HomeMy WebLinkAbout026-1172-17-000 Visconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division "
INSPECTION REPORT Sanitary Permit No: 479461 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Marek, Todd Richmond, Town of 026- 1172 -17 -000
CST BM Elev: r Insp. BM Elev: r SM Description: Section/Town /Range /Map No:
c7D . O 00 .O e 0� = CS'C 8 &" ( 35.30.18.1378
TANK INFORMATION ELEVATION DATA
TYPE MANUFACT�RE� CAPACITY STATION BS HI FS ELEV.
Septic Benc ark (2.0 t r
Dosing Alt. BM , r
Aeration Bldg. Sewer
z•qo oq./o r
Holding St/Ht Inlet 3. gD Og "Zo
' L O •�Z r
TANK SETBAC INFORMATION St/Ht Outlet
TANK TO P/L WELL Vent to Air Intake ROAD Dt Inlet
Septic 3 Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Q.
Holding Sot. System
PUMP /SIPHON INFORMATION Final Grade
ManufactdFAr GPM nd St CovM '4A
I �3 ' O " /
Model Num r
TDH Lift Fricti Loss System Head TD Ft
Forcemain Len I 'a. Dist. to Well
SOIL ABSORPTION SYSTEM
MqftRENC o Width I Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSMS 3 1 ID q Q
SETBACK SYSTEM TO /L JBLDG WELL LAKE /STREAM LEACHING Manufacturer. (� /
INFORMATION Ty Of S t CHAMBER OR ... l
Yp Y V • stem: l i (.o UNIT Model N ber
I � J � DISTRIBUTION SYSTEM "tD L-94-
Header /Manifold Distribution x Ho ize x Hole S acing Vent to Air Intake
c L rd Pipe(s)
Length �S Dia 1 Length pace g
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
t a Yes ] No n Yes �] No
C MENTS� ncl P ud j e de discrepencies, persons present, etc.) inspection #1: 1 / D O Z� Inspection #2:
Lorafion: 1397 128th "Avenue New Richmond, WI 54017 (SE 1/4 NE 1/4 35 T30N R18W) Sunset Hollow Lot 17 Parcel No: 35.30.18.1378
1.) Alt BM Description= 5 ' I g p� �•
2.) Bldg sewer length = 2 ' _
6
- amount of cover = ) g * � �•••Q Q �_ ).�,. (o " I ; ( 0(• )1 . 7.0 Ito • �
lo.�{D = lo(•6D t�.toa, =lot) •�fo /
Plan revision Required? f Yes No to
Use other side for additional Information.
SBD 6710 (R.3/97) Date fnseQctors Si re Cart. No.
C __?n,E2_0
County ��
Safety and Buildings Division
201 W. Washington e , P.O. Box 7162
Vslcon Madison, W -7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 26 - 5 � �� 9 �G
State Plan I.D. Number
Sanitary Permit Application O
In accord with Comm 83.21, Wis. Adm. Code; personal information you pr pro ec[ Address (if different than mailing address)
may be used for secondary purposes Privacy Law, s15 .04(1)(m) 1
I, Application Information - Please Print All Information �
Property Owner's Na me P reel a Lot N / Block >Y
Ol!1 L(o /u 5 9 10 0 o d
_ Z' C,
/09Q 4 o oso
Property 0 ner's M ailing Address •, LINTY P operty Location��
Q ZONING OFFICE
�- g®x ZZ O 44, /I/ !,
C b4,Section
City, State Zip Code Phone Number /-�j
0 / d T - �.�!S1N . R ( ci rc l e
o
II. Type of Building (check all that apply) ✓ S
99-1 or. 2 Family Dwelling - Number of Bedrooms
S Subdivision Name CSM Number
❑ Public /Coinmercial - Describe Use u f GG4 LA/
❑ State Owned - Describe Use - ❑City_ ❑Village ®Township of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. IX New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Trnnsfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
1V. TXpe of POWTS System: (Check all that appl 3 g
Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter XLeaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information: 5 Z
De si n Flow (g pd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Propos d (sf) System Elevation / /OV, S
VI. Tank Info Capacity in Total 7Number Manufacturer Prefab. Site Steel fiber plastic
Gallons Gallons w Ii �, A _�� Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank t/ / w t Manufacturer
Aerobic Treaunent Unit /� (/r/
Dosing Chamber
VII. Responsibility Statement- I, (lie undersigned, assume respo[lsibility for Installation of the POWTS shown on tine attached plans.
Plumber's Na me (Print) Plumber's Si gnature MP /A4#RE-Nunnber Business Phone Number
7
Plumber's Addre ss (Street, City, State, Zip C
74
VIII. Count /De artment Use Onl
jA pprov�d ❑ Disapproved Sanitary Permit Fee (il udes Groundwater Date Issued I suing lent =(No
/ Surcharge Fee) O � �
❑ O n for Denial l �
IX. Conditions o nova R van
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / meintaine
as per management plan provided, by plumber.
2. All setback requirements must be maintaii •,,
as per applicable code /ordinances
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 in
ches iu snzo
SBD -6398 (R. 01/03)
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I -
' RECE'V
Wisconsin Department of Commerce L E REPORT Page of
Division of Safety and Buildings
in d c wit Wi . Adm. Code t
) n
pt a �.OU ty
Attach complete site plan on pape of less than 8 1/2 x 11 in es i Plao
include, but not limited to: vertical d ho n (B ect Parcel I.D.
percent slope, scale or dimensions north��d dis rice load.
Please On In orma Ion. Re ewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). J (, �� 2—
Property Owner Property Location
Govt. Lot 1 /4 S j3_T� N R/ E ( W
Property Mailing Address �J Lo # Block # Subd. Name or CSM#
✓/j.� L v O <
City State Zip Code Phone Number O c ity ❑ Villag To Nearest Road
J .51/ o/ 7 ( ) I
R"New Construction Us Residential I Number of bedrooms Code derived design flow rate ! GPD
❑ Replacement ❑ Publi or commercial -Describe: __—
Parent material _ Flood Plain elevation if applicable ft.
General conwrients /
and recommendation e-
L r?� ✓ ����
M Boring # ❑ Boring
Eg- Pit Ground surface elev. I U t ft. Depth to limiting factor / Z in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft?
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I •Eff#2
2 v e, ±"k.y
Boring # Q Boring l
r - Pit Ground surface elev. 1 p S 3 ft. Depth to limiting factor l � � in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDN
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
h
3 36--6
IGO•so
Effluent #1 = BOD > 30 1 220 mg/L and TSS >30 150 mglL * Effluent #2 = BOD < 30 mg/L and TSS < 30 ffgL
CST Name (Please Print) Si CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 � � .�J� 715-246-4516
5 6
Address P,O,Box 228 Shau it
New Richmond Wi 54017
Lot 1_ 7 _ Subdivision Sunset H011ow CS #226900
SE 1/4 NE 1/4S 35 T 30 Date 8/28/05
N /R W
---- Township Richmond
[] Boring 0 Well PL Property Line County ST. CROIX
BM or VRp Assume Elevation 100 ft* Top of 1/2 pipe
System Elevation TBD *HRPSame as Benchmark
128th Ave
Please note: the SW comer lot Scale is 1" = 40'
stake could not be found, this line unless otherwise
must be establish
._______before system can be installed, noted
dimensions from this line are
assumed and may not be
exact!
530' Property Line
B -3 30'
6% Slope
0'
- 70'
B -2
30'
B B.M. * 60'
20
10 24 6' Property Line
101'
Top of 1/2" pipe @ 99.4' 103'
• Well
Property Owner _ Parcel ID # Page of
Ong # ❑ Boring
. J ��j pit Ground surface elev. V � �. Depth to limiting factor /v' � in. Soil A Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfff
in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Eff#1 'Eff#2
S S 4 )14
ICU-so,_
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD. > 30 1220 mg/L and TSS >30 < 150 mgA. ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777.
SOD -8330 (8000)
RECEIVED -
-2 1385
Wisconsin Department Comte/ 13 2003 SOIL EVALUATION REPORT Page I of 3
Division of Safety and B ' ildingS "' ' in accordan with Comm 85, Wis. Adm. Code Steel Soil Service
Attach complete s plan o� z x 11 in County in size. Plan must St. Croix
include, but not lim ed to: v ferang oint (BM), direction and
percent slope, scale or imemsrons, north arrow, and location and distance to nearest road. Parcel I.D.
Pending
Please print all information, Reviewed By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
R.J.C. Development, Inc. Govt. Lot na SE 1/4 NE 1/4 S 35 T 30 N R 18 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1868 CT Hwy " C " 17 na Sunset Hollow
City State Zip Code Phone Number J City _j Village 1/ Town Nearest Road
Somerset I WI 1 54025 651 -488 -3051 Richmond 1 140Th St.
0.1 New Construction Use: 01 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement J Public or commercial - Describe
Parent material Benches and large drainageways of ground moraines. Flood plain elevation, if applicable na
General comments .30 to
and recommendations: Mound design, system elevation 99Oft based on contour line elevation 98.8 0ft. Minimum I of ASTM
C33 sand.
Boring # I Boring
16 Pit Ground Surface elev. 99.00 ft. Depth to limiting factor 36 -/ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 I - Eff#2
1 0 -9 10yr3/1 none sil 2msbk mfr cs 2f .5 .8
2 9 -14 10yr4/4 none sicl 2msbk mfr gw 1 f .4 .6
3 14 -26 10yr4/4 none scl 2msbk dfr gw na .4 .6
4 26 -36 7.5yr4/4 none sl 2msbk mfr gw na .5 .9
5 36 -84 7.5yr4/4 c2d7.5yr5/6 sclAs om mfr na na .0 .0
Boring # J Boring
V1 Pit Ground Surface elev. 99.00 ft. Depth to limiting factor 35 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 - Eff#2
1 0 -9 10yr3/2 none sil 2msbk mfr cs lvf .5 .8
2 9 -35 10yr4/4 none scl 2msbk dfr gw na .4 .6
3 35 -60 5yr4/4 c2d7.5yr5/6 scl 2csbk mfr na na .4 .6
" Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <30 mg/L and TSS < 30 mg /L
CST Name (Please Print) Signature: CST Number
David J. Steel 248956
Address Steel Soil Service Date Evaluation Conducted Telephone Number
1564 CR GG, New Richmond, WI 54017 11/11/2003 715- 246 -5085
Property Owner R.J.C. Development, Inc. Parcel ID # Pending Page 2 of 3
3 ]
F Boring # _j Boring
H Pit Ground Surface elev. 97.90 ft. Depth to limiting factor 44 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -10 10yr3/2 none sil 2msbk mfr cs 1vf .5 .8
2 10 -18 10yr4/6 none sicl 2msbk mfr cs na .4 .6
3 18 -44 7.5yr4/4 none sl /scl 2msbk dfr gw na .4 .6
4 44-86 5yr4//4 c2d7.5yr5/6 Is /scl om mfr na na .0 .0
F-1 Boring # - Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil A ratiorr Rate
PPI� r
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # I Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
*
Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD <_30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
Page 3 of 3
STEEL'S SOIL SERVICE INC.
David J. Steel 1564 Cty Rd GG
CST - POWTSM RJC Development Co. New Richmond,WI 54017
Lic. #248956 SE1 /4,NE1 /4,S35,T30N,R18W Bus.(715) 246 -6200
Town of Richmond, St. Croix Co. Fax.(71 5) 246 -9372
Sunset Hollow, Lot 17
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your
use. The location of this test may or may not be as shown, as permanent lot lines were not established at
the time the soil test was conducted. Legend
1 " =40'
♦ =Benchmark Ele. 100.00Ft
Top of 1/2" pvc pipe
• = Alt Benchmark Ele. 100. l OFt
Top of 1/2" pvc pipe
❑ = Borings
Boring Elevations
B 1 = 99.00Ft
B2 = 99.00Ft
B3 = 97.90Ft
B4 = OO.00Ft
l 7
5 (�
nog-
A irk,
W
N
8 51 sq. ft._ `� _ 78,851 sq. ft. �83, 001 sq. ft.\ ` I l o
81\ acres '1.81 acres \ 1.91 acres ` `�' 0 IN
'^
_ _... __ �\ _.. \\ \\ 1} �I
- 1 OI
3 3'33' `-''x---..190'= _ 190'
� \ — — — � ' � �
� - - 968 1 VENUE � � `-
230 245'
70 \ I I I ° 1
ll
\
pi
\\ LOT 13�' OT �b� �\ �. i LOT 17
12l sq. ft. 21,901 sq. ft. 130,109 sq. ft.
2.80 acres `\ `\ \2.80 acres \ ` \ \ 2.99 acres j
\ \ \ \
\ \ \ \ \ \ \ \ A
230' \ ` 230' \ ` \ 246': X 1 .3 33'
�S89*49'15"E� \ \ 968.88' _ r� O
\ \ \ \ \ \ SOO-08'2 4 I "E J
\ \\ LOT 1 \ \ \\ 839.65' s�
C.S.M. IN VOL_ XX \ \ _
East 1/4 Corner ,
P G._XXXX Section 35 -30 -18
Np _z,, #yick4
STANDARD CHAMBER
52"
Quick4 Standard Chamber 48"
(EFFECTIVE LENGTH)
6
12"
T ism
ism
� = E M Us
34" SIDE VIEW
SECTION VIEW
MultiPort End Cap
R
O
16"
12"
34" SIDE VIEW TOP VIEW
FRONT VIEW
�lr
�"�
sac fit! � a ba�� ¢� nal� �ci €�cat�a ���"�� �;� � �;Multr� art End C � qq► � : � ctf;lC�tt tt < � . � �'�:
�.�
d��Z�
t, �"r�,l
.r� ��y� ,.;k �' {� �',�� e V '� 3�" y d v 4 " r' �!.v xrY�sy�tt'ic'"" �"Gi• i ' v;
5.
1
INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY
(a) The structural integrity of each chamber, and plate, wedge and other accessory manufactured by Infiltrator ( "Units'1, when installed and operated
in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective
materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; pimided, however,
that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences.
To exercise its warranty rights. Holder must notify Infiltrator In writing at its Corporate Headquarters In Old Saybrook, Connecticut within fifteen (15) - • -
days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty.
Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. O
R
(b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT SYSTEMS INC
TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.
(c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator The Limited Warranty does
not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of Environmental Onsite
Wastewater Solutions""
production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. Specifically
excluded from Limited Warranty coverage are damage to the Units due to ordinary weer and tear, alteration, accident, . misuse, abuse or neglect of
the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the 6 Business Park
Road " P.O. Box 768
minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing the Units; failure of
the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or Old Saybrook, CT 06475
any other event not caused by Infiltrator. This United Warranty shall be void if the Holder fails to comply with all of the terms set forth in this United
Warml 860 - 577 - " FAX 860 - 577 -7001
Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third party resufiirg from installation or ship- 00 -221 -4436
ment, a from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be Installed In accordance 8
with all site conditions required by state and local codes; all other applicable laws; and Infiltrators installation instructions.
(r!) No representative of Infiltrator has the authority to change or extend this Untied Warranty. No warranty applies to any party other than the origi-
nal Holder.
The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty require-
marts. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a
copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units.
U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844
Canadian Patents: 1,329,959; 2,004,564 Other patents pending.
Infiltrator, Equalizer and SideWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc.
is a registered trademark in Mexico. Contour, Contour Swivel Connection, MicroLeaching, PolyTuff, SnapLock, ChamberSpacer, PosiLock, QuickCut, QuickPlay RECYCLEOPAPER
and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed in U.S.A. Q011203HP -0
W POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page L of Z
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner DV A-K&K Septic Tank Capacity a l ❑ NA
Permit # T T9 c�. Septic Tank Manufacturer Qj 1z5 ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Z "C —L-- ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ,� 1pv ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA
Estimated flow (average) (f gal/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA
Soil Application Rate + al /da /ft2 Pump Model �- ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510` cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other' ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑ year(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
3 .®- year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
Oyear(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: — ❑ month(s) ❑ NA
❑ year(s)
Other: At least once every: ❑ month(s) ❑ NA
❑ year(s)
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y 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 chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, 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 provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
w
Page Z of Z
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions 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 cell(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 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 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 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.
ABANDONMENT
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 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 taken, to provide a code compliant
replacement system:
Er 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 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 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
Name pb�-L /v Name - fl
Phone Z t,L Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name Z-0 n/1
Phone Phone .6 �- gD
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer /!/(
Mailing Address Z Z g �� (C 6F ✓vt �v lo GtJ �f �o/
Property Address 3 ,c /7 v C
(Verification required from Planning & Zoning Department for new cons ction.)
S�
City /State Parcel Identification Number
LEGAL DESCRIPTION o Z - //:T Z - 1 �—C (.1378)
Property Location '/4 , N C " /4 , Sec. �E T J3�N R/ 9 W, Town of CY Ofo A/l
Subdivision §GLc;oW _ , Lot #
Certified Survey Map # , Volume // , Page #
Warranty Deed # �(� 3 7 3 Volume b Page #
Spec house yes io Lot lines identifiable yes jw
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
0 6 m� ( :�L
SIGNATURE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
U 2 8 6 9 P 14 1 803735
KATHLEEN H. WALSH
State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS
WARRANTY DEED ST. CROIX CO.. WI
Document Number Document Name
RECEIVED FOR RECORD
08117/2005 02:00PH
WARRANTY DEED
THIS DEED, made between RJC Development, Inc. EXERT #
REC FEE: 11.00
( "Grantor," whether one or more), TRANS FEE: 363.00
and Todd Marek COPY FEE:
CC FEE:
PAGES: 1
( "Grantee," whether one or more).
Recording Area
Grantor, for a valuable consideration, conveys and warrants to Grantee the following �
described real estate, together with the rents, profits, fixtures and other appurtenant � DSVIa J. Estreen W `
interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space 304 Locust Street l G —Q %g
is needed, plc attach addendum): W1 5401
Lots I, 9 an 17, Sunset Hollow. St. Croix County, Wisconsin Hudson,
026 - 1099-60 -050:026- 1099 - 10.000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated RJC Development, Inc.
(SEAL) V �, (SEAL)
* *By John H. Carlson
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) RJC Development, Inc.
By: John H. Carlson- STATE OF )
authenticated ) ss.
COUNTY )
*Kristine Oaland Personally came before me on ,
TITLE: MEMBER TATE BAR OF WISCONSIN the above -named
(If not, to me known to be the person(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
*
Attorney Kristina Osrland Notary Public, State of
Hudson. WI 54016 My Commission (is permanent) (expires: )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED 0 2003 STATE BAIT OF WISCONSIN FORM NO. 2-2003
Type name below signatures. INFO -PROTM Legal Forms 800 - 855 -2021 www.infoproforms.com
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