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HomeMy WebLinkAbout042-1087-50-200 (2) ueprtmem.m PRIVATE SEWAGE SYSTEM St. Croix 3as^~ a^a tiuuo ro Om s.c.. INSPECTION REPORT "N GENERAL INFORMATION At IA(;F- 10 PERMI') `r n: 607076, Ier:. rl:m:alun'ibu Pm': itlc ma' .cc'to utlv:v {'".q •s IF-raci -all '-'b.GA hmlJ 1mnt-Oloee5 Name ,i:y vnlap[ . . , I Ii0 Pamcl Tax No Daniel and Kathryn O'Brien TOWN OF WARREN 042-1087-50-200 I Rhl PI,- .-RN b F'1~ . ~aaJU 31,28,18.486A-20 TANK INFORMATION ELEVATION DATA Ty.- MANU=ACTURFR STATION PS HI FS ELEV I Septet , 1 Benrlm.14 Awes 0.5 91' 9a. 77 411 91v 7-4 Ae:aharr BIdC Scn•!:T Hrlninq SUH1 rk:! SVH: TANK SETBACK INFORMATION Guile! (o U.NK Ji_ F7:i4C UI Inlel ` Sept¢ 5 Z3 / 17 SCI ~ 1>t Bolbru \ Closing HeaderAvtan /a r Qt,l .rip ro So.(07- lokinrg ''ot. Systun /l.b 79-b - PUMP/SIPHON INFORMATION 1nal :;I ante 1 ,5 Ivlanufadurcr _ ' rlylanl S: Coverr`- Mode Na - C''(( 00 SDI Ld1 Hr.:eon 1 oss Syst ae IT-)H R 4ncrnrain I ecglt'. Dr: alst 1G1^iNl / - _ 1 -1 SOIL ABSORPTION SYSTEM d RFD7RFNCH %Ndl, =nq:0 4r. OI Trenc-es PIT DIMENSIONS N.: L~ aenoc Uis morn Cw{iP DIMENSIONS t SETBACK "YSTLV J Pll B__1G1 VIE::. _AKFiSIRFAN IFACHIN6 Man.'sc:m ,l INFORMATION t CHAMRFR OR i y:,:-OI 'zy;tnr I UNIT Rra Nunrbri a I I 'f 51 /a$ DISTRIBUTION SYSTEM 0 2 L L c dy 14U Jul-, ~Iq Hcuac^Mu°d~:: rr _ristrinuvon r hale z:ve x Hnip `.r:eu:m:: \'en.' IQQ Fn P,'ty' ke LenoID~ U,=~ copal _ Dis a::nui SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only ~ :,r:~ln ~n~r- Uc:,m ooe x. oev:n m .,e~acdr:;:,dd~- xx Mwa~ea yeor r_nd~acnle' 'J_ ~ &e0rl enor iauc: ~ Tevsmi ~ . Nn vn; Nt COMMENTS: dndude cuie drs<~epen°ies. ce $Ons preaent CIC.i I/r}.nection #r Inspection #2 Location: F`{.,41ST ST LAI_ t i Bi 81.4 wui en6on = L_i Bltlq Sewn I!:ngll` = L r amouni of cover = L Kt 5) r rl Ilk J L ~fae~- ~e~JG 6 6/aA~ Plan revision Required/ YesNr. Ib J(~ G83~7 Use other Side to. - adddlonal Intormaiion, Y/ 7 Tate u15e0olor' Jona:ur - - ;,ert No - - A S' era J ee Pj S }v - o q _ 0_~ _7 - - - Indunn Scrvicc Divisiuo uus - p MKI E Washm-Eun Ave - ~r ~BOiX _$p 14 FIR 26 2D 19 P0Box 6 ~5>nitt, Pcmnt Number (to he filled iu by CoJ T Madison u. S., 7162 ,^n--•/t ..../r~ ra 1 _ f I lL/`~ ! O SmlitarY Pen-nit Applicilti":- - tateT saai:: umber r,Wdancc with SI ti S 1 \ - Ad.n Code. submission of Otis form :n :ncenpr nnat nit ~ D'Oui poor tbtai un mt ry 1 : m t kme: Appiicatim+ forms to SWIC-o•.vntti l t I\ l arc submiucu , P . .jcctAdd+c.,, ; d: (tnern }:un maiiin~ addratis) n -p:utmrnt of S f ty : t I I r -n: Sc-s < Pea mat - Ifonnano. %m prmidc he ird in -and=r; mxet in u.eM,.rt vi!h dt I In(r) P licatiun fnl +rmnttnn I'll c Print 41l 11 fnf tt not "pony Onmtt. Name Parcc!;; ~ ,4n11,1 _ d /J/Z/C^t ' 1 OYd- /087- So -pirty On to s4btibng.Wdreca _ - Prupeny Lucatior. j a~,8_t_/LJ~i ~1Ge 91'r 5r O IDW/f q frvvt,vt - r FI -54d /7uOSOA, (JI Sta1 sc ;nn _ 55'Oi6 G/,? 900- S 9 jarele Oti~s _t 't typeck ail that a Iv O- of _ - - ~Z-- (T I 9 N: R _ ~8 * 140 2 Family ]Meiling-Nuniber of Bcdrt nms 3 5 mdtl- sisiun Name - `~~µL[fiock- _ I`ublieiCmnntereial - pescnbc Urc Q-C-ny of ntc Owned - Dcacritc Un. CSA7 Nvmhcr Z z:-";.gc of 4-, 4A 'i ype of Permit (Check nni line A Compietc Iiuc B it applicable) '..I Nea S)5tcm ~G Ky>la<emrnt System I t rcntrwntiHolding Tank Aopiuvcnx-n On:';• .J Other 11cAlfic-P t t (vistmg Systan Q Penn Rotnstmt Chan a of Plwohcr U L t I a tu;. Pen ut ♦u'nbu and W4 imam g 1 cmut T.-.u+sicr to Nc•w I R 9„ fya,ion /./f OEcr'[B 9-]f-p0 Omcr tettuCom opent/Device: Chock all that apply) \.:n-Pre~svmed L+~vnin ❑ Ptmsurl¢cd In{imund ❑ At-(imde ❑ Mound_ 24 in. of saimbic soil ❑ \founc J, n; Idinc T'mF ,Other Dispnsnl C'nmpoocui lcxptamnl Pr n r n .n. 1 s (v it "its asaVtrcatm • 4rea Information: _ - - - ~7:X JC~777 '_n Floa rgpJl Dmr Soil Apj+huuion Ra fpdsl) Dispc_s i Arc Required (sl) DtY+us:+I ..-ea: r sC "1 I: a L e. alt n ~f S ysO --~G 7So ,88F-~ ~b9a 79.G' 'Tank info , Caivaq in IuLd 4r nu lento- G4lnns 1 Uons i Gail+ t, / Ncx Tatks tc¢un • T ra I G✓JBes~- 6F/0 = M j J.!lOUEST r n~OnMcr 1 Responsibility Statement- 1, the undenigucd, sss"We responsibility for Iaslullation of the 1,0111 S shots on the attached plans. ilmixr•s ),ante IPrinQ n Phtmbe 'S: a re~ MP/biMS Number Rum lis Phone Ntnnber loNv ,/JECi<E _1-- err( f-~ d i/3YG 7~S G77-sacL Lu-nocr's :lddress i5ucct, CO ,State, _A/G,?98 S hwr ~ ~u~nNO~ G/I J 173, nund Ice:+r'm on i u Unit _ 1-1 c - l t t Fe 1 Date I uui j Issuin rot Signatwc - - I C 566. 13. r.nndlr f NNW .M Mf a11'a~r eWtEh' 4fF~ ~ o SBD 43013 fR. fn; I. ,X ~ 'er 3 M1 r~ I N. ~ v a ' ` o ? Q P ~ v ~ .4 n x J- `~t:l I r ~ ~f V I' 01, v _ vl V ~ I ~ ,W W Y• 'v Y. h n W ~ T eQ I L z Y h 0 it ~ O ~ Z V ~ v ~ I A~j 1 ti 1 I I I I i~ M I Q ! it it ` 14 41 Y ~ I I I x` W ~ 0 e" ~aA a c L 3 I I zt~ Q J YI 1` 1/~ ~ IL Q M h : J: ~O ■ I, x I I Pa,~c ul r. u'irrNir`L U iJd;E~/- ,3- Apt /,✓cao „ro i~c;~rs CilEi°LI[Ei9l+Ir/ n •ti ner's Name• r /.7 Sao - TG 7 9 . ;:~a~ Uescriptiun'. _ ..S4J 3 ± d 9 N+ /8!J iunicipality: Towwn. V44age, C;ky of G/A tRAw _ Number: 7__- Block Number: CSM Number: -/O- ~,79ay dcbdivision Name: _ - G/9 9/ #-r Sr. D. Number: O'/?- /a87- So- ?ao Page I Index and Title Pa;_t Page 2 Plot Plan with Cross-Section n•. Plan Vic•a Page 3 D/UE-,e rcA uatuE i,~r/o Page 4 PONWTS Owner's Manual & Managcma._ F'„c' Page 5 POwTS Owner's i',ianc;.l S- p~,i aii._ce n::-!,., i'.~r. Page 6 Filter Informatiior Name of Designer: _ To*.i `ELKS ce,l5 /yj - ~3 /3 y~ Signature: ~>-r \ Date: ~/-//-.70/9 - I ; Desi¢nedRg~~rlgt to the fulls>.win~ I J .'~'1 S_~ _.g~n~ncnt ~1~n;ial_gn_:i :•)SLS JS' SBD-10705-P (N.01/01, IL.10 12) `J _ . , y .,,n Attacnmcm: Soil Lral•.tatiun RCF)i'r. W at ~ Q ~ h iI W V v a ~ W " 2 00~ a `O ; W e I+ ZI h `h Oo I @f o o t ~ o- W I Cif e „ ry v Z R7 I~ vs z 0 ;r P.i Q J 2\ 4 v V s~ 04 -,j 1l11 J ~ h j 1?~ `V Q h, !Q O 0 ku 1i q,P ^ X 4 V 1 rl I ~L ~ z ~ ~ , a I I I H; 144 vs 11 -I lu ~ O ~ pp Z V W 1 V .t N o I N N M W \oi 'l ~ a s c< M h~ v J ~S ~l it, \41 Z l1 ti Z I. 0 x T C r h o' I vt 1, ti A I DIVERTER AND BACKWATER VALVES ~i. 3ef t s the simplest, strongest. and most economical diverter valve ever invented for septic tank leach fields. It is made cr rough molded plastic that will not shatter, bend. rust or corrode. It is lighter in weight, easier to handle and less iis!ve to ship, <A;verter valve stem flow may be. controlled to individual or rnultip,e fields (up ,,o three} it any combination. Willi a ?-way valve stem, flow may be diverted to any two outlets. To allow flow through all outlets, the valve stem may oe :red from the assembly. C,nPcI 4" plastic sewer and drain pipe to inlets and outlets on the four way distribution box. (Unwanted outlets may be by installing caps). The Diverter shield which houses the diverter stem may be cut to desired length. 1.305 Pkg. W1. Ed. Product Port No. Description Cobr Qty. 165.1 Class o7=P 4-?V3 Divener Valve `Nhi!e 4.50 P 4' ASS Divenef Velve f31ac. ±.~C l ClO5r0 t 2 3 d, l 0 000G. TANK TANK TANK 4 5 !APMC :,1,J 0°-~ 0o *m RFAkM TANK LANK i RrSTFM TANK .1j:-- y e.aity flow Backwater V I e_ i; :!e!= cfned to Dro'ecl cv are-s or base°-ents from the backflmv cf wart eat Sewers. It is available in arc 2e_ rlara1131 I, 1 :_os1 . _ a e.-h 9IIy ins ctant , ative to cast iron valve;: i;Ulck action flapper allo'is _!'i GEt. ctrl L r' -._CiIL" c' 7 11b E.aS n A!I n9kNt :r ?fl@ .a..i?6r fir!. ! 95 ;l9tB~l~]!'t I Flapper can be easily remcved and replaced if required. aced access cap is designed for hand tightening. Access cap neoprene gasket provides a positive seat. Va v b r. r-:s fit 2". 3", 4". or 6- DW V pipe and may be adapted to 2". 3", 4% or 6" sewer and drain pipe with NDS DvdV '.c per & Drain Adapters. weight, easy to install. Horizonte: installation required with arrows on top of the valve hub pointing in the du, h flow of water Access riser with i offers a simple. economical G` Item Number A B C Riser Height Riser Di, ss to the valve for inspection and ?75P. 2-5 2.18 5.03 3.53 16 h tenance. The riser maybe cut to 275PR 2.16 5.03 3 53 15 4 i.a aeSlfed length. 37SP. 375 351 7.56 6.i0 16 6 375PR 375n 3.51 7.56 6.1o 16 6 ` _ }[II 475P. ,475 4 4.47 11.18 7!6 t6 n A 1 F C " 4?5P 4 47 C b 5'SR C is?5 5.50 1525 L90 ib r~ _ 1`.~ :err. A _ S r' nF:gprdlu 1. F'wclx w , er,e : IJnre All riimw.~b.re un ,+a.i"ol. AA ..yiq{w ar• for finr+pin n"•r>+.. M4Y 2 "(I'" I S OVv'NLR'S N ANUAL, AND AIANA61EML:N•I PLAN I ll t {\6OI \t 1l lO\ _ _ SYSTEM SPFCD I(AI'IONS ru ' - I non # ~ Le tu[ c TnnF l: tpauh' 44~ gal O Vr1 Scntic Tank Mond wturcr _ '-f 112 wES r C3 Nri Itl SIG NPARVsILEERS I - tmd>cr of !1,,l oms I 100_ 2d+bed.von,) --3 ulnaled Ilow El fluent rdter ManuiaUurer _ ,¢j EST O O _NA VA ItOuentFilicrA4odcl (rf-/D ' - (average) f'amp'I' u1k Capavily al li NA st m rot ommu'units YSO gaV'day Pump fvlauu cr O NA 1kl nl ow DW -?oo, gal/day _i Pump Lank Manufacturer O NA l{ _7( ) - estimated z 19 - ~L'i :lpplicmiun Rate L-gaUday;liy Pump Model nNA ialhieno`Elllurm Quality'(O VA) ~Monthly Avctage Pretreatment l;nit(0AA) - I Sand'(;revel Filler O Pcalfiller Pats. Oil & Grease IFOG) < 3(I mWE O Mechanical Actation O Wetland Biochemical Oxygen Demand (1101);) _ 220 rngil. 7 Disinfection O Other. 'total Suspended SuVids ("fSS) 5 15() mgrL i Manul'acturer Model: I'rarcated Gflluent Quality (W NA) Monthly, Avcrage~ Soil Absorption Component (rl NA) Biochemical Ozyecn tkmand(IiOD,) I 30 ' 1 SI In-ground (gravity) OIn-giom,d(premurizetl) m a, Total Suspended Solids FSS) 30 m-II O .At-giude O Mound Fa:c:al ('olil'orn: (geometric mean) ` 10 cfull l00ntl. CJ Drip-line 'I Other: Vc tic:d C)utance 1 ank Bottom to Service Pad: /Q fl d iximum Effluent Particle Size j 11 inch diameter 1lotaontal Distance Tank(s) to Service Pad. f/Sz Ill Dispersal Unit NlfgJModel Number: _ IAIfiZ;-AAFd1L 4Q1ZA 1/ Z1/4M4ERS O NA • Iculatiuns: Soil Dispersal End Cap (Dispersal i:nlt GISAI goolicatign Rate grca lie wired - EIS. A 4- onTrcnch Width, _ _ }Units of Taal lci th uf-ICench si y,S"o - • = 7so - yGt..r - _~6. o r ~ a c~AnaE..s 11! SIGN CRITERIA -r') - 7 "Design of Pressure Distrihulion NeurnrFs for Scptir l:tnFSc+il Absorption Systems" Publication 7.6155W'~II' Manual)--- n "ICC Flowleeh Mound Component Manual" Version I.? ~ I " J I love Mound Component Manual" Version &20+'2007 n SRD- 10854-P (R.1! 12) "At Grade Component Manual Using Pressure Distribution" Vcrsion 2.0 XSBD- 10705-11 (N.01101)"In Ground Soil Absorption Component Manual" Version 2.0 O SBD - 10691 P IN 01101) "Mound Component Manual" Vcrsion 2.0 O SET) - 10657-P IR6/99) "Drip-line Effluent Disposal Component Marl rl SI11) - 10706-P (N.011011 "Pressure Dim6hudon Component Sfanuar' Veeior. 2.0 7 Other. b1:xIN''fF:NAN('F: MONITORING SCFIEDULE - MAIN'1'EN:~N('F: ANT) ~1ANAGf:MENT st:mccl,cnl knuc fr ors Pump. dispersal cell(s) clean filler At Iwsi once even 9 13 months lY 3 years C7 Other: Inspeer pump & pump controls alarr,~reheaunem unit At least once even: -1 months O 3 years X NA I It sh ;aid pressure test I sere s At least once c, en: O _ awntle, O 3) year, $ N.A START UP AND OPERATION: For new construction, prior to using the POW`TS check treatment tank(s) for the presence ul painting products or other chemicals Thal may imperil the treatmcm process and%or damage the dispetsa. 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 a pshall not occur when soil conditions are frozen at the infiltrative surface. the pmpeny owner is responsible for the opertlloc and maintenance of the POW IS and submission of required reports. The quantity and geality of the wastewater stream will alTect the performance and Iougevily of }our POW FS. Thu installation of water-saving appliances and fixtures along with prompt repair of leak's reduces the wastewater volume. Also the brine or waste from ,vater softeners, iron removal unto:. other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste. shmcers. dishwater. oc. This system is designed to handle domestic strength wastewater, however- the disposal of fired based greases. oils, vegetable/Quit pe_ R. seeds. bones, and fond solids, such as those pruduced by a garbage disposal should be minimized. Toilet tmsue is the only paper that slnmlo he discharged into rho eyewrn Other nun•biodegradahle items each as hahy wipe, tampon., sanitary napkins condoms. 6sareov huu.- dental !loss, and colmn swabs, should not enter the sys!cm. Chemicals, such as peholewn products. paint, disinfectants. pesticid,, obi: nic r. r.: urns, uc, s :i i].I a i I r ar.>P~., in, lP_ ,,,..t, r.l 'u<urc ~a-+. sar sr -ai. rs h tla:n h_ wr I'r ~ ` a'i, rnl,nnin arc v'.r iri-.~ing water mppiy. Vlaintam a rc"eWar sready t!uw by spreadmg launcin washing throughout the •.veek Avoid vchide haftic over _1I -stem components. Compaction ofsmw overthe dispersal unit may cause it to freeze up. 1 ,SPECTIONS & MAIN'T'ENANCE: Inspection shall be made by an individual carrying one of the following licenses or nilications: Mauer. Plumbcr. Mastcr Plumbcr Restricted Sewer, POWTS Maintainer, or Scptagc Servicing Operator (per Elie attached . "intenance Schcdulei. Tank inspections must include a visual inspection of the tank to identify any mussing or broken hardware, r`:~I)lity anv cracks or Icaks, measure the ,ulume of combined sludge and scum and check for any backup or pending of effluent to the .Mend surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings :ncr than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. 4d'1~ n the combination of sludge and scum in any tank exceeds one-third (li3) ormore of the tank volume, the entire contents of the i`: shall he removed by a Septage Servicing Operator and disposed of in accordance with Ch. NR 113, Wisconsin Admin. Code. ;;:chic servicing mechanics must be provided if vertical is >15 feet or if horizontal is>) 50 feet and instructions to be provided below. v chit ter f ilter(s) sha 11 be inspected and cleaned to remove any acetunulated solids according to manu f acturer s Specifications. Soli(1c shed front the filter shalt tw retained in are tank. Fitter cleaning may be necessary at more tiequcnt intervals than stated in the r. =intenanceschedule to keep thesystcntoperafinp. inns should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, t-c is noinialty it I day reserve under regular operating conditions, however water should be conserved until any problems with the I-acm are corrected to prevent back-up of sewage into the d%vclling or surfacing. . ANDONMFINT: When the PoiivrS faits and/or is permanently taken out of service the following steps shall tulz -n :o si'slem is properly and safety abandoned in compliance with Ch. SPS 383.33, Wisconsin Admin. Code All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks ;aid pits shall be removed and property disposed of by a Septage Servicing Opeiaci After pumping, all tanks and pis shall be excavated and removed or their covers removed and the voiL ci, co Tll, ,d eravel, or other inert solid material. ONTINGENCY PLAN: I f the POWTS fails and cannot be repaired the following measures have been, or must he taken, to provitir Ic compliant replacement system. X A suitable replacement area has been evaluated and may oc utilized for the location of a replacement soil absorption system. i h, replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbuck.. from existing and proposed structure, lot lines and welts. Failure to protect the repiacement area renders it unusable. Replacement systems must comply with the rules in effect at the time of replacement. -1 A suitable replacement area is not available due to setback anchor soil limitations. Barring advances in POWTS technology holding tank may be installed a% a last resort to replace the ('ailed POWTS. -1 "rho site has not been eva!uated to identify a suitable replacement area. Vpon failure of the POWYS a soil acid site cvaluution n,,, . be pcrtotmed to locale a suitable replacement Area- It no replacement area is available a holding tank may be installed as a il,~ resort to replace the tailed VOWTS Mound and at,grdde soil absorption systems may be reconstructed in place following removal of the biomat at the infiltra:n surface. Reconsuvctions of such systems must comply with the rules in effect at that time. p: njNIN 'oo SEPTC, PI""NIP, AND o-rHER TREATMENT TANKS MAY CON MN LETHAL GASSES AND/OR INSUFFICIE] OXYGEN. DO NOT ENTER A SEPTIC:, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEAI H '.;;.N'RESULI'.RESCIIFOFAPERSON FRO NI THE INTERIOR OFATANKMAY BE DIFFTCU I:TOR IMPOSSIBLE. i~:Jl'1'I OisAL COMMT-.N T'S: QE/L At Fi.1E.Jf STE.7 Te ,6E /+15 Y4 41f0 /dC•c Tla UAIUE nWTS INSTALLER POWTS MAINTAINER me: .YJONJ ftae! 13 I Name: ~LKE Lurid/J[ tone: 7/s Phony. 71s- 4/7-2 - S•?GG _ SLPTAGE SERVICING OPERATOR (Pumper)-? LOCAL RE_C. U I.ATO RYAU/THORITN' q Name: Name $T L.[O rX_ LOn.7uJ/Tr NEUElc/MC+'7- I o E lp 0'6 zz ya c c - 5 N 9 ccF E vl a SLI _E ~ ~ o a S c 1 ! - ~ ~ ~ os o oy ~2 ag h' 1 G u C g o _ ^ q x L- yV rok =ads ~ ~ as ` ~ C J L ~ ~ S a i ' ~ ry J y _ ~ 9 m 7 p 1. N rL.e y va'. ~ m _Cp 1 L y ~ m F N V B W _ T 1 r~ ~ o a L t„ ~ 3 vLy ? 6 C O s= ~ ~ y 4 =u n v C r., c i l b !J w _L (b~-/' U ~sv Z'". O N G p u O O m - O q ° ZE 22, ® ~ w i' ow MDC ~ T r. c :7z C4 x u ~ ~ 111 u n. r7 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT F")R UTILIZATION OF EXISTING SEPTIC TANK(S) 1 his is -.o certify that I have inspected the existing septic and/or dose tank presently serving the following r $ide cc: (Street address) located i' : 5K.) '/a, Section 3) Town 2-41 N, Range l $ W, I own of ~l~~t~~•-. St. Croix County Wisconsin. pon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) ,ppear(s) to be tunctioning properly. Q \'lost recent date of inspection or service ~j - p U mlx~ Did flow back occur from absorption system? Yes No- (if (if no, skip next line.) Approximate volume or length of time: _ gallons _ minutes Tank Capacity: WOO Construction: Prefab Concrete X Steel Other Manufacturer (if known): YV'az-e-f>+ Age of Tank (if known): _ '2,C<~O Permit number (if known) '6 tj (L' used Plumber Signature) (Print Name) I1~ 2 313 (Title) (License Numbed MP!MPRS r2Z-7-D-~ - (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 I't ` \1 CROIN(OUN11, SEPTIC TANK hiAitvTLNANCP AGREF%iL'iJT AND OWNERSHIP CERTU (CATION FORM Ow~erBu)er I~/~Z t..: el La'~'(,•~ M d~~), ~ ( hailingAddrtxs_ 1rj~ 9sj 16/C~~ 7t ~tG~l01r u(fcz7al~ Property Address / f S~'e (-F~ l~r~, , i ✓T SAD (Yeril)cstwu requ4ad (rota PlataioA R 7aeui DgwmrYOt fur v.v rauuvctaa ) City/Slate Parcel Idm i(ication Number LEGAL DES[ U23a t / Prvpetty Location ,v. -IL. T ~N R~\V. Town of tlN G (fGN Subditision Iat a Certified Survey Map # t 7u~ /9 ~ S~IZtX/ , volume L9 / ~ Pace a Z Warranty Deed 0 volume /S trp(*~~ page a Spa boom ys>~j Lot Iwes AmbfabIc no SYSTEM MAT\TENANCF. AND OWNER FRTIFICATION fapropcr um maf mainteaaace of your septic system could much in its ptcaatm failure to haadte wastes. Proper mairmeaatsce eonstM of pumpaw out the mpu c tank every three yeah err soomr, if meded, by a licensed pumper. Wbat you put We tbo system an affect the function of the septic tank as a ueamnna Mae in the waste deposal system Own" vriewhawc responsibilities are specified an f Comm 8352(1) and is Chapter 12 - Se Croix County Sanitary Ordimnce. The piopestp owner agrees to submit Be St. Croix Cmrory Fuming 4 Zoa sg Department a eertificauon form signed by the owner and by a caster plumber. joumeymao Plumber, restricted plumber or a licensed pumper verifying that (1) the oo-site wastewater deposal eywas is in proper operating condition and'ot (2) after inspection and ptuoping (if naeasary), the septic tack is less tban 113 fall of slafte. Uwe, the undefaigned bave read the above requirements and Bata to mainnin the private aewaga dmpoul system web the standards set forth, hernia as act by the Departmem of Commerce and the Departamw of Natural Resources, State of W stasis Cettifr dw stating that your septic system has been maintained trust be completed and rea reed to the St. Croix County planning dt Zoning Deparneem within 30 days of (be *JU year expiration dace. Uwe catijy that all statements on this form are true to the best of myloar knowledge. Uwe a nvare the owstt(s) of the property described above, by virtue eta wsmnty deed recorded in Register of Ikeda office. N of6edroo S OF APPLICANT(S) D) TE ***Any infamatioo that k misrepresented may result in the taninty pervnt being mvked by the Planning & Zoeing DepamwnL ••e Include with this application a recorded wamnty deed from the Register of Deeds Office and a copy of the certifted survey imp if reference is trade in the wamnty deed (REV. 08!03) OVA. ♦w edaw A)aM l ~sun pepartment of Commerce ~~~rSE S - Safety end Buildings Dive;IOn PRI ATE SEWAGE SYSTEM county: INSPECTION REPORT IR san.tag3er884 GENERAL INFORMATION (ATTACH TO PERMIT) 338 888 Personal information you provice rmy he used for secondary purposes [Privacy Lays s.15.04 0)(m)]. Per ri1~1.+KGtMI°. e* HARVEY [J Cqy• ffg 17 Tom: State Pan ID No.: - W C 1V > CST BM E ev : Insp. BM Llev : BM DM(nption. - Pare Tax No - * 3 042-1087-50-200 TANK INFORMATION _ EL ATIO DATA TYPE MANUFACTURER CAPACITY STATION BS HI lFS ELEV. Septic rvth&C!5,~_ o B~rufun Z~ •98 Dosing yAeration ldg. Sewer 5-0 1. T 3 Holding St/Ht Inlet [Q~ .SO St•93' TAN ETBACK INFORMATION St / Ht Outle(Q ANKTO P/L WELL BLDG. Vum1ake ROAD Dt Inlet ~r Septic Iq' NA Of Bottom Dosing t NA Header/Man I p Aeration NA Dist. Pie le.00 Hol Bot. System o I s o$ PUMP/ SIPHON INFORMATION Final Grade ou Manufacturer Demand Z (o '_7o. Model Number GPM TDH I ift F ' on y m TDH Ft Force n Length Dia D-st To Well IL AB ORPTION SYSTEM b1 I6EBd NCH Wrdth / Cen,h No 0l Trenches PIT No Of Pits Inside Die t,qu.d Depth IM N I 3 2- 5-0 o2 DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Ma ur -Sa ^ INFORMATION TypeO r r CHAMBER Moe Num er. system 50 32 OR UNIT DISTRIBUTION SYSTEM [leader I n. Old Disinbution Pipe(s) x vole sue x Hole Spacing Vent TOA,t Intake I ength GE DIa engm ~ial~Snacmg - 3_1k7 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over DePth Over xx Depth Of x Seeded/Sod Jed xx Mulched Bed I Trerch Center Bed: I rench t dges I Topsoil [ ❑ Yes ❑ No Q Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: WARREN 31.29.18.486A-20,SW,SW &22-9aRD- T. ET - LOT 7 U'S `l1-.k S*te_A- `f• oQ Re, =1Z' M/21 o Plan revision required? ❑ Yes 11 No p Use other side for additional information. b9t oD ~ryOa~ ~ ( (o SBD-6710(R."7) Date Inspector's Signature Cert No CsT-a~►a-oaf Division Doparr Ser Safety and Professional Sorvlces Division of Industry Servi ces 9 SOIL - F;T Page_/_of_J r Ill accordance with Comm 85, Wis. Adm. Code - - SI ~RO/ C AUach uxnpleto site plan on paper not less than B 112 x 11 inches in size. Plan must County ndude, but not limited to. vetical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O 3/.7' O - SO - ,TOO Please print all information. Rovi by Da77-?117 P,,rsnnal Inforrhaton yrxr provlae may he used tnr secondary purposes (I'dvacy Law. s. 15-04 (1) (m)) Property Owner Property location A111'4 Q rQQ/fl✓ Govt. Lol ,$(.J 1!4 sl✓ 1/4 T ,T 9 N R /,a J< (or) W Property Owners Mailing Address Lot # Bock # Subd. Name a CSM# L/9 /-~',r Sr. 7 o a9ay City State Zip Code Phone Number Elcity 0 Village Town Nearest Road / unaa~ ZJI SYo/! cG/ ) 960-J%7 G/gcc v / 9/i' Sr. New Construction Use® Residential! Number of bedrooms Code derived design flow rate GPD ® Replacement ❑ Public or commercial - Describe. Parent imatenal Zors1 04rr✓4311 Flood Plain elevation if applicable .JA ftGeneral comments 1044o4.l0 P/ew r5 . G A'. aiE.J tAw.r/ REzo/v/x Ey.O 5Y3. EL.- 79. C r and recommendations: / Nors: /oo rIL rf/t o.J S. t//Or f1r /6-M SAL. Z~ X, Boring if ❑ Boring ' . . _J ® Pit Ground surface elev.. 8 2.8 ft. Depth to limiting factor in. _ Sal Application Rate Horizon Depth Dommant Color Rodox Description Texture Structure Consistence Boundary Roots GPDlff _in. Mansell Qu, Sz. Conn Color Gr. Sz. Sh. 'Eff#1 -Eft#2 .8 / O-/O /o YA 31- 1 /v r nr Q W'4 .2 o-1C or.L /1/ Srl ,Z .v s r - 8 q~. 6 3 c- rc y/> /t s 3? 6 ig Pr -/v c s 8-92 7.SYc S/Y sn. l - 7 16 1\ 0_-/_5 roEC N3 l Burl # © Boring ' °Z Pit Ground surface elev. 3, 8 ft. Depth to limiting factor > 91 in. Soil Application Rate Horizon Depth Dominant Cola Rodox Description Texture Structure C , isterce Boundary Roots GP IF in. Musell Qu Sz. Cont. Color _ I Cr. Sz. Sh. 'ER#l 'EfT#2 O-/O oYa .3a_ f r 4 3 .70 O- /a yd- y/`/ - r 1 a 6k K .5 GR/U. r s - G /o ?Y Go 7.src Y/G - s d I)A 1-4 E2 Z, 5 Go rn s/5 fn ~r - L . /0 s " aYd: -3 onEU AY_/9dd3 Effluent #1 = BOD - 30 < 220 M9,11 ii. and TSS >30 < 150 mgrL filuent #2 = BOD 5 30 nxA and TSS < 30 mg/L aSSCI~ Signature CST Number CST Name (Please Pnnq IC at -11 1503 fairway S1. ~ Address Ealt (Iairc, W1 54701 Date vial ducted Telephone Number (H) -15-834-8610 (C) 715-5774383 y_ /y s _ ',~-~~]'~'r SBD-R3311(RC7/171 ,n/ / ~O 9 Property Ow-ner_A,,)1eL 6Z,?1r.) Parcel ID0 7-54 -.76o Page .Z of J Boring # Boring V~ ❑ Pit Ground surface elev. 83,2 ft. Depth to limili 90 In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Co istence Boundary Roots GPDIIF in Munsell Qu. Sz. Cont. Color Or Sz. Sh. 'Eff#1 'Eff#2 / D-/a /oY,a 3 z R 6-a7 oY, - Srl d7 0 .srr Y/6 - As Y o- 07 Y,r Y ~ 11S Il t ~ 11 - ❑ Boling # P Boring V Z' Pit Ground surface elev. fl. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOfff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Ert#2 ❑ Boring # Boring Pit Ground surface elev. H. Depth to limiting factor in. Sol A Ilcadon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM In. Mansell Qu. Sz. Cant. Color Gr. Sz. Sh. 'Eft#1 •Eff#2 • Effluent #1 = BOO, > 30.< 220 mg/L and TSS >30:5 150 m91L ' Effluent m = BOO, < 30 mg1L and TSS < 30 mg1L 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 608-266-1151 or TTY 608-264-8777. 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