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HomeMy WebLinkAbout030-2133-04-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Div;; ion INSPECTION REPORT Sanitary Permit No 463379 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: Western WI Construction I St. Jose h, Town of 030 - 2133 -04 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: t 0 0 -0 (� ft 4" � ?1-1 ( 30.30.19.2004 TANK INFORMATION ELEVATION DATA $. q5 064S 14D TYPE MANUFACTURER CAPACITY STATION ( c S, / o Fill FS ��V. ff�S y U - Septic Benchmark 2 gq �- o Dosing /I AI BM C', L/ �y (� 7 f f 7 J Ii` Aeration Bldg. Sewer� Holding St/Ht Inlet 7'! O Z TANK SETBACK INFORMATION cm' r A2,0- St/Ht Outlet f7� TANK TO P/L WELL BLDG. Ven Air Intake ROAD Dt Inlet Septic 2/ 2, i 410 3 PL B I p. O Dosing Bader an. Aeration Dist. Pipe , 1 /6 • Z7 Holding Bot. System 2 Fin I Grade ! d 1 1L9, . �s PUMP /SIPHON INFORMATION 0Y 8 Manufacturer Demand St Cover / C,ts�n.0 K p • Ll GPM 0 J Model Number E; 7 �"0 aZ� /' _ ��, ` Z, ¢ 3 • �'� /d 2.2 3 TDH ft� Fric i System Bad T ��,,� Ft �„ Forcemain Len Dia. _ y, Dist. to Well -r ' Pj frT rn 2 C / O �� SOIL ABSORPTION SYSTEM N a ,� , 5 I BED /TRENCH Width Length No. Of Tr nche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /6 \ --- SETBACK SYSTEM TO ELS BLDG WE LAKE /STREAM LEACH Manufacturer: INFORMATION R OR 1p Of System: r � o , ► /t Model Number: U �'l.G� 1 V IJi /IJ V J DISTRj0WI0N SYSTEM D rmovv%d Heade nif r � Distribution /� t / �/ i x Hole Size /t x Hole Spacing VentAir l Length Dia Z Length �+ o Dia ' Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over f Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center / ' L- Bed/Trench Edges \ Topsoil q— es No l > e Yes No COMMENTS: (Include code discrepencies persons present, etc.) inspection #1:�! Z / nn j ,,11 inspeec #i2� 1 / Location: 1382 31st Street Houlton, WI 54082 (NW 1/4 NW 1/4 30 T30N R19W) Deer Meadows Lot 4 �"`• V RarcelNo: .3 .1 . U04 1.) Alt BM Description = J ° ���- 4 3 t o-0-0, 2.) Bldg sewer length - amount of cover = Plan revision Required? Yes No OL ' 933 7S Use other side for additional information. Date Insepct s Sign re Cert. No SBD -6710 (R.3/97) Safety an to i� n County Q 0 201 W. Washin V 2 S T ` C4 -0 l sconsin Madison, I Sanitary Permit Number (to b filled in by Co.) Department of Commerce (608) 266 - 3151 3 Sanitary Permit App rl c nfo �\ State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, perso you provide OQ'j -V A-n/S . - 3 Zp(p / may be used for secondary purposes Privacy L04(1)(m) k) 6 Project Address (if different than mailing address) �� / 3 s' J-- I. Application Information - t All Information Property Owner's Na me Parcel k Lot X �/ Block # fyes7Pr IJ/S , ohs �co 30 ��133 ~D o0 Property Owner's M ailing Ad ress Property Location -a � ) 'A d,Section 3 6 City, State Zip Code Phone Number 5V 66 d b L' l gj y ,off (circle one) H. Type of Building (check all that apply) - / 3 Eta T cs N; E or_W W or 2 Family Dwelling - Number of Bedrooms f / ur Subdivision Name CSM Number _. ❑ Public /Commercial - Describe Use / / El State Owned - Describe Use PW �Y(!X , eQff / ��'(p r� �yj �' /rya . [5 ❑City_❑Village Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. N Vew System r" y El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Ty of POWTS System: (Chec all that a 1 ) ❑ Non - Pressurized In- Ground ound > 24 in. of suitable soil Aound < 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 L' ❑ Grav -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Des' p ' n Rate( f) Dispersal Area eq - red (sf) Dispersal Area Proposed (sf) System Elevation 0.3�'c6 o I( D /roar 6D� l��o off. VI. Tank Info city in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks S eptic or Holdine Tank q Aerobic Treatment Unit al Ok SAS Dosing Chamber 120 VII. Responsibility Statement I, the undersigned, assume responsibility for ' POWTS shown on the attached plans. Plumber's Na me (Print) Plu Si gnature M Num Business Phone Number o s aS 9' S� Plumber's Addre ss (Street, Ci 77 State, Zip Code) ,D / �j 9 �l F'� 5 1 , VIII. ount Department Use Onl Approved Disapproved Sanitary Permit Fee mcludes Groundwater Date I ssued issuing A0 ent Si tur Stamps) Surcharge Fee) El Owner Given Reason for Denial U6 �7 IX8 91P&M rovaUReasons f� D va� 1 s p p tic tank, effluent filter and � di cell must all be serviced / maintaine 3) as per management plan provided by plumber. 2 AW requirements mus a main alne 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 SBD -6398 (R. 01/03) � n(1 �dve P, / y Ob b v v r o ® nI v r 1 O 4, 0� Safety and Buildings commerce.wi.gov PO BOX 7162 MADISON WI 53707 -7162 in ■ TDD #: (608) 264 -8777 sco n s 1 ent of C www.commerce.wi.gov /sbt Departm www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary March 22, 2005 C CUST ID No.220673 ATTN. POWTS Inspector CHARLES L WEBSTER ZONING OFFICE OIVIS� gRTj{o f ) WEBSTER EXCAVATING, INC. ST CROIX COUNTY SPIA NOFSAQ rY� N5815 770TH ST 1101 CARMICHAEL RD7 ELLSWORTH WI 54011 HUDSON WI 54016 SEA CORK CONDITIONAL APPROVAL ES pO� PLAN APPROVAL EXPIRES: 03/22/2007 Identification Numbers Transaction ID No. 1120673 SITE• Site ID No. 696028 Scott Green Please refer to both identification numbers, CTH V; Town of Saint Joseph I above, in all correspondence with the agency. St Croix County NW1 /4, NW1 /4, S30, T30N, R19W Lot: 4, Subdivision: Deer Meadows FOR: Description: new 4 -bed mound with Polylok filter Object Type: POWTS Component anulV — al -- Regulated Object ID No.: 1009196 Maintenance required; 600 GPD Flow rate; 34 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /01), Pressure Distribution Component Manual - Version 2.0, SBD - 10706 -P (N.01 /01) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined irk s. 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06, Wisconsin Statutes. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the approved plans and with the 'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD- 10706 -P (N.O1 /O1). • This system is to be constructed and located in accordance with the approved plans and with the component manuals listed above. • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD - 10691- P(N.01 /O1). • The pressure network is to be constructed in accordance with publications SBD - 10706- P(NO1 /0 1) 'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems - Version 2.0" and/or the sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS (01/81) ". CHARLES L WEBSTER Page 2 3/22/2005 A copy of the approved plans, specifications and this letter shall be on -site during onstruction and open to g P inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per s. 101.12(2), Wisconsin Statutes, nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received 175.00 {�y7 Balance Due $ 0.00 J n M MacCubbin Engineering Consultant , Services WiSMARTcode: 7633' (608) 266 -0955, Fax: (608) 264-8795, M - F: 700 am - 330 pm jmaccubbin@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 WEBSTER EXCAVATING, INC. N5815 770th St. Ellsworth, WI 54011 ; X (715) 273 -3430 `ionally OWED COMMERCE \ND BUILDINGS n p� POWTS Index Sheet Page 1 of 8 - AZound System for a 4 Bedroom Residence W, Property Owner/Pro ject Name Western WI Construction & Design, Inc. Lot 4, Deer Meadows Subdivision NW % NW'/ S30 T30N R19 W Town of St. Joseph, St. Croix County, WI Contents Page 1 of 8 Index Sheet Page 2 of 8 Plot Plan Page 3 of 8 Plan View Gross Section Page 4 of 8 Distribution Pipe Layout Page 5 of 8 Pumping Chamber Layout „ Page 6 of 8 Pump Performance Curve Page 7 &8 of 8 Management Plan %5 Ci 0 N S t����► CHARLES L. S WEBSTER = • • E•18803 t (r A ELLSWORTH F W i � WIS. Z► • Component manual used: Name: Mound Component Manual for POWTS Version: 2.0 SBD- 10691 -P Date: January 30, 2001 Name: Pressure Distribution Manual for POINTS Version: 2.0 SBD 10706 -P (.zs-e s I i I J - ^c. � r I V ho M ` u J s S 1 � � v 2 � a ga1'r.2 = 9:.,. tf //, J /f;,, d,•J,, arc p,�oc. 7r- • � 0�- C`R�o.do� 5 , mot W Page 3.Of /P c ra9 Sea t,'gYt Approved Synthetic Covering Distribution Pipe FAST t'1 a - 3' Medium Sand G Topsoil =H= _ =_ F Elev /o , D 3 E .13% $lope Bed Of 2- 2 2 ( Force Main Plowed Aggregate From Pump Layer A-, 0 0- Ft. rL �rn� E f- 8 Ft. Cross Section Of A Mound System Using F - Ft. A Bed For The Absorption Area G G -5_ Ft. A /O Ft. H 01 Ft. Linear Loading Rate =lb OGPD /LN FT B 6" Ft. Design Loading Rate= 0,37GPD /SQ FT j 7 Ft. Ft. K / D Ft. L Ft . , W 3 4- Ft. Observation Pipe t o / ----------------- - - --.i -- �'- 2 -BtoDistribution Bed Of 2 2 Pipe Aggregate /1teN d IJ Observation Pipe '� < <�SB °x w��y (Anchbr securely) �See�o,�g detd��S�leGrf, 4 %HC�es be P�oyi'aled wi th � w�7`l°r t��.�i cdp h!l/C Ttia b.�i►3 �ihCLic.P S�o f7tC of � � C. rc«cre /y ��< <ored� Page Of Perforated Pipe Detail End View Perforoled PVC Pipe / zs� a Holes Located On Bottom, SC C a�ed�/ Are Equally Spaced P n / PVC a� Morifold Pipe 1 );Slrljulion / Pip -� d P ' Ft. Distribution Pip Loyoul S � Ft. fin F h ow /0 a ` P� a 7 S 0 {' / / X 4 Inches p�cS - r(A Y 4- Inches / �' 3- Hole Diameter //8 Inch _ Lateral r /4- Inches) Manifold a Inches r Force Main " oZ Inches r — # of holes /pipe .'9 �otceess b.x tti1,CdC/,c/ �k Invert Elevation of Laterals /o3.0 Ft. Lhf S-ew c,6 e1 Js- T , / 4. — P,• %o . e ,, Place 1st holea from center of manifold with succeeding holes at4 %17 intervals. Lasf ko/e 'to Z�e p z d[n• r ®.11 �r,o/oF' d,rtr'but,a,act /_ Page 5 0f- co '1« �•I,or Surd 90 (No Scale) P /-'17 rest P. > /Of' • .Approved Locking Manhole Covers { ""17 µ,;,sow o� x'- With Warning Labels Attached Weatherproof Approved _ �r Junction Box Vent Cap y,t.a /fir ✓ ✓ee /`9Cj,� 12" �tinimum 4" Minimum I Quick . 18" Minimum __ Discobect 1/4" Weep Pik ���� cevo► Hole 6?_ Baffle � Pol �e k s..t � , n i A Al a rm 6" B On , i t 'f 8�.� P e ' C ci � - APPROVED Off v �4 •S 6' of coy or *, JOINTS WITH d«,1 APPROVED PIPE D 3' ONTO Conc. Block SOLID SOIL y 3" of Be,ddi ng Under Tank -� ,*,,t7F � Y at�eft^m oj! ' rd� ddhd'fe- Number of Doses:S%3 Per Day Gallons Per Day /[ Doses: //1•`} Gallons Volume of Backfl ow:-�-:, 4 <-Q)+ 3 6 Gallons �;�� "k I/e f�- c/1 -Zme Total Dose ' Volume: Voume :........ Gallons _ / , Tank Manufacturer: C —� Tank Size-Septic/Pump: 11--ra / 7s'� Ga ons Alarm Manufacturer: Model Number: D lv C A inches or 4,S/ Gallons Switch Type: sifed/ + B 2 inches or 3a„ Gallons Manufacturer: G..,.lc/ + Cinches or /4, Gallons Pump + D inches or /2 Gallons Model Number: - S' Minimum Discharge ate: :z_ I Total ..... 4Z inches or 7,�-7 Gallons Vertical Difference Between Pump Of and Distribution Pipe Feet S' 0 << 3o J,� ...... + ,3 -Feet M m Required Supply Pressure: ... '..•• - Feet of Force Main x /w /a- Friction Factor /100 Feet: + a•� eet�. Inch Diameter Force Main Total Dynamic Head:...= a�aFeet t 7 Width �6 ' Liquid De th Internal Tank Dimensions: Length � q p .r, /," s D�� � S P� 6 o� GOULDS PUMPS Submersible ,z Effluent Pump PE CWT PUMP b SPECIFICATIONS MOTOR FEATURES Pump — General: General: ■ Corrosion resistant • Discharge: 1 NPT • Single phase construction. • Temperature: 104 °F (40 °C) • 60 Hertz ■ Cast iron body. maximum, continuous when • 115 and 230 volts ■ Thermoplastic impeller and fully submerged. • Built -in thermal overload pro- cover. • Solids handling: Yz" tection with automatic reset. ■ Upper sleeve and lower maximum sphere. • Class B insulation. heavy duty ball bearing • Automatic models include a • Oil- filled design. construction. APPLICATIONS float switch. • High strength carbon steel ■ Motor is permanently • Manual models available. shaft. lubricated for extended Specially designed for the . Pump: Pumping range: see PE31 Motor: service life. following uses: ■ Powered for continuous • 115 volts performance chart or curve. • .33 HP, 3000 RPM • Mound Systems operation. • Effluent/Dosing Systems PE31 p' ■All ratings are within the • Maximum capacity: 53 GPM • Shaded pole design •Low Pressure Pipe Systems p �� working limits of the motor. 5' TDH M • Maximum head: 2 PE41 Motor: ■ Quick disconnect power Basement Draining Q p • .40 HP 3400 R PM •Heavy Duty Sump/ PE41 Pump: cord, 20 standard length, Dewatering • Maximum capacity: 61 GPM • 115 and 230 volts heavy duty 16/3 S1TW with • Maximum head: 29' TDH • PSC design 115 or 230 volt grounding DeH,J., 1�,��Pt►� PE51 Pump: PE51 Motor: r plug. n • Maximum capacity: 70 GPM • .50 HP, 3400 RPM ,■ Complete unit is heavy duty, 177 • Maximum head: 37' TDH • 115 and 230 volts portable and compact. • PSC design ■ Mechanical seal is carbon, METERS FEET ceramic, BUNA and stainless 40 _ _ r _ _. I _•. i _ - - MODELS: PE31, PE41, PE51 steel. PE 1I ` F i r i '- H P: .3% .ao, .so ■ Stainless steel fasteners. L +- L 35 _ -� ` + - —► 2 GPM AGENCY LISTINGS 10 - 30 E — y__ 1 FT + _ w 25 --� C� us ! = - _ r T ested to UL 778 and g a Z 20 — * k CSA 22.2108 Standards }.I _ By Canadian Standards Association 15 File #LR38S49 . O Goulds Pumps is ISO 9001 Registered. 10 ;- _ 5 I LL + 10 20 30 401 I i t 0 0 0 I 50 60 70 GPM 80 0 5 1 1 m3 /h Goulds Pumps CAPACITY © 2004 ITT Water Technology, Inc. ITT Industries Effective June, 2004 BPE31 /41 ntvw Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings of w in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S include, but not limited to: vertical and horizontal reference point (BM), direction and �. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. �a � 3 ' O — Please print all information. evie ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) rty P (m)). Property Owner 5 "° ° r x Property Location OI � r 6ert -teE-- N 1/4 N W 1/4 S 3D T 3 N R Property Owners Mailing Address ; l E (or W ` ` �J Z� � , E J i' Lot # Block # Subd. Name or CSM# �w s City State Zip Coe ;Phone Nwrts r City Village R Town Nearest Road i Lq ® New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate S O I ❑ Replacement GPD Public or commercial - Describe: Parent material Flood Plain elevation if applicable N General comments ft. i and recommendations: ' - AZ\jy, � w lQ x S� 3 ( ` S n � q . JC)Z,o' i Boring # ❑ Boring ® Pit Ground surface elev. 9 ft, L.j 7 Depth to limiting factor in. Soil Appli ation Rate Horizon D epth R Red o x Redox Description Texture Structure Consistence Boundary Roots G /ftz i n. Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Effn2 � o l2 — S) ( Z`Fshk mU�Y- Z S 2 iZ - 3 —' 2-344S ?) �mS�h — .S rQ `Y- C� S R 3 13 s� 1 om M7- a Boring # ❑ Boring Pit Ground surface elev. u - 0 ft. Depth to limiting factor 3 in. Soil Appli bon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0_\3 ) oy (Z3 l Z - si 1 O - Z .S Z 13 -3 l _ s I 3 L1 - tUy iZ Yl ��� Syr�3l3 Si 1 p m`F�. — • o Z Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOO < 30 mg/L and TSS _< 30 mg/L CST Name (Please Print) ie CST Number gnatur Arthur L. Wegerer 03 - �OZ-. 220254 Address [f e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. %lain St. River Falls (7I 54022 6 -I 6- 03 715 -425 -0165 J Property Owner Parcel ID # ��'���)AJ Page z of ❑ Boring # Boring R g + Pit Ground surface elev. ft. Depth to limiting (actor (n, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fl In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2 1 0 -9 )o tt-3Lz - sit Z s `� bk I 231 — s i I bk M fi- 37 bcz pn`f; U - 10Y2. S13 C I& s.Ll fL 3 C�ih, Vv1`Fh _ _ . Z 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 /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring # ❑ Boring F El Pit Ground surface elev. it. Depth to limiting factor 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 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 M' an alternate format, please contact the department at 608 - 266 - 3151 or TTY 608 - 264 - 8777. S1113- 8330(R.6/00) PLOT PLAN Page of 3 Y - / Scale 1' =S0' , I , i r I k f I UST 1 4 Lem / V-;: � �-" �) � Co�.,rnjv�Z fit. I 1 (�- 03715- 425 -0165 220254 03 -1 OZ - CST Signature Date Telephone I-To. CST No. Job NO. POWTS NER'S MA O 8� MA �IAGEIE� PLAN Page or OW FILE INFORMATION SYSTEM SPECIFICATIONS Owner c�es� ��sc, ed.ff,4��, y ,p y Septic Tank Capacity a l ❑ NA Permit # Septic Tank Manufacturer �eSHS- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer d / / K ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 7 S-S` ❑ NA Number of Commercial Units NA Pump Tank Capacity 7,S` p a l ❑ NA Estimated flow (average) 4-,62 � g al/day Pump Tank Manufacturer 6 CowcrtA ❑ NA Design flow (peak), (Estimated x 1.5) 0 0 g al/day . Pump Manufacturer 67. . / d ❑ NA Soil Application Rate G-S` al/da /W Pump Model IbFS` ❑ NA Influent/Effluent Quality Monthly average' Pretreatment Unit NA ❑ Sand/CZravel Filter ❑ Peat Filter Fats, Oil &Grease (FOG) 530 mg /L Biochemical Oxygen Demand (BOD,,) 420 mg /L ❑Mechanical Aeration ❑Wetland Total Suspended Solids (TSS) 5150 m /L ❑ Disinfection ❑ Other. Manufacturer Pretreated Effluent Quality O NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ At -grade ;(Mound Fecal Coliform (geometric mean) 510 cfu/100m1 ❑ Drip-line ❑ Other Maximum Effluent Particle Size Y inch diameter Values typical for domestic (non- commerclaq wastewater and septic tank effluent. •• Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months 14 year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one -third %) of tank volume Inspect dispersal cell(s) At least once every ❑ months Ikyear(s) (Maximum 3 yrs.) Clean effluent filter At least once every 02. K months ❑ year(s) Inspect pump, pump controls & alarm At least once every 0 months K ❑ year(s ❑ NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA Ar o% Other. At least once every ❑ months ❑ year(s) ❑ NA ,Q S /Va < d Other At least once every C ( months ❑ year(s) 110A 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 and to check for an ndin of effluent on the round surface. The onding of effluent on the in the observation pipes a Y Po 9 9 P PP n f the local regulatory authority. indicate a failing condition and r o g ry round surface may g requires the immediate notification 9 Y When the combined accumulation of sludge and scum in any tank equals one -third %) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatfinent components, and any other maintenance or monitoring at intervals of 12 months or less 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. 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. Page of 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. ABANDONM 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 ch. Comm 83:33, WisconsinAdministrative 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: ❑ 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 o w4� �k�W yd�• ,t.-4 c-- Name (�K/�hokh Phone 7!�*' - * - 9 7 & Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Agency St <<..- Cc /' boy.- Phone Phone 713- - 3 6 tS- 4 6t? O This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitatlon agencies. This document meets the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)w and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) ST CROIX COUNTY SEPTIC TANK MAINTBNANCB AGRBBMBNT AND OWNERSHIP CBRTIFICATION FORM awn uyer Mailing Address /0 6 14 14 Property Address $) -� l (Verification required from Planning Department for new construction) City /State ' ('i� b 1 A Parcel Identification Number 3 0 °� 1:23 dG 6 LEGAL DESCRIPTION 200'0 q� Property Location r/s, IV w /., Sec. , T 56 N RW, Town Of Subdivision �' ?'' Lot # Certified Survey Map # , Volume . Page # Warranty Deed # Volume ) `' � 7 - Page # J Spec house 9 yes ❑ no �b a 3 Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE Improper use and mainter anceof 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, The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorphrmber, journeymanplumber, restrictedplumber or a hcensedpumper verifying that (1) the on site wastewaterdisposal 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 Zoning Office within 30 days of the thr year expiration date. `1 4 / -61 � SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in t h e sanitary permit being revoked by the Zoning Department. ** 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 Parcel #: 030- 2133 -04 -000 04/07/2005 03:57 PM PAGE 1 OF 1 Alt. Parcel #: 30.30.19.2004 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner * WESTERN WISCONSIN CONSTR WESTERN WISCONSIN CONSTR & DESIGN INC & DESIGN INC 1117 220TH ST BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1382 31 ST ST SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.100 Plat: 1894 -DEER MEADOWS LOTS 1/8 030/03 SEC 30 T30N R19W PT NW NW DEER MEADOWS Block/Condo Bldg: LOT 04 LOT 4 (3.100AC) Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 30- 30N -19W NW NW Notes: Parcel History: Date Doc # Vol /Page Type 12/19/2003 749623 2477/531 QC 11/19/2003 747019 9/93 PLAT 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 6775 66,300 Valuations: Last Changed: 07/12/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.100 65,200 0 65,200 NO Totals for 2004: General Property 3.100 65,200 0 65,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Il �496c�3 Ir di 2 4 7 7 P 5 3 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 3 - 1998 REGISTER OF DEEDS sT. cROIx Co.. 1+I RECEIVED FOR RECORD 12/19/2003 10:30AH Stuart T. Green and Laurie A. Green, quit - claims to Western Wisc. Constr. & Design, Inc. the following described real estate in St. Croix County, State of QUIT CLAIM DEED EXEMPT i Wisconsin: TRANS 750000 Lots 2, 3 4 nd 8 of Deer Meadows in the Township of St. Joseph. COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address ir 9 5 030 -1086- 20-000 and 030 -1086- 30-000 Parcel Identification Number (PIN) This is not homestead property. Dated this day of "1"' , 2003. �— � /�� ( / / *Stuart T. Green *Laurie A. Green * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. County ) Pers na11y came before me this , day authenticated this p day of of , 2Op3t abo ve named , 2003. ROg Sn !/� /�T .7p [[�� Notary Public 1' oxo� to me known to be the person(s) who executed the st ate foregoi nstru n d acknowledge the same. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) Notary Public , State of Wisconsin THIS INSTRUMENT WAS DRAFTED BY y Commission is permanent. (If not, state expiration date: 20 3 •) Ronald L. Slier VAN DYK, O'BOYLE & SILER, S.C. Post Office Box 118, New Richmond, WI 54017 (Signatures may be authenticated or acknowledge. Both are not necessary.) *Names of persons signing in any capacity should be typed or printed below their signatures QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 -19" INFORMATION PROFESSIONALS COMPANY FOND OU LAC. WI 8004W6 -2021