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HomeMy WebLinkAbout026-1003-90-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Matt & Monica Rominski TOWN OF RICHMOND CST BM Elev: Insp. BM Elev: BM Descr�tion: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Ier__ 5�-qnq 000 Dosing /oL�►�D Aeration E P 1 t to SZ5 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 15 ��� I Dosing � � � , / f ' l0 / _ / t (P Aeration Holding PUMP/SIPHON INFORMATION Manufacturer uemana 4n�/ �('r GPM Model Number r%, 153 %Z TDH Liit, 6S Frictign Loss pSystem Head TDH �t 5 f s�- Forcemain r Leng"? � 37 Dia:-Z •' Dist. to Well ;> SOIL ABSORPTII{ON SYSTEM BED/TRENCH Width ILengZL No. OfTrenDIMENSIONS'er SETBACK SYSTEM TO P/L BLDG WELL INFORMATION Type Of System: YP Z�� gZ.� 7IGb� Lormn 14 a DISTRIBUTION SYSTEM Length � Dia SOIL COVER Center Dia Spacing_ x Pressure Systems Only Depth Over �v Bed/Trench Edges / COMMENTS: (Include code dis%cre'p-encies, persons present, etc) Location: 1735 SHAMR�OIC^K LN/�✓�'L�S � `��� t hs 1.) Alt BM Description 2.) Bldg sewer length amount of cover = 7HZ Plan revision Required? ❑Yes INo Use other side for additional information. ELE ION DATA c°unty: St. Croix Sanitary Permit No: 615476 State Plan ID No: Parcel Tax No: 02&1003-90-000 Section/Town/Range/Map No: 01430018014D STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. IO•'GJ l , Dist. Pipe Bot. System 'r► —rZ It 1 D I J Final Grade / •�(. 13 41 Ili 2ov 5, YI , 26 No. Of Pits AKE/STREAM LEACHING Manufacturer: � �q ` „A��+ CHAMBER OR \T` FttT� Model Number: Hole Size x Hole Spacing Vent to Air Intake ® I P0ZJ- ?'ant xx Mound Or At -Grade Systems xx Depth of xx Seeded/; Topsoil ,�� Inspection #1: 'n 5.�G I�cri lobo Vvo V ems Date Mulched Inspection #2: J Cart. No. ' N'— r,.�q,ySataif 'ti yr COunty at �._------ Safety and Buildings Division St. Croix �+ �1�:. ` �; ; ���� �D 201 W. Washington Ave., P.O. Box 7162 ��"'` 53707-7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI � �'��'��;,.���„ CD%�J �%�O °��y SEP 10 2019 � �`A±SiOiSA� � - st. cp�i�te mit Application State Transaction Number ntal unit In accordance e, submission of thts fottn , Na is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS aze submitted to project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used'for secondary Law 15.04 1 m Stets. � I � A� /��� `s v� !/•� u oses in accordance with the Privac s. Same I. A lication Information — 1 e Print All Information Pazcel # Property Owner's Name � Matt &Monica Rominski 026-1003-90-000 Property Owner's Mailing Address Property Location � , Govt. Lot 1735 Shamrock Ln. NW '/,, SE '/<> Section 01 . City, State Zip Code Phone Number ��(circle one) New Richmond, WI 54017 715 410-4991 T 30 N; R P8 w II. Type of Building (check all that apply) Lot # Na Subdivision Name ®1 or 2 Family Dwelling -Number of Bedrooms 3 q�, Btock # Na ❑ Public/Commercial —Describe Use Na ❑City of ❑ State Owned —Describe Use CSM Number ❑Village of Na Z Ls -w /� �- �� G�,,M, ®Town of Richmond ; a III. Type of Permit: (Check onl o ine A. Complete line B if applicable) `�' ❑New System ®Replacement System Treatment/I-IoldingTank Replacement Only ❑Other Modification to Existing System (explain) ❑Permit New List Previous Permit Number and Date Issued B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber Transfer to Before Expiration Owner IV. Ty a of stem/Component/Device: (Check all that apply) �✓L � � a ® Non -Pressurized In -Ground ❑Pressurized In -Ground ❑ At -Grade ❑Mound > 24 in. of suitable soil ❑Mound < 24 in. of suitabte soil /'�_ �"�'� lding`Fdn Other Dispersal Componen lain) ❑ Pretreatme t Device (explain) V. Dis ersal/Treat ent Area Informatio I tltr for uick 4 Standard Plus chamb s & air end ca s, Pol Lok PL-525 effluent filter Design Flow (gpd) Design Soil Application gpds Dispersal Area Required (sf) Dispersal Area P oposed (sf) System Elevation 450.0 Gpd 0.7 Gpd/Sq. Ft. 642.86 sq. ft. .�. sq• ft. 89.50' VI. Tank Info C aci m ap ty Total # of Manufacturer � o v o Gallons Gallons Units � � � U � � y �., New Tanks Existing Tanks � �� lD� �Z C 7 � U � � � w C7 a (Concrete Septic or Holding Tank ] 000 1,Ot)t) 1 Wies r X Dosing Chamber 650 650 1 Wieser Concrete X VII. Responsibility Statement- I, the unde igned, assu a responsibility costa anon of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ign ure MP/MPRS Number Business Phone Number `� MPRS 30021 715 248-7767 James K. Thom son Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 'S4020 VIII. Count /De artment Use Onl Permit Fee Date sued Issuin nt Signatur pproved tsappr $ �� � • � � � 7 !� Ow tven Reason for Denial 1X. Condit . (Reasons fgr„Disapproval 3� � �j a, 1. ,Septic ark, e;flu��^`tinter atrni , .. y, Gisper:•a•i cell miss[ sll be •.:, ��^:g�.!_r ..,;nt�;et� :�s per rrtan�gemer! plain �r� nue � uY Nlurobe>. � �,p J�� dam- . 2. AU.�k�}}t t't'�,411`�';Zertzs�muuL.ut?:t;'s ;rt,il;e � ui�+t l �rdinnnce_� SIS f Se��..�C- � >1Il P� �--, YU1r,�; n�-� �� : e n......... ....i., ...... nnf iwac than a in�l inches in size Attach to compieie pmns un- we sys,eu� a,.� �..�............ �.... ...... .... —,._- SBD-6398 (R. 11/l l) � W rV� w 17;'S�r� bean 6� tic-�ii,'l_� �rce vv�a;►t. ProPQ�"-� �J WreS�T C�r,Cr��e �is�r;bu.�ion b oX �1,�,.,,, �0�1' ,� 1y�'�. p,�QS.�d�,rW �� �����/�so -F-o� Tr,p/e s.r./,�.c. �— �d yle,i'f�.�-szsr,�'/uL, ® E,r.;SEixj �raclt .tl�.✓.� �Qe�' "��y�9 � � j$'.S ka.� r'o ct� C.4 . �e e..J �•cf ,9+ s» d, v,I. SST' qc� 5��; see, o, T3o�f, �P. i8� �C3c� +doaG-ro®,�-�16=cam �, ;,S a, 9oatcres Kj J� �� ��� µopo�e.da4s�rsa/ci.N• � -� -b'"cn��.S'aE 3 X �i'wtn� Tir/,'/�'{i Tn,�% �. E,'✓t c.�/,la u s ls�: � be �9. SD, 2-0{'/�! Conventional POWTS Index &Title Sheet Project Name: Rominski 3 bedroom Repl Conventional Dispersal Cell Owners Name: Matt &Monica Rominski Owner's address: 1735 Shamrock Rd., New Richmond, WI 54017 Site address: Same Project Location: Subdivision: Na Legal Description: NWl/4 SE1/4, Sec. O1, T.30N., R. 18W., Tn. of Richmond, St. Croix Co., WI. Parcel ID #: 026-1003-90-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calculations Page 4 Dispersal Cell Cross Section Page 5 Infiltrator "Q-4" Chamber Specifications Page 6 Pump Chamber Calculaltions &Float Settings Page 7 Pump Curve Page 8 Septic/Pump Tank Cross Section Page 9 Effluent Filter Specifications Page 10 Distribution Box Cross Section Page 11 Septic Tank Maintenance Agreement Page 12 System Management Plan Page 13 Parcel Map Page 14 Warranty Deed Attached: Soil Evaluation Report Mater Plumb estrl d Service: James K. Thom son, DSPS Credential #30021 Signature: s--- Date:J� �• O 9 2�/f 6 e Page 1 Of 14 Design pursuant to In -Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.O1/O1) e ,"- �'`s�.�la �J,C, Circe w�a;rt. Pro pa ud ---' wre5�� Cm�cr��e di5���bu.�ion b aX S�a�, /off' PropOs�-c�Gc>.�5+�f (rprll �,,�Lp/,cae�GSo -F(JL �d/y �Ce�f'P�-szsrFk'/uti �Qen� '�,� yt�4 �a �}� NCo� i CA �COMlfI s� /T3,,r'.Ska.n ro c�L.�. die e.�l � u(m rri d, �� Ss+�IJ gc�f'4' SEl�; ,Sre, o, T.'3GK, �P. ig� T.O�,Q.G%Mortol, C�.L'roiY�'n ct,; /04/. +�ozG-ioo,�-y161udD �,:� o.9oac�e.s (,�.9;11 m�7 � Qt�� �'cnclv..S'aE 3'X 'T ���tnJ Teti'/t�rn� "q•�r'�ju,� �couc; J c�t...:a,..- - i/p�rtrtit .�-.,tir�. �;✓� .�,� a �r�.-: ,s� 6<�sa Ronunski 3 Bedroom Dispersal Cell Sizing Calculations 1. (3 bedrooms)(100 gallons estimated 11ow)(1.$ design factor) = 450.00 Gad desi ng flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 642.86 sq. ft. 4. Absorption area as proposed: 650 40 sq ft (32 chambers + 2 pair end caps) Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end caps = 5.20 sq.ft, EISA/pair 642.86 sq. ft. — (2 pair endcaps)(5.20) = 632.46 sq. ft. 632.46 sq. ft./20.00 = 31.63 chambers required Number of trenches: 2 16 chambers per trench (32 chambers total) Trench width: 2.83' Trench length: 67.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 12.00'x 67.00' Pg. 3 of 14 r C3 U C_ �N .cn O a U C C'7 W W N Q /a) V i 'n i o. O U C O E E U 2 Nv N c U CL awl O 0 c r ' Quick4 PIusT�' Series Quick4 Plus Standard Chamber Quick4 Plus All-in-Qne 12 Endcap �--- 33' FRONT VIEW Quick4 Plus All -in -One Periscope r :;< �� ���� `rx ■ � � • water tect�noingies QUICK4 PLUS "" !"'-ONE PERISCOPE 0° SWIVEL) j PRESSURIZED PIPE DRILL 1TIONS 12.7"INVERT 4 Business Park Road P.O. Box 768 Old Saybrook, CT 06475 860-577-7000 � Fax 860-577-7001 1-600-221-4436 vvww, infiltratorwater.com 48" EFFECTIVE LENGTH iRT SIDE VIEW INFILTRATOR WATER TECHNOLOGIES, LLC ("INFILTRATOR") Infiltrator Water Technologies, LLC STANDARD LIMITED Drainfield WARRANTY (a) The structural integrity of each chamber, endcap, EZflow expanded polystyrene and/or other accessory manufactured by Infiltrator ("Units', when installed and operated in a Ieachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original pur- chaser ("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; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installa- tion 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. (b} THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a} ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT 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 Toss of 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 io ordinary wear 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 instal- lation instructions; failure to maintain the minimum ground covers set forth in the installation instruc- tions; 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 any other event not caused by Infiltrator. This Umited Warranty shall be void if the Holder fails to comply with all of the terms set forth in this Limited Wazranty. Further, in no event shall Infiltrator be responsible for any Toss or damage to the Holder, the Units, or any third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's installation instructions. (d) No representative of Infiltrator has the authority to change or extend this Umited Warranty. No warranty applies to any party other than the original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different war- ranty requirements, 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,t t 6; 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, Quick4, and SideW nder are registered trademarks of Infiltrator Water Technologies. InFlltrator is a registered trademark in France. Infiltrator Water Technologies is a registered trademark in Mexico. Contour, MlcroLeaching, PolyTuff, ChamherSpacer, MultiPort, Posilock, QuickCut, QuickPlay, SnapLock and StraightLock are trademarks of Infiltrator Water Technologies. PolyLok is a trademark of PolyLok, Inc. TUF-TfTE is a registered trademark of TUF-TITE, INC. Ultra -Rib is a trademark of IPEX Inc. © 2016 Infiltrator Water Techndogies, LLC. All rights reserved. Printed In U.S.A. PLUS05 0816 I�� . SoFr� r Rominski 3-bedroom Dose Conventional Pump Chamber Calculations r 1. Force Main: 2. Total dynamic head (per inspection report) Diameter 2" Min. supply pressure 0.00' Length 40 Vertical lift 4625' Flow rate 45.00 gal./min.± Friction loss 1065' Friction loss 10653 (401)(4.11 ft./100ft.) = 1.644 ft. Total dynamic head = 5.90' 3. Pump selection: Manufacturer: Zoeller Model number: BN 53 Pump will discharge approx. 42.0 gpm @ 5.90' TDH or 4.284 ft./sec. flow rate nq 4. Dose chamber: Wieser 111LP1 000/650-FDL Triple Comb ST/PC - 41 00" 15 93 gal./inch (653.13 gal. actual A) One day holding capacity: 21.00" = 334.53 gal. B) Alarm setting: 2000" = 31.86 gal, r C) Dose volume: 6.00" = 95.58 gal.(450gal.)(.20) + (,164)(40') = 96.56 gal. Max. Dose D) Reserve storage: 12.00" = 191.16 gal. TOTAL 41.00" = 653.13 gal. Velocity in orcematn mush a to 10 fuse Dose Tank Information Electrical as per NEC 300 and —% Comm 16.28 WAC Tank component is properly vented Manufacturer Gallons gal/inch Dimension Inches Gallons A 21.00 334.53 B 2,00 31,86 C 6900 95,58 D 1 12,00 191,16 Total 1 41,001 653,13 Alarm Manuafacturer SJE Rhombus Alarm Model Number JB Plugger XL Pump Manufacturer zoeller Pump Model Number BN 53 Locking cover with warning label and locking device and sealed watertight 4 in. min. Alternate outlet location Forcemain diameter Weep hole or antl- siphon device P� ump off elevation (ft) 86.50 Do�se_tank elevation (ft) 85.50 Pg. 6 of 14 w w �s w x U >- 4 0 J 0 l— C PUMP PERFORMANCE CURVE MODELS 53/55/57159 20 15 10 uoaea� 5 10 20 30 4 50 GALLONS c�OG,o.x C�� S��i! LITERS � 80 160 FLOW PER MINUTE CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level float switches available. • Variable level long cycle systems available. • Available with special cord lengths of 15', 25', 35' and 50'. • Alarm systems available. • Duplex systems available. Sin eSeal Control Selection Llstin s Yodel Volta Phase Mode Am Sim lax Du lax CSA UL M53f55 & M57f59 115 1 Auto 9.7 1 -- Y Y N53/55 & N57l59 115 1 Non 9.7 2 3 or 4 8 5 Y Y • BN53 115 1 Aulo 9.7 -- Y Y • BN57 115 1 Aulo 9.7 -- N Y • BE53157 D53f55 & D57159 E53/55 & E57159 230 230 230 1 1 1 Aulo Auto Non 4.8 4.8 4.8 1 2 -- — 3 or 4 8 5 Y Y Y Y Y Y Single piggyback swildl included. TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENTAND DEWATERING MODEL 53155/57/59 Feet Meters Gal. Liters 5 1.5 43 163 10 3.0 34 129 15 4.6 19 72 Shut-off Head: 19.25 ft.(5.9m) 1 12 NPT 2 _ SKBSe SELECTION GUIDE t. Integral float operated mechanical switch, no external wntrol required. 2. Single piggyback variable level Float switch a double piggyback variable level float switch. Refer to FM0477. 3. Mechanical alternala'M-Pak' 10-0072 a 10-0075. 4. See FM0712 fa correct model of Electrical Alternate. 5. Variable level control switch 10-0225 used as a conUol activator, wflh Electrical Alternate (3) or (4) float system. s cnunon ForinformafiononaddBonalZoellerproducfsreterlocatalogon RggybadkVariableLevelFloalSwildres, FM0477; All inslallaBon of controls, protection devices and wiring should be done by a qualified �ectricalAllernaWr,FM0488;MechanicalAllerrotor,FM0495;SumplSewage8asins,FM0487;andSinglePhase licensed eleclriclan. All electrical and safely codes should be followed including the Simplex Pump ControVNarm Systems, FM0732. most recent National Electric Code (NEC) and the Occupational Satety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX1B347 Lousvilk, ICY 40256-0347 Manulaclurersof.. � SHIP T0: 3849 Cane Run Road ' ��Iv'1/�'�/`ao Loulsvllla, 10' 40211-1881 QlG1l?YPUMPB SNCE ����� ® '` PUMP !O_ (502) 7! AK (502) 77�3B24&PUMP httpJ/www.zoel/ercom _ _ __ _ ___ ©Copyright 2004 Zoeller Co. All rights reserved �c 7o F/�i r_ xi�o�s-000�a� :air 95�b8-5Z�-008 � \ :3tva o0 00 00 :�.do °s��e �^ 'Nooa N3aivw o� unH sn stern �df1N`dW �Ild3S Z •n3a 3138�l10� w � „o—.�=wti � �3wos doM :xe wnvaa ����'m 33dldl 303-099/OOOIdIM � `— O W � Ned � O o zzz Z � � O ¢ QQQ a o� m W c� ca U � � ° gy m Q Q M�OMi Op `r0 N m O NNE � ° If � N -J � � F � � J i- j� WWJ �ZJ .. Mtn � t¢- U Z3m�¢ W W CY ��..tt O �=J�m�3 ¢� ¢ N o W _ W W � � Z � � J ¢ W Q F- v II t 1 I� ,I �/ 11 Ii II it .I I _ _ I I. o it ` 1 If. W �I \ � Ir � w I f Q� � _ �� a =_�— w¢ Q �I „o� -� i'-o'�� II �m t Ij ��\� `�� jl: � / _�: ��GL k W U Z O U J W a � �m a � � m�`' z U �. J O O � � O Z� Y o ¢ � a �rn ¢ � � H � � w U �� Yp z � �F �� zf- � m F to oo ~O U � Q UaW'1 � xX W� �� NO O U � IL Z � O � � V� v 0 �W-'-' H Q m Q e :� a. .. a � m U1 Q o � wo z�maW HO a o Z Q V.. � j v a o � � a � o a o 0 a � a � w a t Z � „�'� � > o � Ili I �. ' �° . . I I. �, .• I � � .� � W I I I: 5 o �I' � � ~ f� I e � '' � �n -���� „5 „s� I „£ �� I (. W J Z - „9ti ooaa • SV ��' r. innovations in Precast, Drainaga & Wastewater Products Inc. I'L-525 Effluent Filter k Inc. PLMAP Filter The PL-525 Filter is rated for 10,000 GPD (gallons per days making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL422, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. I Features: a Rated for 10,000 GPD (gallons per day). • 5251u1ear feet of 1/16" filtration. Accepts 4" and 6" SCHD 40 pipe. ® Built in gas deflector. ® Automatic shut-off ball when. filter is removed. Alarm accessibility. Accepts PVC extension handle. PL 525 Installatian: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1Locate p the outlet of the setic tank . . 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids Fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filtration Slots Accepts 4" & 6" SCHD 40 pipe Outdoor 5martFilterC�� Alarm Polylok, Zabel &Best filters accept the SmartFilter® switch and alarm. Alarm Switch (Optional) Accepts 1" PVC Extension Handle 525 Linear Ft. of 1/16" Filtration Slots Gas Deflector Automatic Shut -Off Ball Extend & hokT^' Easily installs into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 377.765.9565 Fax: 203.234.8514 www.polylok.com :�.va � I �oN n3a �� 9L 133HS:3ll� g��g-5Z�-008 800Z 'Ndf 'A32! \ z � 800Z l.aV(1NVP 31d4 05L45 IM 'NOOa N301VY1 'O�UAH Sfl 9tL£M �yONyw OIld3S �- - iMs:xe r�vaa 31�e�Uo� u�s�im � ��� ,G = Ws:3wos X08 N011f181�l1S1a 3�OH 9 G J O � �-. W � � � O � � -� m O Q� _ o �� o m w - � Q O � N � Q �� r- � � z � F. � c.� o � = owwow w �z� � _ � � m � Q �p z � w W � J 0 Z N N W' 0 z �.t� w w 0 �; 1� Owner/Buyer Mailing Address Property Address City/State ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Matt & Monica Rominsk1 1735 Shamrock Ln., New Richmond, WI 54017 Same (Verification required from Planning &Zoning Department for new construction.) LEGAL DESCRIPTION Ptoperty Location Subdivision Plat: NW ,/4 SE Na Certified Survey Map # Warranty Deed # 1074402 Parcel Identification Number , Sec. 01 , T 30 Spec house Dyes�no 026-1003-90-000 N R 1 $ W, Town of Volume (before 2007)Volume N a Richmond Lot lines identifiable ❑� yes�no SYSTEM MAINTENANCE AND OWNER CERTIFICATION ,Lot # N a Page # Page # Na 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 §SPS. 383.52(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. I/we, 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 Safety And Professional Services 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. I/we certify that all statements on th,' form are true to the best of my/our knowledge property described above, by virtue of a w =ranty deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNA' APPLICANTS) I/we am/are the owner(s) of the 9 /06/19 DATE 0 ***Any information that is misrepresented may result in the sanitary permit being revolted by the Planning &Zoning Department. *** r 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. 04/12) Dose Conventional Septic System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the Polk County Zoning Department at (715) 485-9279. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1 /3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. 6 Pump Tank The pump (dosing) tank shall be inspected annually. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the pump discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell , Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October -March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BODS, I50 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding annually. Ponding levels above 6 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. 6 Pg. 12 of 14 �� i ��� �., t � ,. � s �5 {�,�` 4 Ft �K i. �ii 0 L �O t0 0 C � as rn� a O O N 5 C a%`' N �_ ' tO�NN U � � N jj G Lv3 t-C� U � � N � � O g="= U�� ��o O U Wisconsin Department of Safety, es Pao e,i n 'ssal Services ; Page 1 of 3 Division of Industry Sery �J t 2 1� To SOk EVALUATION PORT In�aWdi%8anee�with SPS 385, Wis. Adm. Code County St, Croix Attach complete site plan on payer not lei thdiY%l/2 X''',l ches in size. Plan must include, Parcel LD. but not limited to: vertical and ho�jzontal re erpnc point (BM), direction and percent slope, 026-1 3-90-000 Ref#2549 scale or dimensions, north arrow, 'and(lo-afion and distance to nearest road. Please print all information. Rev' ed by Dat y iz /9 Personal information you provide may be used for seconds purposes Privac Law, s. 15.04 1 m Property Owner Property Location ❑ Matt & Monica Rominski Govt. Lot NW '/4 SE '/4 SO T 30 R 18 E (or) W Property Owner's Mailing Address Lot # Block # Subd. N me or CSM# 1735 Shamrock Ln. Na Na Na City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road New Richmond WI 54017 Richmond Co. Rd. GG ❑ New Construction Use: ❑Residential / Numberof bedrooms 3 Code derived design flow rate 450 GPD ® Replacement ❑ Public or commercial - Describe: Parent material Glacial Outwash Flood Plan elevation if applicable na ft. General comments and recommendations: Site suitable for In -ground POWTS with 0.7 gpd/sq/ft, design loading rate. Recommended system infiltrative surface elevaton to be 89.501. Lift pumjp wit be required to meet system elevation. 6 I 1 I Boring # ❑ Boring ® Pit Ground surface etev. 94.00 ft. Depth to limiting factor >101" in. Soil A lication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu, Az, Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eff#1 *Eff#2 0-12 10yr3/3 none sil 2fgr mvfr cs 2fm1c 0.6 0.8 1 12-20 10yr4/4 none sil 2fsbk ds cw 2fm1c 0.6 0.8 2 3 20-30 7.5y4/4 none sicl 2msbk dsh gw 2fm OA 0.6 30-36 7.5yr4/6 none Ifs Osg dl gw 1v,f 0.5 1'0 4 36-44 7.5yr4/6 none Is Osg dl gw 1vf 0.7 1.6 5 44-67 7.5yr4/6 none s Osg ml cs 1vf 0.7 1.6 6 67-101 10yr4/6 none s&gr Osg ml - - 0.7 1.6 7 r3S'�rJ ��� I 2 I Boring # 86 ] ti ❑ Boring ®Pit 0 �,roJ Ground surface elev. 93.79 ft. � ' Depth to limiting factor Soil Application >98" in. Rate Depth In. Dominant Color Munsell Redox Qu. Az. Description Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 Horizon 'Eff#1 'Eff#2 0-12 10yr3/3 none sil 2fgr ds cs 2fm1c 0.6 0.8 1 12-19 10yr4/4 none sil 2fsbk ds cw 2fmc 0.6 0.8 2 19-30 7.5yr4/4 none sic[ 2msbk dsh cw 1fmc OA 0.6 3 30-38 7.5yr4/6 none cement ed Ifs Om dsh as 0.0 0.0 4 38-58 7.5yr4/6 none s Osg dl gw 0.7 1.6 5 58-98 10yr5/4 none s Osg dl 0.7 1.6 6 * Effluent #1 = BOD, > 30 5 220 m / and TSS > 30 5 150 m / Effluent #2 = CST Name (Please Print) Sign re �- James K. Thompson Address Date Evaluation Conducte ( 340 Paulson Lake Lane, Osceola, WI 54020-5413 August 23, 2019 i- BOD, > 30 <_ 220 m /L and CST Number 30021 Telephone Number 715 248-7767 TSS > 30 <_ 150 m /L RRrI-R33n (Rn4/4 5) L9_I6 Boring # Boring [:33] ® Pit Ground surface elev. 94.62 ft. Depth to limiting factor >105 in. Soil Application Rate Horizon Depth In, Dominant Color Munsell Redox Description Qu, Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ftz *Eff#1 *Eff#2 1 0-11 10yr3/3 none sil 2fgr dl cw 2fm1c 0.6 0.8 2 11-26 10yr4/4 none sil 2fsbk dl gw 2fm 0.6 0.8 3 26-38 7.5yr4/6 none sicl 2msbk dsh cw 1vf,fm OA 0.6 4 38-45 7.5yr4/6 none cement ed Is Om dsh as 0.0 0.0 5 45-52 7.5yr4/6 none Is Osg dl gw - 0.7 1.6 6 52-78 7.5yr4/6 none s Osg dl gw - 0.7 1.6 7 78-105 10yr4/6 none s&gr Osg dl - 0.7 1.6 �C;b 5 ,f i El F1 Boring I7� Boring # El Pit Ground surface elev. ft. Depth to limiting factor. in. Soil Annlication Rate Horizon Depth In, Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 2FCRvUT ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. 6 Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 <_ 150 mg/L *Effluent #2 = BOD, > 30 5 220 mg/L and TSS > 30 <_ 150 mg/L e y r_ Sla,-,-, /oc�1' ♦ E,r.:sE:� $rode tic%�, .� iQe�' ",t d�9 �aCt�1`ht�r:ca Qo�r;ns�C: � rjsska,., �'o ct�cn. �������d �� s��� gr�.11�� SF�; ire. o, T. 3oK.,,P. i8� T .o{ ���oml, �.Crox� c�: �� �O2G-/Oo3..��G1�cf.�u-. (,�,;� 0.90ac�e.s O .3,aS/.,off K.j J� `� 3 of:'� . TERMINATION OF DECEDENT'S INTEREST DECEDENT'S NAME DATE OF DEATH Margaret M. Anderson Sep#ember 17,.2018 DECEDENT'S ADDRESS AT DATE OF DEATH CITY 5T ZIP 1127 W. 8th 5trae# New Ridunond WI 54017 THE INTEREST OE 7HE DECEDENT IN THE pROPERTY LEGAU.Y DESCRIBED HEREIN 15 TERMINATED PURSUANT TO THE FOLLOWING WI5CgN51N STATUTE AIVD TRANSFEfikEb AS PROVIDED BY STATUTES; ® 867,045 —real property in wh,leh the decedent Was a joint tenant,. hid a vendor's- or mortgagee's Interest, or had a llfe estate. ❑ $fi7.04fr - property of a decedent specffled in a marital property agreement, survivorsh(p marital property;'a third party canfirmatlon; or a nonprobate transfa� on death as described In705.10{S) or 705.15. DOCUMENT UNDER.WNICH DECE[1ENT'S.INTEREST INTHE PROPERTY 15NOW TERMINAT�D— t:ofiy(ias).bf whieH is/are attached: 875495 G1 I.7 Recorded Document No, U I�olume page ® Deed � Transfer on Death Land Contract ❑Mortgage tl Other Unrecorded Document: ❑ Marital Property Agreement ❑ Crther. IIIIIInIII!IIIVIIf I��IIINVI 1074402 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI 11/15/2018 03:34 PM EXEMPT#:11 REC FEE 30.00 PAGES: 10 ReCoTdln� Area NameArid Return Addressc Joseph P. Earley 100 Main Street, P.D. Box 113 $ter Prairie, WI 54Q28 see attgched Parcel Identffiptbn NumpeT: SEND'TAX STATEMENTTQ: Matt.and Monica Rof7tinski 1735 Sha[nrock Lane New F21chmDnd, WI54017 DESCRIPTION OF THE pROPERTY TRANSfERRED (check ali that.appty); C] REAL PROPERTY =legal description as's.et forth In the attached/referenced and previously recorded document tkl REAL PROPERTY -current legal descrfption tf dfJferent.than iheforegoing,document . ❑ NON -REAL PROPERTY. —property Identified In the attached document, including, digital.property, bank accounts and securities Namejs) and address of tiwner(s) of the property iinmedlately after the decedent's death; attach additional Harries &addresses if mote ttrati ohe oWne6 Monica M Rominski, Tnrstee under the Matthew L. and Monica M. Romins i Livined June $, Z008 1735 Shamrock Lane New Richmond, W154017 In xfiid ❑ joint tenant 0 remainder person if a.life estate ❑ mortgagee ❑.land contract vendor ❑ decedent's spouse ❑ beneflclarYof a marital property agreement C7 beneficlarybf a transfer under 705.10(1) of T05.15 � other: DECLARATION. To the',be�t of underslgrseds knpwledge arld belief, the under§igned declaresthat this document is true, atwr�te, Complete and in conformKy with thje�proulsionvs and Ilmftatlons of the Wtsconslh:Statutes. DATE: //'" (lam. "/ 0 DECLARAN SIGNATURE X PRINt AME: MonicaM.Rominski THIS DOCUMENT WAS:DRAFTED BY: Joseph P. Earley Signature of Notary or other person authorized to administer an oath {as per 706,06, 706.07) ACKNOWLEDGMENT STATE PF Wisconsin ) COUNTY OF St, Cr01X } Monica M. Rominski suhstribed and swornto before me on:. li- (v' 2�OIf3� , bythe ahoye named persoh(s) wtio.executed this-dbciiment grid ac/kn dged the same. ///�/� j��j%��,'J//�/ P Name; .kS�C��/-taGe<r otary Public, stag of WI5COnSlf1 Tttlei TlotaryPublic, StateoYWisconsin M Commissioh Is y j permanent} �expires,l0 � .l -� a�av`Z 1. THIS IS A STANDARD FORM, ANY MODIFlCAT10NST0rHIS FORI1ilS.HOULD BE CIEAALY IDENTIFIED. TERMINATION pF DECEDFNT'SINTEREST -Wisconsin Reg. of Deeiis Association farrti HT-110 and TOD-110. Approved 10.5.17 e r St. Croix County 1074402 Page 1 of 10 - 1 i ADDENDUM TO DEED St. Croix County Parcel ID Numbers: 026-1003-90-000, 026-1004-10-000 026-1003-90-000 Part of the NW 1/4 of SE1/4 of Section 1-30-I 8 described as follows: Commence at SE corner of said NWI/4 of SEl /4; thence N20° S I' W 460.50 feet to Place of Beginning; thence N20° S 1' W 200.00 feet to a point in Willow River; thence S69° 09' W 16.70 feet to a point on meander line of said Willow River; thence S69° 09' W 180.00 feet; thence S20° 51' E 200.00 feet; thence N69° 09'E 196.70 feet to Place of Beginning. 026-1004-10-000 A parcel of [and located in the Northwest Quarter of Southeast Quarter (NW1/4 of SE1/4) of Section One (1), Township Thirty (30) North, of Range Eighteen (18} West, more fully described as follows: Commence at an iron pipe set at the Southeast corner of said NW 1/4 of SEI/4 as the Point of Beginning for parcel to be described; thence proceed North 20° 51' West a distance of 460.50 feet to an iron pipe; thence proceed South 69° 09' West a distance of 196.70 feet to an iron pipe set on Town Road; thence proceed South 20° S I' East along the East line of said Town Road a distance of 53.03 feet; thence proceed South ] 0° 39' West along Easterly line of said Town Road a distance of 316.85 feet to the South Line of said NWI/4 of SEl/4; thence proceed South 89° 34' East along said South tine of NWI/4 of SE1/4 a distance of 378.29 feat to Point of Beginning. EXCEPT that part described as follows: Part of the Northwest Quarter of Southeast Quarter (NW 1/4 of SW 1/4) of Section 1, Township 30 North, Rage 18 West, St. Croix County, Wisconsin described as follows: Commencing at the Southeast corner of said Section 1; thence on an assumed bearing along the East line of the Southeast Quarter (SE 114) of said Section 1, North 00° 18' 14" West a distance of 1328.76 feet; thence along the North line of the Southeast Quarter of the Southeast Quarter (SE I/4 of SE I/4) of said Section 1, North 89° 3S' 13" West a distance of 1321.32 feet to the Southeast corner of the Northwest Quarter of the Southeast Quarter (NW l /4 of SE 1 /4) of said Section 1 and point of beginning; thence North 89° 35' 13" West a distance of 76.19 feet along the South line of said Northwest Quarter of the Southeast Quarter (NW 1/4 of SE 1/4) ;thence North 00° 18' 08" West a distance of 27.92 feet; thence South 88° 52' 01" East a distance of 56.13 feet to the Easterly line of that property described in Volume 456, page 338; thence along said Easterly line, South 20° 53' 08" East a distance of 29.20 feet to the point of beginning. Together with: That part of the Northwest Quarter of the Southeast Quarter of Section 1, Township 30 North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin, described as all C.T.H. "GG" right-of-way contained in Volume 456, Page 338. Subject to Shamrock Lane along the Westerly part thereof. Subject to all easements, restrictions and covenants of record. AND t t { 4. 1: t St. Croix County 1074402 Page 2 of 10 ��.���b�