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HomeMy WebLinkAbout022-1003-80-000 c ; N ' :. _ F O ! n p d 2) v O O w l O D �n O v A 7 N N 'ti • m j 3 3 m ° 3 o c 9 ° m � I��� � 0 A v+ N V Z a y °° � o », 3 c c, m W j oD t � O N 00 d N CD 7 N 7 0 CD CD CD co CO w rn 3 O y H 3 :or O N f�q 3 O O lr W Z D a cn ! fn D eD .. cn iD cn D W a y W a w ! m e m CL IS• -1 a o o N 3 O O C ! O Ul N N W Q W z co y 0 0 O N N O I o 0000 0000 °Y• O g "V 0 C y N g eD N ii G d 0 •• O O .. O N `• � � N! N CL O W D W Z .r .► =� DDo D�o O O O (D CD j • CD CD v 0 �• ro �• C c m w m C. a a 3 3 o o a AZ C X CL a i A (n N 0o v W T CL a Z C r► ! 00 F 0 m °D U) y C,3 to oo cn o a m S O M o a (D $ ny a. a y 3 != a mfDm N�a a - m c == m c c �o m ° o o a ?!� w o a �=o ~ c Y m �c CL 5 CD CA CD 7 - CD (D S W A : ;:w C N co O — o ! ( to .. S C) CD O A. CD M O O :D 3 N O vC A .". CCD y O fD •p co 7 O a N O p O �l p FL w d O O b (D m th 0 0 z `o f �s . AS BUILT SANITARY SYSTEM REPORT Cl/ OWNER �p fiJ j�; � 7" /- TOWNSHIP �4 %,vn, �/��,� SEC. _T -R / ADDRESS /Q"'j E q ct / ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZ I ON /; 98 2 r PLAN VIEW Off Distances and dimensions to meet requirements of H63 qwnj EVE THING WITHIN 100 FEET OF SYSTEM 1 1 � o o- I di a e o th A ro Sc L PINCHMARK: (Permanent reference Point). Describe : f{oKZ. #50M orK-T. 404 po /A; r xb 00r O� 'ro/ o? *"& *Ar#*a st GoeNt�e. Slevation of vertical reference point: 100,0 Slope at site: SEPTIC TANK: Manufacturer. 4 t Fp_s Liquid Capacity: 1000 6A L $umber of rings on cover : g _ Tan manhole cover elevation: Tank' Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cyc a gallons; total capacity of distribution lines gallon: size OT pump head; gallon per minute horsepower ; ran name of pump and model number ; Type of warning device ti BALDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device &PAGE PIT SIZE: N umber o pits feet ameter t t liquid d4pt _ seepage pit in e� t pipe - elevation bottom of seepage pit evation feet. SEEPAGE BED SIZE; dumber cif lines _I wi th = length &5 the depth SEEPAGE TRENCH: ' wtdth length PgXCOLATION RATE, ��AREA_ REQUI I D 8U T INSPECTOR .TED PLUMBER ON JOB LICENSE NUMBER I h 0.EPA#.tME{JT OF INDUSTRY INSPECTION REPORT FOR r . SAFETY & BUILDINGS LA60R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.'BOX 7969 BUREAU OF PLUMBING MADISON, WI, h3707 CONVENTIONAL ❑ALTERNATIVE I SIM. Plan IQ Numbar asdpneal " ❑Holding Tank ❑ In- Ground Pressure ❑Mound IN I NAME OF PCHMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: NCH MARK IPennanrm nleronce pomtl DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV /, / Na. m of PI-1— MP /MPRSW No. Coun1v. Sa ..I&,V Pe Number 2 9 SEPTIC T NK / HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV. WARNING LAB L LOCKING COV R P O IDED: PROVI ' b O U YES ❑NO ❑ N O BEDDING V ENT CIA. VENT ATL HIGH WATER PILIMfI'ROFr: ROAD: PROPERTY WELL: BUILDING. VENT H ALARM LINE. AI 1 YES ONO 01 �❑ NO F r!RQI :.` ( C) O O f qt; �. DOSING CHAMBER: MANUFACTURE It BEDDING. LEL J PUMP/SJPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: IQU C.AP C11 PUMP MOD O ❑YES ❑ 1 0YES ONO I DYES ONO GALLONS PER CYCLE; MP AN CONTROLS OPERATIONA L NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LI AIR INLET NEAR PUMP ON AND OFF) DYES El NO _ SOIL ABSORPTION SYSTEM. ec a soil moist re at the depth of plowing I ENGTH IAMETEII MATERIAL AND MARKING or excavation. Ili soil can be r ed Into B wire, c struction shall cease until FORri ' the soil is dry enough to contin .) CONVENTIONAL SYSTEM: _ ' " WIUTH - LENGTH I ND OF DISTR P E SPACING COVER LIQUID INSIUE DIA #PITS a R NCr I' /ry 7 THE NHE5 Y MA L: PIT 5 1`C�_ DEPTH. A 1 FILL DEPTH UISTH ; F UISTH PIPE DISTR. PIPE MATERIAL. NO. OIST NUMBER OF PROPE TY WELL: BUILDING. V NT JO FRESH BE LOW PIPES ABU VECOVE 111,11 I 1 ELEV ENU PIPE IINF AI LET & �) 8 9G S7 Nv C- FEET;FRQM + OUND SYSTEM: 9 • I `' Mound site plo p rpe 'dic r to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows th psi e mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. El S NO VER TE 1 FIE PERMANENT MARKERS OBSERVATION WELLS OYES ONO ❑YES NO DEPTH OVER THENC ED U PTH OVER TREN ffiBEU DEPTH OF TOPSOIL SODDED SEEDED MULCHE -' If1� R QG E S ❑YES ❑NO ❑YES ❑NO [:]YES ❑NO PRESSURIZED DI TRIBUtjQk S STEM. WIDTH 4 NOTH• NO. OF LATERAL PACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. s� TRENCHES- I r ? MANIFO 0 P M MANIFOLD DISTR PIPE MANIFOLD MATERIAL. N¢ DISTR. DISTR. PIPE (ZI RIBUTION PIPE MATERIAL a MARKING T ` ELEV. EI V. CIA. ELEV. .. PIPES. DIA.: T A . ; AbfJTIQ. OLE S E HO E SPACING DRILLED CORRECTLY ER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED ... PLANS. COV ONO 1:1 YES E] NO COMMENTS: ERI�ANENT MARKERS: OBSERVATION WELLS: NUMBER OF`"' • PROPERTY WELL BUILDING. FEET FRC LINE.- OYE§ El NO OYES 1:1 NO 10-S. 9. 11 10,29 OA 1 u Z a;l Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE N, TITLE I.HR SSO 6710 (R. 01/82) DEPAATMENT APPLICATION SAFETY &BUILDINGS INDUStRY FOR SANITARY DIVISION LABOR PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. i Property Owner. M ing Address: o M ! N 5 1 t, / /3ox IVO lPoh4t5;P1 Property Locatio : p � -ViW"e or Township County: N_% SE Y 4S 2 iT i N/ R W Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: ti14— 7)Mvr / 6ve Id (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* . ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY ,V�¢ LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: C a oc i EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPO ED (Square feet): 1 New Replacement ❑ Experimental Seepage Bed El Seepage Pit 3 (D /5 �0 3J �) El (specify) ❑Seepage Trench J Water Supply: Owner's Name as Listed on Soil Test Report (if otker than present owner): rVI I Private . ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign re: MP /MPRSW N .: hone Number: TpAv 49 Plumber's Address: Name of De 1 22 A4 0 DF_ COUNTY /DEPARTMENT USE ONLY S n t e of Issuing gen Fee: Date: APPROVED Sanitary Permit Number: clad 110 L ❑ DISAPPROVED yO Reason for Disapproval: Alternate course(s) of Action Available: i Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR -SBD -6398 (R.07/81) ` - i e L x , ' r i 4 t T • ..fit . 1 s w 'wci f w... �'IYY•- .a�Y�¢�. it ,MWw:lw/M�MN!YMIIM!','�d.�"'.s N O Milk tv f ypjL rES s How REF �r � o Ta of PL B (o 7 ; I c,00 a Al I A#k Do r w p i . 00 fauwD�r %vy S� PL,QT and CRO55 �rriov = S EM O N PIA N S BOO D ,i Tv ° .W eeZ $00 G �� E \ Ps ' ap 'ARC A �w 0 - - - - 1 ,4 5 iAE -/o r � Fr. boa E ,1 y „ �.. 3 yr. sp��� �Fy f y , S �,T Ls ik.IP I ova Fresh Air' Inlets And Observation Pipe ( � Approved Vent Cap to 2 Above V. Wa Grad Abov6 Pipe 4" Cast Iron To grade Vent Pipe a a Ha . # Or Syntheti Covering Min. 2 Aggregate Over Pipe Div Tee Pip —'�' o 0 0 0 0 44 )0/ ;V/ - Aggregote o Perforated Pipe Beiow 3eneotn Pipe , o Coupling Terminating At Bottom Of System F DEPARTMENT OF ��', -'' ETY & BUILDINGS ` INDUSTRY REPORT ON SOIL BORINGS r—' ,� t DIVISION L4BOR ANA PERCOLATION TESTS ( 11 RFrF �vE� P.O. BOX 7969 HUMAN RELATIONS \ ISON, WI 53707 MAY 1 1J-3e LOCATION: SECTION: �— TOWNSHIP /MUNICIPALITY: OT N NO.: (&VISION E: AT 1 / / Z - /T If N / /e E (or► W ; A11'e 1 W /e , t COUNTY• O BUYER'S NAME: MAILING ADDRESS: t ��'o Tam - 5 ri9C y E.vgESPGI, R -PT 6 x v1- ,Po6r USE DATES OBSM4NQLtLC&ftJfikDE Fig NO. BEDRMS.: COMMERC AL DESCRIPTION: NS: TS: Residence ❑New Replace BBL 2 -1 WI- .2 RATING: S= Site suitable for system U= Site unsuitable for system 7 �� CONVENTIONAL: MOUND: IN- GROUNDPRESSU E: S STEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) 61S•-- SQ �T- S ❑ ®S ❑ ©S ❑U ❑S ®U ❑ U 4 4 0,0 ULU714t14L ' If Percolation Tests are NOT required DESIGN RATE: STE I If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indi Floodplain e l e vation: R PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIG HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B- e ; f110 e (yam �n) I PERCOLATION TESTS #TEST TD EPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERT D2 PER PERINCH 44 1 P- Z 2 < 3 P P- _ 3 Y T 1 1 2 < 3 1 P� ` PLAN VIEW: Show locations of percolat�tesoll borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference p w their location on the plot plan. Show thesurface elevation at all borings and the direction and percent of land sloe. �'�'�" w 0Ak wolerS ktj, sxjeTG y SYSTEM ELEVATION' 77t UE,fT REF P T Rt)VD "' N1_. j_...( REF P' .._ ATro, S I A r f lie IAJ i XiSNr�j ! uE" }�ar ca �y jCcG^ fo rE,yvT o D � /3�Poo �• _..... .,..._... . -. . i pu� . I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print�o�� gllkel� / T Me L z y COM / O N: 5u 2 -- - ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): l3 �.t'C / /�/� v�So.v Gtj /S • 55 'off -�z— CS SIGNATU E: r DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page - Property Owner, 4th page -Soil Tester. DILHR -SBD -6395 (N. 03/81) F T i t o; L �r r- Tom & Stacy Engesether NE SE Sec 2 Kinnic R.R. 1 Box 46 Roberts, WI 54023 Sanitary Permit 6 -7 -82 24098 -67 Conventional Replacement N S �-� Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430172 0 GENERAQNFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: En esether, Thomas --T Township 022 - 1004 -20 -000 CST BM Elev: Insp. BM Elev. BM Des 'lion: // Sectionlrown /Range /Map No: `�� lS O s �k 4A - 02.28.18. TANK INFORMATION 9LEVATION DATA TYPE MANYFACTUR&R CAPACITY STATION BS HI FS ELEV. Septic Benchmark - /a pes1Tfg p ,, �� f Alt. BM �l Aeration U Bldg. Sewe Gti 61.vF 9- 30 l (v r!9 — - St/1-11: �/� 3 SUHt Outle Z�v l h J TANK SETBACK INFORMATION TANK TO P/L WEtL BLDG. Vent to Air Intali, ROAD Dt Inlet d � 4 4 0 7 Septic Dt Bottom / H eader /Man. NA Aeration Dist. Pipe Z 1!•7'* Holding Bot. System 'X 93 Final Grade PUMP /SIPHON INFORMATION f 40 'j ,?',P Manufacturer St Cov GPM c Dl S Model Number J�, TDH Lift Friction System Head H Ft d� J N Foro%PALwTngth Dia. Dist. to Well SOIL ABSORPTION SYSTEM Ct BEDITRENCH Width Length No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAK /STREAM LEACHING Manu t �y�J INFORMATION HAMBER O / Typ f System: / / Model Number: S 7 (° ! cntii� �S S� DISTRIBUTION SYSTEM Header /Mani fgld Distribution f x Jdole Size x Hole Spacing Vent to Air Intake f Pipe(s) �� /,,,�►�' Length 1 2 Dia Length Dia acin ✓ I �/ �✓ 9 P 9 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes [] No Yes a No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 1 Inspection #2: / / Location: 538 Trout Brook DrrRob,,e_rts, WI 540 (SW 1/4 SE 1/4 2 T28N N,A� Lot �L Q - -_ Parcel No: 0*2..28`.- 18.,x, 1.) Alt BM Description = t � _ r � f 2. Bldg sewer length - )) 5 Z - amount of cover = Plan revision Required? Yes ' F %No `, _ - -- - - -- - -- — �I Use other side for additional information. SBD -6710 (R.3/97) - _ Date Insepctor's Signat a Cert. o. Safety and Buildings Division County or 201 W. Washington Ave., P.O. Box 7162 - 5 — k . ce.o NN i scon si n Madison, Wl '53707 - 7162 Site Address. Qepartmi�nt of Commerce Sanitary Permit Application Sanitary Permit Number PAID In accord with Comm 83.21, Wis. Adm. Code, personal don you provide �� O I may be used for second purposes Privacy , s15 ❑ Check if Revision I. Application Information - Please Print All Information rl tl �z State Plan I.D. Number Property Owner's Name Parcel Number r ho m Q-5 E�r� ETlI �!L 20u o�� -�d a�t - (3 o o a.�- )ap3a- o -pc.e Property Owner's Mailing Address Property Location 538 T R©tiT" ca �.-. �5� u Taa N,Rfb City, State Zip Code Phone Number Lot Number Block Number o 18 J' A T S Wr 5 yo 3 � '71 g - - q a S "' Subdivision Name CSM Number (o8 1,3 — II. Type of Building (check all that apply) /� , \ / ❑City 1( I or 2 Family Dwelling - Number of Bedrooms (�+ 6lvL� ❑Village ❑ Public/Commercial - Describe Use RR. p t< _ JVNxKz N N Z �. ownshi !�- ❑ State Owned Nearest Road RotiT ,B Roo k D R III. Type of Permit: (Check o box on line A (numbering scheme for internal use). Complete line B if applicable) L LS ❑ New 2 0( Replacement System 3 ❑ Replacement of 6 11 Addition to For County use stem Talk Onl Existin S stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number 7 r sued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 Other V. Dis ersnl /Treatment Area Information: 7 - -Zo V $ to Z ZZ Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed 7- Rate(Gals. /Days /Sq.Ft.) (Min./Inch) -ri q 7 AS" Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks w! _ /0 � Concrete Constructed Glass t New Existing Tanks Tanks Septic or Holding Tank A j 0* o ISAJ o2 w / 1 � �6 /A �r Dosing Chamber „ r• r VII. Responsibility Statement I, the undersigned, assmrie responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number: 0 4(f e>` AJ¢ c k , l( ( 41 y" a A 7 7 10 -715 7y °� 3 3 Plumber's Address (Street, City, State, Zip Code) 9 & 7 14 ftj G s ° a 3 VIII. Count /De artment Use Onl ® Approved ❑ Disapproved ' Sanitary Permit Fee (includes Groundwater Date Issued Issuing gent Signature (No Stamps) Surcharge Fee) / El Owner Given Initial Adverse. Determination 2E� IX. Conditlons of Approval/Reasons for Disapproval n ID,v U v L.e U&kk A-� 7 �z - 3 Vep-rS �} Attach complete pram 06 the Conity only) for the system on po of less than SIM 11 Inches In she SBD -6398 (R. 05101) I 1 441" - ® � �! 1 � I Two I Irk ci 4C& w o • i r � tu 1) CIf ca CIA s., 3 d � 1 Wisconsin Department of Commerce SOIL EVA LUATION REPORT Page 3 Division of Safety and Buildings of in accordance with Comm 85, Wis. Adm. Code tl Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST' CSC d � include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.O. O percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 49 • 1603 .8p • o00 Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner c Property Location - 4Q,q J¢ S G N�J� 6 7 #A—k- Govt. Lot 5 4) 1/4 q5 - 1/4 S L T 2 V N R /v E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 538 TI?00 Seoo* Dk . C State Zip Code Phone Number E] City E] Village J9 Town Nearest Road o�EI21 S w1 Slw (7/S ) 9 ZS • �9�3 I�,i / ' .vi•C ?lE'o�T /3R D,� �'/ � ❑ New Construction Use: K Residential / Number of bedrooms Code derived design flow rate GPD i4.Replacement ❑ Public or commercial - Describe: Parent material �,y/> J/ O �!(1j¢ s Ft d PI�iq ft General comments r �- e,r : f t and recommendations: r� S2002 F/-1 Boring # Boring � ' ,_�..._, �,,!- YX Pit Ground surface elev. 77 77 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eft#2 o• /� /Yoe 2 /3 1-5 14,0 X .� w Z [ . Z z �y. . s s ,� / s e 6-f w .,� . Z . 3 9• y 7• yR y /aYR s. o� se s 30% Ual /o YRs s . D , s �P,2 &+ � � Boring# ❑Boring go - ZgIlb•Z . TY y //o Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In . Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • /oy� 2/-3 .4 S I'W 41 .? 1 • Z ii • 7.5 SL 2f s b,(< / e v ez S • s . 8 •S �e fs/ n�. -�P• s. D. S t c s -- , 7 134 I. z. Z � lDq -LS Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Zi'� ��� Signature / � Number 'Ro f3� C2T' Address Date Evaluation Conducted Telephone Number /— a4v/ 7!S •3 • oO s Ulbricht & Associates Private Sewage Consultants �� /•ST�ivG- S i sreA -i r ' S 655 O'Nail Rd. J Hudson, Wis. 54016 %v God CDtir a �i,�.t✓ /'" Soi /S a.r,, 13e L el-j /N ref c 7- d6-z- ORI IN AL Property Owner ov S8rAtt, L 3 Parcel ID # ❑ 3 Boring # ❑ Boring ,Q Page of 0-Pit Ground surface elev. �V ft. Depth to limiti y �� � p ng factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roots Sal Application Rate In. Munsell ry GPD /ftZ Qu. Sz. Cont. Color Gr. Sz. Sh.' 'Eff#1 •Eff#2 'i io yR JW 3 . /o AO -- rPrly SL 2 -f,5 n� , F�- c s — S loo 7' S �y iw,��Q• S. C' , S Is • � c S . 7 /. Z 8' ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roots Soil Appllc /ft2 Rate rY In. Munsell GPD ft Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 F1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L _ 9 'Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.6=) I N � �~ w , c C V V R N \ DO W CIO � n y yy d N ao _ m Cl , �► Tl� �1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ) of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 6J6t ET.M&-Z_ Septic Tank Capacity ❑ NA al Permit # 30 Septic Tank Manufacturer GJ �, l`d,,,�„ P,,o�D NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model j q - /o o ❑ NA Number of Public Facility Units PSNA Pump Tank Capacity a l 19NA Estimated flow (average) 30 o g al/day Pump Tank Manufacturer K NA Design flow (peak), (Estimated x 1.5) 4 1 5 -0 al /day Pump Manufacturer IV NA Soil Application Rate • 7 gal/day /ft2 Pump Model EK NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit WNA Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD _ <2 m /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L b(In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L AIA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ANA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 0 year(s) month earl 1(s) (Maximum 3 years) 13 NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell !� yeaarr (s) (s) s) At least once every: 3 ❑ m ) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) E3 NA K year(s) Inspect pump, pump controls & alarm At least once every: ❑ year( month )^A ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) NA Other: ❑ month(s) At least once every: ❑ year(s) eQ NA 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; Septage Servicing Operator. 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 combined sludge and scum and to check for any back up or ponding 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 ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing 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 Septage 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 filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 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. GMW (4/01) Page START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) 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 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) 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 properly 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 pits 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 If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: IN 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 sy tems must comply with h rules e� in effect t t ha��mw � � E C, • A suitable replacement +- area • �is not available due to setba an I /or soil limitations. 'E arrin3 �-ag advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no 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 systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > 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 POWTS INSTALLER POWTS MAINTAINER Name L3 Name 0 ► Phone 71 _ 4 Q- 3 Phone -7 7 4 4 — 33 l SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name rp 5+-�. Sr-�t0 Name Sr. CO Phone - -7 - o S 3 Phone - 7 j $-. 3 b- clip 8 O This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.540►, (2) & (3), Wisconsin Administrative Code. ST CROIX COMM SEPTIC TANK MAINTENANCE AGREEMENT AND ` OWNERSHIP CERTUICATION FORM Owner/Buyer N G�t7 Mailing Address 538 �J 9�0A �� C" 3 g1'�`S IA/� � Properly Address (Verification required from Planning Department for new construction) O a P- lO0 y 0 ZO w ofd 0 City/State a t. Parcel Identification Number of 0 3 8 0 . oo a LEGAL DESCRIPTION Property Location S '/4, S i /4, Sec. x . T a 9 N -R 1 o W, Town of - 9 Subdivision Lot # Certified Survey Map # /Y1 6 Volume . .Page # Warranty Deed # 22 111 , Volume j y 6 9 . Page # S �O Spec house ❑ yes IQ no Lot lines identifiable IR yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restricted plumber or a li cense d pum verifying that (1) the on-site wastewaterdisposal 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 disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. *IATURE F PLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the perty described above, by virtue of a warranty deed recorded in Register of Deeds Office. A l/ l'#lOZ SIGNA APPLICANT DATE ** * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Dep ailment. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed /o VOL 1- 4 09FAu550 599179 DOCUMENT NO, QUIT CLAIM DEED REGISTER I. S REGISTER TGTSiEk OF DEE DTEDS 5'i. CRLIIX CO., WI RECEIVED FOR RECORD Thomas A. Engesether and Stacy J. Engesether, husband and wife, 03- 10-1999 10:00 AM quit claim to Thomas A. Engesether and Stacy J. Engesether, EXEMPTLNIM DEED 9M hushand.and-wife as survivorship marital property,.the following. CERT COPY FEE described real estate in St. Croix Count State of Wisconsin: COPY FEE: Y+ TRANSFER FEE: RECORDING FEE: 10.00 PAGES: t Judith A. Remington REMINGTON LAW OFFICES P. O. Box 177 7 New Richmond, WI 54017 Tax Parcel No: 022 - 1003 -90 A parcel of land located in the Northeast Quarter of the Southeast Quarter (NE1 /4 of SEl /4) and the Northwest Quarter of the Southeast Quarter (NW1 /4 of SE1 /4) of Section 2, Township 28 North, Range 18 West, Town of Kinnickinnic, being further described as follows: (Bearings referenced to the South line of the Southeast Quarter of Section 2, assumed bearing West.) Commencing at the Southeast comer of Section 2; thence North 41 0 48'50" West 1761.70 feet to the point of beginning; thence South 89'57'10" West 395.43 feet; thence North 00 °02'50" West 33.00 feet; thence North 46 °22' 10" East 145.25 feet; thence North 65 °46'10" East 89.70 feet; thence South 85 *48 East 201.35 feet; thence South 02 0 51'00" East 155.21 feet to the point of beginning. This is homestead property. Dated this */k day of March, 1999. A wl-IL d• L i � (SEAL) *THOMAS A. EN SETHER SEAL) *STA J. #NGt8VHER ACKNOWLEDGMENT STATE OF WISCONSIN ) ) sS. ST. CROIX COUNTY ) Personally came before me this&t day of March, 1999;-th6' above -named Thomas A. Engesether and Stacy J. Engesether, to me known to be the persons who execute the foregoing THIS DOCUMENT DRAFTED BY: instrument and acknowledge the same. Judith A. Remington eu a • y}(M�a+ REMINGTON LAW OFFICES ith A. Remington I . s 126 S. Knowles Avenue Notary Public, St. Croix County, Wis. Y' P.O. Box 177 My Commission Is Permanent. New Richmond, WI 54017 (715) 246 -3422