin the wastewater stream may improve the performance: and prolong the life of the treatment
tanks and soil absorption system: acids, antibiotics, baby wipe', cigarette bulls, condoms, cotton swabs, degreases.;, dental floss,
diapers, disinfectants, fats, fetindation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat
scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with s. Comm £33.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed -
• the contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper).
• After pumping, all tanks and pits shall be excavated and retrieved or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the. FOWLS fails arid cannot be repaired the following measures have been, or must be taken, to provide a code compliant
l eplacoment system:
A suitable replacernent area has been evaluated and may be utili/ed for the location of a replacement soil absorption system.
The replacement area should be protested from disturbance and compaction and should not be. infringed upon by required
setbacks from existing and proposed structure, lot lines arid wells. Failure to protect the replacement area will result in the need
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at the time of their permit issuance.
I ; A suitable replacement area is not available due to setback and/or sal limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
Ll The site has not been ovaluated to identify a suitable replacement area. Upon failure of the. POWTS a soil and site evaluation
must be pet forrned to locate a suitable replacement area. line replacement area is available a holding tank may be installed as a
last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systerns may be reconstnicted 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 CON-rAIN 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.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWfS MAINTAINER
Name
Names
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
.Name. Name
Phone Phone
-ibis document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTs regulatory agencies in compliance with smirtms
Comm 83.22(2)(b)(i)(d)&(1) and 83.54(1), (2) R (3), Wisconsin Administrative Code.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN rage et__
FILF, INFORMATION SYSTEM SPECIFICATIONS
Owner
r lank Manufacturer UNA
Permit # [M Septic U Dose ❑ Bolding volume: (gal)
DESIGN PARAMETERS Tank Manufacturer. y- NA
Number of Bedrooms: I7 NA ❑ Septic ❑ Dose U I IolJng Volume: (gal)
Numbrx of Public Facility tJnits Ef NA Vertical Distance Tank Bottom(s) to Service Pad: (a)
Estimated (average) I low : (yavday) Horizontal Distance Tank(s) to Service Pad: (it)
Specific servicing mechanics must be provided if vertical is >15 feet or
Design (peak) Row = (estimated x 1.5): _ -L (yavday) it hori/ontal m>150 root. Specific insfmdions to be provided on bark.
In Sill Sal Application Ratr,: - (yaVdayAh) effluent I-iltrr Manufacturer
❑ NA
Standard (Domestic) Influent/Lftlucnt Monthly average E(flucnt Filler Model: -
Fals, Oil & Grease (FOG) <30my/l Pump Manufacturer:
Biochemical Oxygen Demand (HODS) x220 my/L ❑ NA F1 NA
Total suspended Solids (TSS) <:150 111.0 Pump Model:
I figh Strength InfluenUFffluent Monthly average Pretreatment Unit
(FOG) >30 mart Manufacturer
(BODs) >220 mgrl LA NA Jj NA
El Mechanical Peat Fitter
_ _(TSS) >75g rng/i I I Uis fPsudecion ❑ Weiland
Pretreated Effluent Monthly average ❑ sand/Gravel rile ❑ Othe:: _
(Hobs) ctn mart Soil Absorption System
(TSS) --30 mga J.-I NA
Feral Cuiiform (geomotric moan) s10, 4 hh-[around (gramly) L I InGround (pressure) L] NA
t - At-Gride L] Mound
Maximum Lffluent Particle Size 5 in dia. [71 U Drip-line 1-1 Omer
Other. I I NA Other CI NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out conlents of tank(s) When cembined sludge and scums equals one-third (Y,) of tank volume
❑ Nlhen the high water alaml is activated
Inspect condition of tank(s) At least once every: U nam0(s)
year(s) (Maximum 3 years) U NA
-
Insped dispersal cell(s) At least once every: - I I morili(s) -
_ fAyear(s) (Maximum 3 years) ❑NA
Clcan ofHuent filter At least once every: - ❑mnth(s) - -
Ll NA
Inspect pump, pump controls & alarm At least once every I.1 month(s) - p NA
UYear(s)
Flush laterals and pressure test Al least once every: 1,1 mrnth(s) NA
❑ Y_earl r~
otthvr. ❑ month l"
At least once every U year(s)`) I 1 NA
Olhff* ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absor, tion systems shall be made by an individual carrying one of the following licenses or certifications:
Master Plundxrn, Master Plumber Restricted Server, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combiner) sludge and scum and a check for any bade up or pending of effluent on the yruund surface. The soil
absorption system shall be visually inspected to check [lie effluent levels in the observation pipe-x and to check for any ponding of effluent
on the ground surface. fho pending of effluent on the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory, authority.
When the combined viocumulation of sludge and scum in any treatment lank equals one-third (R) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with c:li aptel NR 113.
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanirml or pressurized romponents, pretreatment units,
and any servicing of intervals of <_12 months, shall be performed by a mKified POW I S Maintainer. -
A service report shall be provided to the local regulatory authority within 30 flays of completion of any service event.
GMW-005 (02/05)
ST. CROIX COUNTY
SEPTIC TAKK 1-AINT 21 ANCE AGRFPAO~'
AND
OW"MERSY.IP CERTI]•TCATTON FORM
OwnerR3uver 1~ b&rA
y~~ Li Y11~
ivf~rAddress 14L 7- 142-nd TIY~ P(c~ d\ `~l~Yl wl~J~)
And'`"'-' /Sy 3 121
~ 5+ rr~
(tijerifi=(M required from Plmamag & Zoumg Dgmua t for new cnmstruzda a.)
C7tylStaxe Parcel Identification Number c~ - lyC, 6 ~r
LEr,-e DESCRIPTIaN
Property Loc don..L. - V4, = v , See. T NR Town of . a-'la
Subdivision Plat r-kc 4 A1111L1 Lot 4
Certified Survey Map n Volume . Page
a'ruz au'Y Deed (befom 20477)Volu e _ PP& 9
spec house,; yes; ao Lot Imes iderr iiiablagyea D'no
SYSTEM A AUfMNANCE AND OWNER URTMCATION
improper use and maint=ance of your septic system could result in its preMebre fume to handle wastes. ripper
maintenance consists of pumping out the septic tank _every three years or sooner, if needed, by a licensed pumper. What you put into
me system can affect the fimction of ~e septic tauk ~ a reatmeat saga in the waste disposal Voe m! Owner maintenance
esponsibilities are specified h2 §SPS. 38352(l) and fn Chapter 12 - St Croix County Sanitary Ordinance
The property owner agrees to submit to St Croix C0uM PIa & Zoning Department a muffealiom form, signed by the
owner and by a master plumber, journeyman Phnnbea, restricted plumber or a licensed pumper verifying that (I) the on-site
wastewater disposal system is is proper operating condimon and/or (2) after inspection and pumping (ifneounry), the septic tank is
less than 1.3 fiili of sludge.
Uwe; the uncersigaed have read the above requirements and agree to maintain the private sewage disposal system with the
standards sat fixes, haein, as sea by the Depar== of Safe'ay And Ptoiessiiioual Seavices and the
Da tme and re aNOMURI Resources
-State of BTzsi~msiou. Ce`ti,5ixiitm suing that your septic system has beet,, maIDtaIDeC must be completed let ~ and returned rmed to fire SL Croix
Couomy Plannin & Zoning Depar4Lemwig 34 days bi rbetbw ytr eapirnign dare.
I/we certify that all statz m is on thi I to are true to the best ofmy/our latowledge. Uwe am/am the ouner(s) of the
property described above, by virtue of a s y deed recorded in Register of Deeds Office.
'.Number of Bedrooms
SIGNAT J O APPI.ICAI I (S). 1JATE
"*any ormation that is misrepresented may result in the sanitary permit being revoked by the planning & Zoning Departinent s«.
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 tsarzwq deed
CR v, "IZ)
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• Gh 78,549 sq. It.
' E O 1.80 acres
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272.39' ~~26 G
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N89'48'27•E 265.11' WE .97.x 0'
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S89'48'2YW 354.19' Easement
303.38' .81' Nit.
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2.14 acres LOT V
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,Wsconsin Department of Commerce SOIL EVALUATION REPORT Page I Of
3
Division of Safety and Buildings
in accordance with Comm 85. Wis. Adm. Code
County SL Croix
Attach complete site plan on paper not less than 8 12 x 11 inches in size. Plan must
include, but not limited to* vertical and horizontal reference point (BM). direction and Parcel I.D. spercent slope, scale or dimensions, north arrow, and location and distance
to nearest road.
Please print all information. Reviewed by Date
Penu, nil information you provide may be used for secondary proposes (Pnviicy Law, e. 15.04 (1) (m)) -70 Q S
Property Owner Property Location
Steve Derrick Govt Lot NE 114 SE 114 S 15 T 3f) N R 18 EE((or))W
Property Owner's Mailing Address (.of # Block # Subd. Name or CSW
1438 County Rd G 25 - Cherry' Knolls I st Addition
City State Zip Code Phone Number
riY tillage L!jTown Nearest Road
New Richmond W1 5401' ( ) County Rd G
0 New Construction UwE] Residential I Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD
Replacement El Public or commercial - Describe
Parent material Lkcss over outwash _ Flood Plain elevation if applicable Lyra ft.
General comments This site is suitable for a conventional below grade system, recomnlerlding that a pressurized system with equal
and recommendations: distribution be used so as to distribute the effluent over the entire available area due to the niassive(0n1) sl. This is
not a code requirement, but rather a suggestion.
' with I" hands of sl, Om, 7.5yr44
I❑ Boring # ❑ Boring
a Pit Ground surface elev- 107.00 ft. Depth to limning factor -'-104 in.
Soil Application Rafe
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflf
in. Munsell Qu. Sz. Coro. Color Gr. Sz. Sh 'E"ll 'Eff#2
1 0-10 IOyr3 3 - Is Osg mvfr as 2f .7 1.6
2 10-18 7.5vr44 - Is OS mvfr ew If .7 1.6
3 18-28' 7.5,vr4,'4 - Is Osg nnli uw If ,7 1.6
4 28-104 7.5yr5:8 s Osg fill .7 1.6
a Boring # L1 Boring 105,30 ---90
Q Pit Ground surface elev. ft. Depth to limiting factor in
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods GPDtfF
in. Munsell Qu. Sz. Cod. Color Gr. Sz. Sh. 'Eft#1 'E##2
1 0-9 10yr3l~3 Is Osg mvfr as 2f .7 1.6
2 9-40 7.5 r4i4 Is Osg mvfr cw I f .7 1.6
3 40-71 7,57T5;8 - s Osg rill cw - .7 1.6
4 71-90 7.5yr,S.+6 s Osg fill - .7 1.6
' Effluent #1 = SOD > 30 220 mgr- and TSS >30 < 150 mgrL • Endued #2 = 8 D < 30 mglL and TSS < 30 m;VL
CST Name (Please Print) Signature CST Number
Thomas C Nelson 227387
Adder Date Evaluation Conducted Telephone Number
1432 12001 Street, New Richmond, W l update 6;28!04 715-246-2454
Property Owner Derrick Parcel ID # fending Page 2 of 3
❑ Bonn # Boring 101.10 y`
Pit Ground surface elev. ft Depth to limiting factor in. Soil Applicaton Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtW
in. Munsell Qu. Sz. Com Color Gr. Sz. Sh *E"1 'Elf#2
1 0-11 10y6r:3 - Is Osg In%f' as 2f .7 1.6
2 II-28 7.5N-W(i Is Osg m%G cw If ,7 1.6
7 28-38 7,Svr4'4 - sl Imsbk mfr cw - .4 .6
4 38-48 10),64 c2d5 5!8 sicl Imsbk
yr mfr cw .0 .2
5 48-62 1Ovr5i8 - fs* Osg ml cw - 2* .6*
6 62-92 IOyrSM - s* Osg nd - - .2* .6*
+ Boring # Boring 102.50 _
Pit Ground surface elev. ft. Depth to limiting factor - 98 n. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf
in. Munsell Qu. Sz. Cont. Color Gr Sz, Sh. •Eff#1 'Eff#2
1 0-8 IOyr313 - A 2utsbk ml'r as If .6 .N
2 8-24 10y r4-6 sit 2msbk rn(F cw - .6 .8
3 24-35 IOvW6 1-20N,6r8 A Imsbk mfr car' - .4 .6
4 35-98 7.5yr5i8 s Osg ml 7 1.6
Baring # S Bang 1020) >94
• Pit Ground surface elev. ft. Depth to Ixnr6ng factor m.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDRF
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'EB#1 'Eft#2
1 0-30 IOvr3r2 Is Osg mvfr as If .7 1.6
2 30-48 10YO-A Ifs Osg mvfr cw .5 1.0
3 48-94 75 r5i8 s Osg ml - - .7 L6 ag, Effluent #1 = BOD, > 30 < 220 mgt and TSS >30 < 150 mgA. ' Effluent #2 = BODe < 30 nglL and TSS < 30
mg/L
-
'I he Department of Commerce is an ey ual opportunity service provider and em player. If you need ass istanec to access services or
need material in an :dlem¢de format please ennlact the department at 608-2663 151 or TTY 608 264.877
.
.Cherry Knolls 1st Addition
Lot25
272.39' \ 1
58' 0 106' 104'
NW lot comer BM2 102' 100,
/AIM
10' /01 BM1
B, 0 g4
82~
4-il
-do Of T IM'
696
0 115' slope
W
n
85'
R B5
0
a
B3
N~~h
Sc e1"=30'
8 1 Top of NE Lot comer 100.00'
M2 Top of conduit 106.85'
B1 107.00'
B2 105.30'
B3 104.10'
B4 102.50'
B5 102.00'
Thomas Nelson
227387
Vrtsconsin Department of Commerce SOIL EVALUATION REPORT Page, of flimsion at Safely and Buildings
in accordancewith Comm 85; Wis. Adm. Code
County St. Croix
Attach complete site plan on paper pot less than 81 f2 x 11 Inches in size. Plan must
include. but not limited to- vertical arldhorizontal relerernz pain (BM) l direction and parcel LD. r
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pending
Please print all information. R - Date
Personal information you provide may tie used for secondary purposes (Privacy law s. 15.04 (1) (mo. G(~Cry✓y~. / 7
Property Owner Property Location ❑ a
Steve. Derrick Govt Lot 1/4 SE 114 S 15 T 30 N R IN E (or) W
Property Owners Mailing Address L Block # SLL7C. Name or CSM#
1438 County Rd (i 25 - Cherry Knolls 1st Addition
City Stale Zip Code Phone Number Xy []Village • own Nearest Road
New Richmond W[ 54017 ( ) County Rd (i
New Constn,dion UseQ Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 61X) GPD
Replacement ❑ Public or commercial - Describe
Parent material Loess over oulwash Flood Plain elevation if applicable R.
General comments This site is suitable for a conventional below grade system, recommending that a pressurized system with equal
and recommendations' distribution be used so as to distribute the effluent over the entire available area due to the massive(Otn) A. This is
33 OA,f `lug S Y ~r _ nota code-requisemembutrathef-a miggcsIion.
-o " with I" bands ol'sl, 0111, 7.5yr4,4
J5 5~
Boring # Boring nht~IE - -
a pit Ground surface elev. 108.18 R Depth to limiting factor '94 in.
a
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Constance Boundary Roots GP Q&
in. Munsell Qu. Sz. Con. Color Gr. Sz. Sh. 'EH#1 'EB#2
1 0-10 1Ovr3/3 Is Ng mvfr as 2f .7 1.6
2 10-18 7.5 r4,4 - Is Osg nivfr cw If .7 1.6
3 18-28- 7.5yr4,'4 - Is Nsg mvfr cw 11' .7 1.6
4 28-94 7.5yr5B - s Usg nil - - .7 1.6
2] Boring # Boding 105.10 =-rx)
Pit Ground surface elev.. ft Depth to limiting factor in.
SoA Applicabon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM
in. Munsell Qu. Sz. Cond. Color Gr. Sz. Sh. 'E##1 'Eff#2
1 0-9 1(W613 Is (hg mvfr as 21' .7 1.6
2 9-40 7.5 •r4i4 - Is Osg mvfr cw If .7 1-6
3 40-71 7.5yr5;8 s Osg nil cw _ .7 1.6
4 71-90 7.5yr5i(i s Osg lot - - .7 1.6
Effluent #1 = BOD, - 30 < 220 nVfL and TSS >30 < 150 mg/- ' Effluent 92.= BOD < 30 mgr- and TSS < 30 mWL.
CST Name (Please Print) Signature CST Number
Thomas C Nelson 227387
Address Dale Evaluabon Conducted Telephone Number
1432 120th Street, New Richmond, WI 4.,T04 715-246-2454
Property Owner Derrick Parcel ID# ['ending Page 2 of 3
Bonng
❑ Boring # ❑ pit Ground surface elev. 104.70 ft. Depth to limiting factor 42 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence EBoundary Roots GPDAW
in. Munsell Ou. Sz. Corn Color Gr. Sz. Sh. 'Eff#1 -Ef(#2
I 0-11 IOyr3 3 - Is Osg In%li 2f .7 L6
2 I1-28 7.5 4/6 Is Os mvli If .7 1.6
3 28-38 7.5yr4..4 sl Imsbk ntG _ .4 .6
4 38-48 IOyr5r4 •.2~Sa Si Imsbk mfr cw - - U - 2
5 48-62 IOyrfi'g - fs• Osg nil cw- -,2`---
6 62-I2 1ON- 5i8 - s• Osg ml - - .2• .6•
❑ Boring X H Boring
Pit Gmund surface elev. ft. Depth to limiting factor in Shc licabon Rate
Honzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM
in. Munsell Qu Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Eft#2
Bonng # Bong
Pit Ground surface elev. ft. Depth to limiting factor in
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eft#2
Effluent #1 = BOO, > 30:5 220 mWL and TSS >30 < 150 nV& ' Effluent #2 - BOD, < 30 mg4 and TSS < 30 mgt
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1IIU NiygnilK{~.,
Cherry Knolls 1st Addition
Lot 25 I~t) (
16
N1Y lot. cornr
52' 272.39'
1 BM2
NOO 95'
11'
•I BN11
13'2
16'
8%
Slope
108'
23'
B3
10(i'
Beale 1" ' 30'
BN4I Top of iron pipe 100.00'
104' BN12 Top o conduit pipe 106.40'
131 108.18'
132 10:1.10'
102' B3 1(4.70'
10(1'
Thomas Nelson
227389 ac