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HomeMy WebLinkAbout030-2123-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488218 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)J. Permit Holder's Name: City Village X Township Parcel Tax No: McCormack, Scott I St. Joseph, Town of 030- 2123 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /Dp AN 1 L5 ( 33.30.19.999 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI I FS ELEV. Septic I 3 � Benchmark gQS-ijg Alt. BM / Aeration Bldg. Sewer Holding St/ Ht Inlet a� S.65 9l• 57 TANK SETBACK INFORMATION S t /Ht Outlet 3Z TANK TO P/L WELL BLDG. en o it Intake net p B ottom e Ic 7 2S � $(�� �$ / LI / osIng Header/Man. /6.35 A eration is . ipe / c17- 2 7 0 •' 9 & • i:7 7361 g o . ys em r, //, �/5 7(,,./7 ma rG ra e PUMP /SIPHON INFORMATION - ak- C t 7. /QD. raL m anufact urer uemana SrUo—ver j '/ GPM t CoJtl 1 //Z 7 L . 3 143 M odel Nu 6 W t ric ion em rlea 1 r F-d rcemain I LengM ia. u1sx. 10 Well orw Mr-MA-1 MUM 01 1 MUM Of PIES Inslue Lila. I N01VF40 INK). [qulu Uupul DIMENSIONS 3 w$ re INFORMATION CHAMBER OR i UNIT t 7 d-17 = 4 '/ Pipe(s) 7,1 t1 \ \ ` , ! d M— Length �_ Dia i Length Dia Spacing � 53 ' Pressure Systems Only xx Mound Or At - Grade Systems Only Bed/Trench Center 7 Bed/Trench Edges Topsoil \,-,Yes No \ ' Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 572 128th Ave Somerset, WI 54025 (NW 1/4 NE 1/4 33 T30N R19W) Perch Lake Estates Lot 1 Parcel No: 33.30.19.999 1.) Alt BM Description = C --, k� Cc oe_�_ 6Z J ec 5 2.) Bldg sewer length - �� - amount of cover = Z r ��� �,,�_ 0 1 �•SVI� �-� LL I t ZD tTb 5 a fc�cR.. w I Jee v% OL - At J1e �J�-y z251_ >4 z _ J a Plan revision Required? i i1 Yes 'No Use other side for additional information. .tor` tur SBD -6710 (R.3/97) Sa and B 62� P N visconsin 201 W. Was on ve., P.O. i o Madison, W 3707 — 7162 Sanita Permit Number (to be filled in by Co.) Department of Commerce (608) -31,�N U 5 � Q� State Ian I.D. umber VV Sanitary Permit Application ST. CROrxca ,;r In accord with Comm 83.21, Wis. Adm. Code, personal Information you provide Uf r may be used for secondary purposes Privacy Law, sl5.04(1)(m) Proj t Address (if different than mailing address) I. Application Information —Please Print All Information 2 9 *' Property Owner's Name Parcel # Lot z 4f C'62/M c(z o 3 Ziz o o C> Property Owner's Mailing Address Property Location A OI -4f , A4114, AI C �'A, Section e3 City, State Zip Code Phone Number 99 T N R (c (• / f . H. Type of Building (check all that a pp l y) o1C. aS P! o � 91 or 2 Family Dwelling - Number of Bedrooms � AkA tom Subdivision Name CSM Number �.. .. I ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use 6? 5 LJ 7 �15 City_❑Village VTownship of .5�+ -LP III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. WNew System p y g p y g y ❑ Re S ❑ Treatment/Holdin Tank Re Onl El 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. Type of POWTS System: Check all that appl 19 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ ConX;t cted Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) 1 V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rat gpdsf) Dispersal Area Required Di o sal Area ( System Elevation 1�5­6 � 1 - 7 1 &Awev, p z< ;) 5 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel er a hic Gallons Gallons of Units Concrete Constructed Glass a New Existing rJ Tanks Tanks Septic of Holdin Tank �, s y_. `,� h. Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plu tier's Name (Print) Plumb 's Signatur MP /MPR3 Number Business Phone Number © � NC��sa� 2 2 7 3 K L Plumber's Address (Street, City, State, Zip C046) VII .ount � /De artment Use Onl pproved �.Brpo d Sanitary Permit Fee includes Groundwater Date sue Issuing A ignature tamps) (J S� Surcharge Fee) ' „ iven Reas o enial tJ IX. Conditions of Approval /Reasons for Disapproval t SYSTEM OWNER: Mw and 3) ✓ l �,k, W1 � 5 dispersal cell must all be services I Jmiftined as per manaysmertt plan provided by pIUMber. / t Z. AN sold* npuire rmft must be 1rob tainO e rS 1 n wry coda / ordirltrlcss. G - ok -7 �- C s -- S r/ J4 Attach complete plans (to the County only) for the system on paper not less than ST 11 inches in size SBD -6398 (R. 01/03) �,,, kCC4- ✓ S P Co` A/V c Cop- I. C- p � Z 1 l � top � 3 � IA;VL -E- y Vk /4 Z �o� 1 Pemcr+ (-Ai<& f bl g� top 01 1A�-r4L4%V �y - �L Wisconsin Department of Commerce S E LUATION REPORT Page 1 of 2 Division of Safety and Buildings in accordance mm 8 , dm. ode Amy ST. CROIX Attach complete site plan on paper not less than 8 1/2 x 11 inches es . Plan include, but not limited to: vertical and horizontal reference point (BM , dl nand Parcel I.D. 030/2123/ - 000 percent slope, scale or dimensions, north ar ow, a Qe +o oce to n st road. Please print a I information. v Reviewed Date Personal information you provide may be used fo secondary urp a (P ' aw, s. 1 .04 (1) (m)). bo O Property Owner Pro erty Location SCOTT MCCORM K ST. CROIX COUNTY Go . Lot ---- NW 1/4 NE 1/4 S T 30 N R 19 E (or) E] W Property Owner's Mailing Address Lot Block # Subd. Name or CSM# 1 -- Perch Lake Estates City State Zip Code Phone Number DCity [:]Village ■ Town Nearest Road St laseph ( ) 128th Avenue 0 New Construction UseE] Residential / Number of bedrooms 3 o r 4 Code derived design flow rate 450 or 600 GPD ❑ Replacement Public or commercial - Describe: Parent material outwash Flood Plain elevation if applicable N A ft. General comments Addendum to Soil Report submitted 09 -15 -05 due to location of proposed dwelling. and recommendations: Conventional In ground trenches -- 0.7 loading rate 1-71 Boring # Boring Q pit Ground surface elev. 99.78 ft. Depth to limiting factor 116 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -3 10YR3/2 - sl 2fsbk ds cs 3vf-m 0.6 0.8 2 3 -9 10YR3/2 sl 3fabk ds cs 2vf -m 0.6 0.8 3 9 -16 10YR3 /4 A 2fabk mfr as 2vf -m 0.6 0.8 4 16 -20 10YR3/4 is lmsbk mvfr cs lvf -m 0,7 1.6 5 20 -43 7.5YR4/4 !t '�' s Osg ml as -- 0.7 1.6 6 43 -53 7.5YR4/3 f-, 3 cos Osg ml as -- 0.7 1.6 7 53 -116 10YR5 /4 s Osg dl -- -- 0.7 1.6 5 Boring # ❑ Boring 100.23 120 Q pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *042 1 0 -5 10YR3 /2 1 3f -mabk ds cb 3vf -m 0.6 0.8 2 5 -17 10YR3/2 -- it 1 2f -mabk I ds ab 2vf -m 0.6 0.8 3 17-25 10YR3 /3 P sil 2f -mabk mfr cs lvf -m 0.6 0.8 4 25-44 10YR3/4 sil 3fabk mfr cs lvf - -m 0.6 0.8 5 44 -120 7.5YR3/4 - is Osg ml -- -- 0.7 1.6 Horizon 5 has some layers of 10YR4/3 cos and 20- 25% gravel; I few cobbles. * Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Mary Jo Hollister / 224832 Address l a va uation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 06-05-06 (715) 426 - 1775 Plot Plan for Site and Soil Evaluation Page z of ? Property Owner N`ccov- Ak %c\<, 5 cD - m I"= 40 ft Legal Description Lar- k . peat u psKm P-s«-nas. (except where noted) NW'/g oF- -r+�� `l� scc, a, Tw N��,gw -co�� aF � = Backhoe pit 3.07 AcR;s North No WELL - t ,��ti`a� �1b3 �'tZd'1`�YP'C +GUNK Q p5� 9 �J A14 l'A FRott' �RO'v►J o F1eLp -10° lab.00 �0. V000, 10 Site Location: �z8* A� <M. W. �a s�c� as a Wisconsin Department of Commerce S L E TI O PORT Page of Division of Safety and Buildings in accordance Comm 85, Wis. e /t 7� Attach complete site plan on paper not less than 8 1/2 1 inchesih �Ye. Plan mu County � include, but not limited to: vertical and horizontal refer ce (BM), directyan and Parcel I.D. percent slope, scale or dimensions, north arrow, and I ion n tance 4o st road. i � 0/ , " � Revie by Date Please print all nformat�on. ti C� Personal information you provide may be used for secondary purposes (Priva ". t5'p4 (1) ( S Property Owner perty cation 4 A , Govt. t 1/4 JU�1 /4 S 3T 3 R E (o W Property Owner's Mailing Address Lot # 1 Block # Subd. Name CSM# 2- er� s City State Zip Code Phone Number City [I Village Town Nearest Road New Construction esidential / Number of bedrooms Code derived design flow rate �� GPD ❑ Replacement El Pubic oWom - Describe: __— Parent material /'—' 4 2b' Flood Plain elevation if applicable General comments and recommendations: s y �` ie w ! �j ✓GvY v l �� 0 p2 Boring # E] Boring l / 01pit Ground surface elev. �' ft. Depth to limiting factor (a in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 — S VAS / 1 [aBodrig # ❑ Boring t Ground surface elev. l L ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 7' i /0;� D S ✓1 l l Ly It ' Effluent #1 = BOO > 30 1 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/- and TSS < 30 mg/L CST Name (Please Print) re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 540— � --��— 715 - 246 -4516 Property Owner _ Parcel ID # Page of a Boring # ❑ Boring (l (� . Z Pit Ground surface elev. U ft. Depth to limiting factor 1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I •Eff#2 rl �0 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 "Eff#2 I Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (Rbroo) Soil Test Plot Pla Project Name Garth VanderVorst Sh it Add_ ress 584 128th Ave Hudson Wi 54016 lf TM #226900 Lot 1 Subdivision Perch Lake Estates Dat 9/15/05 NW 114 NE 1/4S 33 T 30 N /R19 W Township St. Joseph Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation 93.0/93.2 *HRpSameasBenchmark Property Line Scale is 1" = 40' unless otherwise noted 98' 97' B -1 B.M. 75' 50' 36' 30' 4% Slope B -3 Alt. B.M. is top 35' of leaning fence post @ 97.8' B -2 10 Property Line '17R'Pmpt-.rt4 Tint-, Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County St. Cr oix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not 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. pending Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Del Ma sam Govt. Lot NW 1/4 NE 1/4 S 33 T 30 N R 19 W or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 950 N. Knowles Ave. 1 1 na Perch Lake Estates City State Zip Code Phone Number ❑ City ❑ Village U Town Nearest Road New Richmond ( ) _ St. Joseph Ek New Construction Use: El Residential / Number of bedrooms 4 Code derived design flow rate i ! ' GPD ❑ Replacement ❑ Public or commercial - Describe: ' t Parent material outwash Flood Plain elevation if applicable - .".\ -`•ft. C General comments and recommendations: t ^ "' 790 j trenches @ el. 97.70'. spaced to code 4.00 below grade r te', l Boring # Boring F 1 +1 0() `,•.� ; `� , ZON4NG O pit Ground surface elev. 01 .70 ft. Depth to limiting factor in , i - Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary + flbots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff#2 1 0 -15 sil .8 2 15-33 ms 0 7 3 33 -43 7.5 4 4 ml 4 43-100 7.5 4/6 none F 2 Boring # E] Boring 1 01.70 pit Ground surface elev. ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color .. Gr. Sz. Sh. 'Eff#1 - Eff#2 1 0 -8 10yr4/3 none sil 2msbk mfr cs 2f 2 8 -36 10yr4/4 none sicl 2msbk mfr 3 36 -64 7.5yr4 4 none cos Osg ml gw na .7 1.2 4 4 -100 7.5 4/6 none .7 1.2 Effluent #1 = BOD > 30< 220 mglL and TSS >30 < 150 mg /L ent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Gary L. Steel 02298 Address a rvaiukon Conducte Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -12 -2001 715- 246 -6200 ' � a 1• Property Owner _ Del Mag Parcel ID # pendi Page 2 of - ❑ Boring # ❑ Boring 3 [ pit Ground surface elev. 100.00 ft. Depth to limiting factor 1 ()O in. Soil � Applicafion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 1 0 -10 10yr4/3 none sil 2msbk mfr cs 2f .5 .8 2 10 -22 1Oyr4/4 none sicl 2msbk mfr qw If 4 6 3 22-101 7.5yr4/6 none ms 0S ❑Boring # F1 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 GPDlff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 `Eff#2 F Boring Boring # Ground surface elev. ft. Depth to limiting factor in. 1:1 pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2 Effluent #1 = BOD > 30< 220 mg/L and TSS >30 5 150 mg /L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.6100) STEEL'S SOIL SERVICE Gary L. Steel Del Magsam 1554 200th Ave. CSTM2298 , NW4NE4 , s33 T - R 19w New Richmond, WI 54017 MPRSW -3254 town of Somerset (715) 246 -6200 lot #1 -Perch Lake Estates This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1 11 =40' BM-= top of survey stake @ el. 100.00' alt. BM.= top of survey stake @ el. 98.85' b- 5 to '' -48 ` 51 N U-10 Kj -37� / Gary L. Steel 6 -12 -2001 II ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer Mailing Address Property Addres Q& (Verification required from P inning & Zoning Department for new construction.) City /Stat e��¢_,p,� Parcel Identification Number LEGAL DESCRIPTION Property Location ' /a , '/a , Sec., T ; Town of Q. Subdivision , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house ❑ yes 14 o Lot lines identifiab S ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 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. Number of bedrooms IGN OF APPLICANTS �DATE� A R ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ��o G G vtti l L It rAf / V mic*4 A TANDARD CHAMBER 4kev 52" Quill Standard Chamber/ 48" (EFFECTIVE LENGTH) Ulf 12" /1✓ 8 34" SIDE VIEW SECTION VIEW MultiPort End Cap A 16" 12" 34" SIDE VIEW TOP VIEW FRONT VIEW No t INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( `Uoitsj, when installed and operated In a leachfield of an onshe septic system in accordance with Infittrator's instructions. is warranted to the original purchaser ( "Holder") against detective materials and workmanshP for one yew from the data 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 (he date that hstallaticn of Una septic system commences. To exercise its warranty fights, Holder roust notify Infiltrator In writing at its Corporate Headquarters In Old Saybrook, Corvhectcut 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 . • 10 1 Infiltralo s liability specifically excludes the cost of removal andror hstallatlon of the Units. O (b) THE UMI TED WARRANTY AND REMEDIES IN SU8PARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT R TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE SYSTEMS INC (c) This Limited Warranty shall be void t any part of the chamber system is manufactured by anyone other than Infiltrator. The Limned Warranty does not extend to incidental, consequential, special a indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, Including bas of Environmental Onsite wastewater solutions"" production and profits, labor and materials, overhead costs, or other bases or expenses incurred by the Holler or any Uhird party. Specifically excluded from Umited Warranty coverage are damage to the Units clue to ordinary wear and test, altwatlon, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the Installation hamctions; failure to maintain the 6 Business Park Road • P.O. Box 768 minimum ground covers set forth In the Installation khstRICtiOrha; the placement of Improper materials Into the system containing the Units; failure of the Units or the septic system due to improper Siang or improper Sizing, excessive water usage, Improper grease dlsposal, or improper operation; or Old Saybrook, CT 06475 any other event not caused by Infiltrator. This Limited Warranty shell be void if the Holder fails to comply with all of the terms set forth in this Limited 860- 577 -7000 •FAX 860 - 577 -7001 Warramy Further, In no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, a any third party resulting from Installation a ship- 800 - 221 -4436 men, a from any product liability G w claims of Holder ary third party. For this Limited Warranty to apply, the Units must be installed In accordance with all site conditions required by stale and local codes; all other applicable laws; and Infiltrators hatafiatlon Instructions. (d) No representative of Infiltrator has the authority to change or extend this United Warranty. No warranty applies to any party other than the origi- nal Holder. The above represents the Standard Urnited Warranty offered by Infiltrator. A limned number of states and counties have different warranty require- ments. Any purchaser of Urns should contact Infiltrator's Corporate Headquarters In Old Saybrook, Connecticut, poor to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer and SldeiNindar are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour, Contour Swivel Connection, Microl-eaching, PolyTuff, SnapLock, ChamberSpace, Posill QuickCu, QuickPlay RECYCLED PAPER and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed in U.S.A. 0011203HP -0 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa I— of L FILE INFORMATION SYSTEM SPECIFICATIONS W f 0 ne °G 0 G GoAt4 l G K Septic Tank Capacity � al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Z L ❑ NA Number of Bedrooms ,3 ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units --- ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) 3'v u g al/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) 4 �6� - D g al/day Pump Manufacturer ❑ NA Soil Application Rate o 7 al /da /ftz Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L 09 In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. 13 NA Other: 13 NA Other: E3 NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA 9 year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA ® ear(s) ❑ month(s) ❑ NA Clean effluent filter At least once every: ® year(s) Inspect pump, pump controls &alarm At least once every: 3 ❑ month(s) ❑ NA IN year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA '® year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding failing condition and re q uires the f ace may indicate a of ef on the round surface. The ponding of effluent on the round surf y g immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing. of effluent filters, mechanical or pressurized components,. pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page ?_ of 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 fank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the call(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed., • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ 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 © & 2 L SO/V Name Phone S -' Z 7 3 - ! Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 8261376 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number Document Name 06/06/2006 02:20PK WARRANTY DEED EXEMPT # THIS DEED, made between Garth E. VanderVorst and Jennifer H. Vandervorst, husband and wife TRANS FEE t 11.00 TRA FEE: 367.50 ("Grantor," whether one or more), COPY FEE: and Scott D. McCormack and Bonnie L. McCormack, husband and wife CC FEE: PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is EStmen & 0g land jj 1 needed, please attach addendum): 1'8@t Lot 1, Perch Lake Estates. St. Croix County, Wisconsin. ' 3 4SO C �� St bl)St I G I II 030-2123 -10 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated /7�L (SEAZ*GE. (SEAL) * Va derVorst (SEA (SEAL) * H. Van erVors AUTHENTICATION ACKNOWLEDGMENT Signature(s) Garth E. VanderVorst and Jennifer H. VanderVorst husband and wife STATE OF ) authenticated on ?i O ) ss. COUNTY ) *Kristine O land 17 Personally came before me on TITLE: MEMBER ST4fE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Oeland Notary Public, State of Hudson. WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type ' 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - VANDERVORST, GARTH E & JENNIFER GARTH E & JENNIFER VANDERVORST 584 128TH AVE HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 572 128TH AVE SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.070 Plat: 2295 -PERCH LAKE ESTATES 02 SEC 33 T30N R19W NW NE LOT 1 PERCH LAKE Block/Condo Bldg: LOT 1 ESTATES Tract(s): (Sec- Twn -Rng 401/4 1601/4) 33- 30N -19W NW NE Notes: Parcel History: Date Doc # Vol /Page Type 12/21/2004 783098 2719/337 WD 03/03/2003 711939 2160/439 WD 03/03/2003 711938 2160/438 WD 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations Last Changed: 07/12/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.070 80,100 0 80,100 NO Totals for 2006: General Property 3.070 80,100 0 80,100 Woodland 0.000 0 0 Totals for 2005: General Property 3.070 80,100 0 80,100 Woodland 0.000 0 0 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 J