HomeMy WebLinkAbout042-1053-60-000
i r51n c"parn~"n~p1=u"'° =r- PRIVATE SEWAGE SYSTEM St. Croix
oa'cy a' y &ultl G oi51c
INSPECTION REPORT "'r•v Pcm; N.
GENERAL INFORMATION :A 11,1 '0 I'hRPal [I 3fe 11131, D No 615422
°ms,n:al m'c^'ralu;" Jue prcemc 1,a'; ec . 'd lo. sespnc_rr --rpcses ('-vary ; s 15 Or 11-:II
P1,-rt Ifoltl rc. N:rrr y :rill:rye runaulnp r_ far. NL.
Ogburn, Phillip & Peggy TOWN OF WARREN 042-1053-60-000
Csl 9ld Jr 1'nspEIJ cc: ~I.rL-stet or c]om IOP'NRa^po'Lf::pNo
19.29.18.303C
TANK INFORMATION ELEVATION DATA
IYPF VAN(.-AC I IkiF N. ;;APACI'Y S`ATP-N LIS d'. FS F1F`J.
II
Sr is L'erchii
ooSIrq All awl
Awallorl 611n Sewer
•.ottl r:; SUHI Inlet
TANK SETBACK INFORMATION S:r't Outle:
TANK Yi P+I r*-II NI iw( -m 'o av l-ta-.e R-AG Cl In et
Si :A Bottom
Doslrlp readeuR4an
Aerat i Dist Pipe
Hcloi-r) Bol. Sys:ern
III
PUMP/SIPHON INFORMATION FI'la Grade
D.1allU`2CId'Cr Demand SI Oaver
GPh7 i
Model Number
-DH Lilt I 'IChun Les; System Heed -DH FI
'orCBll'artI Ler.91n Cid 'del tr "'11
SOIL ABSORPTION SYSTEM
BE[eTRENCH lu:f: I T."T , IT, 01 111111:11-:: PIT UJIIENSION$ N., tP Fee; I-sec Gear cwtl Ceps
DIMENSIONS
SETBACK SYt;-Ft'l If) Pll HI IN; 'vdELL LAKEiSTRFATI LEACHING
INFORMATION CHAMBER OR
"ype t;' S~s:err UNIT Idr:;lrl r,ur, D-r
DISTRIBUTION SYSTEM
Ile:: d."'V.r ',:I.: )ASf ?u'ion "uIC $ CC x HDIc Spac Cn:4: !A r nlnF
peisi
Lens C e _..^qth ❑ n :°q _
SOIL COVER x Pressure Systems Only xx Mound Or At-Grado Systems Only
c=pt -.-r rs 7evth a' `occduAl$vc:^etl :x NoL:Led
Eca: Trc.-c1, C:,1, :.r I. -nol:I dq-~: lopsatl ~
Elc rc,
COMMENTS: i ncaiuee coae drscrepenaes. persons present, eto.:l nspecf or kl. Insr+:cl:on z2:
Location: gay. N--T" AV---
- . j AI: B1,7 Desoriphon =
2) Hldy slnroi :a,glh =
- al-lourl of cover =
Plan revision Required? Yes No I
Use olhm side [of aoeltonal m'onnot oil
J:Ce I^sextcrs Sienalwe Carl No.
SBD-e? r e ;R e:971
r Pi
< /PcP Db\~t - I C,
v,+ - - Industry 5erviCCs iJrs9t>St County
4 -T
14001: WLshington Ave y?~' < f\~~/~
13o1r7162 Sw+itary Permit NUmlxr(ro be U7ll mb)by Co)
v ►f r Madisoa, WI 53707•-01_6.2-
- - - Stan Traiuection Nwnher
Sanitary Permit Application Nf~
In att'mdance wdh SPS 383 21(2), Wis- Adm. Cate•.rdmuicswn ofniis form to dw appropriate gove nacoul unit
i> required prior to oblaming a sanilwy lwmmt Nu.. Apphe:um, forms for state-ownod K)WIS, awsubmied to Prq;WAddress(1fdI c1Cr1lthenma114tgaddre55)
the I)rpa Im tit >f SaI<ty and Professional Senic s Prrvwwl m(omution you provide ma be uud lo; sc:widwy
'4 lc --i
w 'w.xwNar-c mWtlro POVacY L+w,. ISDJ(Igm)suis _ >/`.'i fyb .1h
f ~Y td liC~noo Inforum a - Pleau Print All Information
Prup ity O . i s Nana - Parcel a
- i
M
) 1 , lrG~C.- :T/-
P l ty O+ Mail ng Address RopenY location
i GOVL Wu
_L
City, slate Zip Code Phooc Noudur SC 7•-Section
r> circle on/yll
~~-J7~_-_~.._ T <P __N k f. Hn`WI
I l.'1'ype of Building (chieck all that apply) LoW _
/ Subdivision Name
}(ry l w 2 Family Dwclhng - Number of lkdraa+m.
Lrq~f~ _ S~ BlockA _
❑ Pubitc2Commerc3al - Dt%cribe Use G"~ ❑ City of
CSAI Nmnbcr ❑Yillagc of
I~ 17 SWIC O'Swd- 1)~cnbc Use jIil.fypmof Permit- (C.hmkonl ne box on line A. Complete line B ifapplicabie) ❑Nnv S)_Acm cpiaccment System UReplaA O:her Modikation to
GrixinSSystem("Plain)
revinus Ptrrnil Number and tkne lss
D I'cunn Itenewal ❑ Ped 1(evision ❑ Chm le: of phonon ❑ Pemot Transte, Ieborc Expiration ON'tief - -;y ,1'/3 S/ Z g
IV. 7~pgof PONTS SvsterolComponcnUDevicr. -Check .fl that apply)----_.
;KiNon-Prcw,unzodIn-(;vound D P.nwd ln-(rowld n At-Grad,,[ D Mound? 24 m of wmd,Ic su:1 13 Mound, 24 in. ol'ai :table sod
f)Haldmglank -CylTher UispcrsU (.anpgwrl (t+pfain) !'1C-f~f~F !-rG'iie' 4/IY[]Weucvlmenl Dnl¢(rxpbiin)
1'. Dis rs.lVflealmcut Area lnformatton:
Dmgn I In (MI) Design Sod Applica7 on W~1Ml!pQSt) Dapcn.A Airu Roquirtd (s0 Oi.rxasal Area Dlttrtd (s1) System FJevabon
L.__.
Yt. Tank info Capacity in 7o1a1 ovf Manufacmmr
Gallons (:Edens Units
New Tres Piosiin~T-, , u a g ~
r ~ U in ri: u. l7 Y
ITUAC.Ym'icr
~V(LRespomibility Stattmtat. t.lae undenigud imerva biluy ro alfattoooflhe POWIVSabownon thealtached plans
Plum sNw=(I'rmI) 1'Imnlwr' Sign c ! MPP.NI10% Number TB-- Phune huibel
Plumbers Address (Street, City, Stan, Lip Cale)
u-~~ CZN. .5 !:I'tc/\ FyI~L<. L.J>rJ2 z
Y711 oum /Depar[mwl Use Only
grnl Signal
pproved f urv Permit Ftb Dat Ij uM' [min
f~$ali -I Donal 5 8 A
IX. t'nnAit'on. l !R'° .9 i faPProva1 3) ~t kfe,
b V, /
ahpel: crl' oust all kja9+i _S ' 1' t illk.. 2L I
ss per ma r 4. w* rr;emen' plan ij t:w i Lv ,.wnhe'. \ - ",0-
n ' L
Ill 2. All tte!Mr'k rtx,(ir91^tm',s mutt w I-,.crt: n ( : J.1g ~ ALj
perep wbl up'i?!;rdmxtj- 4/1
wituA roruvpbre elms roc tM r»trm ant rw.o.a to roe Coney Daly on paprr iw1 iw clan%in a at iaehr. la she
S131)4698 (R. 08x14)
Page ~:tof
1
Z-0 P_
//~7/V~/g E JuKN (exceptwherenoted!
gai Description: Of TNt zE/'q~
= backhoe pig
l_z~1N !\ISinJ~ Tcb `iJ tr 4.i~PRBA ' oq ly C6 U t' W ISC ~~=>l./~`
Hlorih
i'
pfd
s; ~ VI 4 , r~
r- 1 4 Chi
~y
V ~ ~ U
y 1.
h '
fJ V Y
A U-1
l
1
_ ~(l'~D~Ofr4~.O~J WEcK5~~i~~7n(J~:
}9^L~i ~ 'E:XI_~i.U: ~QT "Ic B~: Sn%~'.i~'~F}/+ti/JJ
titD i R?f'~,oStED?•; p~u rn k.JL
:-r( ue,D 5t Z, T r/-; 7wr fF $7
~7•k91.,Y! my A~%EA,1 .
Tja, rl t'i D4= 1o` OF PAD Foc, E teal-`iR+C rlf!
9`I<I,>' 7~c Cof.NE R-%{S.6U.:~EL' /OG. :.y '
!_7 is%7 fi
y ~ yofi 7n sys7E:r.
l a- Y
cjEt~
'COPY
J CCI/Lr~ C3C~ ~id PAGE 'I
In-Ground Gravity Plan
index & Cover Sheet
component nffa wef Design Reftrenws-
version 2.0, SBD-10705-P (N.01101, R. 10112)
Fig 1 of '6 index & Cover Sheet
Pg 2 of Plot Plan
Pg 3 of 1`363 /NSpccF,•.
Pg 4.5 of yj Management Plan
Attachments: Enc u
POYVfS Application for Review
~IW,z Soil Evaluation Report & Site Ma
- - Sir~t C 7.AN i< /}b~b~ittEn77 _
Project Name / Description
owner Name(s): sPhone:
Owner Address: (,~l 7Jp:
Project Address: Pr.hoc;^'
Govt. Lot: _W 114 of _ - 114, Sedum , f L=1 N R E ®or W
Township: _(i i/1 ~J 'l- l•` County: 57 C Aux
Projeci:Parcel RD# &1Z
Designer Information
aesign"Name: lrUUEY ._1 _Nu('~'tKT Phone: 7iS I +75
Designer Addre58:.?1,Li`J'1 Kr &A,-l wfzs_ L°+_ QMPyse✓,wa ztP: 4~I8so
I_-tnaii: h0U(sf~r~les~n~a oufIcoK.~oe~ T~s~~ ~2 ~Pp6*9yS~MP
License Number: 109 - 00 7 '
demarks:
I t ;~7 Cc,Un ~•~5~~ r"G' JZ r..+ 1 6 8G'0
a,
' ~~~Yf1YJ~MININSINN>~
Signature. Date:
SPY.
f
Page ,~fi
i ----1
PROPERTY O AINER:_PH/LUPA!, y S._ -~k OCBG(Rn~ °z -O FT.
~p4/zl~/g 6uRN~ (except where noted)
Legal Description: Pe4. LQ^g1E0 /A/ Ty/C- 5W VF 7Hc s cC
backhoe pit
r N ~181,Ji Tou/N cF APRe.U,, -:._C<O(X L'OU.U7Y~.,INi zwsiNn /6.8~O.~ICie
North
U~
z~
V Q V
` t
"3 El
` (J~lD00G~4t~-O/J WEBKsJfANK
d 'Exiar l.ur Q ?a e3E SNSPr.-C'~D A.UD
GC -
° Avnl4oVt-D F,~! PLUME:ER
r-WnaniD Sv CE I A&/I 3.~.~ \ :4Z. 7W IF !SCl°T? a TA;.~l< ODUF-01 /OB 57
C~a 'f ARIA
BZ Cl V Y: 70l' of PAD r-oe E t~4`nz C Liu
eo"EK-ASSWANF=L:~ 106.6C'
L7
N WEU- > 7n svs-rVA
i
i
u.>.Hwy. ,rte I
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it -fir t
AtENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY rk BUILDINGS :G
DIVISION
PI
aNLMANRELATIONS PRIVATE SEWAGE SYSTEMS LJ-~D x
pUREAU DF PLUA181NG
NIX 71169 '
^f lv ~ ' ~
.ISON, 141 63707
CONVENT IONAI. 0ALTERNATIVE
CI Holding Tank 0 In-Ground Pressure ❑ Mound
~>iiNtE 044 I x Earn AwXtw g."I'T xoLOEli.~------ INVf.aDAVI-Dave (:dyer 761 Br.ookviea Std. ,WOOdbu:-y, MK
fl T FLf V
-fM"FX Yam-~w:u.Mnw.vm^TTCC Ant IF 604 EELYNT FROMCIAN
1 II Stf SE, Section 19, T29N-R18W, Warren Township
' vLn, el P.,mMr WNIAEW ILS. F '
7561 Wit. Cro1;; '.i
I David. 3. PogartY 34813
`
^EPTIC TANKJROLOINO TANK: AgNI L LOC«IxLC vt
-
'1 iµTiupw U tft Ltauto OAIACITY~ TAN«INLFT ELEV TwxN OUTLCT [LLV' oA v to OvIVE0
TCS'D 45 z ?;4.96 YES ❑NO ❑vsVP3Tno
AatP v w u wnawe: v N^ d"1 x
F h;topx., vtxi a vtnrvw L NL NUMBER OF h eo wP L
A0.PN [FELT FROM ~U1J f .1/vb~-1 A /~~!`r J i1,
! L7YfS NO l._IV - .,If{_Q NEAREST - _ ~._L =
!JOIN O CNAM ER•
VAx~tN OnIL t UI J➢ACITY 1'VLL'NOOEL fUN)/$w,:::!: Mnl.Jf niaWtll YIAANII,O LAML LOE:NIHO COVfn-I
_ IPOVIOEO FAOVIOEO
OYES 0 L1YES LINO OYES LINO
[.ALLONS Ptft CYCLE: ~ FTA71TMTfi7TNfi1 . I' - fxrwEnrr w u' a M1olxo v N
Uh10 f:ft OF vxE Am IULEr 1,
!IDIFFERENCE BE IL'JECN I'LCT FROM
)PUP.IP ON AND OFF) DV LINO _ TJCAREST
SOIL ABSORPTION 8Y07EM. Chsck lan:od mmuure et lhYLfaptho(plo.vlnq rla_r.: nAUUIx A IALAAOMA!:IVL
nr Y«CAVWpn. (11 LOd LIIT h]'Olled into U mro, Cons mew" thrill Cease..fit FORGE:
ii ',ho 1011 U OIV Ynoueh to canW wc.) 1 "'IN
C V N IONAL BYSTEM: -
?St -~-i n IOw
wlp I L NG", x b~Ud'YiF7TA I. talrer
'I BED7TRENCR TRENCHES t Ac .It U P(EI
pV o-
I
DIMENS{DNS / gi J
v( V Bi E
CREVlC6TFTit- iL D! r~T- m..lfn 14T o UM6E~OF ul I 3S' N
inu.oN P,fts euv[wvm utv rt u
a uNx 3 J LI f
uEl tv [xw o - n~ let FEET FRp;
I I v2 9s.gq ~I~~ NEAREST- IaDT4 -_~-_J
Ii MOUND SYSTEM:
Mound site plowed perpendicular to slope Check th0 texture the fill atnrr 'for 1 PROVIDE A DIAGRAM OF SYSTEM
y
and furrows thrown upslopa: j W EILEVA-
mound sys(om5 Ab flake rteu hat ( O?I REVERSE SIDE. SHO
s It. T14NS MEASURED.
ets thaTate at ilia um
me
I
OIL mul DYES ONO •p nnm ~NVn noN wl ui
TEAT-,
YES DILIVES ❑NO
tiUnd' x xr o pE N v t oxon role f o o NL I ~I
tire" EplBt I
_ ❑V S ❑NO DYES i_.IN [DYES DNO
{
PRESSURIZED DISTRIBUTION SYSTEM=
-'T~4il t t,x -b7-
w7" 2YFF.lv'I: E1rfL tZfi/INtLI ~Ini 01718 1~
UEUI7RENCH IXtxc..
OIMEN810NS - _
YANi OLJ w M•N, l > GEIX. I,FF I l Ar Illwt ~~OtSYx~'"~ >I$TK-DIY{ t' INI N LIN MA \N,AL «Llnu%INV I'
,LEY ELEV DMA EIEr n[l L Ou
(ELEVATION AND '
! O18TRIOUTIOAI.T- v x. Lbw to A% ov7u
INFORMATION ndCE tlrt lu LI .rnaxE. u{> <:CiilXuuL A .nwT Ft.L.vs
I YES 0 [DYES UNO
'Otn W I Yuu w
tADA Y •YS.vw u FEET FROMF
Lou
1 L_.~ LI YES I-IND L.~ _ES NEAR S
.I
-1
'kowh Syuxul un Retain in co.eny file for audit.
law's, Sill. SI-T(nRl-..
)ILHR SOD 117101R. 011021 -L___.-.. .-.-~J
~'1
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page et
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner ~h , x"11,- /.t qtr` Septic. Tank Capacity /LIUC: gal C NA
Permit % 1 ~5..~ Ci Septic Tank Manufacturer _f~ol f(y F NA
DESIGN PARAMETERS Eftiuent Fitter Manufacturer Po o~Z C NA
Number of Bedrooms NA Effluent Filter Model (ZZ. C NA
Number of Public Facility Units L_: NA Pump Tank Capacity gal C NA
Estimated flow laveragel galidav Pump Tank Manufacturer_ J C NA
Design flow Ipeetk).:Estimated x 1.51 SQ 9AUday. Pump Manufacturer G NA
Soil Application Rate L1 t _1 aliday:h' Pump Model L NA
-
S-ancard InfiuentrEfflunnt Quality Monthly average' Pretreatment Unit C NA
Fats. Oil & Grease (FOG: ,30 rng'L = Sand;Gravel Filter 0 Feat Filter
Biochemical Oxygen Demand (SOD.? -220 mg,1 C NA - Machanica. Aeration C Wetland
Total Suspended Solids (TSS? I -150 mg!L ❑ Disinfection. C Other:
?•etreated Effluent Quality Monthy average Dispe:sal Cellist C KA
Biochemical Oxyger Demand (BOD,) ='30 mg,'L i"g-jn-Ground igravityi C In-Ground (pressurized;
Total Sus9onded Solids (TSSI <_30 mgrL NA 0 At-Grade rl Mound
Fecal Coliforrn Igdometric meanl e"10' cfur100m' C Drip Line ❑ Other:
Maximum Effluent 'article Ste in dia. NA Other. 0 NA
Cther: ] NA Other. ❑ NA
'dalusc typical for no:nesic sas'[r:;Men and seam tank rPuyn:. Other. C NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑ mnnrhls
Inspect condition of tarikisi At :east once every: 1$year(s_ IMaximum 3 years) C NA
Pump out contents o- tanklsV When combined sluoge and scum equals ore-third I;,I of tank volume 0 NA
i:espc:rt dispersal rsll(sl At yeast once eve y: month)sj (Maximum 3 yearsl C NA
O yeartsi
0 i ionth(s) .19 NA
Clean effluent filler Al least once everY: ~carlsi
0 mont:nls) '$ldA
Inspect pump, pump controls & alarm At least once every: 0 yearlsi
0 montnsl .~%NA
Flush laterals and pressure test At leas: once every: ❑ year(s),
.-her. - - A; e_( ast ends -every: montnlsl ❑ NA
year(s)
Other: - - ❑ NA
MAINTENANCE INSTRUCTIONS
ji. jarctlons of tanks and disperses. cciN shall be mane by an individual carrying one of the following lircrtses o- certifications:
Master Plumber, Master Plumber Restricted Slower; PO'WTS Inspector; 'OV,7S Maintainer; Septage Servicing Q.^.crator. Tank
inspections must include a visua. inspection of the iariklsl to identify any missing o: broken hardware, identify am' cracks or leaks.
rnrasure the volurnt: of combined sludge and scum anc to check for any back up or pond rig of effluent on the ground surace.
fhe dispersal cellts; shall tie vis.tally inspected to check the effluent levees in the observation pipes and to check for any ponding
of effluent on the ground surface. The printing of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory aumoriry.
When the combined adournuiatior. of sludge and scum in any tans equals one-third or mo•e of the tank volume, the entire
vxttents of the tank shall he removed by a Septage Survicing Coarator and disposed of in accordance with dhapter NR 113,
':'disc nnsir Administrative Code.
All other services, mciudng our not limited to the se vicing of effwe:r fitters, mechanical o- pressurised components, pretreatment
snits, and anv servicinc a- intervals of <_12 months., wall be performed by a certified POWTS Maintainer.
P. service report shad ne provided to the local -agulatcr; autnority wifhir I 'J days of ^emnletion of any service even'...
°aoe nt^
START UP AND OPERATION 3_~
For now construction, prior is use of the PCAVTS chec< vestment .anltis' for the presence of painting products or oche; chemicals
that may impede the troatmen-. process and~or damage the dispersal cell;s:. If hign concentrations are detected have the contents
a` the tankW removed by a Seotaga servicing operator prior to use.
Svsthm star, up shall not occu• when soil conditions are f•czen at the infiftrativc surface.
=luring power outagos pumc tanks may till above norms. highwatar levels. %",tnen power is restore7f the excess wastewater wil; be
dischargeb to the dispersa' cellis! m one arge dose, overloading the ce!lfsl and may result in the backup or surface discharge of
effluent. To avoid this situation have The cpnleris of the pump tank removed by a Septage Servicing Operator prior t., restoring
power to the effluent pump or cortact a Plumper or POW-S Mainrainor to assist in manually operating the pump controls to
::!sture norms: levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive D• park over, or otherwise disturb or compact, the area
w tn.n ' 5 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 pe,rormance and prolong the life of the
°DbVTS: an:ibiozies; baby wipes; cigarette hunts: conoomn; cotton swabs: degreasers; dental floss: dupers; disinfectants ta"
foundation drain ;sump pumpf water; fruit and vegetaD.e peelings; gasoline; grease; herbicioes: mca: scraps; :medications, DPI;
Pontine prod=s: pesticides: sanitary flapKlns; tampons; and water softener bane.
ABANDONMENT
's'vhen the POeVIS faits and 'or is permanently taken out of service the tollwving steps shall be takeri to insure that the systps• s
pruperly and safol% abase Died in compliance vv8h chapter Comm 23.33. Wisconsin .Administrative Code:
• All piping to tanks and pits shall be discunnoc:ed and the abandoned pine openings sealed.
• The contents of all tanks and pits shall be removed and prooorly dsposed of by a Septage Servicinc Operator.
• After pumping, al: tanks anc pits shall be excavated and removed or thei• covers removed and the void space filled with
spit, gravel or another inert solid mater;al.
CONTINGENCY PLAN
If the 710V%75 fails and cannot be repaired the `allowing measures have been. or. must be taken, to p'ovioe a code complia:rt
replacement system:
A suitable replacement area has been evaluated and may he utilwed for the location of a replacement soil absorption
=ystorn. The rcolacoment 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 replacemon: area will
resu:t in the need for a new sail 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 soi' limitations. Barring advances in P3b17S
technology a holding tank may, be instailod as a last resort to repla:,e the failed POWTS.
hasps-bat.-ntr•-}strr a.' .
nonlumed lz~ identify 4_171.p
•alua•~ - u¢ o a . - s. itatrt- -no 'S• trip tank
Fail be' :~::fe tai en ~'RDN18rFSI_,. 'FDR-/JO1•J Con1STRU~-fit D*l
Mound and at-grade sui: absorption systems may be reronstrocted in pace followirg removal of the biornat at the
infi:t:aiive surface. Reconstructions of such systems mist comoiv w:ln 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
Marne p` v Name
Phurie Phones
SEPTAGE SERVICING OPERATOR IPUMPERi LOCAL REGULATORY AUTHORITY
Name Natnc ,J 20/v t
?none Phone 7 V (O p 'D
-'his document v. drattuc in corn fiance vtith chaetar Coma. E312fZifhli';~diFrf anc F3.54 I i. 12! & 13:. Wisconsin Administrative Cocu,
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING: SEPTIC TANK(S)
This is to certify that 1 have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) `}!55 1Vc U~+E
_ located
at: ,l Section & , Town _,~L N, Range.-- JS' W,
Town of 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 SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur front absorption system? Yes No.
(t no, skip next line.)
Approximate volume or length of time: _ gallons _ minutes
Tank Capacity: I f C / ra~p,j
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Pennit number (if known)
(Licensed Plumber Signature) (Print Name)
(Title) (i,icense Number) I4WMPRS
(Dat6)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
1L_4i-'J'4 C
AND
ttiWNERSI-BP CERTLFICAT10M FORM
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(Verification remamod Run P. tawiM & Zoning Lepatmswt for uem coustructioo.)
wSt;ite > a Li D el y v ;t Parm) Identification Numbe 042. l r?.~"3... 4,0 , _ 060
GAIL Dl~+scltlPriox
rnptrw Location .5VC T z/ N RAW, Town of
Subdivision Plot
c-bfwd SnreLey Map # - Volume - Page #
M; aF -nts Dee-, # (befotc 20,37)Volume Page #
SpeolsouaeQyes o fotlines identifiabJ~yesono
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S~'~ f'F: wt' haAlti Ci:, eeiNCE AND OWNER CKRTMCATION
Improps We and MahItCOWWo ofyoar septie system could result in its premature failure to handle %vates. Proper
n-~irt ommce consists of pnuping out the septic took every thrco years or sooner, if needed, by a licensed pumper. Whatyou put into
Ina system can affect the finetion of the septic tank as a treatment stage in the waste disposal syst m Owner mamtemwee
re4viosibilides too speed in §SPS. 353.52(1) and in Chapter 12 -St Croix Comfy Sanitary Ordroeace.
no property owner agrees to submit to St. Crux County Pieming & Zoning Dopmtmem a oertification form, signed by the
,,woer and by a nest erplomber> Joumeymtm plumber, restricted plumber or a licensed pumper verifying that (I) the on Zito
, +-stetvater disposal system is in proper operating condition anbor (2) after inspection and pwq=g (if necessary), the septic tank is
less than 113 full of siudye.
Uwe, the undersigned have read the above regmramer& and agree to maintain the private sewago disposal system vends die
atmdards set: to* herein, as an bythe Department of Safxty AndProfessiooat Services sad the Department of Nat" Reswrws,
Stasa of Vrttsoonsm Certification stmww that your sopic system has been msottamed amt be completed and returned to the St Croix
County Planning& Zoning Deparhment within 30 days of the three year wqt iratioa date.
Vwe certify that all statements on this form are Iron to the ban of ny&w hmowlodgo. Vwo amtaro Ibo oan w(s) of rho
property 6escribed above, by vhtm of a waumaty deed ramnbd'm Register of Dmft Office.
rquL= Scr of bedswoms _7
0-C,'.~
SiGNATURN OF APPLICANT(S) DATE r
-Any infi nnsfiao that u: mi¢eprnsmied may rawtt ne the mulary permit being ntioked by the Planning & Zoaiag Deper mot
Iractnde with this apptieabon a racardod wamoty dead from the Pegisaw of Deeds Office sod a copy of the c atrl' reed survey roap if
rdbrmco is made in the wavvety deed.
(REV. 04M)
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Wucensm Doparunenl of Safety and Professional Services
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Divsion of Industry Services SOIL EVALUATION REPORT fg/n^ _nyt
in accordance wRh SPS 383. Wis. Adm. Code
County S'I- CRUIX
Attach cortTilele sia plan on paper not less than F t;2 x t' inches in size Plan must
include, but not limited to vertical aid horizontal refinance pant (RMj. direction and Parcel I D t _ t O5 y bD 000
percent slope, scale ordunansions. north arrow, and location and distance to nearest road
Please print aU information. Rcvi cd by Oate
I'Claelibl LtIOfmBIiOf. yid prouUB clay Ue Use: I::.ec'oti~niy mnlaav5lPL•mcY .::.r, 's 1,04:i IfCl 1. $ /,J I
P,nperry Owner Propet/Location
PHILLIP N. & PF.GGY S-'1'R OGI" IRN Gov. (o! ' W 1141 L 114 I` t N N R IN E (orlW
,operty Owner's Mailing Address 11I o:# Rlrck# Sutxl Nar,' cr CShri#
62963 Ennui Street
;wry Stale Zip Code Phone Nor lei f .ity J VdIage ~ Tara, Nearest Road
13chA. I UI2~ <177U3 ( t. r. S(hh ;lvcuuc
New Construction Use Residenfal;Numbero(becroon><,_ I Goon dorivcd dosign flow rate 150 GPD
Replacement ElPubli6 or ccmmeiaai - Describe. _
Paiint matenal sandy Flood Plain efera!ion Itapplicable
GSneral cemc•,er~ts
sod reommendations: Pits conducted to Icconuect to exlshng system. New test required as nrcvious test was dune un 115 limn.
Replacement area has been also tested.
I I Aonry # ❑ Boling
Pit Groundswfaccclev. 1(11.82 _h Depth to hmmny factor '96 u1.
_ Rate
Soil A scat:on_
Horizon Depth Dornnant Color Redox Do=ption Textile Shuclwe CcnsstenceRourdary Roofs GPDfB
_ in Munsell _Ou. Sz Con; Color Gi Sz. S11. 'Eff#l 'Ef(62
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Ilonzou,l$ lore till.
Rocng
j I fin(:ng it r11 97 42 -:)2
L-~ IJ Pit Ground surface elev. _ft. Depth to IrniUr:a factor 111
SUiI /lopll;ahon Rate
i Honzon Cepth Don'mant Color Renox Dexc,.pbon Toxlme Structare !Consistence Boundary) Root, GPDift
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rMuent #1 = ROD- > 30 c 220 n1gA. and TSS >31 - !50 mgil. Effluant #2 - ROD 30 nzt)l and TSS < It. 'nga
CSI Ni. (Phase Print) CST Number
MARY' tO HUI'PE_ RT dlollistcll Soil 1'csting&Dcsl~ni_ : Y,7/--~ C l '2483?
Address _ J Dale E• alai .)f. Conrl+s'7ari T".phnne Number
'!R4971CinF :4nhur's Court. 6anhury, CJI 3,1810 04-24,201+i ?15--1)n-i??5
Property Owner OGRURN, Phillip ( Parker) Parcel ID # 042 - 10$3 - 60 - 000 Page of 4
1 Boring
0 Boring # Q Pit Groundsurtaceelev 98.87 ft. Depth to limiting factor in Sot A icati Rate
Honzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDI
m. Munsell Du Sz C``ort. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
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ERA C1:! j'H/cui' s +e~ty S. 7K Q66 Aj 40 FT.
~VtnN2K$u! {except where noted)
eoai Description: PAL. 1Eq !.V T/iC S" `ZF '7Nt i~
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Parcel 042-1053-60-000 Valid as of 0411 11201 9 03:17 PM
All. Parcel#: 19.29.18.303C TOWN OF WARREN
_
y - ST. OAO1X COUNTY,
I +V WISCONSIN
Owner and Mailing Address: Co-Owner(s):
r~ e ,r PHILLIP N & PEGGY S TR OGBURN -
62963 FRESCA ST Physical Property
BEND OR 97703-1581 Address(es):
Districts: _ '95580THAVE
Dists Description Parcel History:2422 SCI I D ST CROIX CFNI RAL _
Date Doc a VWlpage Type
1700 WITC 01:05;2009 AMEND SO
01-105-12009 ORDER
Legal Description: Acres: 16.800 02.1612005 _ 2751i313 TD
SEC 19 T29N R18W SW SE THAT PART OF SW 12-12011999 14791212 WD
SE LYING S Of BADLANDS RD TOGETHER WITH more
AND SUBJECT TO 66 WIEiF PRIVATE ROAD F...
mole.
Plat Tract (S-T-R 40!h 1604. GL) BlocluCondo Bldg
MA-NOT AVAILABLE 19-29N 18W
2019 Valuations: Values Last Chaogeo or
O9~ 04:2018
Class and Description Acres Land Improvement Total
G4-AGRICULTURAL 11.000 200.00 0.00 200.00
G5-UNDFVFIOPFD 14.800 29.600.00 0.00 29.600.00
G7-OTHFR 1.000 22.500.00 12,000.00 34,500.00
Totals for 2019
General Property 16.800 52,300.00 12,000.00 64.300.00
Woodland 0.000 0.00 0.00 0.00
Totals for 2018
General Property 16.800 52.300.00 12.UW.00 64,300.00
Woodland 0.000 0.00 0.00 0.00
2019 Taxes
Taxes have not yet been calculated.
Key
Pririrry