HomeMy WebLinkAbout026-1149-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
463005 0
(ATTACH TO PERMIT)
GENERAL INFORMATION 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:
Johnson, Matt & Veronica I Richmond Township 026- 1149 -20 -000
CST BM Elev: / Insp. BM Elev: BM Description: Section/Town /Range /Map No:
6 ' / 6 � D 1 rh � �/J.� d t� ��Lc� L� 36.30.18.1120
TANK INFORMATION ELEVATION ATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Ben ark X02•
is 5 133 2.3 r •v
Dosing - Alt. BM ,L
Aeration - Q Q Bldg. Sewer
Holding St/Ht Inlet
a ( 8
St/Ht Outlet
TANK SETBACK INFORMATION r
TANK TO P/L WE BLDG. Vent to Air Intake ROAD Dt Inlet 7
_
Septic f 1s T �/ Dt Bottom 3 6 V
Dosing ryt 3 t ,,j Header / Mqn. •, X023 c� �'J
Aeration D ist. Pipe L t S
- •8
Holding Bot. System '1
3 s•� 6 ��
Final Grade
PUMP /SIPHON INFORMATION O ALCC - S ►` �•? hD
Manufacturer Demand St Cover 5-
GPM I PS�Y Urt 3 Z. Z�
Model Number d �• / 02 Q3 X
TDH Lift -7 Fric , -� s Syst N e T Ft
Forcemain Length Dia. Z ,� Dist. to> Well x /
SOIL ABSORPTION SYSTEM 'z I k 3 ;`=
L No. Of Trenc es PIT DIMENSIONS No. O Inside Dia. Liquid Depth
BED/TRENCH Width /
DIMENSIONS_,
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Ma ufa ' Y
INFORMATION CHAMBER OR
Typ Of System: r
I f ' UNIT odel Number: K� S.
D IBUTION SYSTEM / V tT vt� -a6�-
Header/ anifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
f Gr
Pipe(s) D q r �!fh_ i �� t
T Length = l Dia Length Dia 5 f acing
SOIL COVER x Pressure Systems Only xx Mound Or rot - Grade Systems Only 'J
Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched Ma&
Bed/Trench Center S Bed/Trench Edges Topsoil
7 � Yes E,] No Yes ! No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / 2#1 A ry Inspection #2:
If I
Location: 1411 126th Avenue Neww�Rich nd, WI 54017 (SW 1/4 NW 1/4 36 T30N R1 8W) Torey Pines II Lot 20 Parcel No: 36.30.18.1120
1.) Alt BM Description=
" 'S <l - (�('`�ST f ��•(�jl S`% L
2.) Bldg sewer length = �g f / __ __,, y. c oil —}
- ✓ ' ' /
- amount of cover = r � � r,�lnn,e.Q �p'V
Plan revision Required? Yes o
Use other side for additional information. Vure� SBD - 6710 (R.3/97) Date Insepctors Sig Cert. No.
Safety and Buildings Division City
W 201 W. Wasbington Ave., P.O. Box 7162
irscansin Madison, WI 53707 - 7162 Sanitary Permit Number ( ,o be filled in by Co.)
Department of Commerce (6D8) 266 (O ?> 0 0
Sanitary Permit App State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, infy�ourbvirde
may be used for secondary purposes Privacy Law, sl5.04(lxm) Project Address (if different than mailing address)
I. Application Information - Please Print All Information!
Property Owner's Na me I Parcel # ( 1120) Lot ! Block l+
i
Property Owner's M ailing Address Property Location
T I L cZ - �KL u lAol l4,Section r
City, State 9 j Zip Code / qaQ
44/4 t n w '1^ J` 7� S 7�} b o�� (circle
(t E o
II. Type of Building (check all that apply) T .3 N' R
Subdivision Nam
CSM Number
13'1 or 2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use _. ❑City_ ❑Village PPownship of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A ' VNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision 11 Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. of POWTS : (Check aR that apply) S �' 8/• Z s 3 s'
Mon 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 ❑ Leaching Chamber ❑ Drip Lice ❑ Gravel -less Pipe 00 ther (explain w \
V. rsal/TYeatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gldsf) Dispersal Area Required (sO Dispersal Area Proposed (s ystem Elevation C f FP i
I C- - &- lif•�•
12. 9 C- 3
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks W
Septic or HekinyTank
't
VII. Responsibility Statement- I, the assume for hwatation of the POWTS shown on the attached plans.
Plumber's Na me (Print) Plu 7 � s Si tore I�fMPRS Number Bps ness Phone Number
Fogerty Plumbing ` ^ cE4G GS.,- y�- .a,✓o6
# yr 7�T 63� —fE6
P1umfteA# AMNEPIW Stan:, Zip Code) _
Spooner, WI 54801 ,r �j - 970 — /73 7
VIII. Cozen en UsrOnl
)I Approved proved Sanitary Permit Fee (includes Groundwater Date Issued Agent Signature Stamps)
Surcharge Fee) rnrn I,- luau txr for Denial 2'v
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1 Septic tank, effluent filter and ,� f . (� L pis
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
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"sWingin Ddpartment of commerce SOIL EVALUATION REPORT Page of 3
'Divisions of SpfetN and Buildings
• in accordance with Comm 85. Wis. Adm. Code
County r ( . c Q
Attach complete site plan on paper not less than 81R x 11 inches in size. Plan must - T
include. but dot limited to: vertical and horizontal reference point (BM); direction and parcel I.D.
percent slope. scale or dimensions, north arrow. and location and distance to nearest road.
Please print all information. Date
Personal information you provide may be used for secondary purposes (Privacy Law. s. 1504 (1) (m)). 9 (f 3
Property Owner _. Property Locati eviewed .. ...
P e LLC Govt. Lot ) 1/4NLt_)1/4 S 3(Q T N R E(or)CW)
Property Owner's Mailing Address Lot # Block # I Subd. Name or CSM# _
— '
City State ! Zip Code Phone Number ❑ City ❑ Village Town Ne t Road
be k3cocl
New Construction Use:•®- Residential / Number of bedrooms 6 - Code derived design I ow rate G coo GPD
❑ Replacement � ❑ Public or commercial - Describe:
Parent material TI { Flood Plain elevation If app cable ft.
General comments
and recommenda.' ns•
Boring # ❑ Boring d
a 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/it=
In. Munsell Qu. Sz. Cont. Color Gr. Sz. SK. 'Eff#1 'EN#2
I O -I Ip 31Z .I Z ff C5
c5 — g
q.
Boring # ❑ Boring
a ®. pit Ground surface elev. 99� ld ft. Depth to limiting factor _ in.
Sal Application Rate
Horizon I 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
2 r C
I - 5
3 2�} 10 y Icy — m 5 ►� I - ` . r .
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) ' nature CST Number t
Adam 3C. \ maker 25 3' 09
Address Date Evaluation Conducted Telephone Number
7
n I ,
Properly Owner 5 i ny � l'lt , L �.�. Parcel ID # Page of
/ 1-5i Boring
#, Ong
Pit Ground surface elev. Ov ff d IL Depth to limiting factor in.
• : , Soil App {iption Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
In. Munsell Gil. Sz Cont. Color -": Gr. Sz. Sh. •Eff#1 'Etf#2
-t2 t0 3(Z — S'i ,. Z rro'a_ ,"w c-,
2 - 1 1 2-40 1O y��} 5 .. � 2 m rr r cS _ g
9
[-7] 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/11
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
Boring # ❑ Boring
❑ Pic - Ground surface elev. ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/ft
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eft#1 •Et##2
• Effluent #1 = BODS > 30 < 220 mg/1-and TSS >30 < 150 mg/L • Effluent ##2 = BOD < 30 mg/l. and TSS < 30 mg/L
r�
The Department of Commerce Lis 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.
SBD4330 (8.07100)
PAGE 3 OF
NAME TOT# 2- LEGAL DESCRIPTION S w Y Nu X ,S 3G T . 3; 0 .N,R, / E(or)'o
SCALE: I"= I w
i
ELEVATION BM 1 EL 1 b J
BM I DESCRIPTION Iv Q
BM 2 ELEVATION
BM 2 DESCRIPTION 4o 0 o VC-
SYSTEM ELEVATION
SYSTEM TYPE (o v ✓� 1 �` O` i
CONTOUR ELEVATION
� 2
l
loo, J
°"
SIGNATURE DATE 2
-� STORM WATER I ' �2.0 ACRkS)
RETENTION AREA
H.W.L. = 1009.0 317' /
i
l �
I i 12A
66
x1005.81 340' / IV
—� MIN FFE ',� / i of
=
1008.00
008.00,
,- LOT ,22- w �
�' 1.7 -dCRF.S w �v iL ' j _ �b0' a 1000 1 -
1 4 ACRES) /2 i
/ /340 / / i / / / / TORM WATER
�Mi60g ( �/ `�� R TION ARE
\ i H.W.L. 1007.0 I
•J 1 " \
1 1 \
1 � (l 6 dCIVES ,02, zo I \ `� \� ,� �\ �- �►
l �► � '� j \ ^`� M FIsF,
LOT
O T 1 �� `� (3.2 ACRES)
�P
(, .aACRES) `\ \ \ `� ' 1019.46 -
\ 1'
o� M�Nt
475'
340 e9°
0 001 ,
Only mlo mv
1 N'• ,/.
0) LOT 23 / or' �� / �.:.: .
a�
f
N 2.027 ACRES (88,314 SQ. FT.).
T.)
ti
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w w .y� QQ'
�....... '.0�/
r.........:g� ti
r s ' / / �....... .
j 89°51'4• E T60 � / /
457.19' 14. ...... .
'OWN ROAD .
" E 457.19 2 ..... .I
38,
r4 GF r r4 " S 89
-
A N CD \ 9-6 N 89
. . . . . . . . . . . . . . . O.
22 ^? p Eurv ATlON= 1003.35
2,052 SQ. FT.) N ..
o� r .................. LC
LOT 2 r /
Z m _ ... _ ...... / 2.066 ACRE,
0 w /. .. ...........
.489 ACRES 1 433 SQ. -F7- J .... ....... � .. .
0 C.0 ........................o Z MIN FF
Y ni / ....... STORM WATER - ' oar o 1
.......... RETENTION AREA ... 0 ....
MIN FFE = 1009.00 ......................... ..� 1
A o
............ H :W.E. =.1.00.7.D '.. ,.....
.
] _ C o 78 . :::......... ......: ..... 408.
�s� •� .....�.N:$9'5.1.'46".E ....� '..$1.7.: .. i
56'
�.. . .......I
..........................
.......�
Al ..
CAI V
A I.........��� o
LOT 21 1 ........ o G, LOl
'....... 0 -
3.745 A - l" SO. FT.) 1 \. ., ^ 3.604 ACRES
O MIN FFE = 1009. 30' � - MIN FFE
JIM
30 DRAINAGE EASEMENT 1 1 1
I
SOUTH UNE OF THE NW 1/4 1
474.76' 1 1 1
381.80 .28` 62.68
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Nov 17 04 09:10p FOGERTY PLUMBING 17156355286 p.3
Fogerty Plumbing
#221180
282 ^3, %IcKenzie Rd.
�D,e,. /r,�v�s 3L LoT � 5poc rter, WI 54801
{7 1� � ��6 .
Combination Tank Component Cross Section
Approved Manhole Covers With Warning Labels
and Locking Device / 4" Min. Above Final Grade
Weather Proof Junction Box
Electric per NEC 300 & COMM.
4" Vent 16.28 WAC
> or r = = to 12"
Above Final Grade NV
Disco ct
Alternate Outlet Location
W /Approved 4" Sleeve _
Inlet Approved Force Main Diam.
Effluent Filter
Baffle < or = to 1/8" Weep Hole or Anti Siphon Device
Particle Size A
B Pump Off Elev.
C
Tank Mfr. �
Dose Tank Elev. T
Vertical Difference Between Pump Off and Distribution Pipe= _ f�/
S
Minimum Required Supply Pressure ....... ............................... - -D- �d 40W .
/Lf FT. of Force Main x . 7Y Friction Factor /100FT.... _ L2!Z'
Total Dynamic Head - /s 1 ��� , , •
Number of Doses... _ —+— Per Day Gal. Per Day/ #of Doses= /.S o Gal.
Volume Backflow ..................................... ............................... = zP Gal.
Total Dose Volume ...................................... ............................... = i7r Gal.
Pump Tank Capacity L Gallons Dimensions Inches Gallons
Pump Tank Volune /Y! GaWnch A 21- Yak_ 9
B 2 mef, 3
Pump Mfr. C /Z, /7Y. 3
Pump Model �f D L_
Minimum Discharge Rate �_ GPM
Alarm Mfr. .f . Total= S3 Zy77
Alarm Model 691 O //f
Bed Tank per COMM. 83.45(5)
Anchor Tank as necessary to negate buoyant forces per COMM. 83.43(8)(8).
Nov 17 04 09:11p FOGERTY PLUMBING 17156355286 p.4
MODEL DVP03 MODEL 3871
1 I,
i
Vertical 1
• •
Su bmersible Pump
all 11
r
GOULDS
i
I Y.
o M
to
ry! / "`7i _s s r �•('•'J:� °
�
, 3 :f :Pump`Specifications , .,..
-� HP•
METE FEET
Up
t0 40 GPM ,o
` ?` t °- MODEL: 3871
Discharge size 1' NPT . F` " ° 3 I
Solids: �: ' /: maximum
Motor 7 u 1 I
Single phase: 115V _ 5
Materials of Co,struction _ I
Brass/thermop(pstic 5 ,s
Features and Benefits o ' I EP05
-Top suction eliminates ' '°
1 impeller clogging. 2
-Corrosion resistant
construction.
1
- Float -actuated switch. o z
e o o° ,0 20 ,o ��
e ,o
CAPACITY
METES FEET
i Pump Specifications Features and Benefits
a 7 MODEL OVP03 20 '/m and 'h HP • EPO4 impeller- semi -open design
I Up to 60 GPM with pump out vanes to protect
Maximum head to 32' mechanical seal.
rc ` Discharge size 1 NPT • EP05 impeller - enclosed design
' ' '°
Solids: 3 /4" maximum for improved performance.
• Rugged glass-filled thermoplastic
5 I All Mo motors feature ball casing and base design provides
i
0 o bearing construction. superior strength and corrosion
0 5 ,° IS 20 26 W APM resistance.
o i ; e e 10„ Single phase: 115V •
CAPACITY Materials of Construction Cast iron motor housing for
Cast iron efficient heat transfer, strength,
Thermoplastic and durability.
Stainless steel • Corrosion resistant threaded
stainless steel shaft.
i • Available for automatic and
manual operation.
! • CSA listed models available.
i
All Models are designed for continuous operation and feature stainless steel hardware.
Nov 17 04 09:10p FOGERTY PLUMBING 17156355286 p.1
FOGERTY PLUMBING & PERK TESTING
28288 McKenzie Rd.
Spooner, WI 54801
(715) 635 -9609
Fax (715) 635 -5286 /
17 -- 951
/Jr�SSff r°E: 1 .✓ ®ltc�/� � ��'il �r/�?" �Y�d,E � LF.+�3- ttRT:ro.,d
4 -IV AVW G --A1,= AAQt It g&07 Asir c...fs - M
SG T v,E rar-itif'
fZE ® orvse�
Fogerty Plumbing
#221180 rAGI cF
�
28288 McKenzie Rd. PWAP CHAMeLR CROS5 SECTIO ANG SPECIFICATIMS
Spooner, WI 54801
(715) 635 -9609
VENT CAP
4 C.I. VEUT PIPE WEATHERPROOF APPROVED LOCKIAIG
JUWCTION BOX MAWHOLE COVER
Z5 =RO."1 DOOR. •
0 WINDOW OR FRESH 12 MIU.
AIR INTAKE I
GRADE I y + MIS
18" I'�IIJ,
COWDUIT -- ---- - - - - --
� 18
"MIN. `^ --- - - - - --
PROVIDE - - - --
WILE T AIRTIGHT SEA
I Ili
f \A
I I
i i I ALARM
I
OM, .
O *APPROVED
�; JOINTS WITH-,
ELEV FT APPROVED P fPE - __j
I PUMP OFF --�
- � 3 ONTO,' .�
D � SOL I D/ISO I L
CONCRETE BLOCK
RISER EXIT PERM1,;dED'\0&JLy IF TAWK MAIJUFACTURE:R HAS SUCH APPROVAL
� r Z. SPEC.IFI
SEPTIC f /r/!/ GA
DOSE '
TANKS MAMUFACTURE� (DU
�� MBER OF DOSES: PER OAS
TAMK SIZE : G)►LLOWS DOSE VOLUME
ALARM MANUFACT ER: erg INCLUDING BACKFLO GALL
MODEL UMDER: �_ ali \ CAPACITIES: A= � IIJCRES OR yGd7} " GALL
SWIT TtJPC: B
Z IWCHES OR 2 I GALL
PUMP MA UFACTURCR: f� 96y C = yd AX14ES OR GALL
6
ODEL IJUMBEK L�uG� ��e D s INCHES OR y FG ALL
SWITCH TYPE: ����� -- MOTE: PUMP AND ALARM ARE TO BE
MIM DISCHARGE RATE GP�� INSTALLED ON SEPARATE CIRCUIT
VE TICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION kPE.. F EET
+ MINItALIM NETWORK SUPPLY PRESSLHLE MET
Y . . . . .... .. '
+ —4 F OF FORCE MAIN X � /oo FLFRIC*10' FACTOR;° _,9L FEET '
{ = TOTAL DYNAMIC HEAD � -FEET
ILITCRLIAI n1MF11Ct^LIC f1F - rkL16(' 1 F'LI!_T41 /(1rL5 It - W1nTL1 06 A/ .'1 IAl11D nrPTH .� - --
M ODEL P0MOD
Vertical • • PO4 P0
Submersi •
V .
i
GOULDS
' I
fed v � • ,. r S _ a, wr� 4 ,
T °r1l i` a� ' 2 .J
�r Pump Specificattons
J._
,+".j , I i METERS FEET
HP SL? w jr
7
Up to 40 GPM ` 0 MODEL: 3871
Discharge size 1'/: NPT . } yf' '' 9 30
/6
Solids: maximum �_ 6
i 25
Motor
I Single phase: 115V
6 20 -
Materials of Construction
�? 5
BrassAhermopfptic a 15 EPOS
Features and Benefits < '
-Top suction eliminates a 0 '°
impeller clogging. 2 EM
5
• Corrosion resistant
construction.
• Float actuated switch. ° °0 ,0 20 �o ,o so us
0 2 4 6 8 10 12 N
CAPACITY
METERS FEET
25 MODEL DVP03 Pump Specifications Features and Benefits
7. 0 620 ° /,0 and 1 /2 HP • EPO4 impeller- semi -open design
5 Up to 60 GPM with pump out vanes to protect
,5 Maximum head to 32' mechanical seal. 1
Z 4-Discharge size 1 NPT • EP05 impeller - enclosed design
'
3-10 Solids:' /:' maximum for improved performance.
s 2 -Rugged. glass-filled thermoplastic 1✓
5 Motor casing and base design provides ,
I + All motors feature ball superior strength and corrosiol��
0 0 bearing construction. U
0 5 ,0 15 20 25 90 as ao U.. bearing resistance. 4 Single phase: 115V
0 2 < 6 6 ,om�mr • Cast iron motor housing for
CAPACITY Materials of Construction efficient heat transfer, strength,tk�/ Cast iron
Thermoplastic and durability. �'
Stainless steel • Corrosion resistant threaded `b
stainless steel shaft.
• Available for automatic and
manual operation.
! • CSA listed models available.
All Models are designed for continuous operation and feature stainless steel hardware.
' rV VV 1 a7 VVVIYen a IVIAIVUMI.. at 1v1M1VIMt3"V .1V ■ I rnyu T fit - AL
FILE INFORMATION \ SYSTEPA SPECIFICATIONS
Owner Septic Tank Capacity �Q 9NA
Permit 3 04 Septic Tank Manufacturer � OESIGN PARAMETERS
Effluent Filter Manufactl� z,* G ❑ N
Number of Bedrooms ❑ NA Effluent Filter Model _ oe ❑ NA
Number of Public Facility Units XNA Pump Tank Capacity gal 13 NA
Estimated flow (average) al/day Pump Tank Manufacturer C-1 NA
Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer NA
Soil Application Rate gal/day /fe Pump Model 0 13 NA
Standard Influent/Effluent Quality Monthly average` Pretreatment UnitA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter -
Biochemical Oxygen Demand (BOD X20 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pre_ treated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODJ X30 mg/L )q In- Ground (gravity)"' ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :51W cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA
Other. ❑ NA
Other: ❑ NA Ott' ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA
MAINTENANCE SCHEDULE
Service Event Service fancy
❑ MOrith(s) (Maximum 3 years) d NA
Inspect condition of tank(s) At least once every: Kyear(s)
Pump out contents of tanks) When combined sludge and scum equals one-third (Y of tank volume ❑ NA
❑ moiith(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: 3 year(s)
❑ month(s) ❑ NA
Clean effluent filter At least once every: �, I year(s)
❑ month(s) aNA
Inspect pump, pump controls & alarm At least once every: ❑ yearls)
❑ month(s) Q NA
Flush- laterals and pressure test At least once every: ❑ year(s)
❑ month(s) _ CI NA
Other:- At least once every: ❑ year(s)
Other: j2-NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
nspector; POWTS Maintainer;
Master Plumber; Master Plumber Restricted Sewer; POWTS I, e Servicing Operator. Tank
g or broken hardware,
inspections must include a visual inspection of the tank(s) to identify any missin 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.
J �
2 &
.^14T UP AND OPERA=N
For new constructwtr, 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 tankls) 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:
0 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.
!8 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:
X A suitable replacement area has been evaluated and may be utiC¢ed 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 ones 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> > — DO NOT
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN.
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.
#221180
c en e Rd.
Stloone . wl 6�tt1
(715) 635 - 96M J
POWTS INSTALLER POWTS MAINTAINER
Name I ( v Name
Phone °7 /S� �3 & Phone �
SkPTAG SERVICING OPERAT R (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name 1 �.� X-N�
Phone Cy Phone �'(S7 O"
This docume t was drafted in compliance with chapter Comm 83.22(2)(b)1111d1 &(0 and 83.54(1). (2) & (3). Wisconsin Administrative Code.
I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
_ F AND
OWNERSHIP CERTIFICATION FORM
Owner/ -ljer 116A�-Z - Q� y=XQ41xn* - yffAsf0 I
Mailin g Address L T �I q.�,. ►-, p Ol S
i
Property Address �� 6
(Verification required from Planning Department for new construction)
City/State 19W ,G,F2'A"A-O fo Lztr Parcel Identification Number oaf - iit/ f -so - mm&
LEGAL DESCRIPTION
Property Location _--cu %,, ,r/U/ '/+, Sec. _3 6 . T 3r� N -R 1,L_ Town of •er�i�s:.e y�
Subdivision sI Lot # ad
T
Certifled Survey Map # - Volume . Page #
Warranty Deed # 77 reQ . Volume za Y/ . Page #
Spec house ❑ yes Lino Lot lines identifiable Dyes ❑ no
SYSTEM MAINTENANCE
Impropermc=dmabbeaamccfy awscoCsyskmcaaldiestdtinibpnmut himetoLamdiewastos .Pmpermainienance
consists of pnmpl g od se septic tuk every Gins Yeses r wo■rr, , if n edcd iy a li c maed pub What you past into► the system
can aHeet dce fincdon of the septic tnk as a heaka 8t s fte in Se vm disposal systma.
The popaty owmx agrees In submit to SL Ckek Zmiog Deparbuent a cectr6artion Faao, sigaod by the owner and by a
maswpinmbex,joorneym np restdctedplawmberaraliceasedp ery dis posal system
>s m p[oper apera6ag amditim aedfar (2) after and powf ft (Knecessiory), the septic tic is Iasi tLrm W full of sludge -
Ilwc, the rmele aedhave read the above rats aed agree tau nuintain the p haft sewage &qxnd ! c sumdards
set fa bomb. as set by the D4mft eat of Comm me amd the Depmmoteatof brad Zte=m=:s, Std& "� ptti 1
astb, catim
stag dW your septic has been maietamedmma be compieood andnetame I m the St. Germ ivitbffi 0
days errpsi date"
SJUiZ4 PLICANr DATE
OWNER CERTIFICATION
I (we) cerfiy that all statdnents on this fort are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pproperty e, by virtue of i waccanty deed reooided in Register of Deeds Office.
SIGNATURE PLICANT DATE -
«. « « «« Any information that is mis replenuted may resuh in the stmituy pcmdt being nvo)wd by the Zoning DeeenL
** 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
i
J -.26`i1 P 636 �
STATE BAR OF WISCONSIN FORM 2 - 1999 '7 "7 2 3 010
Document Number WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO -, WI
This Deed, made between Ames Investment Corporation, a RECEIVED FOR RECORD
Minnesota Limited Liability Com»a__t,Lv Grantor,
and Matthews J Johnson and V ronica Cr. Joh?an, husband and wife 08/23/2004 10:15AN
Grantee. WARRANTY DEED
Grantor, for a valuable consideration, conveys and warrants to Grantee UBM 0
the following described real estate in St. Croix County, State of Wisconsin REC FEE. 11.00
space is needed, please attach addendum): TRANS FEE: 164.70
V Ot 2 Plat of Torey Pines II in the Town of Richmond, St. Croix COPY FEE:
w. CC FEES
nty, Wisconsin
PAGES: 1
Recording Area
Name and Return Address
R�lNt <__YqA_ I
0264149-20-M
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 this c2:6 - day of August 1 2004
/l
- -- Y -- // - - - --- ----- ----------;---------------------
* Ames tment Corporation
AUTHENTICATION CKNOWLEDGMENT
Signature(s) _- STATE OF 42! )
�_. m, ) ss.
Tra
- - �- �umer . --- -_— ,(�; County )
authenticated this
day of Notary Public day
Sae of- Vlliseon Personally came before me thi day of
August , 2004 the above named
Ames Investment Corporation a Minnes Limited __ --
* Liability Company _
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to ml known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) ins eandack ledg me. THIS INSTRUMENT WAS DRAFTED BY _ - - Attorney Kristina Opland - — _ -- _.._._. � -
- -- Hu dson, WI 54016 Notary f Ln ,p� r
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) 2 )
i Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co.. Fond du Lac. W I
STATE BAR OF WISCONSIN 900 -655 -2021
WARRANTY DEED FORM No. 2 - 1999
Jun 21 04 12 :00p Shawn Carlson 715 - 549 -5965 p.6
08/11/04 08:52 FAX 715 263 3524 0XD0 SALES /AC Q003
v .w I;
�- \` r -�'. •-�.�` •`•l �` l j ' ! L.��
_LOT 26 2.0 ACRE
k mewwn 330.ao'
op
J 1 /'' - ~ ` �`. ��-- • .1 / � LOT iq-
LOT " 1 2.3 ACRES •;, _ ' / >) . � � .-- 2 b�Ri
1 'at �) I 1 •`� LOT 24
/ I-Al ACRES /
d e
'�" • _Z.�T /1CF'e0 : •� �` �'� ' �xe� .4 1 i
_ w '`� •• '� / SSA- O �
I ' .fir. -�_ '•��...1 ;..., N-• J �i� i • • /• r / v f� � - /
op
Q r ��.gl(( Mw1�7FA 1 2.0 AC I i �� i / f r �� y �• r / f Q
REtEM ION IoiEl► '' ,' j 1 i j � � � , 1 ! % , i ! : •�'! / f , •` � a o �
2W ! ' Mfr _! / r / i �.. _... - . ..,p.. .•
. 44 -•y — , �— _- t- -PRp 1T01fYi1' �--��� • • ' �i� / /�" -�- ; r i .
w0o6.0� arD �• . ` �'. r �, 'for. i
ON AFiE M" FFE i � �'i � j; • � - f� % f � .a ' �' --- —
1 . 00'.' 1.7,- 1[CNEg v .! Q f ¢ / �.1ar LOT
"to AME-
K70cat wATEA
RVif4T10NAnFA I
1 •�` ,l ; W7 '� ' ; '� '1.�' ►furl. 1 4 } 1001.0
Boa "" ��'.�`•, `` ,`• / 1 l
ol
• . s. -. r • 1 I �'• •• W
+r _.�• . �, .' /� ' F1 .'" COT IV
• 3.6 ACRES
�: ►7 r LOY.i o ?fs� j
r
3U #k hl
Woo r 1� •� •'•... � • .0. ``, • , 11s ' 1 ! � , i � r ' '�:
i (113,802 SQ. FT.)
S 81 � ,•
/ MIN FFE = 1009.00
r 5'40' E 417,,, . • �/ .
�.... �,
LOT 23 . .
.
2.027 ACRES (88,314 SQ. FT.) ' .' . i!• • • • ....
Q
Q) / ��.......
89°51'48 - E T60:19 S6 / / � .'_'..¢`':. ��..... .
457.19 1 740 — �i....' .'-
-TOWN ROAD
1'46' E 457.19 4 ; ��4 E• .... l
. — . — . BaM $ j
N6 =- 31.85' I•— •— • —• —•—
TER \ r54 ,r4 +IV S 89°51'
AREA
. N 89°5
30 (72,052 SQ. FT.) N ..' .........:... ..... ..EI.EViA . 1003.35
z m LOT 20 ��
�
C2 ' / 2.066 AC
w 2.489 A ` '
N MIN
. 00' � ....................... ?....I
. ...1
MIN FFE = 1009.00 ....... ... R ETENTION. �.... 1
0 H:W.E,= .1.007,
a4 _ �� :: :::::.... .............'.'..'.'I
Z ..........'.'.'.'.'.'.'.:'• • • • 1
4(
- - -- ' ' . $1.7:56'.•1
.
�...' .............. .......
10 .....'.'.'. _ s
N i .............' .'.' .
j ...'.'.'.'.'..'.� o
LOT 21 I ....... �� S :@ U
p 3.745 ACRES (163,117 SQ. FT.) 1�.'.y 3.604 ACRE
a4 Q MIN FFE = 1009.00 4 30 � $ MIN F
30' DRAINAGE EASEMENT--__,yjl �m
J
TH
SOU UNE OF THE NW 1/4 1 jl
474.76 t+ 1 30
- x - - — 381.80' 8268'
t 889°6 7'
VLIV � _ � �(�p�pD� Q�v�►ilfnlC�D ° U l�J U WLSQ�