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HomeMy WebLinkAbout032-1046-40-125 PRIVATE SEWAGE SYSTEM - St -roix _afcN antl hw emu lirv;: or INSPECTION REPORT GENERAL INFORMATION 4.1 'ACH - 0 PERM T', c 615424 lan In r., I'e •s On31 nd: n m; Gmn 'i nU er0':Nr n,oy t' osIC `Or 1~11r N: t'y nnlrr es I;'nI.ed. J4 11,m11 nn;'ticker. Nam- L; it. 'Jilhgr Tawny-rv Gorrnl Ts, No Todd Root TOWN OF SOMERSET 032-1046-40-125. I,:G 9L1 p I-v n.r. FA, E cv 31.1 fc cr p, r.r - ~op;c^! I own,I:a:,.tNLf a-tNc rzlE k 16.3119.233C-25 TANK INFORMATION ELEVATION DATA -YF'C NS A:: '_T !,-I _)N WO CiII concYCk O o _ ' new %rav Au r;r,, -gaL ok - oviti ck 1-1 C) P K 1 OIi 13194 5!• nor & x I bov- H::Id1•':I SUI II Pr,g S2-S I_IaL TANK SETBACK INFORMATION st H ,.tt t Tr,,ar:. l-; R11 - w6l-in .I 95.'15 vvc. ,n..... RDAO C•I,Ei nlw +Xtn 50 qK •q o 12-' 1 6, I N A NR us , D' k-1 "w 0u4,- -»5 yy .Vs 'l . i 9.21 XSf- ►3 7:;;97 n 1 t7, +V A 4V t an r'tvfa'1 Dist PIP,. q. S.OZ 6oI. flgsl_^n (tow) i Lo q2, ow tna [st rl,h' PUMPlSIPHON INFORMATION T IaNSdt Zm t~ts~~tacturer - - ?;nvar =t, k .18 .2Z ;9nne1 Nu - ,c1 1 1 lJCI ~1~ D ' 17.: I iB ~ o as Sysl!•:u 'Far. 1 )H O -t • ~ O ` O LL -l[3 ror.:etrtatn --9th 4_1~ SOIL ABSORPTION SYSTEM BEDrTRENCII 111 I t Z- PR DIMFNSIONS N, J,"a: DIMENSIONS -70 SETBACK irh' Tc=' I' Qw1B1 U:7 Ar __LL AK=15; TR-AL, LLACHING V..w'a., INFORMAIIUN _ aC CHAMBER OR 67- PlouQ5 e cT' [:yo-^n ~ 1 ~ UNIT 0 el \~io(LQ~ 14,5`1 6o tlvl NUn,nm DISTRIBUTION SYSTEM I,Ir,nl1ot~ 1 I 4 Ll,re..1.. `J~ • tl ~ a \ ` , I,.n:. S,z ~ Ho.r ;u...tnr, „n, I. a.:,r I tr ` , t - ~ 5 end s - SOIL COVER x Pressure Syslerns Only xx Mound Or At-Grade Systems Only runt- :1,+Ah it last' a 3o~oed,3cooetl L,wcncrl fedT ti ':.,ntr' - 5d 5 It , r -nnr; ,_01 vcc NE Yr. Vr COMMENTS: I:In~luot:::;:U.:• riie.cr~(Y•1;;IC•;. persons a-esant. cl:: Ins Pe~tr,ntta' y~l l Irspt•::I~'1?t~ 1 Location:-14F C:1-.:T ~fit` ~~I s V-IQ~,1,W O{n {~(kS~t~ ~L. per LoV L:srnpn:;t, muk1v1I Co--+e _ ` ..;inn eewe•lenu:rl=ClCiS~'tYleJ~ 30'Ts of, - :t,n,nlnt of cov - ,JJaddl.d ~Jan(L ~'I•- Qu r ,Presr-r~~ -o k. -7 Fr b~tny k new tj~ for :-s \N 'gar r m .on R . d6 19 ~ 1 C6 sp ,t - -r for dadi in, Y tna Division -qty c lo;x C CEF'~ © Safety and Buildings & ` B S 1 2 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (robe sued mby Co.) kcs; PsAUG 08 201 Madison.Wl 53707-7162 " pp ication StateTrAnsacbmNlrmba ordance with SPS 393.21(2), W isAdm. Code, submissimt of this form to the appropriate g vernments[ unit ired prior to obthcring a sanitary permit. Note: Application forms for sUtcowned POWTS arc submitted ro Itgcc[ Address (if different Man mailing address) partment of Safety and Professional Savior. Personal information you provide may be used for secondary in accordance with the Privacy law, s. 15.(4(1 xm), Starts. _ T' ZI ~ r vT"~ L Application Information - Please Print All Inf l matia _ Property Owner's Name - - - Parcel It Z _ o~~ ~oof o32- /a Y6- Yo- Property Owner's Mailing Adrhess Property Location a / yy S4 GOYL Lot City, site zip Cade Phone Number Nw Y., SW YS saga, !l vM t GAT S o2 S 71s- y7oz ucle rnmc~ T31 N: R_yon ~yJ H. Type of Building (check all that apply) Lot k Subdivision Name 1 or 2 Family Dwelling- Number of Bedrrroooaaa~~'fpp~///~~ 13 BlockA -_IOGL+'~~ PublidCommuciel - t?esaibe Use ❑ City of V;Dage of ❑ State Owned - Describe Use CSM Numb" Z w 7 >s `7 EZ Z-/ 1 41 Town of -5'0 1"erll t' III. Type of Permit: (Check only o #e box on line A. Complete line B inapplicable) A' ❑ New System Replacement System ❑ Treatment4lolding Tank Repl=ment Only ❑ Imxr Modification to Existing Systern (explain) B. ❑ Permit Renewal' ❑ Pettit Revision ❑ (,Tanga of Plumba ❑ Permit Transferto New List Previous Permit Number and Dare Issued Before Expiration Owner W. T of POWTS S _ m/Component/Devicec (Check all that apply) ~ ~ - XNon-Pressurimd In-Ground ❑ Pressur-❑LriIn-Ground ❑ At-Grade U Mound 24 in of suitable soil ❑ Mound <24 in. of suitable soil Milms -1 ark OOtherDispersalCompaunt(explain)-__ ❑PretreabnrnlDevice (explain) V._Di~rpersal/Treat at Area Information: Design Flow (gpd) Design Soil Application Pale ------m / f) Dispersal Area Requirtd (sf) Dispersal Area Proposed ( Syste Glevahonn 7so 0-7 9.r7, .2 VT. Tank Info Capacity in Total a of Manufacturer Gallons Gallons Units SZS ` v v Ncw'rmks Existing Tmdu V rn m_ 5b is yo v - rn L•. U 0. Septieor F[okkngTank uosuig Chamber - - VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. -Ptum-'-'-ba - - ._m P 's Name (thing Plumber's Sign bfP/MPAS Numbs Business Phone Number f3jr 4A 1614CIt ,,pper L23 r s r y 715-TO oyes _ - Pmbch Address (Street. City. State, Zip Codc) cL U C So/nerrf e A- /tin 5r02 _S7 VI 'cunt /De artment Use Onl Apprtmved i Isappro Permit Fee Dat Issue Iriuin arnt Si_m art oa 8 /li l sSod' ;ven Rmtm for fenial ! IX. CondWAsTjM ` easons for Disapproval O C r 1. 'S'apfr .k. ettkx c Ater vml 3~ ~p ,-k 4ve41 tasper:rm cell ewer ell be s.arIC.?s 'r.:: ec ~ f ea per Tlarayemen'. plan p•o,iaerl by plmnbe~. rl a _ 2. N eatbvtk r1a;Lkar:Mn1 nvnu W r.: Irt 4 A M Qef pll}! i Cfd:111lM:Ef. ' nmrh to romplctn pram for the tyLem and sohnnit to the Cmmty only on paper not Ins Ming IC i l l inchm in we SBD-6398 (k. 11/11) v-N' NIER r n rave I of ?Name -7-0A rtoo Y Brian Parnell Address IR Vz5 t St CST 231314 S D me Ise 10- KvT SY62S Date 604- /F ® Benchmark 1 ® Benchmark Soil Borinl- _ _I Suitable Area 40' Sc_alc_ I I I! I T--1 - i ! ! I I ! l i~ l i l t l i ! I { ' + : t I I I~i}r_u ,D.lo3~-10 6-yo-•~o iti. I'0 t i I I 3 I, I, I I j : S+ i I I j bl~ I I ~ l t~ I I I~~-T-' I i ! I ! I '~o tr b F l i r 1 I ! I i j f ! i i i i I I I ! I i- ~~iA""I lT--- I 1-4 o~__I I ! I i I I! I I ~ ~ v! i t i l l I ~ i - r- --1- T -F - T - I it lil I t i l , i ! i , l I l f I l i ' I 1( I l i l l! I I I y- ---1- c - I ! I I I I 11 l i l i l, ! i I I i ( I O!- I_ I ' i 1 1 t a ill i 1 l i l i !II I ! ! iili I, i' I I i I l I i : I _ I f ! l i l I 1 I i i I I; I! I I~t 1- 7-71 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: -7-ogi jll 6D f nwner's Name: R60 / Owner's Address: _ yy_ 7 h ~T' SOmt/Sct- wZ ,SS/oZ.S Legal Description: /r fir/ SW ~y Sec . / 6 -T 31 Township: So M ee rep- ` County: S/4-, t_ lo% k- Subdivision Name: Lot Number. o7Z- ~6 y6- yo Parcel ID Number. Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Designer/Plumber: Ffrcan G/A e/~ license Number 23/31Y' Dnte Phone Number760' y~ Signature Designed pursuant to the In-Ground Soll Absorption Component Manual for PGVVrS Version 2.0 SBD-10705-P (4.01101). Page 1 OWNER Name o 0o Page 3 of3 Address es/~/9 5~6 Sf Brian Parnell Sosne~sci CST 231314 SY6?S Date e -d- SBenchmarkl Co., care Ro-e W./*-0e,T~r - Benchmark 2 TOP Al !V Got ca,-n e.,- Soil Boring _ j Suitable Area 1"=40' Scale 2 I rtt .T: qo . s~e I 1 I 1 I I ~ ~ 1 f I I I I ( i A \72 i V==i tV 17 i I /LLI I I 1 f~ y I /o I r e 1 I O ~!7 I + :]:TTT7 /V 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - SOIL ABS"OOR/PPTT~ION1 1SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Pago_o1 Project Name: R60 No. of Cells 7 Per Cell 3 n Cell Width Total No of ~Z X 203- /o 70 r, Cell Length 3 s-o sq It EISA Per Cell ~'t Cell Spacing 100 sq ft Total EISA Mantlaclurer Model Laying Length EISA Rating Infiltrator F21203H_5ft 50, 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer. 4"4 Gravelless Leaching Unit Model: Typical Cross Section Finished Grade q ts• 1 ft \ Observation Pipe with approved cap or vent • n. 3 Soil Barkfill = Geotextile Fabric 92. Infiltrative Surface 12 in 0 / - 07ft Limiting Factor SS -In ~Slotted and Anchored Vent] / Observation Pipe with Cap Plumber/Designer Signature::: 0 License; ~3I ~1 / Date: (6- 7- 2019 S/z % P f;~ L7 ~Se Fps/~,~~ ~~ODgee / ~o~ci~fc TG'r!c Ne W F l o f G/ 7sf .l ~~aJ f T ~ k fen ¢oce C'Yc% lour/o~ , C ~ /C gay = d.7 so,/ r~at~ = ~y~. ~S2M;~ _ y~Z ~~ows ~ " /4 /n ~.'/ttu tee 120 7U0 acl 70 ' ,`t h 7 Pin. ]fit INSTALLATION INSTRUCTIONS PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS cerder Rker wih opwav + - e trr - lrr~ _ ir--- - V1 Ocn ue ' ' ~n`}7 d niP Lok Y Step 1: Step 2: (A) Locate the outlet of the septic tank (q Step 3: (B) Remove tank cover and ) Before installation, place the out Glue the filter housing on the if pump tank filter housing on to the outlet pipe. outlet pipe. e. necessary (B) Make sure that the [rousing (B) Insert the filter is positioned so the fiker can be9e in the removed from the tank for Ong, making sure the fitter maintenance and service. ~ FS aligned property and corner he housing. inserted in n the MAINTENANCE INSTRUCTIONS Mtv U Step 1: Step Y. La:.aie the outlet of the sepbu tank q Steps: . if nssary tank cover and pump (/y Insert the fitter cartridge back into the the [rousing making sure • • (B) Pull the filter out of the housing. the fi tar is properly alighed USERUBBLRGLO1lE8 (C) Hose of the filler ov 1haaepliclark and completely inserted. HEN (;LEANING FILTER A't'ake sure all solids fall back into the (B) Replace septic tank cover septic tank POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page-o'.- FILE INFORMATION SYSTEM SPECFiCATKM Owner O QO Septic Tank Capacity y7s al ❑ NA Permit Septic Tank Manufacturer ~~;`/itr•i ❑ NA DESIGN PARAMETERS Eftkrettt Filter Manufacturer P j,o k ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model 5-9S7- ❑ NA Number of public Facility Units ❑ NA Puny Tank Capacity al ❑ NA Estimated flow (average) 300 Pump Tank Manufacturer 0 NA Design flow (peak), IEstmated x 1.5) ys0 Pump Mwwfacttrar ❑ NA gWday Soil Application Rate b, Ae Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average' prstreabnerrt Unit - ❑ NA Fats, Oil & Grease tFOG) 530 mg/L - ❑ Sand/Gravel Filter ❑ Peat Fitter Biochemical Oxygen Demand IBODJ ! = mg/L NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Soids (TSS) 5150 rtg/L ❑ Dsinfecpon ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cells) NA Biochemical Oxygen Demand (BODJ 530 mg/L KW.Groud (gravity) ❑ In-Cxaxd (pressisked) Total Suspended Solids am) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Corrform (geometric mean) 5104 du/1 Ooml ❑ Drip-Line ❑ Other: Maxmxen Effluent Particle Stte Y. in db. ❑ NA Other. _ ❑ NA Other ❑ NA ❑ NA 'vakhas typical far domestic watews ax and septk tank effkmra. Omer ❑ NA MAMTENANCE SCHEDULE Service Even - Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ (Mardaram 3 Yeas) ❑ NA Pump out contents of tank(s) When combined sl dge.and saarh equals one-third )14311 of tank volume ❑ NA Inspect dispersal cells) At least once every: 3 ❑ earfs) sl (Madman 3 years) ❑ NA Clean effluent filter - At bast once every: ❑ month(s) ❑ NA 3 ;aZaris) ;nsoect pump, pump controls & alarm At bast once every: - ❑ month(sl ❑ NA ❑ year(s) s` 'eerals and pressure test At bast once every: ❑ month(s) ❑ NA ❑ year(s) At least once every: ❑ month(s) El NA Caner. ❑ yearls) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal ceps shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Pkanber Raslik"d Sews; POWTS Inspector POWTS Maknakner Septage Servicing Operator. Tank inspections must nc ide a visual inspection of the tank(s) to identify any missing or broken hardware, identity any cracks or leaks, measure the volume of combined sledge and scum and to check far arty back tip or ponding of effluent on the [Found surface. The dispersal cell(s) shag be visually, Inspected to check the effluent levels in the observation Pipas and to check for arty ponding of effluent on the ground surface. The pondng of eff inin on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sledge and scum in any tank equals on"vird (Y31 or more of the tank volume. the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with charter NR 113, Wisconsin Administrative Code. All other services, including but not lrriited to the servicing of effluent fates, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provdad to the kucal regulatory authority within 10 days of Completion of any service event. _ of START UP AND OPERATION Page For new construction, prior to use of the POWT$ Cheek treetnen[ tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the disperad cad(s). If high concentrations are detected have the contents of the tank(s) removed by a septege servicing opxator prior to use. System start up shall not occur when soil conditions are frozen at the Infiltrative surface. During power outages pump tanks may IM above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloadag the tee(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pup tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contect a Pksttber or POWTS Ma'ertai er to assist in manually operating the pump controls to restore. normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or Compact, the area within 15 feet down slope of any mound or at-,gads soil absorption area. Reduction or elimination of the following from the wastewater stream may anprova the performance and prolong the life of the POWTS: amiltiotics; baby wipes; cigarette butts: condomin cotton swabs; degreasers: dental floss; drapers; disinfectants; fat; foundation drain (sump pump) water, fruh and vegetable peelings; gasoline: geese; herbicides; meet scraps; medications; oil; painting products; pesticides; sanitary napkins; tarnporm and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to inane that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shag be disconnected and the abandoned pipe openings sealed. • The contents of sa tanks and pat shall be removed and pmperfy disposed of by a Sepaaae Servicing Operator- • After pumping, all tanks and pits shall. be excavated and removed or thek covers removed and the vold space tolled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following meenses have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be uti¢ed for the location of a replaosmaM sod absorption system. The replacement area should be protected from disturbance and convection and should not be Infringed upon by required setbacks from existirhg and proposed structure, lot Ines and wells. Failure to protect the replacement area will result in the need for a now still and site evaluation to establish a suit" replacement area Replacement systems must comply with the rules in effect at that time. ❑ A suitable repiseemert area is not oval" due to setbabk and/or sal limitations. Barring advances in POWTS technology a holding tank may be Installed as a test resort to replace the failed POWTS. ❑ The site has not bent evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be perfartned to boom a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the felled POWTS. ❑ Mound and at-grade sod absorption system may be reconstructed in place following removal of the Monet at the Infiltrative surface. Reconstructions of such systems insist comply with the rubs in effect at that time. < < WARNING> > SEPTIC, PUMP AND OTHER TRREATM E NI TANKS MAY CONTAIN LETHAL GASSES ANDfOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CWXWNISTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE 00440iLT OR RAPOSSIBLE ADDITIONAL. COMMENTS POINTS INSTALLER POWTS MAINTAINER Name 1 13 Pica 4r4e l l Name Phone 1715-- 7 0 - Phone SEPTAGE SERVKWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name L Nacre Phone Phone - This document was dra`:e_ -sane with chapter Co rrn 83.22(2)(b)(1)(d)&M and 83.541), (2) & (3). Wisconsin Adm'sistrarive Cade. ^ of _ -TART UP AND OPERATION Page For new construction, prior to use of the POWTS check treatment tank(s) for the presence of pairdrrg products or other chemicals that may impede the treatment process and/or damage the dispersal ceg(sl. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System stat up shall not occur when soil concifti ris are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cuff(s) and may result in the backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Pkimber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the fife of the POWTS: iotics; baby wipes; cigarette butts; condoms; cotton swabs: degreasers; dental floss; drapers; disinfectants: fat; foundation drmn (sump pump) water, fruit and vile peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. %BANDONNIHNT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shat be diaconnaeted and the abandoned pipe openings seabed. • The contents of all tanks and pits shall be removed and property dssposed of by a Septaw Servicing Operator. • After pumping, all tanks and pits shah be excavated and removed or their covers removed and the void space filled with soil, graved or another inert solid material. "ONTINGE7NCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement sot absorption system. The replacement area should be protected from disturbance and compaction and should not be lydringed upon by required setbacks from existing and proposed structure, lot fees and wails. Failure to protect the replacement area will result in the need for a new sod and site evaluation to establish a suitable replacement area Replacement systems must comply with the rules in effect at that time- • A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replecerterrt area. If no replacement area is avertable 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 it place following removal of the biomat at the infiltrative surtax. Reconstructions of such systems rrxust comply with the rules in effect at that time. < <WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR RNSUFRCIINT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTEMR OF A TANK MAY BE D1FRCULT OR IMPOSSIBLE 4DDITIONAL COMMENTS 'OWTS INSTALLER POWTS MAINTAINER Name riaa G.ine/~ Name Phone 7-610 - Phw,a - >EPTAGE SERVICING OPERATOR (PUMPER) FOCAL REGULATORY AUTHORITY Name Name Phone Phone 15 - 3 s( A}(; 4J CJ -~,r:s document was drat.=__ Fiance with chapter Comes 8322(2)(b)(1)(d)&(f) aid 83.54(1). (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 02 / y9 yot~ Sf- Son,vf t~ wr located at: Nu' '/e, Su' Section 16 'Town 71 N, Range /9 W, "Town of SomeiJ~>- St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 7 2 9 ' / y Did flow back occur from absorption system? Yes X No (if no, skip next line.) Approximate volume or length of time: /,SU gallons minutes Tank Capacity: ~Oo o / Construction: Prefab Concrete X Steel Other Manufacturer (if known): - Age of Tank (if known): Permit number (if known) (Licensed Plumber Signature) (Print Name) "23/3/V (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 1 13 Wisconsin Administrative Code) Rev. 9/2008 IM-540 ~INFILTRATOR° tanks Features & Benefits Strong injection molded polypropylene construction Lightweight plastic construction and inboard lifting lugs allow for e f easy delivery and handling Integral heavy-duty green lids that interconnect with TW'• risers and pipe riser solutions Structurally reinforced access ports eliminate distortion during installation and pump-outs Reinforced structural ribbing offers additional strength Can be installed with 6" to 48" of cover • Can be pumped dry during pump-outs Suitable for use as a pump tank or rainwater (non-potable) tank The Infiltrator IM-540 is a lightweight strong and durable septic/pump tank. No special installation, backfill This watertight tank design is offered with Infiltrator's line of custom-fit or water filling procedures risers and heavy-duty lids. Infiltrator injection molded tanks provide a are required revolutionary improvement in plastic tank design, offering long-term special water filling reeq quirements are necessary exceptional strength and watertightness. The tank may be backfilled with suitable native soil. See installation instructions for guidance. TANK CUTAWAY MID-SEAM CUTAWAY RISER CUTAWAY --Reinforced 94 " Custom fit structural TW Riser access poll Reinforced _ watertight mid-scam gasketed connection Protecting the Environment with Innovative Wastewater Treatment Solutions I N F I LT R ATO W water technologies IM-540 General Specifications and Illustrations - A A' The IM-540 is an injection molded two piece mid-seam C plastic tank. The IM-540 injection molded plastic design allows for a mid-seam joint that has precise dimensions fi' L m for rii R for accepting an engineered EPDM gasket. Infiltrator's ^ gasket design utilizes technology from the water industry to deliver proven means of maintaining a watertight seal. The two-piece design is permanently fastened using a series of non-corrosive plastic alignment dowels and rw 6I1 R+sI E.TFB1pC IFNFJ - ur11R6s w+ locking seam clips. The IM-540 is assembled and sold TOP VIEW rvl through a network of certified Infiltrator distributors. TYV' 14,0 71,-6W 0, Must be backfilled and installed in accordance with Infiltrator Water Technologies, Infiltrator IM-Series Septic Tank General Installation Instructions and for shallow itil p Ill ground water conditions reference the Infiltrator IM- Series Tank Buoyancy Control Guidance. 6 1 ;138?I cy;.y-r.y.y;.y l.y LMTrRIOR r V Please visit uwvw.infiltratorwater.com/images/pdf/ ,i:lcllr I III I ManualsGuides/TANK01.pdf for the latest information. 1 , ENO VIEW Total Gapraciry b52 gal 12090 LI Length 84.9"(1648 mm)=,L,.., ~_r.,~.•:.I,l~wtr F;_.h. I,~ Width 61.7.. 1'567 rnrn) .n, n. - INt:-' Height 54.6" ('387 mm) Maximum Burial Depth 48" (1219 mrril Minimum Burial Depth 6- (152 mm) Maximum Pipe Diamelei 4- (100 mml Weight - 169 Ibs (77 kg) SECTION A. A' N, 14 -I'll IT TAtItl1P "I0 - "All It" I AAp "ERIJR (K4Y[1 I 9:,110\Y e 0uP., R:. MID-HEIGHT SEAM Po : l SECTION DETAIL CIJ ,57,'-U:h CT Of.6CA- INFILTRATOR` ;aao.221"38r8f~'1f""" water technologies www.intittrat0M8Ix,r.C0"% U.S. PSerc 4,:59.w. 5.0111 W. 5, 114401 '.n n It r. b.u:;' 4110: 54' I. J 1.S-161E3.5f43.7:8.5W9.844QOy,}Nl Patert5.•.3299592C61,C$i Ulrn 010Ml rt,Wi ] Eyjalsa, eLkk,i sW h::.•.VnD:rt at i . •aarnu.:. Intl .,ii . vtnlr Tath ; lwl'I, h, t,19 .ttgi5m. vrenvM it f•xlce heltraly W'91d R<~mU9c<--- e9.ra14~ mVnr.* n VA.:e-l Oadw• V crcLmcr'iry. Pw,T,°, l%•an,M p m.-, Mtlrm,. Y:cll q*, GIC G ,I 0"3. .Pbt. j' •.LW.A :Vd St.irtllw, :aP L.Lwo lmkS.N hI,IVnI V''NA0 t t,r.wnl Poh•LRU::a:raecrnar.of Vdyt:R1.. I I A 111f r. a"'ll"d:•a?ar1wko( TUF-II P.C.L?a-Pibisvpa:a^,ak~• 0'EA1,.. I)P`13lrlh tv Wale In:Wl'-JAS, I E:;. A 1, 9N5 rB52nN: llvte In US~% IN I'1-16 ST. CROIX COUNTY SEPTIC TAN& MARfrENANCg AQLEM4ENT AND OWMMMU COLTIFICATION FORM UW=r/Bua ~f!4~ ll6o t Maihng Addrem C ~//7p9 yd ""A Sf JO M eiftt ~z S~o 7 -Prop", , Address oC 7 / SAO rh Sf 1001 el-f e f- Z -Y02-5 (Ve n ri regnaed fic>m Pita nwg & Y;-x; Dgt~t fbrnew Wit)) City/Stare- DM e~fcr' Pa1rx1 hie~fitx5on Number 03Z - I/- /U- 0 00 F,9A✓ DESCRIPTION ° rL«aaam N~ y,sw V., See ~/.NR /y W,Town0f Somelre, - Subdivision I.of 4 CertMed SurnT Map # Vohmm Warranty Deed # Vohmne Page # Spechouse sq IotFtr Awfis ble 16) no SYSTEM A rnrrtzNANCS AND OWM CRR77FIC a rvsx lmpaopaoseaad ceofpaasepticsystrmcouldnsal iniM, I cfmieemhmd'rrr&M& fkgyc canoe consists cfp orttbe septic tank eves9>hnn yeses orsomeS ifneeded, by a herasrdpmrp m What yon pot lute the system can affbM Me function of file 3epta tzmk as a hcanmr r stage hi the west disposals YSam Owam z>amtmmcc zspoastbtWn am specified is §Comm 83.52(1) and in Chapter 12 - St Cto$ ComtySanitary Ordi The property owner agrees to ssb.t to St Cmix CaoatyPl+MMiogdt Zoomg DAR a cmfificifion faam, srgrrai by the ovr,wgM by a master plmnbm jonmeyman pmmbm nseicted phtmber Ora Iiomged P®PQ vaifyiag eid (I) ft on-sit wastetvatr disposal sysnem ism proper opetatiog omdfaem and/or (2)aftr mVecom audptm pmg (ify), die septic tank ; less rhea 1/3 fnn ofslvdge_ I/wC time w0erm¢ned bane read the above reqturmus and agM to ma>ntamthe pavane sewage 1Bspoeai system with the Ada cset forth Lenin as serby to Depatr>neur ofCorimettx and ft Depeavaeaff afNaaml Resama , Stet of Wises. CcrtTlc t;ou stating that your septic sysRm bas been> iud mmtbe ca®piewd andxetrmed to fist 9L Ccoia Comdy Pit v_ Xc Zwunm D a.-tment withal 30 days of the dm year exp=pnw dal. " Dwe certify that all sta0emeals mare true to the best ofmy/oor bwwbdga Uwe a~ the owner(s) of the Propaty desrnbed above, b) vittoa of a tked recorded is Register odDeeds Offnce. Number of bedrooms 3 SIGNATURE OF APPLICANTP DATE 'Any Mfim>atian datrs m t I xmy= km dw=nauyl 1+p bytiGPlamiwg&Zmiogl t - _:_de roitb this apph=tioa a rermded .warranty deed from the Register ofDeeds Office and a copy of the nertified survey amp if 7t2r is =de in the wartaaty deej pg-per Wis. Dept. of Safety andprak~w~al _ SOIL EVALUATION REPORT Page ~ of 3 D•vision of Safety and Buildings in accordance with SPS 385, Nis. Adm. Code ! I-0 • C' J'4' Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County S7 - include, but not limited to: vertical and horizontal reference point (BM), direction and parcel ID. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. D Please print all information. Re by Date Personal information you provide may oe used for secondary purposes (Prhey iaw, s. 15.04 (1) re)). i Property Owwrneerr' Property Location k p Roo GovL Lot Nov 1)4 IV 1,4 T N R / / f (orl \•V Property Owners Mailing Address IpA S ~ Lot # Blotlc # Subd. Na or CSM# 2111 9 C~ty - State Zip Code Phone Number ❑ City ❑ Vilage ®Town Nearest Road ~6me~set 46~rj 5-`JbZS-(71r) Zy?- 702 ,SOmeiS~t' i of4 `ASt. ❑ New Construction Use U Residential I Number of bedrooms 3 Code derived design flow rate - y _ GPD ~4Replaoement ❑ Public or commercial - Describe:.,__ Parentmaterial_b(tfG!k~~r Flood Plain elevation it appl"ble ft. Generalcomrnents S S~e~y f ~r 92•'~ ✓ and recommendations. cl Gd1~- ~oP Occ1 /tr p;Pc FtTErs;l;af /o0af.l rusk ELr 9s.a2 i I Boring # Boring - ® pit Ground surface elev. , ft. Depth to limiting factor/ /O'? in. _ Soil licatwn Rate Horizon llepth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in Munsell Ou. Sz. Cant Color Gr Sz. Sh. ff#1 ff#2 1 0-16--Lo fi ~ /V.4 SL /m MZ (f 21, 0,(/ 0, 0,7 16-3Y 7 ~rR ! - N/f- _ _r_n os~ m~ c i~f I o. ~ 1, 6__ 3 3Y-I 6 7,5V 64 IV- -ins- I o mL ® Boring # ❑ Borng q \ ® Pit Ground surface elev. / 7r ft, Depth to limiting factor > /20 in. Soil Apphration Rate Horizon Depth Dominant Color Redox Desorption Texture Structure unsistence Boundary Roots GPD/ft ' in Munsell Qu. Sz- Cont. Color lit Sz Sh. tf#1 -eu2 f o-/6 -o Y2 z 2 /6 y0 7. YR%6 /v rhs asy G cw i; 0, 7 1,61 3 yo- r 75 YR %6 IVA MS' o s _ M Z_ D, . 41 --C 161 Effluent #1 = BOO , > 30 < 220 mg1L and TSS =30 _ 150 mq•L ' Effi.ient #2 = BOO 30 mgrr an. TSS 30 mg/L CST Name (Please Print) Signature CST Ntanber 13r,"- Itea/n[// a3131y Address Date Evaluation Conoucted Telephone Number 398-/9~ a ~c 50m,'rfer wz sYo25- 40- g-6 /9 7/s-ZY7-3Z03 ~ p. oou _ grope ^y Owner -rlo hi 960~- Parcel ID " 3 Z' ~ aage of? Boring # ❑ Boring 9,{ ft. Depth to lwAN factor:~-~ m C~ ® pit Ground surface elev. L - Soil Applicator, Rate liorvon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD1ft ' _ in. Munsell Qu. Sz. Cont. Color Gr. Sz- Sh. ff#1 02 6-6 /Oj~4 /2 1~ SL /m /ytL C c~ /M - 6 36 7,5"/R s /YIS DS`Q G cw /.p 0,7 3 36 !~9 7,SYR 6 h7S 6 s G - 6 Z IVA 111 7 ~I L4 6" Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil ApplicA'tion Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft ' in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 111#1 02 ❑ Boring Boring # E] Pit Ground surface elev. k Depth to limiting facto in. Soil tication Rate LHorLvon Depth Dominant Color Redox Description Texture Structure onsistence Elioundary Roots GPDf t ' in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. if#1 ff#2 I T-I Effluent Fi' = isOD - 30 < 22:i -nsl and TSS -K - 1 `,J mqA ' Etuent #2 - BOD <,30 m9,1 an I SS , 3o mprl. T:lc Dept. o -G;P.;h and 1 r ,[essioral Sc[vioec ;,c ar. equal opportan.t; ~crvicc provider and employer. tf-c ❑ccd nSts;an;re n. aceess services or need inatertal in an altematc fonnai. cmuact the deparvnent at 6OS-266 151 or 1TY through Relay. st,t~avo cxr vm ~roxm~ C.v°er 10 a:ce' IDS _ Page o' J Bdnng# J But inc Q~ Q `J pit Ground surface elet. / ~ - ft. yulh tc limiting factor. /D 9 in ^;;oil Ii:auoc Rate ionzor Deptn Dominan! Coot Redo). Descrotior I Texwre Structure onsistonce oundary Roots GPD;- m. Mun! Qu. Sz. Cont. Coior Gr. Sz SI, ff#1 •~ff82 AIA 2 6-36 '7,SYR / /nS pSy L cw d,7 3 36 /09' 7.57 6,7 j IBoring a* Bu:rv: '~--J ❑ Pit Ground surface elev- 7epM to iimitirc facto: ir.. T'~- Sal lUnLcahon Raie i+p n'~vrbfdh Irlnmm~n`:_nhrl i:uiwrbc~i~tin_. T=vb~ re nnNrn..~ in. Munseh Qu. Sz. Con, Color Gr. Sz. Sr. 'Ells ff#2 i ~ i !J Boing boring F . ❑ ?it Ground surface elev, ft. Deptin to fimiting facto- in. _ _ SolSo7 App~:ation Rate 'icrizun Deptn Dominant Coior' ked::x .'k!Smpbon Tc#urc Stro;dure F.F. Steow 60"dary GPD/:7 in. Mun_seli Qu. Sz Con! Color Gr. Sz. Sri. -Ffi#1 ff62 i i i ~ " cfflceit s' = BOD > 30 < 220 mgiL and TSS >K < 150 rrurl ' 'filu_nt 42 =307 < 30 or, and TSB _ K, ~n~rL The Jep:, o`Safen' and Professional Servi:cs is an equal opporiumtp scrvicc nrorider and ::;npio~ cr. If % n--d asa::aance to acres; services or nmd material in an atmmatc format. contact the deparrncni ar. or chmu^P. Re:ao $aJ-SAC Qcn VI I I OWNER Name -r sj Roof' Page 3 of 3 Address /yq yl0 Sf Brian Parnell So mt ist wt S~/6~S CST 231314 Date S Benchmark 1 Conc.a~e F/~, cva/you r ~Gbo / Benchmark 2 70 /V GW G or Ce.n ei 99~ ❑ Soil Boring _-i Suitable Area 40'_Scale, 1 , I 0I I I I ~om ~ ~ i l i l I i t ~S , 1~ ! 1 I i i ! i I_ ` I I I s ~ l ~ lil ~ I--- o I al) 1 f, y - - I r e O I -