HomeMy WebLinkAbout024-1030-50-200 Nisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
.6 (ATTACH TO PERMIT) 430167 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide maybe used for secondary purposes (Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Jacobson, Dean I Pleasant Valley Township 024- 1030 -50 -200
CST BM Elev: Insp. BM Elev: BM Description: /, Section/Town /Range/Map No:
i DO, b D- 0 jyl / / q I 21.28.17.189A20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic D Benchmark t 3
/ (.7� ate - d
Dosing f 3 Alt. �M /
10 —�
Aeration Bldg. Sewer
13.(, / 00.3
Holding
St/Ht Inlet v
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WEL BLDG. Vent to Air Intake ROAD Dt Inlet /
Septic I yr Dt Bottom
Dosing Header /Ma_ , f�, ID l3
Aeration Dist. Pipe D/ �, I
Holding Bot. System V, �'? / 1 Z • �
Final Grade
PUMP /SIPHON INFORMATION fi Sa / Y �'
Manufacturer Demand St Cover i
GPM s 1'� fit I,l G I -O D
Model Number 6 rJ 1 r3 3
`� . 2
TDH Lift Friction pss Syste Head TDH Ft
11 .2� .3 ZS,
Forcemain Len th ) Dia. sr Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width �) Length No. Of Tr�nc es PIT DIMENSIO No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S et I
SETBACK SYSTEM TO P/L BLDG WEL LAKE /STREAM LXACH94G Manufacturer:
INFORMATION Type Qf ystem: CHAIVID& OR
m irkil'i /DO q/ / - T Model Number.
DISTRII�UTION SYSTEM /
Head r /Ma if Id e
Distribution x Hole Size x Hole Spacing h nt to Air Intake
Length Dia 0 Length � Dia /' Spacing t 3 I (p 2 i a l S
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over ,r Depth Over xx Depth of xx Seeded /Sodded xx Mulc ed
Bed/Trench CentYI�� Bed/Trench Edges Topsoil T � Y o Yes o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 7 i Ins ection #2: 1
Location: 1788 22nd Ave Hammond, WI 54015 (NE 1/4 SE 1/4 21 T28N R17W) NA Lo
i v Parcel No: 21.28.20
1.) Alt BM Description P o�
2.) Bldg sewer length = �() 7
- amount of cover = , u I / r
Plan revision Required Yes =, No
J
Use other side for additional information.
SBO -6710 (R.3/97) Date Insepctor's Signature Cert. No.
Safety and Buildings Division Count r
201 W. Washington Ave., P.O. Box 7162 Or. PM /,,�
N
I�cO���� Madison, WI 53707 - 7162 Sanitary Permit Number (to be fine by Co.
(608} 266 -3151 30 �Fj -
Department of Commerce
State Plan I.D. Number
Sanitary Permit Application 9-7-E "S , �o ��
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide than mailing address)
may be used for secondary purposes Privacy 15.04(1)(m) Proj Address if different g
I. Application Informatii n - Print All Informat'
l
C _
Parcel #
Lot # Block #
Property Owner's Na me 2 0 0 Z
0(,
Property Location
Property Owner's M ailing Address
-5-7 � S
Zip Code Phone Number t /,S ectio ro
t /
n circl one)
l J D 7 N; RJ o W
II. ype of Building (check all that apply) 3 CSM Number
1 or 2 Family Dwelling - Number of Bedrooms 6 SZ 2g C 1 �� SKIS
❑ Public,`Commercial - Describe U
t —__ -- - ❑City _ ❑Vipage ship of
r State Owned - Describe Use v
.0 2
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 0 2 — 1 30 - A —
A. ❑ Treatment/Holding Tank Re lacement Only ❑Other Modification to Existing System
w System ❑Replacement System g p
❑ ❑ ❑ Change of Permit Transfer to New
List Previous Permit Number and Date Issu
B. Permit Renewal Permit Revision ed
Before Expiration Plumber Owner
IV. Type of POWTS System: ( Check all that apply)
❑ Non - Pressurized In- Ground � le soil ❑ At -Grade ound > 24 in. of suitable soil ❑ Mound < 24 in. of suitab
[I Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit . ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter
❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information: stem Elevation
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dis ersal Area Pro o Sy
l d ��0
� Capacity in Total Number Manufacturer refab Site Steel Fiber Plastic
VI. Tank Info Ca P Y Concrete Constructed Glass
Gallons Gallons of Units
New Existing
Tanks Tanks
Septic or Holding'fank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement I, the undersigned tune responsibility for installation of the POWTS shown on the attached plans.
MP /MPRS Number Business Phone Number
Plumber's Na me (Print) � Plumber's tore
Plumber's Addre ss (Street, City, State, Zi
VII Count / Department Use Only Si atur ( Stamps)
Salutary Permit Fe includes Groundwater Date Issued Issu ng g ent gn
Approved ❑ Disapproved Surcharge Fee) 3 [', f�
❑ Owner Given Reason for Denial / ✓ v
IX. Conditions of Approval/Reasons for Disapproval � �{�
L �t &
1
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
PLOT PLAN
jJacobson ADDRESS 257 Ctv Rd T Hammond Wi 54015
E 1/4s 21 /T 28 N/R 17 W TOWN Pleasant Valley COUNTY ST. CROIX
6/11/03
Shaun Bird 226900 DATE BEDROOM 3
VENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 454 # of chambers none
BENCHMARK V.R.P. Top of 1.25" Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL •H.R.P. Same as Benchmark
SYSTEM ELEVATION 111.8- B-1
111' ❑
110'
Scale = 1/4 = 10'
Huffcutt Combo Tank
3% 112'
Pro 3 Slope ❑ B-2
Bedroom B-3
House
Area 1 Below System
is to re ain undisturbed 110.8'
Well is to meet all
setbacks found in
Comm. 83 - Grading is to be done to
divert run -off away
from system 236'
Tank is to be properly bedded
and provided with lockdown
covers with approved warning
labels
Please note: reason a Z
at -grade was not
used on this site was
the 2nd horizon at -°
0
12" was a sicl and -a
installer was not
comfortable
r
installing a at -grade
over this soil type
500' Alt. B.M. B.M. `
Private Road South Fence Line To C Rd T
Safety and Buildings
4003 N KINNEY COULEE RD
LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777 erc
6consin w
www.comm .wis c ons
ww.wisonsin.gov
Department of Commerce
Jim Doyle, Governor
Cory L. Nettles, Secretary
June 25, 2003
CUST ID No.226900 ATTN: POWTS Inspector
SHAUN R BIRD ZONING OFFICE
BIRD PLUMBING, INC ST CROIX COUNTY SPIA
1008 192ND AVE 1101 CARMICHAEL RD
NEW RICHMOND WI 54017 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 06/25/2005 Identification Numbers
Transaction ID No. 878770
SITE• Site ID No. 660831
Dean Jacobsen Please refer to both identification numbers,
County Road T above, in all correspondence with the agency:
Town of Pleasant Valley, 54015
St Croix County
NE1 /4, SE1 /4, S21, T28N, R17W
FOR:
Description: Three Bedroom Mound System
Object Type: POWT System Regulated Object ID No.: 908855
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes Condit
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. APP RZ �
The following conditions shall be met during construction or installation and prior to occupancy or use: DERARTMENTa
N =OFE
Z
General Approval Requirements: SEE CORRES
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /O1)
and the 'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems
VERSION 2.0" SBD - 10706 -P (N.01 101).
• Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area.
Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal
are prohibited.
• The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption
area. chs. NR 811 & 812c
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the
designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat
• Comm 83.22(7) A copy of the approved plans, specifications and this letter shall be on -site during construction
and open to inspection by authorized representatives of the Department, which may include local inspectors.
SHAUN R BIRD Page 2 6/25/03
• Distribution laterals are to terminate inside an access box or capped pipe. This stabilized access box or capped
pipe is to be brought up to finished grade with the laterals terminating within six inches of the cap.
Owner Responsibilities:
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the
county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the
component(s) utilized in the POWTS.
All permits required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions
should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this
review shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible
for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
� J
Charles L Bratz
POWTS Reviewer II , Integrated Services W iS MART 'code: 7633'
(608)789-7893, 7:45 am - 4:30 pm Monday - Friday
cbratz@commerce.state.wi.us
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
I
Cover Page
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017 RECEIVED
715- 246 -4516
Date: 6/11/03 SAFETY & BLDGS DIV.
Owner: Dean Jacobson
Location: NE1 /4 SE1 /4 S 21 T28 N,R 17W Cty Rd T Pleasant Valley
System type: Mound System
Manuals Used: Mound Component Manual version 2.0 (01/31)
Pressure Distribution Manual version 2.0 (01/31)
Page#
1. Cover Page V
2. Mound Plot Plan ? V8D
3. Mound Cross Section f MERCK
Z
LDlNGs
4. Pipe Cross Section /Pipe Layout PQNpEN
5. Pump Chamber Cross Section
6. Pump Curve
7 -9. Maintance and Contigepi plan
10 -12 Soil test
Signature
License nu r 226900
PLOT PLAN
PROJECT Dean'Jacobson ADDRESS 257 Ctv Rd T Hammond Wi 54015
NE 1/4 SE 1/43 21 /T 28 N/R 17 W TOWN Pleasant Valley COUNTY ST. CROIX
MPI;S Shaun Bird 226900 DATE 6/11/03 BEDROOM 3
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND )= SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 454 # of chambers none
BENCHMARK V.R.P. Top of 1.25" Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 111 8'
B -1
111' ❑
110'
Scale = 1/4 = 10'
Huffcutt Combo Tank
112'
3%
Pro 3 Slope ❑ B-2
Bedroom B-3
House
Area 15' Below System
is to remain undisturbed 110.8'
Well is to meet all
setbacks found in
Comm. 83 Grading is to be done to
divert run -off away
from system 236'
Tank is to be properly bedded
and provided with lockdown
covers with approved warning
labels
Please note: reason a Z
at -grade was not
used on this site was
the 2nd horizon at o
12" was a sicl and m
installer was not
comfortable r
installing a at -grade m
over this soil type
500' Alt. B.M. B. M. "
Private Road South Fence Line To C Rd T oo Ilk
Desi er No
Date
Non -Woven Filter Fabric
4" Observation Pipe Perforated Distribution Pipe
Below Filter Fabric
ASTM C -33 Sand - -�
' tH G
F
Topsoil —� �i = = =__ _ o_
r
?'. Slope `�
F Bed Of t 2 Main
Z Layer
Drain Pock From Pump
ID
Cress S ection Of A Mound System Using F
A tied For The Absorption Area G �—
A Ft. ' -
6 Ft.
d
2. � Ft.
K�Ft_
L'S, OFt.
L
4. Observation Pipe
i A �� 1 Farce Moin
- - -- m p
From PUMP
t'
c ,
3 Bed 0f
° Distribution
D '
Pipe Drain ROCK
I ,
4 Observation Pipe Permanent Marker
Pipe or Rods
Pion View Of Mound U61n4 A Bed For The A bsorpt ion Area
_ PAGE OF
L� Pe- $o:a Pipe Oetoii
1-11 0
End Veer
PVC P-Pe
A / / � ! Fit �Or4 two �•
Holes Located On 801:om,
Ara Equatty SPecea
'
L' e
PVC Force MOM
' ro Cor1t1QC't'c
i ` �sICST 1.141.2 ty>i.YY
1
PVC
Pipe
NSCnifa.d P�3e
t
T C.L A _ � ?v_ J islribu;hon 4iPe LOYOUT X 13 4 , , C
R.
` -2 `� i nches
es
�; .
nches
Signed. Hole Diameter /�� Inch
La teral " Inch (es
+tense Number: ,
Manifold F' - ---- Inches
I}ate = Force Main Inches
of W esi A
Invert -ievation of Laterals . a Ft.
'D "F C f CAI I ON S
p
,OSS S
TANX L F Ci C
A�50_'3E GRADE
4" ci VENT Jlu'NCTI'T�N BOX APPRONED
2 5 t FROM DOOR, -VINDOW CR 'H E C OV F
T`- MA N , 0 L
Ul
Inc INfAKE W! PADLOCK
F. fi-RADE WARNING LPtB_
411 MT�4
T IN LET
WATER T'!C__-fT SEALS T TGFT
Fill-
A JOINTS WITH
9 ,
v--,ALez 1 1 APPROVED PIPE
APPFRMWO ED 3' ONTO
-SOLIC SOIL
PIPE 3
ONTO SOL101
SOIL pijytp ;7LEV FT - j -4
D
3" ; EDDING UNDER TANK
B
PAD
E C I F I C AT 1 0 N S
SEPTIC DOSE NUMBER DOSES FER Dlt
TANK -MANUFACTURER. DOSE I NG
I I NC LUD - - ,�� V AL-
TANK SI ZES : SEPTIC AL, 1 j3WBACi(:
,_ �: � �_ � 1 , -
DOSE GAL- e-, --!
CA. - ES: A
AIARM MANUFACIUREF.; GAL�
MODEL -WMBER:
SWITCH T'�PE; _Z6 G GA
INCHES
.l:VMP MANUFACTURER: Fb L
MODEL NUMBER:
SWITC TYPE-- 16- 23 WA_
R
F_ AL-AURM AS PER (-yv�
;zZq.�-RED DISCHARGE RATE
FEN pTiMP 0-F-F AND DlS,FlFU_ p
vEIZTICAL DIFFE—RENCE BE'rl;
SUPPLY p c S 5 u _R 7 E
-, R T
MINTMUM FACiOF ;7T
F T 1 0 :"-' - r___ 1}r b OTA YNAM
-03 -T
FEET f RCEY IN lia-kD
DIAMLTEF
w
N l-1
L TF
AK:
N EIR N A LIQUID
DATE-,
• TOIAL 0'(,NA.'Vi!C ;4F.AD/CAf"'ACJy
?FR m,Afffr-
CARVE
HEAD CAPACITY CURVE
EFFLUENT AN DIIPATERINI�
5j
L I
522/153 153
V,07DELI MODEL.
Col Liter� 1
L- f
50
?91
69 61 1 7 i
1 53
3 1
o
53 21011 6, 1 231
40) 15 4.6
12 152 i
44 6 7 52 1.97
20 6 1 —
1,
25 7.6 29
7 1 33 3 125
3
— - ----------
42
20 40 1 12 2 1
(1 �4[1'-
Cc""' 4 4f,
10
l I
- 7 —
GAt LONS 20 40 60 30 100 1 7— C 1/4
3 27/
o
'160 240
F1 OW PER MINUTE
CIAL APPLICATIONS 7
CONSULT FACTORY FOR SPE
e4e(
5 27
Timed dosing panels available.
Electrical alternators, for duplex sy stems, are available and supplied with
an alarm.
Variable level control switches are available for controlling single phase
systems.
Double piggyback variable level float switches are available for variable
level long and short cycle controls.
• Sealed Qwi k-Box available for outdoor installations. See FM1 420.
Over 130 °F. (54*C.) special qu otation required.
1521153 Series
control
152115 — MODEL - S
D u lex /s
115 1 8-5 Non SK2064
-- L-- --
PN152 115 1 Auto 8.5 Included 2 or 3
T
152 — 23 0 1 N 4.3 2 o
I nc l uded 2 or 3
I L _ - —
BE-I 2io —
43
_qtIL2 Auto 1 Iluded
N153 115 1 Non 10.5 1 1 2of 3 SELECTION GUIDE
Single piggyback vari 115 1 Au Included
—TO-5— '2 or 3
BN1 to switCh or double piggyback variable level float
able level flo2i
230 1 Non ,, 1 3 1 �o' — I-
E753
Included 3, 930 1 Auto 3 — 2 or 3 switch. Refer to FM0477.
2. See FM0712 for correct model of E Alternator E-Pak-
All installation Of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10-0225 used as a control a ctivator, specify duplex
(3)
licensed electrician. All electrical and safety codes should be followed including the most or (4) float system.
recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every - -oelter pump
MAIL TO, P.O SOX 15347
Louisville, KY 40256-0347 1 ,v anujacturersof
SHIP TO: 3649 Cane Run Road
Louisville, KY 40211 -1961
-2731 - 1 (800) 926-PUMP
http.j1www.zoeIIencoM PUMP fY (502) 776 FAX (502) 774-3624
onnn 7nr-lipr Co. Ail rights reserved
Maintenance and Contingency Plan for a Mound System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Dose Chamber is to be pumped at the same time as the septic tank.
3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
4. Once every 3 years the mound is to be inspected via the inspections pipes in the at-
grade. The laterals are to be inspected via the cleanouts.
5. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
6. Pump and electrical components are to be checked at the time of the pumping.
7. Owner agrees to leave the area 15' below mound undisturbed.
8. The owner agrees to save this plan.
9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is
not be driven over.
10. Effluent Quality is not to excede the requirements found in Comm. 83
Contingency Plan
1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if
needed, then bypass pump float and try pump without float. If this works, float is bad,
replace float. If pump still does not work, check power at the pump with a electrical device
such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is
power, then pump is bad and needs to be replaced by a plumber.
2. If mound fails, determine cause of failure, test another area or remove pipe and sewer
rock, retill soil, install new mound system.
3. Replace any other failing components as needed.
Important Phone Numbers
Plumber: Shaun Bird 715 - 246 -4516
Pumper: Tom Mondor 715 - 246 -5148
St. Croix County Zoning 715 - 386 -4680
pC) TS OWNER'S MANUAL & MANAGEMENT PLAN
P age of
SYSTEM SPECIFICATIONS
PILE INFORMATION Septic Tank Capacity al ❑ NA
OwneC LJ,?�z�: �. t, ;[� / ❑ NA
Septic Tank Manufacturer ��,
� Permit #. Effluent Etter Manufacturer ,p ❑ NA
. DESIGN PARAMETERS ❑ NA Effluent Fitter Model 11 NA
�
Number of Bedrooms Pump Tank Capacity al ❑ NA
r of Commercial Units rer 0 NA
Number M
=' al/da PumE
a
Estimated flow (average) cturer �? w❑ � aUd Pum
Design flow (Peak). (Estimated x 1.5) `� :.; ❑ NA
G aVda z
Pump Model
Sot? Application Rate A
Monthly average' Petreabrnent Unit E] Peat Filter
Influent/Effluent Quality ❑ Sand/Gravel Filter
Fats, Oil t Grease (FOG) S30 mg/- [I Mechanical Aeration ❑ Wetland
1L ❑ Other
Biochemical Oxygen Demand (SOD 5220 mg ❑Disinfection
Total Suspended Solids (TSS ) 5150 m lL Manufacturer
Monthly average" Dispersal Ce11(s) ressurized)
pretreated Effluent Quality ❑ In -ground (gravity) ❑ I -ground (p
Sus en Demand (80(8013:5) 530 mg1L ❑ At -grade ;Nfound
Biochemical
Total Suspended Solids (TSS) 0, cfu�100ml ❑ Dri line 0 Other
Fecal Coiiforrn (geometric mean)
nocr- carnmercla0 wastewater and
Y inch diameter values typical for domestic
LMEm:u�mEfflu�entrticle Size septic tank effluent-
values typical for pre•feated wastewater_
MAINTENANCE SCHEDULE Service Frequency
Service Event -7 ❑months ar(s) (Maximurn 3 yrs.)
At least once every
Inspect condition of tank(s)
--y
When combined sludge and scum equals one-third (Y,) of tank volume
Pump out contents of tank(s) ,- ❑ months ar(s) (Maximum 3 yrs.)
At least once every
Inspect dispersal cell(s) p months ar(s)
Clean effluent least once every
NA
ffluent filter
Pump. um controls &alarm At least once every � ❑months r(s) ❑
Inspect p p. P P ''' ❑ months carts) ❑ NA
At least once every
Flush laterals and pressure test ❑ months ❑ year(s) ❑ NA
Other At least once every
At least once every
❑ months E] yea r(s) ❑ NA
Other
MAINTENANCE INSTRUCTIONS one of the hollowing licenses or
inspections of tanks and dispersal cells shalt be made by an individual carrying S inspe ctor pOWTS Maintainer; Septage
ce tffications: Master Plumber Master plumber Restricted Sewer, POWTS to identify any missing or broken
up
Servicing Operator. Tank inspections must i U e volume of c ommbined of sludge and scurr, and to check for nu levels
hardware. Identify any cracks or leaks, measure tad to check the
or ponding of effluent on the ground surface - The dispersal cell(s) shall ou d surface. a ponding of effluent on the
ndin of effluent on the g n of t're focal reg u l a tory authority
in the observation pipes and to check for any po g requires the immediate notificatio
ground surface may indicate a failing condition and req ) or more of the tank volume' the
When the combined accumulation r by a Sep sludge and scum tag g any tank eq e Servicing o perato r s a tnd disposed of in accordance'K'th ch. NR
entire contets of the tank shall be removed
113, Wisconsin Administrative Code_ retreat ment components,
The servicing of effluent filters, mechanical or P and any
Pre POWTS components p b certified POWTS Maintainer.
rf ormed Y
other maintenance or monitoring at intervals of 12 months or less shall be pz of completion of any service event.
A servicp report shall be provided to the local regulatory authority within 10 days
t for the presence of painting products or other
START Up AND OPERATION if high concentrations are
For new construction, prior to use of the POWTS check treatment tanks, ersal ce11(s). 9
chemicals that may impede the treatment process andlor damage the dis o rator prior to use_
detected have the contents of the tank(s) removed by a septa
ge servicing Pe
Page cf
System Start Shall not occur when soil conditions are frozen at the infiltrative surface.
wer outages pump tanks may fill above normal highwater
levels. When power is restored the excess
During po l cell (s) in one la dose, overloading
the cell s) and may result in e
th
o the di O g
w will be discharged t dispersa
backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a
Septage Servicing Operator pnor-t° 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 oompact,
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.
ABANDONMMENT
When the POWTS falls and/or is permanently taken out of service the following steps shall he taken to insure that the
system is properly and safety abandoned In compliance with ch. Comm 83.33, Wisconsin Atiministrative Code:
P
All piping to
tanks and its 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 toter, to provide a code
compliant replacement system:
• 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 systems must comply with the rules in effect at tha° time.
p
• A
suitable replacement area is not available due to setback and /or soil limitations_ Earring advances in POWTS
'technology a holding tank may be installed as a last resort to replace the failed POWTS-
X T - e 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
04""7 71 �����
Name/
Phone j
SEPTAGE SERVICING OPE TOR PUMPER LOCAL REGULATORY AUTHORITY
Agency.
r''� r �Z.� ^✓
Name /� - ;
n j
Phone'_�� Phone
en
This document was drafted by the staffs of the Green Lake, Marquett vr�sconsin Administrative C e and Wausham County Zoning and Sanitation ede- ag des- This doarment meets Use
of this document does not
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)8(f) and 83.54 ( 1), (2) 8 (3), Grutw (2101)
guarantee the performance of the POWTS_
wiscx,4isin Department of Commerce SOIL AND SITE EVALUATION 3
Division of Safety and, Buildings " Page f
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code tf
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. r1 rrbuetQunty 11
include, but not limited to: vertical and horizontal reference point (BM), 1 and �Tr G�O 1X
percent slope, scale or dimensions, north arrow, and location and dis near Parcel .D. #
APPLICANT INFORMATION - Please print all inform .fijcin. _ fr �e Reviewed Date
Personal information you provide may be used for secondary purposes (Privacy 15.04 (1) ( )L
( (RIJfX
Prop erty Owner ^L '" Pro tion
(C � OG yrl G �Cl G 6 ,07 rr y ., I 'OFFI / 1/4; 'Si1C1 /4,S k1 T 7eN,R /7 E (or) 1l
Properly is Mailing Address L Block / / # Sdbd. Name or CSM#
Q6_7 e O T 1 �0 CtCreS
State Zip Code Phone Number ❑ g�i Village ICI Town Nearest Road
amp an� GJ/ f61y 1( - 5)7%4 7%4 5"1 a s C
I� New Construction Use: ❑ Residential / Number of bedrooms - 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily low S`O i
y gpd Recommended design loading rate � ,1 bed, gpd/fl • trench, gpd/ft
Absorption area required _ _ bed, ft ?7 trench, ft Maximum design loading rate gy bed, gpd4F trench, gpd/ft
Recommended infiltration surface elevation(s) A��i' ft (as referred to site plan benchmark)
Additional design/site considerations ';W04' , 04 -V S e" �1
Parent material S - i:w e Flood plain elevation, if applicable �i7 ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ❑ S W U IZI S ❑ U ❑ s ®U I ❑ s ®u I ❑ s ®U I ❑ s g] u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /f12
13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Z - 03
Ground 3 y .S y` ��1 t- Q� G v S ! of= ,
eleV
V �P� �6
Depth to
limiting
Win.
Remarks: ynb r ^ a �s S a-A";, C, 7L
Boring # I
c
Z.
bu
Ground /e j 7 ✓`y. 3 �� — '
ele� ;
Depth to
limiting �f
factor mn. Remarks: �nD </ l' .S �>�c r 1
CST Name (Please Print) gnamra A 01 Telephone No.
David J. Steel 715- 246 -5085
Address Date CST Number
1564 Cty Rd GG, New Richmond, WI 54017 fT CST #248956
1
.��,c� SOIL DESCRIPTION REPORT 3
PROPERTY OWNER �' " Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gepjft2
M
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
3 M
0e ,d,-Z Zu s rte S I v%
IBM
Ground 3 , y ON
-Q.. AC kDl� v' Fr` G S 1 , T S
Slay. /o
Depth to
limiting
factor
Remarks: i tS 5 o�- efh �� P3Cc �'riK c �jL�
Boring #
Ground
elev.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
z�
z ,
Ground
elev.
ft.
Depth to
limiting
factor
— in. Remarks:
Boring #
L l
Ground
Slay.
tt. '
Depth to
limiting
factor
' Remarks:
SBD -8330 (R. 07/96)
WiwlonsO Department of Commerce SOIL AND SITE EVALUATION
• • Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. IL $3 Q9, Wis. Adm. Code
Attach complete site plan on paper not less than B 112 x 11 inches in si Phan "must County
include, but not limited to: vertical and horizontal reference point (B dhc@clion nd - .
percent slope, scale or dimensions, north arrow, and location and d' tiro r to neitr19 Parcel I.D. #
APPLICANT INFORMATION - Please print all infor r r T f " ` ^^ Review y Date
Personal information you provide may be used for secondary purposes (Priva , aw s. 15.04 (J (0WQt
Property OwnAr .. '��n - � � /
C -¢ f _J`J`/ 4 �Gv a j Govt. Lot 4 S 1/4,S 21 T ,N,R / 7 E (or�
Property Owners Mailing Address �� Lot Bto� Subd Name or CSM#
2S? c 7 4C. e
city State Zip Code Phone Number
El city ❑Village [Z T own Nearest Road
P/
t 4S N a I le I C T hl tr y �•
[� New Construction Use: ❑ Residential / Number of bedrooms -3 Addition to existing building y�
❑ Replacement ,, // El Public or commercial - Describe: P4
Code derived daily flow 7�o gpd Recommended design loading rate _ ,l �bed, gpd/ft • � trench, gpd/ft
Absorption area required , ft _ 3 7-J5 trench, ft2 Maximum design loading rate • T bed, gpolftz • �`' trench, gpdJft
Z/ - 0
Recommended infiltration surf a elevation(s) �) . n (as referred to site plan benchmark)
Additional design/site co rdera 'ons ° ' / 0 k n C/ / S lfrn ,/
Parent material i 7" Flood plain elevation, if applicable 1 1 1 4 - ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system [Is ®u 0S ❑ u ❑ S ®u I ❑ S ®u ❑ s ® u ❑ S ® u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Ll Bed , Trench
Z o : 1 3 2- ohm J_- -e 01 C L.;2 14:
. re
Ground 3 . 3_
7, S /e Clx- .5 h�') �r' C • `T , . S
elev.�p
nl- %
Depth to
limiting
fac
?i3 Remarks: O 1 #1 / .
Boring #
2 Z Z -3>o s f M Tc r ,,J l4: S
36 " 7, Sail' `� - 7,s 6 / s m V �r- c S I ,� •S
Ground ✓ 71 C 2 a 7,3_11'! 5 L k W►
elay-
Depth to
li mit i ng
L in. Remarks: o771- h f„$ S14,47;'7 Cl/- J(' y �
CST Name (Please Print) Signature Telephone No.
David J. Steep 715- 246 -5085
Address Date CST Number
1564 Cty Rd GG, New Richmond, WI 54017 CST #248956
f'
• 1 £ •+
PROPERTY OWNER C� �4GOb SOIL DESCRIPTION REPORT
.Page Z of J
PARCEL 1.0.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots C010
A .
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed , Trench
�� � D� D 3 2 o r��e � � YYl �r GS 1 ,w.. .� � • �
Ground 3 21 -.b3 7. 716 �j ! 1j N'► t! F"r C ,S. ✓-� .41 , • S
elev. gy p_
Depth to
limiting
f r
n•
Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
,
0 i
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
Boring #
LM X
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
SBD -8330 (R. 07/96)
log �l�
IV
Of '
7,ZW 4Cl7
' I
j
I
Sys�e„? 72�
Slgde COrl��r'
la'h c
3 0 A KCA I
5 /6�
• - / % JI- -eel
i S k4 L-- `e I/a t / bl9j Ors 1
CST 2����
S'o K��l �e - i ne Alf$I'? .1 �►'� �� � - �
2,Z-n� A
f
Rod Eslinger
From: Jansky, Leroy [Ijansky @commerce.state.wi.us]
Sent: Monday, November 08, 1999 11:13 AM
To: 'Rod Eslinger'
Subject: RE: David Steel's soil test
Either he screwed up on the depth or he simply should have another horizon.
Either way it's not correct.
> - - - -- Original Message - - - --
* From: Rod Eslinger [ SMTP:Rode @CO.Saint- Croix.W[.US]
> Sent: Wednesday, November 03, 1999 8:50 AM
• To: Leroy Jansky (E -mail)
• Subject: David Steel's soil test
> Hi Leroy:
• I'm sending you a copy of a soil test that I scanned, I hope you can open
• it. It's in jpeg format. If not, I'll fax it to you. It may open up
• right into your windows explorer.
• I haven't see the depth to limiting factor describe this way before. I
• think that the depth to limiting factor should start at the third horizon.
• David indicates on his soil report that mottling actually occurs at 44
• inches. He described the third boring the same way. Just wondering
• what's
• the state interpretation.
> <<David Steel soil test.jpg>>
• Thanks
• Rod
> << File: David Steel soil test.jpg >>
1
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �a �✓ C� C U U S P r�
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location ��! �'/4, 15� ' /., Sec. ( . TpN- W, Town of 1'�Ia4t,44
°—+ .
Subdivision Lot # rn
Certified Survey Map # ��v��l' , Volume , . Page #
Warranty Deed # �/ , Volume Page #�
Spec house ❑ yes no Lot lines identifiab✓l) 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, joumeymanplumber, restrictedplumber or a licensedpumper 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 tic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
_.�,,ays the ear expiration date
OF APPLICANT DATE
OWNER CERTIFICATION
(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
.'' the rty des above, b v' a of warranty deed recorded in Register of Deeds Office.
IGNA F APPLIC DATE
«« « « ««
Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Dep artment."""
«« 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
7 2 1 7 a
a
• STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
This Deed, made between Clyde Jacobson, a/k/a Clyde S. Jacobson RECEIVED FOR RECORD
and Jo Anne Jacobson, alk/a Jo Anne E. Jacobson, husband and wife 05/16/2003 10: 20AM
- - -- WARRANTY DEED
EXEMPT #
Grantor, and Dean E. Jacobson and Jean M. Jacobson, husband and
wife REC FEE: 11.00
TRANS FEE: 15.00
COPY FEE: 2.00
CC FEE:
Grantee. PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to
Grantee the following described real estate in St. Croix
County, State of Wisconsin (if more space is needed, please attach addendum:)
Part of the Northeast Quarter of the Southeast Quarter (NE 1/4 of SE Recording Area
1/4) of Section Twenty -one (21), Township Twenty-eight (28) North, Name and Return Address
Range Seventeen (17) West, Town of Pleasant Valley, St. Croix County, /
Wisconsin, more particularly described as follows: P° A+^+ j 4.40 4 s e yI
Lot Tw?(2f Certified Survey Map dated April 20, 2001, and recorded
, in Volume 15 of Certified Survey Maps, at Page 413 , as
Document No. 652129 o ce of the Register of Deeds for St. Croix
County, Wisconsin. 024-1029-40
Parcel Id tion Number (PIN)
�s not homestead property.
(is) (is not)
Exceptions to warranties:
Easements and restrictions of record.
Dated this — day of , 2003 Q
* * e S. Jacobs
i
* * Jo Anne E. Jacobson
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix County )
authenticated this day of Persorfall came before me this day of
2003 the above named
Clyde S. Ja bson and Jo Anne E. Jacobson
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, — to own to be.ffi`pers )olecuted the foregoing
authorized by § 706.06, Wis. Stats.) t rutzent an i .c
THIS INSTRUMENT WAS DRAFTED BY
Thomas A. McCormack _ Notary Public, Staft�D£ WW
Baldwin, WI 54002 My Commission iS atzent. M v44 sthti expiration date:
(Signatures may be authenticated or acknowledged Both are not necessary.) �., '�!�r -��-- , +1 ' )
* Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 2000 INFO -PRO (800 www.infoproforms.com
r rn ►-, S
'J W 3 oc e g
a:W F cu
N 3 Q • W
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WWO 4J
N WHY ,�� I Ma cjta. cn =cn
:r" cW� I cw�sa C-)
s U ERTIFIED SURVEY MAP
Clyde and Jo Anne Jacobson
Located in part of the Northeast %4 the Southeast 1 / 4 of Section 21, Township 28 North,
Range 17 West, Town of Pleasant Valley, St. Croix County, Wisconsin.
APPROVED
ST. CROIX COUNTY
Plannino Ionino and Parks Committee
JUL 2 5 2001
N LEGEND It not recorded within 30 days of
INDICATES 1'x 24 "IRON PIPE SET approval date approval shall be
BEARINGS ARE REFERENCED 0 null and void
TO THE EAST LMOF THE (MIN. WT 1.13 LBAIN. FT )
SOUTHEAST 114 OF SECTION 21, 0 SECTION CORNER MONUMENT (AS NOTED)
T28 N, R 17 W, ASSUMED AS
S 00 W.
EAST 114 CORNER
SCALE JN FEET 1' =150' SECTOV 21, T 28 R 17 W i
C) ! /
ALUMINUM MONUMENT % s
5b 6 0 1 0 1 Z`T �O �c7— SM C� —
C
OWNER'S ADDRESS �O / � 20 °
257 COUNTY TRUNK HIGHWAY "T"
HAMMOND, WI 54015 3
------- ---- -- FD LANDS _
S 89 0 55'31" E 466.00 NBVW31 -W 424.W �
C LOT 2 $ ,
M i
CERTIFIED SURVEY MAP
Clyde and Jo Anne Jacobson
Located in part of the Northeast �,, the Southeast ' /s of Section 21, Township 28 North,
Range 17 West, Town of Pleasant Valley, St. Croix County, Wisconsin.
Description
That certain parcel of land located in part of the Northeast '/4 of the Southeast 1 /4 of Section 21, Township 28
North, Range 17 West, Town of Pleasant Valley, St. Croix County, Wisconsin, more fully described as follows:
Commencing at the East' /4 corner of said Section 21; thence S 00° 14' 54" W, (assumed bearing on the East
line of the Southeast 1 /4 of said Section 21), a distance of 810.49; thence N 89° 55' 31" W, 424.56' to the
POINT OF BEGINNING of the parcel to be herein described; thence S 00° 27' 56" W, 467.50' to a point on
the North right of way line of 22' Avenue; thence along said North right of way line, N 89° 55' 31" W,
466.00'; thence N 00° 27' 56" E, 467.50'; thence S 89° 55' 31" E, 466.00' to the POINT OF BEGINNING,
containing 217,850 square feet or 5.001 acres, being subject to easements -and restrictions of record.
State of Wisconsin)
County of Pierce)
I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Clyde
and Jo Anne Jacobson, I have surveyed and divided the lands shown hereon in accordance with official records,
Chapter 236.34 of Wisconsin Statutes and the Ordinances of St. Croix County and that this map and
description are a true and correct representation thereof.
Dated: April 12, 2001.