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HomeMy WebLinkAbout026-1018-10-350Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic V Aeration - TANK SETBACK INFORMATION wN PLIMP/SIPHON INFORMATION Manufa urer - \ Dertlapd GPM Mo I Numl - TDH Lift = icfitIifs _. System Head TDH Ft Forcem In Length Dia. 19151to Well _ .� EM fro • oM\�_ �4R011l�O/t_� �jr��x -A yam_ -��....,,,. -- O -- SOIL ABSORPTION SYSTEM . au 44 , I BEDrrRENCH Width Length DIMENSIONS �rf')t No. Of Trenches lVL �7 L✓� PIT DIMENSI N o. Of Pits Inside Dia. Liquid Depth ' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: l INFORMATION Type Of System: Y� � Vir1 CHAMBER OR UNIT I t h'ri Model Number: t 1 4 DISTRIRLITION SYSTEM Q HeaderlManifold f —Lq1 i.jt Length Dia Distribution Q Pipes, V Length Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake IVC)V SOIL COVER x Pressure Systems Only 1 1� _^ COMMENTS: lInclude code discrepencies, persons present, etc.) �v[ ` Location: X1005TH ST ���j�j,44 /R(Gtyr4l 1.) All BM Description = �J - 6C '51� t �3 2.) Bldg sewer length = - amount of cover Plan revision Required? [ Yes o Use other side for additional informati D w Date SBD-6710 (R.3197) xy Mnund Or At -Grade Svstams Only Depth Over ! t Depth Over xx Depth of '.Jxx Seeded/Sodded xx Mulched Bed/Trench Center 1 �7 � 1�' 1/ Bed/Trench Edges Topsoil Yes 0 No es F� No r i�I Inspection #1: 2/ (' I zo Inspection #2: r #�� Ylelll I .S a Vd3 �- r— c{rt �Sit In clor's Signature Cert. No. C Industry Services Division ouj,.,,, Sanitary Permit Number (to be filled in by Co.) ®S 1400 E Washington Ave > PS P.O.4462 JUN 21 2019 Madison, 62 / ! �Oj l`ssrorn� 1(J / ,J JJ / 53< 7 Cornmu In it Application State Transretion Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate vem 1 unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for'seconday purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. 4 11 7 ,) � / LL �j ,AII 1. A n Application Informs Please Pgnt All Informal Property Owner's Name 1 Parcel # d G-/o1$-/0 - bl ProP, Owner's Mailing Address Property Location USA 3o, 1 g, (3 E 0t 0 x S Govi. Lot N E'/,,5 ix V., Section S Cit), S to t Zip Code Phone Number U-t / � �LO �715-_ — 3/Q T 3QN R/ ctrcle Eoro e II. Type of Building (check all that apply) Lot # Subdivision Name (Wj or 2 Family Dwelling - Number of Bedrooms (J)L/ OK ❑ Public/Commercial -Describe Use Block # City of ❑ State Owned - Describe Use ❑ Village of erGjl6 6( ^^ Q 3 -f C ! U- G Tom nof �J.a4- GEt�' w a III. T eck onv one box on line A. Complete line B if applicable) New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV_ onent/Device: Check all that apply) Non -Pressurized In -Ground Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding T r ispersal Component (explain) ❑ Pretreatment Device (explain) r f TI J,I V. Dis ersal/TreatmenArea Information: Design Flow (gpd) Design Soil Appliclition Rate(gpdst)a, Dispersal rea R�eica^red (st) �a Dispersal Area Proposed (st) System Elevation (78 / J �t/ C © V1. Tank Info Capacity in = =a Gallons Total Gallons # of Units anufacturer �LIG c U r s K New Tanks Existing Tanks W a s Septic or Holding Tank 0400 d Dp ` ❑ Dosing Chamber ❑ ❑ ❑ ❑ [ VIL Responsibility Statement- I, the undersigned, assu a responsibility for installation of the POH'TS shown on the attached plans. Plumber's N (Print) Plumb isn re MPAIPRS Number Business Phone Number Plum 's Address (Street, City, State, ZZiip Code) G ry VIII untvlDe artment Use Only Approved prove Permit Fel Dat Issued Issui Agent Sienatu �n Reason for Denial 5 CO IX. Cond' p tstIt �fi it Disapproval 3� 1.- il VW_—w C0 gust all ¢get Ic+� I tri Ii si / ae per amen! plan pro tided by pluiy gtell J 2. MjieR r1111z ro!.;erwy nvxttu: r,Alt l a IM per apiiedili wb: / crd'cancca. Attach to complete plans for the system and submit to the County only on paper not less than 8 In ill inches in size t+ pea `G yo �bs Q 13M13 t�- 1 s r/COA CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name:nir,.. Owner's Address: OS' -5 T.' N.Q.u1- w�SZ'olT Legal Description Township: (� County: -s / , �CT�LIL ( O � � �9 g VOL 1. E" Subdivision Name: S/%AL L Lot Number: J lY•,G Parcel ID Number: 6,�U �bl p ' 1t: ✓ 7 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross -Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. 5 10l Dz License Number: r d 4 -5— Date: 1 ! ZY Phone Number 715�— ;74 6 c%X4 Signature 91 Designed pursuant to the In 4and Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 i6, , , ._ .., If5lI L .n.w �. zl9e k r. �s �48"� (EFFECTIVE LENGTH) -- -- - 12" a � f — -- — �34"mot `✓ e «,^ �'�7f.� i .m)t ', $�... E.�.-�." to .._ ,:.??S.. CI g°5 I"3'c rt, i?3A, i`�n— 5�....'id 1+✓�:�C-v;s—. 11.2" 17 t 13" 1 8" INVERTI—M 8" INVERTfilm5.3" INVERT 33"- �1 r,:,'S:`�. ;'• `''i.,:,^ T-6Z'-3,}.;"4_ 4D �:r,� s:.'F? OUICRa PLUS RLL.IN.ONE PERISCOPE---� (3W SWNEI I OUICK4 PLUS 12.7" INVERT ENDC P 12 ENDCM rj" Quick4 Plus Standard Chamber Specifications Size (W x L x H) ............. 34" x 53" x 12" (86 cm x 135 cm x 31 cm) Invert Height ................. 0.6", 5.3", 8.0", 12.7" Effective Length........................................................ 48" (122 cm) (1.5 cm, 8.4 cnT; 18.5 cm, 22.6 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) r-a c.::: e t, e. C ,T.cc _ J C ..e :._ :f c;re, ac.:essor; ^at ( J'ts I rr.en nstaad a,d cp ate.. _ - _., � ar seo' a c,croe- ac_ .. _ r _ • f' a s rsv.. crs a . m ertea a Ire org ra oa¢rase, ( Hotaer 1 ago _ cg;, ._ alo.. _ s,ol:,D c,_ _ c _._'cat+eseo'ope,-, ,t e .ad ry esep'esa:e^t coma �,rg the Unts gh:, den .,.,_ .. a SeL' c ,e 5 c - c Pc a.', e , a"a^ty us, pJ - Z: q - _QC, "e date that .'c...l ato" G" the Sept C.,,.'.. =-Ile, _ > F .^'-a-c, .. y a''s i!"-ieappaarte's ' QCSa orco,, ,r tcal ., T, L, n, n a r_o by -f 1:n . to le bDCleC! by a L a- 'a - a_ o- a- s s C is (n)T1-ELYAI Y %DRtItEv,c ( o F ARE EXCL,`,E Vbx Red IES''r HF ECI T 0 TH_ I� . 7 N. L, ':, -- rC ?,1PLLC VIARR ES „ �T C ' ptTG�Zz FCC PJ9POSE ._ 1.5 LO irep ar a ', e c re •.JU - a^y cart at the C^a"`oc' Sr>:: s _ ar.,'eeta,ep b' o' y.^tee ome"ha, r; 1rator L ­`Iiea V rar'g a- s _t extern to ,. au^ a carsecee r, 3 special or ,narc✓ cage,-, ' "d'p= S _ I,able for perm'es c a.. da,ed ea'nagee _c " g toss of prod,. C' a-d -,cf is labo, and ma'er�als ty e,head ccs's V -1,e, Csses o' eepe-ses ^cuvad cy'P3 -lode, C' r y t'1 ro Sa-cexctadce Niananty, coverage are aamage'c the .,rts ove'a op-r; rear and car arterat,or acc va=t rr sse ;bse or regr rt o'too Urts I, .;. 's berg s.,blected to -3fre G' e�ra_r oar at^,s :.e.cr -,a )a* car: -,rated by'he rs.a _ a 'o �arta r me m nr n o _-o covers set f-th -s'e ar or 'st�actcns '^e oaCe-ert of n ^ coe ,-'ate'.,,. e _,� e c..a se tr=e J-ts fa wre of the 1. � s .,e sept c system a.,e Ic ' .r ;aaI srr,c or 'norope, s¢ rag a,cess :e oaLe, .,sage -raga- gease csoc=as er nprODe, Ceerahon or a C^er event not caaseo G, .otp, The L,-tea dffi'd`Hr s^a1be : o C t Te rto Oe' 1a e C-0 , ;h a ., tar ^s Se, 109r s Li,I, :a^ty Fh't-c .. _ _ _ -a:nt -ra o' be esoo is e e , .,_n c _EI 'O ✓ tra -1 15 C a J m o be Y ,cling fur rs'a _n or s„ ri, a y pr,.., c' a. 'h, c'a=-s o ce, r a .., tn,s L.-tea V a dGc I n2 tfrlt$ r'tG51 b2 n5,9i EJ r ac"or:13"Gce = e'e COrG!'p^5'e0,.'ea b! 5'ate 3ra I{,ydpo :able IaAS ano Inf, t'� c's tr St3 e' — ,ts*,,,cf,Ons (d) Rc reprb,entat ve of rf wator has the a,rpr.;y ;o change Gr e.-E-d Ile _mreo :',or ,-:y No :.ar,anty acc as to any parry oller Ta- the ar 6 ra! holder Tr _= aoo:e 'apreser*s to Star oard Lrtnted 6Var'aaty f`ele- by '.nhitrator A Inr tea numte' .> sta'es orb ccntas na:e ddferenr .;ar,a,ty rea,>e-er:s Any pvchaser of Lr Is src� J contac' ,0 -ao, s Ca-oora e Heado-a:e's m Co Sa;e,00e Comectic.:t prior b sr,& purcnase, to rctair, a cPpy of If e apprbsole v,,ran!y c ri s,,- d Cd'e'.: J'eao''a'W5rha^'y orc, to ire ,u,zf-3se of Un:ts INFILTRATOR 6 Bustness Park Road • P.O. Box 768 Old Saybrook, CT 06475 860.577,7000 • FAX 860,577.7001 800,221 .4436 www,infi ltratorsystems.com iC P,—Ic `7rn FF'i SI'7/d' SI{CJPA 5'1Qr.n17 ,I'- III G,_.+41Cr=�Ir'.linl 7 7:G r-P GCr.P17P LiO 4.1, i ♦- i i t i :MI 71t#t i t r 4" Sd>edule 40 PVC Vent Pipe With Vent Cap r' 71 Leaching Trench Chambers Vent Or Eton Pipe I Trench . Trenc:. C Dia. Header t.eachinq Chamber Specifications Manufacturer And Model EISA Rating _ �5_�-' sq It per chamber «. Soil Application Rate .6gpolsq ft t�TA pd Design Flaw Soli Application Rate /,70 EISA = .S r 2,161hambers rows of __ — chambers each. 1 V 3 e. s'7 Page of "''""" U CHECK - EXCEPTS 6" SHD 40 FOR INLET EXTENTION ETRIISHINA PY(FPTS -•-. CH ?5 FILTER HOUSING N0. - 30142-525 TRIAL: HOUSING - POLYPROPYLENE OUTLET BUSHING - PVC 6.5 BALL - HDPE i - - 10.68---------�I 5.23 18.34 --i 33.02 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 2 FILE INFORMATION Owner �ermrt +: --------- ----------------------------- ------ DESIGN PARAMETERS Numosr of Bedrooms Numbe, of Public Facility Units NA Est':mated flow lave -age, T 3©eO gal•dav Design fiovv toeak', !Estimated s 1.51 L2(�Q ga„uav -- ---- Sol; Aopiication Rate - - ❑a.'aay'f --- S.andard m4iuect°Effwent Quad, Fats, Grease 5_K mg .- Biochemical Oxyaea Demand (30G) -22 mg L rvA Total Suso-nded Spiids -3S! ' i gp m91L -,-treated Erlpent Quality Mont'nry av-rape BiDshemica: �'xlgen Daman:: (30D_1 -31, mg - -ota' SusDan,ded Solids i i SS) <33 -ng '. _ r.,A Fecal ''o0orr7,� ioaometric mean; _"j' cfr.'? '3 1 Maxim Jm Effluent "articie S;zE ;. it b:a. 3,ne-: t��A `Va'.ua_-ypical Tor eo-test:- RI.J :t_-J_ SYSTEM SPECIFICATIONS Septic Tank Capacity 1600 cal - -( NA Sentic Tank Manufaotrie` � --- 7 NA. .flues rilter Manu-actu,er ` NA EffluentFilter fYMooe'--�- p2 N A sumo TanK Capacitti• -- gal = NA cumo rank fvianufacture- Z NA ump Ffanufacture J NA .Ump Mode: C NA o'a'reatment Jni: _ %A Sand,Grave� Fiit3r :1 Peat Rite- _ Me::ha-voa, Aerat.on J Wetlanc DanrectiDn Otner: O,sDersal Collis NA f�`-3-ound Igraviry; in -Ground (pressurized) -.At-3-ade 72 Miound Of•ler: J = � Na — _ Na Service Event Service Frequency inspect conditipr of tar.Kai =+= east c-o= ev _ _ montn s! -__ _3- �'yearis, (Maximum 3 yews) n .4A. Dump out oo-iten?s of ts-Tkis? _ : er : n nnir•-❑ si.idge and scum equals one-tniro (_� of tank volume D NA rasped? disoersai dallier At leas: once eve-v: 3 ❑ monthis; 8' yearts (Maximum 3 years) NA _ Clean `fluent fi;Ter T � '-- .= --- ------ �.: e =>: once eve q --1--� moatnls,-- 13 years -- _ ----------------__._. -- -- = Na _.�. —�— -- inspect pump, oump consuls & alarm ------_.----- - Al leas: once eve.v: --- �. mcritals yearis ❑ NA Mush laterais and oressura test —---- A: least once evary: ----------� IT10r1TRIS. ^ inch ? yearjnth>-: 7 NA P AT leas,* onc__ vent m onznis� on ❑ NA acne;. --- ❑ NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells snal; be mace oy an irldiviouai carrying one of the following licenses or certifications: Master Piumber: Master Plumber Restricted =ewe-: p0:'i'TS Inspector; PCW'TS Maintainer. S-ptage Servicing Operator. Tank inspec=.'ions must inciude a visua; inspection cf the TanWs; tc iden?iiv anv -niss,ng or broken haroware, identify any cracks or laaKs, measure the volume of combined sivage and scum anu to cne:;K for d ty DacK uc Or ponding of effluent. on the ground surface. The dispersa cellist shall be visually inspectec tc check the effluent )eves in the orservation oirles and t., check for anv pording of of fluent on the ground su=ace. The pondinc Df effluent on the ground surface may indicate a faiiing condnion and requires the immedia-e notification of the lanai regulatory authority. %,inen the combinea accurnuation of sludge and sc�rr in ar, t�_nK ooua s one -Third (a or more of the tank volume, the entire contents of the tank snal. oe removed m a Sen:age Servicing Coe-arD an❑ disposed of in accordance v✓ith iiapter NR '?3. "Viaconsin Admcustralive ,use. Al: other sp-vices, including bU: n0* limited to the St-"Vidillg -)i C iiUe:li Elliot S. ❑Iedi anidal JI pre SS 1riZed components, pretreatment units, ano any servicing at intervals of =? 2 months, seal. be periormcd oy a certified POVt -S Maintainer. A service report shall be provideC i0 the IDcal regulato•, aUtn Onty Piivijr nnv� Qi ::dmDieii^, 07 9n) Se -Vile ev9nt ?a:le v of START UP AND OPERATION new construction, prior to use of the PoVi'-S cnece treatmen"anr,s fo, the oresence of painting proaucts or other chemicals that may impede the treatment process and,or damage the dispersa! ce!us). If high condent;atiens are detected have the contents of the tankts, removed by a seotage servi:iing Dporator prio- -_ use. Svstem start up snal::io: occur rlhan soil CcnOa:O'.s a e a: the intllt'a2 LB-..,rfaze During power Outages DUMP tanks ma, ill above norma, nig nwat9' teve�s. 'Vv'hen DOWer is restored the excess wastewater wil, be discharged io the dispersal cellisi in one iarge dcse, ove,.oading -he cellist and r.av resin' in the backup or surface discharoe of effluent. -o avoic :his situation nave the contents of the pump tank rernoved by a Septage Servicing Operator prior tc resiorime powe,- to the effluent pump or contact a Plumber or POVd`S Niaimainer to assist in manually operating the pump controls to restore normal levels within the pump tan:. Oc not drive or pai'K vehicias over tanks and disoersal cel:s. Cc not Ori: a or park over, cr Otnarwise disturb or compact, the area within I E fee: doW.-) siDDe or any mDunc or at-g-ade soi, acsorarion area. Reduction or elimination of the fol+owing from the W21stewaie- stream may, improve the performance and prolong the life of the POWTS: antibiotics; baby wiDes; cigarette butts; condo rs: cotter, swabs; cegreasers; dental floss; diaoars; disinfect n Isants: fat - foundation grain pump' water, fruit and vege.ab:e peei!ngs; caso.i-ie: g'ease; herbicides; meat scraps nedigations; oi;; canting prooucts; pestleides: sara-y nauKms; tarlDDnS: ale Later s; ewe p rre. ABANDONMENT V.'-Ien the POL4'TS fars 3na:o :S pefmanently taker o'Jt oT ser:ice me 10 -o tvin:g steps shall be :aKen 10 nSUre 111a: the St'Ste_T 1s Property and safety abannonea in compiiance with ghap,er CclTlrr'. E3.C3, \4'is2cnsia Admi-listrative Coce: • Ali olJing tf] t.:n Ks anu pits shalt be dlsconneete.^. and ine apandoneC pipe comings sealed. • r1O CO'ttei 's GC al: 'a^,KS and Clt> sfial: be '.',:a'J\'ei, ar-•C p-Opar,y eSc--se1 Jr e. a Se DtagE SerVl Ciao OparaCOr. • lifter Dampng, all tanks ane pis shall be excavated ant remover, or r-e- cowers eemoved and the void space filled with. soil, g-avw or another inert solid riateria'. CONTINGENCY PLAN IL the PCA'1'73 TailF a:Id Darinet De lepwie_1 ttie ibil0:. ',1Ea54'a i.a7e cee7. O; ?-;St be :aKen, to D70vile a CObe C.^.Mpl'an: leplacamen- system. A sJGable replagemen! area i�as Dee- e'al.la`.e^. and maaL De utilizeC 'Or the +ocatior of a replacement soli abso-ptlor� system. Trio replacement area should be mo-ectea frgm dlsturcanoe and comoactlon and should not be +nfring=d aoan by reouired setbacks from existing and p-oposed structure. tat Imes ane wells. PaHure to protect the replacement area will sl!T it t:e nead for a rev., soil and s.-_ e:�avaticn t�. as:apls a suitap+a r p;acemen. area. replacement systems must irc;mn!v %vh-1 tree r.:ies !r E=fec- at that -ine. A. s-Ittaole replaDament area :s not avaiia!e a'1e tO aat7aCK an❑ or SO,. Itm .atDrS. Barring advances IC POVITS technology a holding tank may be installed as a iast resort zo repiace the `aiiar POV.'TS. ..... . - „_ .a 3 . DICI-1 _;a ,r. r De i e Ta!lepi�y� hr AtiiSTR(GJlD^) Mound ano at Grade so; absorption systec.s me'; be -.;cortsructad i- o ace fohow.ti :: remcca; of the hiomat at the ;nf:IL-al ve 5u-laCa. Rezonst-u Caans of S. cn sys=e^'s must Compiy %%,it t,-- races i-, e:feC: a: i 1d_ .rne. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR 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 'Liam POWTS MAINTAINER ream= { PnonE SEPTAGE SERVICING OPERATOR !PUMPER) :.00AL REGULATORY jAUTHORITY Name . Name none ---- ?;;one - ]!�— - ��iOi -,,.= aocumsn'. wr:s orattec ;o coma; ante_ chapter -gm:n F"_.22:2 In:'1_�d•&:f, wl; 23.o4'7I ,3.. it:secr.sx Aamin:sira;ive ;;owe. Owner/Buyer Mailing Address ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 0k Property Address 4� 0 `p %dam 4 ` sr— NJQ� /�-c�� u4 C (Verification required from Planning & Zoning Department for new construction.) City/State IJRALr Parcel Identification Number N)w %6137— /d— 400 LEGAL DESCRIPTION (Q� Property Location PA"E" 1/4 , LA� 1/4 , Sec. T 6N R /8 W, Town of Subdivision Plat: Lot # t. _ Certified Survey Map # (L D U I! )Volume _, Page # �M (�`") Warranty Deed # /62,? 7S (before 2007)Volume ,Page # Spec house O yes kno Lot lines identifiableNes 0 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date. L/we certify that all statements fonsorm are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of ay deed recorded in Register of Deeds Office. Numbe of bedrooms_ SIGN A O APPLICANT(S) 6.fZl�l / 9 DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * * * Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) �������IIIIIIII Imo! ��I�II�������'i IIIIIIIIIII IIIIIIIIIII I IIIIIIIII IIII l� �,Il � �'����`�� ��������'' I II II" ����� IIIIII I��III��� �''!, Ililllllll III 0 I IIIIIIIIIIIIIIIIIIIIIIIIII ililililililill44111ilililih` I t! r91 I J r 11 IIIIIIIIIIIIIIIII 111 1 1 1 IIII 11 111 1 1 it p l,il I I, L �1111111,1 alllllll Ilallllllllll IIIIII 441P14444444h44h1 i l� i i i� 1144h4h44h4ylly11111 ............. I I lllllllllllllllllllllllllltllt .� n I I i •, I I, I IIIIIIIIIIIIIIIiilillllllltl 1, �� n I I IIIIII IIIIII IIII IIII IIII III_ I� Illlllll l�lilllllllib:l I IIIIIIII� I IIII IIIIII GENERAL NOTES: ALL x WµIII IUIUYVO MITI µ: A4RICN1 F LOCAL STAR NATIONAL NATIONCOP ANC MdN4U MA P 4) : nainU NMNpJN49OIC)NN r Ni MMCi pRMiNO)ANOYNL:NnnFri4OP,DE rtA 6.WY CICAMANCrte ICW.9 MfpM910CUPNO WIixlNlw)M IKLCYFA'TONe LAN, M.4 IYC"'Ni n{ STI"FIPi µ1 YAEArA:IMI.. WOYIN2EFbNO MIT. nE WO9I ORARMERANE MNOWAAtOM..CT. APUNCQ"WT a v2 LABOR A,IONALS III W I... AE.I ITC 1� IINAOTOORAND .O.. WOUINpGRCAp9RCiIVCN IK e IM ttRFANSA1 VM FROONIRUµ"NW eANP COMgLil ➢ � �INTB WWI: Y NEC THE CONTRACTOR YWl Y xYM1v:YVI FORMAL CRIALLWp AMP EOOROIMnM • INC.wimia wnNrYNvwOM"rn"eion'iw�'ri nouiw ale ai of c°o°vrR�`non wicefaW"N!N°cionalo"niwEOREn iinwmIRRIO"uT4.1K.avxenianrNY (FEWER Or ADS O TIME TO CAMP OIPTKVAE AIx AC...TN T NVI"RMOTIE coMRACf COf.IwEMY ALL nupmW, YEONANICµ. MC ELECTRICAL WINES I910 ME COORDINATED OPPOSE )NE TRACER AM MN OF THEM IRErM1APON I~ e CO"AMTcneM:CMamv.. WCIWA`PCW EunMOrC..I PEIMNML TNEALTY OF DDLPNO DUNINE OONETFACTNIN ) ALL 11.IIW vME AND STRE NG.WI W IF MIT LNTEO TO VISITOR POW, RtlYWO W EI EYRNOn TRIM AMC INM1nIOR MC E.REnwn MuwQN, ETC EINL EE.MIOY o BYGUITO W n �oM A. MµE r XE DRW NU WITTLE DW UVME WINES TWEE KKCE➢ENCA RCHED PMM&PN TM CMMCIOSEWLLNEEN ALL OWBNX)IMiORgCRMNY.I.IN ALAN. REPORT INI TO LUgMAV NIxM TOCORE WYIINI Cl I. WAR MO TOY .,I FOR "'A"lx FNATOTMETATEOrcwvMM ARNi MycoNrRYTon eMNL'M rvTxI SIdMW11 OLB'OILMDe WTN W\lnNlW cWEINO NE VGTKNE NbrvwM TR LOCAL ELLDERES S.rW wW..Ic,vWM IMmWll eIECIµ LOAdIV EddnwE EYYbNYWLY WnNIGvNLgKEMNOu DIMENSIONS: ABBREVIATIONS: i WNOEW 81uLL'MIYNogYExeWiYecµYfP040.M,MCnOM MM4:eONOWNn1e6 CONC OCNI . 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C(JN[D�[i Cl r. of muxmwxranmw Cwvewwwartufw wxxrr.wxwwmxdvv' aucw waoa Va.exoixo w uw mwr ocxmmxn DMC ..vwrwewxd wwwwnmve wuf rfx drxerrxu+ncoxawVx roxamx �DMT� x0°r�awi�x�eaw�iruux:exiowwea"wmvwi ewrwxrwb raroCwxiwxxiwrorw wwar. aauau eaww ' coxc row+p TVP COLUMN BFARINf6 QrTAII feytlai<i NN' • � ra z13�iiri7. CFC.TInN n.Q =P. BFAM+POCKFT n�nr" jiii•: ie� fei.wiif�ir i a� l9YCJ/LzrrsYlYlrYll]rY. u _ _ _ --- I� HIM ii �I 11 r ene &19lZ019 ffw tlN••fw1 Wisconsin TDepartment of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County / include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Re ' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). /rJ Property Owner Property Location Govt. Lot ,� 1/4,/e%1/4,S T,1O ,N,R /� E (oqtf� Property Owner's Mailing Address L Block# Subd. Name CSM# City State Zip Code Phone Number City ❑ Village To Nearest Road I / v'i I � ajl V/SVV�9-3>0� �(, o,�: / I New Construction Use: LgResidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow ��� gpd Recommended design loading rate ' D bed, gpd/ft2 trench, gpd/ft2 Absorption area required ,/3 bed, rench, ft2 Maximum design loading rate - ` bed, gpd/tt2__,Z_trench, gpd/ft2 Recommended infiftration surface elevations) ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system IDS ❑ U I I S ❑ u Q'S ❑ U I 21-S ❑ U ❑s 2'U ❑s (emu SOIL DESCRIPTION REPORT Boring # a 1y3. Ground elev. lOi�ft. Depth to limiting factor Boring # a, Ground �plev. Avft. / Depff3i 1o/ limiting Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roo GPD/ft2 Bed , Trenc Ao adz It r ; d Remarks: J in. Remarks: Name (Please Print) Signature rNC�F ass/ eb h ; Telephone No. L CST Number - %�i ' 37 'V e 3 of Ol //i rtiyf/�/ P SOIL DESCRIPTION REPORT PROPERTY OWNER s% PARCEL I.D.# f • Page Of Boring # 0 Ground elev /IV1,, 7 Depth to limiting fact9r �9'(o in. 3, 7 Boring # 91 Ground /,4elev ! -ft. Depth to limiting factor A-Cl in. a3 Boring # Ground eleti. 1pG $_n. Depth to limiting factor X�in. Boring # Ground elev. ft. Mottles Qu. Sz. Cont. Color � 1 Remarks: MME Mr Mid i , 9 ' ✓ I/L�i®, Remarks: Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDHt2 Bed Trench Remarks: Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) PROPERTY OWNER ✓1 v/ a. 1 /r/ ol� SOIL DESCRIPTION REPORT Page _ of PARCEL I.D.!# Boring # Ground elev _ ✓� /. Depth to limiting factor 'y in. Boring # Ground eiev Depth to limiting factor 7 in. Boring # Ground eley. /rJl. fin. Depth to limiting factor Boring # Ground elev. ft. Depth to limiting Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots Bed Trench l to /yz r eV4 Remarks: MM Remarks: Horizon Remarks: Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft Bed Trench / , Remarks: factor in. Remarks: SBD-8330 (R. 07/96) Vlsconsin Depdrtment of Commerce SOIL AND SITE EVALUATION Division of SAfety and Buildings Page of Bursau,of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and G percent slope, scale or dimensions, north arrow, and location and distance to nearest road. I Parcel I.D. # 0. (-/f,Yr'lo__;�ca APPLICANT INFORMATION - Please print all information. No, awed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). it Property Owner Property Location l f Govt. Lot 1/4 1/4,S �� T �,N,R ZI E (oQS2 Property Owner's Mailing Address L Block# Subd. Name or CSM# City State, Zip Code Phone Number City Village SrTo Nearest Road 1� New Construction Use: E31Residenllal / Number of bedrooms c Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: (6, Code derived daily flow � > gpd ^ Recommended design loading rate bed, gpd/ft2 L� trench, gpd/ft2 Absorption area required bed, ft2� trench, ft2 Maximum design loading rate bed, gpd/fl2_,_ff_trench, gWt2 Recommended infiltration surface elevafion(s) It (as referred to site plan benchmark) Additional design/site considerations -<J y� Parent material Flood plain elevation, if applicable /�� ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system IS S❑ u s ❑ u s ❑ u Ids ❑ u ❑ s u ❑ s u SOIL DESCRIPTION REPORT Boring # rF2.Y4 Ground elev. %(Lft. Depth to limiting ta��c�ttg9rr > in. Boring # Ground elev. e;��ft. 3 `6 Depth to limiting factor �f�,_in. Remarks: CST Name (Please Print) Address Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed , Trench Remarks: Z0f G OFFICE ; 40 a No. Date CST Number 3 �/ -/ ��� SOIL DESCRIPTION REPORT PROPERTY OWNER fT PARCEL I.D.A . , 1 '' w Page ` of s, Boring # 13 gGround n Depth to limiting factor /Qin. -1/6 Boring # U] Ground �elev. 7i('=n Depth to limiting fMUMr >/fib in. Boring # E3 Ground 0 ft. Depth to limiting factor Borirsg # 01 Ground elev. n. Depth to limiting factor _in. Remarks: on Mottles Qu Sz. Cont. Color =MOW Remarks: Remarks: Mottles Qu. Sz. Cont. Color SBD-8330 (R. 07/96) PROPERTY OWNER o?u- ����—, SOIL DESCRIPTION REPORT Page _ of PAR6EL I.D.# Ground elev. n. Depth to limiting factor Z/V/ Boring # Ground elev. ft. Depth to limiting factor 7/eb in. Boring # �ffr Ground ft. Depth to limiting factor S Bo ' g # ....:.'.a+. i Ground elev. ft Depth to limiting factor in. Remarks: SBD-MO (R. 07/96) Horizon Depth in. Dominant Color Munsell, Mottles Qu. Sz. Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary RootsGVDtV Bed , Trench / L�L Remarks: Remarks: Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed , Trench n NE�S�A--), 5e_c. SR t 30"* ef8 W dot 3 + Lw+ \ e� 9� Y *^!F N43 GorfzLv- of koO's r 7 Icy% , / cD,Do as s- � s f fl ! lot eG v\ry, 7 . - 7+� eN Tn Part 04OFl $— 11`I -199Q 601 i FEB 11 20��s 0 CS T -a?od0 �—IM Dept. of Safety an! Praessional ervices SOIL EVALUATION REPORT Page _ of Division of@fety and.Buildit Cr, ; r `, in accordance with SPS 385 Wis. Adm. Code eloDment County �r D.' Attach complete site plane ,ot less than 81§/2 x 11 inches in size. Plan musts-r C. include, but not limited to vertical and horizontal reference int (BM), direction and Parcel I.D. ^ �' 0 percent slope, scale or dimensions. north arrow, and locat jd1ance,,,,o,,nearest road. (,e% p - /O• ap Please print all inerm Re w d by Date Personal information you provide may be used for secaoondary pw , .o (1) (m)). Property Owner Location "VQ-kC r 4 rt-%A C Et Govt. Lot N f 1/4 1J 114 S IS T 3Q N R 12 E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# I n 'r ti 5k . - '� City State Zip Code Phone Number �AFer t e 111 ❑City ❑Village ®Town Nearest Road ►c1w�g wI S`ha� ( t5)4071SR;rrhrarn to •e'�` St ❑ New Construction Use ❑ Residential / Number of bedrooms Code derived design flow rate 5 GPO 5LReplarement ❑ Public or commercial - Describe __ Parent material D V t t,3 Q s )" Hood Plain elevation if applicable T.IUft. General comments ..+ q and recommendations y 5 J J8� s + 3 ' ? ��^ < <` S C. y) 0. l� �j �} q9 3,1,D V� Boring # Boring J , Pit Ground surface elev. D.is ft. Depth to limiting factor i 3 S in. — Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ft ff#1 ff#2 -li C, -4 1 5 &- I I f 55 K 1 5. 1n I e— F . `� , 7 L 4 IFV G w 1 J Fr 1, 0 < j FSb A �L — -� 7 ©Boring # ❑ Boring A 50 Pit Ground surface elev. 79.3S ft Depth to limiting factor _1.-5 in. Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh, onsistence Boundary Roots GPD/ft ff#1 ff#2 a F__ 1,0 _ -1,4RY/ .----- L.F _ 6_4 c w F . 7 i aiLLtri-Vvv ' _GGV I K,ILGIIU 100,- a IOU IIHY/L CM-Je"L Fe=6vU 0dU mg/Lana iAJ <bU mg/L C -,dame (Please Print) Signatur CST Number �o n n Z. 5to r IC �. ►-t a �3w �L- ? 11 q to AQ;Jess � L4 Date Evaluation Conducted Telephone Number L•"1/(�1_5 I SBD-8330 (RI I'll 1) Property Owner �4fr + E)Onqfir ^ft I: Parcel ID # 0 Boring # ❑ Boring ,.3.y �. pit Ground surface elev. 0 .1 p. [3eptt Q-Wniting factor I 3S in. Page _j;L of Horizon Depth in. Dominant Color Munsell Redox Description '' Qu. Sz. Cont. Color `�'exture �, -� Sfr_4�re Gr. Sz. Sh. on stence Boundary Roots GPD/ft ff#1 ff#2 1. -- 07 - ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth n. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ft ' ff#1 11#2 Boring ❑ Boring # Pit ftGround surface elev. . Depth to limiting factor in. ❑ Soil Aool�cation Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ft 2 ff#1 ff#2 * Effluent #1 = BOD 5 > 30 < 220 mg,L and TSS >30 < 150 mg/L * Effluent #2 = BOD , < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format. contact the department at 608-266-3151 or TTY through Relay. SBD-3330(R 1191) ■o ■R so ■