HomeMy WebLinkAbout006-1041-10-010
a; s;.r o.-canrent c:,rnc.c`:e PRIVATE SEWAGE SYSTEM
St. Croix
S:dety ano 3.i tlmg :Lvra;,n
INSPECTION REPORT sanitary Pe"l No
GENERAL INFORMATION (ATTACH TO PERI0ITi S;am c Ian 10 No 615346
_ elsnnal vdo'nabc yC' .-'ay be urea Iei :mac-Jary aurposrs IPii•;a_y LaHt s. "•.i:A ;nimj]
Pu-n' Fbc'Je's tJS is C ty Villas "CM^6h a Parecl Tax Na.
David Daggett TOWN OF CYLON 006-1041-10-010
5- Inv. t1e' n+p [RE Pear 6'A ❑c^.c'.wat9 1 SocLC^"rixNRange rMaP No
100. OD 1~l Ii, larl kft (I qz abort 19.31.16.278A
TANK INFORMATION ELEVATION DATA
YPP ANUrnc-uK~. CAPACITY S1A110: 6s lu is FIFV.
r
Septic ~ Gencnrn rk
i C S -f-'r j OW _75U'Oo~eln N A- 0.0 II 0l Ito. -oa
fj~ r o ~oel~ 25 +,II ja- -)eC qAO
c9 1001-50
Acrati ,n PIr1n Server
~~.olrl:n5 tiliH; nlet `
l~•
TANK SETBACK INFORMATION S!_toxlel
ANK TC Fi :bEL_ sLrG v,-I to sir Intake ROAII Df hiet
of P+
Septic 1101 ,tool ( n Ut BCttarn
Dosion Header.-Ma',
Aerallo'l Dist PIDZ
T + n.~a 1i•~o
r•oldir~ Sot. System _
Foal Glare nI
PUMP/SIPHON INFORMATION D. ' q
Warufacture' hem S! Cover
4
Nlz,lel . ter
11',H 1,111 on Loss Sysle-n -ean I Dli Ft
=nD:err t I er~th .Jla
SOIL ABSORPTION SYSTEM
RED/TRENCH !ct• 1 ~niph~~f •Jc Of PIT DIMENSIONS M1O !%Pr D•: C.. I m,h
DIMENSIONS "3(
SETBACK SYSTEM P:L E3-7G :"JFII Il.KC.'371RCAIJ LEACHING marufam'er Em
INFORMATION CHAMBER OR
lyre :il SyL•.... I 1 I UNIT `dccci GL-r;:r
(0(Wfy1ki0n0A 700 X100 >(00
DISTRIBUTION SYSTEM .5+, 10 ~CAI
-1c Jenfran'cl] -it-v[i0n trln ;,.r -elo $p3[^p 'v'c"f ta.4ir l-:axe
1 uI C: :,r;a n;, Slr en g
SOIL COVER X Pressure Systems Only *'Mound Or Al-Grade Systems Only _
[:rP'h Ovm Cec;h Over xx,Tepth oI yr Snncc;NSudcrb a Id,- cd
Iin~;;T / F+'c~Trc'ch t:]e5 TC 050:' YQS `JC Ves
COMMENTS: ;.VC r.tlecode:llsucocnriespersons presenl,elci InsneetirI1#1. Ir.spec!iun#2.S_is-►~
1.06 RIA 2-,'.43 i to A`J,c,F-~ t"~~~ O~ (f J I`''I
i ; All ll Description n - -d. c COJe Nt.
2.; 61tlg se vrer length = ' 1pi~x
P
- amount of cover =
>H2, rn. (o-)-e('
an levison Reqj red?
jdjit Yes Nc (I h
Use other Sldc for r addiBOial infor•naoon. -1
$OLb.IIC . _ .ale i^ p'I" SIQ'eL" _roll Nn
. IndusUy Services Ihvisinn County
i /B \c 1400 F. Worthington Ave
a P.U. Box 7162
sanaary Pamit Number (to be filled to by Ca)
~~s ' I Mad' S3 -7162
I ApIphca stay Transaction Number
In wca dace wrM SMJRT21(2). W e& Adm. Cade, submission of ttus forth to the approm it
er requited pun to abminng n smeary permit. Note: Appli ation fanner for stuo-owned POWTS are subus Pro)oct Address (if dif acct than ma0ng address)
the Department of Safety and ProkssiorW Sc view personal ailomusion you provide may be used fv
purposes in aw.dace with the Prrvacy Iran s. I S. 1 mA Sbds- _
1. AtsDBcatiw tdonmatm - Please Pt afermtioe «D 9 3 l L)- ,A b c N i1E
Ffopeny (Nona's Name I
I~!!L'1D ~h[---T7 Parod # 006-~Oy1-16-ciU
Pnpaty Owna's Mailing Address - Property I.M.
I V, /a JFq
Pty. G ~zl _
cawh Id
city. State zip Code f~-7 Phomc Number AV, . Aj iF V, sect"
E - ~JZ FZfSt \,~y 5LIC0/ 7/7 .339' ya1,0 T 3/_ N: R (erneovw:)T
11. Type of Baiwot (C" all that apply) Int M ---Lfir- V
I v 2 Family Dwelling - Nsmsbcr of Bananas Subdmsian Name
6lo #a
❑ Publid('ommacal - Ikxish Use
r/ ❑ City of
❑ state owned - Descr*c the CSM Number ❑ Village of
/ Tom of C--YLvj-_----
2 Gel(,
Ill. Ty k one bas a line A. Complete line B if applitabk)
A' New Sysmn ❑ Replecanaq symn ❑ Treatmad/Ho41in Tank
B Replaxnnera Only ❑ Other Mod,fintion to Existing Sysmn (explain)
B. ❑ Permit Rawv d ❑ Permit Revision ❑ (lmhge of Dumber ❑ PamitTramfa to New List Previom Patten Number real Dare Issued
Before b Twat on Owner
z" I
FV. T --o (C'heek ad Nat apply)
n
NarPrcroaiad trf(ira.d ❑ Rcssraiad b"jround ❑ At4kade ❑ Mead > 24 in. of witabk aW ❑ Moux1<24 m ofsuibble soil
Holding Tank ❑ raba Dispa,el Co mpmnaa (anplain)_. ❑ PnGmanrca Devioe (eapla.)
V. Bis rea t Area lafortaatioa: -
Dcsip Flow (Wd) Design Soil applsorunn Rat<(gy Diapaso Arcs Raryimd (sf) Dispersal Area ( System M"Miom
SOC~
9s . z- 3
VL Tatidt Info capacity in Tom( E 04 Moral
Cullers Gallons Units
N. Tats - E-im"T.*. y g _ ~ q
-7 5 O
_ I/ /o la~ ~LG_ o ci us a ayn s.. c> a
Vtl. Re"asibillitySistiseapeat- kthe. asome responsibility for imetaftellaw of the POW7S e w the amebae Plans.
% ba's Name (Rim n % 's Signature PRS Number Business Phone Number
Pitmber's Addtets sbea, et'. sate Zip
or' e LJ
fns ~,.e o.rr
m, Pennd Fee Disk tuwng sigintuo - -
a Reason for Daniel S56, 0 • C~ C. /T /
Ix Coadit~hl{~usoas F" Deappsovai
t $ept tad r n nc rvi o c t Rw-
is p-r:)pr nen_ plan o-o io, ,L f~', I 1 s
2. All %CSQgr* recur-..mn(s r~Lr T> To.A.. Pal- ~UR.aUD (may- (t.aC ~ ^
as persffixubli coei / cKrax ~v1
Aaaca NSriPkn•ata fr hers ryab sa waallNNnCw.y rla'rlraP ~Itr Natl latW MWs l
b w ~'Orr" (.t/o re i
all b~:l~: c,+rWJLS
SBD-6398 (R 08/14) '
7zO F~ Z o ~ Pt'. ^1 oc .
Plot Plan Page a of'/
PROPERTY OWNER:- ~I ID N f c. T r ' -
f 1 = 40 FT.
Legal Desc iption: NF lq ot: nr; ~lE`f sic. I1 -r w Kvw (except ire noted)
Y ,
IVA) of @ ° badc~ vft
70
- '-0w, 5T. CROtX Coin WtiscONS~N.
40
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Site location: ` °
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In-Ground Gravity Plan PAGE 1 OF 4
Index & Cover Sheet
Co~ Version 2-0, SBD-1070&P (N.01101, R. 10112)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: E ores:
POWTS lication for Review
Soil Evaluation Report & Site 11Aa
- SEPTIC T -JK PraKC-E- eAT
Project Name / Description
Owner Name(s): u t D ) { 7 T Phi: 7i _ J~ y
Owner Address: L txxx 22t. DL FW - '1 KK L 1
ProfectAddress: Zr)~ zi0 t1v 'u~ 0 7
Govt Lot: - N = 1/4 of ME 1/4, Section f c . T 31 N R l(o EQor WM
Township: C~ Y L C'v ~
County: 57: c RaX
Project Parrel ID /c y / (~,7,
Designer Information
Designer Nerve: Al AF V ~ +IuPVe RT Phone: 715
DegneAkies: 21
497 KIAI& 1rTHUKS C+ p uekeg ,T zip:
y8~5p
E-m N: h011 sfie_r~(es,~~, fooK. eom This MN~Y' 3/01,.
H~St8mj7.
License Number: fi- ,
•
Remarks:
* MUPAIr~ ••'t
D IBM e
~FAl.LSr,: c~$
Signature: ~ lL~ roam
Date. ~ ZfJ ~ 0
aid Copy. 1
Plot Plan PVe ML of gel
PROPERTY OWNER: _v .
1 - 40 Ff.
Lega[ Win: NE A pF "rz AEt (e=ept w twm nod)
S8C . /9 -r3f N R M. W @ - baMvoe pit
70 WA) OF G,~L-O w 3r C ROt
X COUNT y, WfSCONSiN.
- DOb-/Dyl-/p_ Dou/ 2~c~' 2~p+~ /iJFN(AF Lift) y'1eRFS
North
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Site location: rt~ QIO 3
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t INSTALLATION INSTRUCTIONS
:~.y,•- PL-122/PLA20L.625.:.Fikult " -
INSTALLATION INSTRUCTIONS
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F, H~Z 1
60
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,
AGYeoaWppe or
! PC"ElisegrW A toxC
tA) iouWe the outlet of the septa; tank. tA) Aefore ingtasabon, place ttie
~~i {?erlovE tank cover and pump tank flter housing on to the ougal pipe. OUutset Glue the fNtar hR;uSai~j rn (tx:
it ttecrs~aty. 4i o VWe. Comm" to is Make sure l th Aoea h sing, tarter e e in the
~Lrr urea as is positioned so the filler can n be hcwsing mai aidrp sure re the fig"
removed from ft tank for Cartridge is properly aligned red
matntenance and service. compWdy wmarted in the housing.
MA,,K i EMANCE WSTRUCTIONS
` I I
1- f
t
Step 1: Step 2: Stop 3:
the outlet of the septic tartk. (A) Remove tank cover and pump (A) insert the filler wrtridge b
(i if nek:essary, into the the housing malung re
(8) Puff the filter out of the housing. the filter is property atkjtled
(-)those or ale flew owsr Vie septc aw*. and completely inserted.
i r; ks t ; 3 t:. ei . Make We as s[ds fag t 3ktto the (a) Replace septic tank cover
"FM Ci PA W40 PA il;F j septic tank.
Pdylok, ;nC. 3 Farr:tavl ekvn. 7r~ttarupprn. Cl "4qZ Toll Fr 577.785.9385 F:nk~ A" Z" tt574 wwr! PnMM Zorn
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE A(iRl?EMFNT
AND
OWNERSHIP CERTIFICATION FORM
OwneaBuyer David Daggett
Mailing Address PO Box 221, Deer Park, Wi 54007
Property A(LAtess 2093 210th Ave
(Verification required hour Planning r'• ning Department lur new conriruclion. )
('ity:%State New Richmond, Wi (Pending) UG6_ ~a¢~-io -ao
Parcel Identification Number
LEGAL DESCRIPTION
Property Location N E , N E y1 . Sec. 19 1'31 N R16 W. Town of Cylon
Subdivision Plat: NIA Lot # -
Certified Survey Map # Volume Page it
Warranty Deed # NSA (befi>re 2007)Volume Page K
Spec hues: OVCSEbo Lot lines identifiable 0) es❑mt
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system Could result in its premature failure to hand le wastes. Proper
maintenance consists of pumping out the septic tank every three years or smtner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
Ic.punsibililies arc specified im §SPS. 383.5:211) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The propcm mwncr agrees to submit to St. Croix County Planning Zoning Dcpartntcnt a certification form, signed by the
owtrer and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and-or (2) after inspection and pumping (if necessary), the septic tank is
less than 1+3 fullofsludge.
Iwo, the undersigned have read the above requncurents and agree to maintain the private sewage Disposal system with the
standards set firth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources.
slue of i'v iseonsin. Certification stating that your septic system has been maintained must be completed and returned to the St. ('Tois
I. ount}' Planning & Zoning Dcpartntcnt within 30 day's of the three year expiration date.
Ir'we certify that all statement/onis thin arc true to the best of urvnor knowledge. Iwe amare the owner(,) of the
pn+peny Described above.bV virtue uly deed recorded in Ketp,a•r o( Dods Office.
Nu of bedroom: 2
i
SI(;N.ATURE F APPLICANT(S) DATE
""Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department, '
Include with this application a recorded warranty decd from the IteykIcr of Decds Oflice and a copy of the coot ied survey map 11
reference is made in the warranty' deed.
(REV. 041/12)
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"9,-ansin Department of Safety and Prpfesslonal Services
Uiv1110n of ludi9lry Sevic 1, 1 f
n
SOIL N F
€VA -REPORT Page I of 4
1111 .i in accordance with SPS 383. Wis. Adm. Code
arach complete site p;an on paper notl ss an 8 112 x 11 inches in sire. Plan mull County ST. CROIX
include, but riot limited to, vertical. ani zontal reference point (BM), direction and parcel I.D. WK
percent slope, scale or dimension , arrow, and location and distance to nearest road. O ' - Ill; I - I0 j""'
Please print all information. Revie d by oat Q
"e ?Ial nformabon yourrovde nay be ased'or sewndary pugpvws(Prrva'y Law, s. 15.01(t?rm1). I q ~ 1
I PropertyOwner Property Location /
D.AY'ID 6't SUSAN DAGW--i T Govt lot NL 114 NE t!4 19 T i t N R 16 E for)
Property Owner's Marling Address Lot # Block # Subd. Nance or CSM#
2087 21 Orh Avenue
City State Zip Code Phone Number arty []Village Town New-st Road
Dcci Park. W I 5.1007 ( 71 S) 338 - 4060 210th Avenue
New Construction UseE] Residential.' Number of bedrooms NK _ Code derived design flow rate NK GPD
El Replacement Public or commercial - Describe:
Parent material sandy outw'ash Flood Plain elevation it applicable `'r1 ft.
General comments -
and recommendations: Bathroom in shed siring for loo 8pcI 0 (i loading rate
Z x
Boring # ❑ Boring -
Q Pit Ground surface elev. 10195 ft. Depth to limiting factor -87
is
Soil Avolication Ra6+
Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff _
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
'Eff#1 'Efitt2
1 0-14 10YR,12 sit 3Mbk nivlr Cs 2vl'-f 0.6 O,x
1.1-24 10Y'It4r4 - sil 2fibk ntfr cs Ivf-f 0.6 O,x
24-34 7.5YR3A grlysl Os_
f £ ml Cs Ivf-f 0.6 I ~I
4 34-62 7.5Y'R3i3
_rl • is Osg fill Cs Ivf-f 0.7 16
5 63-87 7.5YR4/3 grlysl (k°
fill Ivl=f 0.6 111
Cobs.
r~ C n~ d p
I - ' Boring# ❑ Boring r~
101.90 ->89
Q' pit Ground surface elev._ _ ft. Depth to limiting factor in.
Soil Acolication Rat,,
I Horizon Depth Dominant Color Redox Description
Texture Structure Consistence Boundary I Roots GPDIff
in. Munsell Go. Sz. Cons Color Gr. Sz- Sh. •Eff#I 'EfkO'2
1 0-12 IOYR3;2 Nil 3fabk nyvfr Cs NT-l'
0.(i 0.8
I2-24 10YR4!4 -
A Imabk mfr Cs Ivf=f 0.4C 0.6
3 24-32 7.5YR;.4 rrlyls ON; I; nt1 cs Ivf-f 0.7 1.6
It 32-42 7.5Y'R3 ;3 - .
grlysl Usg ntI CN 2off 0.6
LU
5 42-89 I0YR4'4
Lrtlys 0sg dl IGf 0.7 1.6
' Effluent #1 = BOD, > 30 < 220 mglL and iSS >30 < 150 myL ' Effluent #2 = BCD, 30 mg7L and TSS < 30 mgil
CST Name (Please Print) CST Number
MAR YJO IIUPPHR'P llollister'sSoilTcstin hUcsiml LL //4-/ 224832
Address _ Date Evaluation C nducted Telephone Number
28497 King Arthur's Court. Danhury. WI 54830 07 - 12. 20I8 715-4211
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