HomeMy WebLinkAbout002-1063-70-100 (3)mm ^' PRIVATE SEWAGE SYSTEM
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INSPECTION REPORT
GENERAL INFORMATON (ATTACK TO PERMIT)
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Isla U xmllScott&Holly
N26
PhilllppB csy .w. TOWN OF BALDWIN63-70-100
63886-1
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPAOOY
STATION
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TANK SETBACK INFORMATION
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Index & Tilte Sheet - Mound POWTS Rejuvination
Pr jectNme: PoJIipy MounddispersuleellrelwaYita WIWLile NeIpMW ATD
Owlron Niant SWI&H011yphillipps
O sWw>. 254380th Aw, We NV e, W154028
Sib eddrtn: Same
Pmita Lp[atim'
subibmics
IeSelOmiltim NEI/4NW1/4Sx 21 I6W.Town ofBaww SLQou Ca WI
Penal mpWL1063-70-100
Puge I
Index uW Title Sheet
Pap
Troahnmt Tank/AN msWWlon om,a n
nige3
AM POWTS AS anoet
PBe4
AN POWTS Ssvia Conueq
PW5
ATU POWIS Mamleveva&Cnntipgmcy PLm
Page
&1"Tedi TmkC fiction
PW7
SepOtTm MawmmPe ABA gt
Page
While l(n10t AN PrWuet Appmnl Letter
Page
Parcel Map
Page to
We W Deed
Amtl S, Soil Ev uvow R
Dupre Cell Sure Uceiihions
Mtlm Pl , Data Huudie,%DSPSC�ikritial WL/3o853 'J
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KIWETZIMAT 1 1Ia
Gwvneme.de.66twI'
Sad M & xouy I.. Poi:ly¢
25638M AW
Wwdvil WI MRS
This m@000q made by O er and Ner uncommon in mbsti own
1`0 1 (PrlvmeOvib Wvhwamr TrmMmt Syal®) regoning m8ular
mitofmg and meingaiin amrtlenm with he mcornmendid
Pmeedoris, Them pmcednv most be pmfmmtl by amewfecbum aMmisl
St Cmh Cw lmEDevebpmmt Dept
scviw provider licensed by the Smm of Wirwum b pmfum those mrvion.
1101 CmmYSael Bid.
RuolraofWmepoeMmm eheB berepneEmtic appopi9e Govammmbl
HtdemW N016
Uvnv regowf by cMe
W VIm of PoV TS
PvicellPa: WI-1053-]0.100
254380 Ave. WJ1 Block:�n CSM: Vol. 20_ P¢, 5096. Being prat of. NBY.NWV..
Sec. 26,
T29 N. &16 W . In, OfDWdRl SL LTOI Colon, WmcwsN
14) f DESCRIPTION
Om(1) WWb Knight WKdO commenting we(I)notation eemnimt wn mth hv1M efllum
dwlmVdm�mounddope cmp
•ail1,1i kaw.
Jhvn vmN, Bonn Poetiw& Molly Phillip. lmuwn to me to be me nng finegoing
ail� m rt t Subsand mom thfame this dey Of20N
y'N R EIIOLIG.Sbm fWmcooeN
-'MYSommt"vioRkapima Augg 202J
Instalment UMM BY: Imav K noncom
Pg.3 of IO
ATU POWTS SERVICE CONTRACT
The proper operafim mtlmemmommafMe umpmmts bell belowwin sigotiecmilly mfNmu the
perfommce and lit, eapscGnry oftbef(WM(Pnvue OVHe Wastewater Dentition System) Thu
egrtnnmt euAaves A.0 E. Soil k Sm Evaluatiau, L L C. ammmel (Seloice Provider) m Ibeh
rtpmmtwve access to the Po WTS mmpnnmu during regular bwkev hoursto perform rtgulm
kapenima and motion: mamtmmce of three componmb.
It u hereby agreed by met between (lownr and Service Irnvider 0m in eensideeavon of tot pnyonenb
provided fmhvein, Service Poovndm will provide a mono frontier barred and Seam licensed mspmmr m
perform paiodk ivpechova ofNe PJWTS <omponmuuam font below. Service PmvWerwill prepare
writkn hupectian report aflm inch uupec4on cnnbmkg my rccmrunmdmma Ion the opetYlw,
molntmance, mdmeepo throw POWlStlemmiapprWbaamend Service Pmvidm.Ampy oftM
ropMwill be ices, p rm or lamnntly enter oprlete 0ovemmmW Unit. Swim Providawill mpply
additional services, parU. m labor only Wm mMmlrtllan by purchoeac.
This egmereent does not mawm mry resporm161libes or obligations Jed art normally We rcapwWbllldm
and nbligatiom of Le Owner and ewe not cover my WM1s estoc not with g urrom,mBmttlNYte and or
«pair nfthe POUTS Intlevmd to, to nice PmvidryM msponsible frc my orecidmwrspumtlel
one t' eq including hur not mi leaned lass oftime, injury to person or Ixapny, wmndmml ewnomic toil
mnm rgnpmmt fulnre for mat reason wheuoevrr
Me ngm,mem aholl mmem to effem for. pence of two (z) years from the Nk of10WIS iwwlonono
mid wiu M atonement eazb year Jiaufkr unlers ammtlN aemmllMby enter fancy with 30
Jets vriltm nonce. Thk agtxmml mry M cmmllyd by Owner only dreplxetl by a vavim ingaestiwSomme o m
anoJict smire pmvidmmWuiud m iniRctand meinuin Ne specific Po/W�}(�$)cmnpamb .
Purchsser agrees to My Servta Ptovidm the awn of T500 leer uupecboXwo U) inpectiam Will
povidel own the! year in ail -month mtri Poynter for Heboon two rust=cbona will M incbbdedN
the mgafNe PON'IS tldl®t One(l) a t=MYmrwillbemn dV Jreeaflmw Min rim
teas billed be the bone oflrupeebpn. Additional fees amockmd with effluent mean& when returned, will be
billed at time ant wrote W cost
POWl9 DESCRIPTION:
one (I) white wngbt'N't cmmining one (I) avnkn pmemmmnr met w?nemed emnmt
dlwhmged m "Mort; Mani d spusal cmnpmmt mubucW in accmunm with Seam Code.
M`VfS Imam
z5e380°Am, WwMriYe,WI., let 03. CSM Vol 20. Pg. 3096, NEY.NW gm ffi T3N..
K 16W , Tn. oftraldwm, SL llouC , Soil, Pont 114)(IY1063-70.1W
gmuwne end adereee
Sorb & Holly Pbidum
25e3 806 Ave.
W Y�
th, h 6 S 13 zO
luv n,rel m col Zr)
Servcee Prnvider
A. il& See Evaluenmm, L LC
OPmis Lake Rind
oarenl., saoz
L 3 2�
It'tmnwn (Deal
Pg 4 of 0
ATU POWTS Maintenance & Contingency Plan
Pyfluntm Wisconsin Dept ofgefdy & RofwiwL Savior 3U.54, Wm Arm, CNe
The PoWTg ilWl M aperYM is organist wild DW'L of5tfety@ lgsl ml gmkm 3V-3114 Wis Arm, Cch,
and rFWI be mambinN in ew.wdmtt wim smpnm[m®uJ SB0.1o'IWPM.o1N1). AO kpl mda tyro nkt
tre syinMvmgnbshould
ebe:
mtlhaaatmmdmmceNm<consistent
mgp1ambnoMllM,Jrvn nThPlumdpwwMn. tlQ(o]eIsSti)w348®-]m6]e wop the News mCounty 1`PoW
Inpamr f
atpl5)1]3b]tl
emnent onaary
The annuls answer wocmtroaou Jesus genermed m this site will be residmam strength effluent as defined by In
Wisconsin Dept of Safety ¢ Pmfenlonel Services. Informed; quality entering the decreased rompmmt of for 10I
may not acme 30mg/L BODS, 30 MG/L T85, end 30 mg/L FW.
Contingency Plan
Bibs wide Vince or my of As wmpnnmn become dAemrve, no cwnponem shill be regional or cornered m keep the
nolml in pmlagaetivg condition. Anetion Tmmlan Onis"I be immMiLLely relmayl wreplecd wim
by
tensioning
of a Mincemeat
mound alpvfwmmm. PaelLlmipmdmB wiWio medispnW cell WIIMtlmwN
by mW Winn of nrtphrmmimamd PoW'IS.
The operators assertion of the septic tanks shall be vvnW on lent are mouldy by xspection. The screw book
course" 'hall M removed when the sludge and scum in me Wk eacxtl 15 the liquid volume of the scot. The women
ofNe mpticwik shall be tllspwN of m accordance win NK 113, Wu. Aden. Cole, by m indwiduad mtieM to smlm
Peptic Inks under s 28148, Sun, If me wnWts of In uM am on removed mne time of We annual aa=vammt
maintorman,, pesonnal shell advise the owner of when xrvee will M seat On less me 143 scorn and sludge
mcmnulainn N Ne Wk. Any occurrence uvkopetmgdaaoee emerged dafative, msublaeb failure shall be
plvea. etpweaaaw opmivga ionsllWwcmM boediA"alackloed MWAeepdcm iammlow
mumori� entlYinm Wksm them' compoo , d No NdlWdwl exooW evambw 0aepdc Wkar pmnp Wk ae
emgerou" guuniey hapreemttlai would uuee tleeW.
$taal-OO Proeetlurt:
1 3 TWegeffiuant woppwlcmnbrofmYetivibww,Ge BAOuDlm, MS.&M ewNhmMnomw,emt. m30daya
Appal Monitoring& Insotttion Prvsxtlurn:
1. Vlwlly mnpen all syamn complexes.
3, MwXttaidingtlispeil¢OmMa and
pxuw iu000fbereq d bmNupmmhYdmNc opua®g aMYiw.
3. Enkum<tingckveb merytic Wl�mtl ps modemuurtgtt'velby mgaaisn
4. Imq«tommtait scotowe eta&woossmda b
s 13mmmmedumlvM oayge lama. coast me mbma a0u.3ga&Pb moplamwwm.
6. AN Wpxtiwu whall includeme falbwmg.
or
Bbwo Wi6 Wpeablowaeii andmmmke, cleeewmpiaw aXaMoeNM Checkfw nmuive hot nnim
inners
AWm Cootro Pme Tot eleMulcnmatiom, current dnw,Jmwue a, pweswitch and Wwuw gh slam.
Atlryeor orcortpeinuneeded.
Ieuox console ug. locks, Yang eee moperating concerning ofinenRby
vistrede&goveming sludge volume mtromtenl Wks determinepH
generally
emuent eNuevtawpld for B.OD., Ph@T.5.5 wolyyis u neMe3 Reple¢Baderlel hroculamre
ually or"recent
Mw.
Pg S of 10
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 1354300t3 Ava. wmi M,W located
at: na Y., " V, Section 26 Towns N, Range 16 W,
Town of samnn St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 394.25, and it (they)
appears) m be functioning properly.
Most recent date of inspection or service Augvn 13. 2ms
Did flow back occur from absorption system? Yes_ No x
(if no, skip next line.)
Approximate volume or length of time: Na gallons Na minutes
Tank Capacity: 1.000galbn
Construction: Prefab Concrete x Steel Other
Manufaetmer(if known): w rcono
Age of Tank (if known): syemonwneasro 14
Permit number (if known) 574342
—7) J7 oala Muaaan
(Licensed Plumber Signature) (Print Name)
MP MPA220553
(Title) (Licence Number) MP/IvIPRS
Augug 13, 3020
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and a. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
p9 6aF�o
ST. CROu COUNTY
SEPT§C TANK MAWTENANCE AGREEMENT
AND
OWNERS§§fP CERTIF§CAnON FORM
OwuadBuya Scott & Holly Phillips
2543 80th Ave., Woodville, WI 54028
Property Addrecv Same
rvenfimtim mqo barn Phoebe&z� DePMmmt far rcw wwe cton)
City/Stare PmmlldermRmRemNumlxr 002-1063-70-100
LEGAL DESCREMON
propmty Lgrstlou NE NWi Sm. 26 T 29N R16,,,ToPm of Baldwin
Sub livim u Plar: Na fig# 03
Certified Survey MEP# 611220 Volume 20 Pap# 5096
WamaXty Deed# 1022429 (before 2007)Volume, Page#
spec Xapae E]yamo lm lrsa iamnr me0mpno
. f 3 I
Impopsuse ma meinlen®w orymeuplN.ntan wwaresWt iv Mptmietwe fidwe bnmak warts.. Proper
maintenance crosMe ofµmpmB ow Ne septic burs every Rose Years w sooner, if named, by a brvued pumper What you put men
the system curs effect tM mission of me septic conk u e beWnent cargo in the waste disposal syskm Owur mannerisms
impossibilities me ryxlfied in §SPS 383 52(1) aM to Chapter 12-St Croix Covey Sammay ONironce.
The papaly owner agenmeubmdb 5[Clva County Plaovvg&b gDePmlmrntaty m.fmmsiendbydie
wmr and by a mover Plumpv.l oumeymx PIumM, rt_smned PIumM m e l ittuwd pumps vpJyine rsal (1) Ibe myi2
mnisPmalsymon u b propaspeumv6 eondium md/rc(2) anm smpxnm mepmgme(Jmw.my), thesepic muu u'
Iwthan I/3 (WI ofsNdge
Love, Ibe remembered have immerse above mqusemuts andagrteto meinmin Nemivaim xwage disposal system Verdi Me
almdmds sal both, hmein, as set by the Depmmtent of Safety Asd Pro@ssiurel Services and the pretreatment of Named Reconvert,
SMleaf Wisconsin Cetli6wtwi, smtmg thin your septic system has been mnimeined muss his committed arm remained m the St Croix
County Plamingrs mine Demmnent withm 30 days of the dome year expirwon due
Vwecemfaove, bualemmmmtNsty dots. welo]M1a bat ofmyf Viseds wldge IAv<am/ve lh<ownar(a7 of We
pmpnty descnbrd above, by value of awamvry dcul recorded in Regular ofOm401fitt.
Nu of had m. 3
08�13�20
SIGNATU OF LICANT(5) DATE
reeAnY mfamabon WLL n miatpruentedrmy rmuX m mM saomrypesmtl bun8«volvd by the PlmnmBA Luw80e�est rrr
huNdcwia PPhuumartuWd wmmnry drcd 4wo IM Rae�aterofCeda Once ®dawpyofthe wti6d uuvry map if
referencereferenceu made in the wmavry dad
(REV.aen2)
Pg. 7aF b
reentere si ed pressse"Pok \t Pmi 606266 bR
lryW \ Wul
eoA>Men6]Vagv WFrail
mwr W707 7ix
+1 � Tony Evers, GOromo
Dean Crum, $tic Iary
�mmuc•
AW 3, 5019
KNIGHT TREATMENT SYSTEMS
MARK C Ni PRIES
281 COUNTY ROUTE 51A
OSWEOO NY 13126
Re. Description CHEMICAL OR PHYSICAL RESTORATION FOR POWTS
Manufacturer KNIGHT TREATMENT SYSTEMS
Product Name (trans No 314O424) WHITE KNIGHT MICROBIAL INOCULATOR/GENERATOR
Global Numbers) WK 60, WK 78, WK150 AND WK 200
Product File No 2018019E
The speoficamem ar morplans fortbis plumbing product have been reviewed and Mlemmned to be in Compliance
wan chapters SPS 382 thr0ugh Call Wisconsin Administrative Code, and Chapters 105 and] IN, Wuxmin
Statutes
TM Department hereby Issues an approval baui on the Wisconsin SlaMes and the Wwnnsin Adminblrabre
Code This apnOvalis valid undo Ina end of Apo 2024
This approval supersedes the approval issued on October 29, 2013 under Product file number 20130302
This approval is mnfungenl upon compliance with the following stipulation(s)
• This product must be utilized in accordance with the manufacturer's printed installation Instructions and this
Product approval It there is a conflict between the manufacturer a Installation Instructions and the product
approval, the product approval requirements will take precedence
• The elevation M the systems infiltrative enriched must be& eye the es0mateb highest groundwater elevation
or bedrock by the distance presimbe0 in column entitled'Fecal Colifmm a10OW eft/l00 h l' in Table SPS
3836t-3, Wis AOm Coda
• A copy 0l this approval littler and the maimprourer's punted installation Ingrual must od supplied to the
am users u theae pmduds
TM ONlel babe M Ih r septic tank, Which has this poduel mrsee ed, must have a department approved
effluent filter installed The eff Her shall he consul of huerhq pansies z %inch in sure or larger
• This product shall be installed by a pmpedy licensed plumber
• A state Sanitary Permit shall be obtained when this product m installed The sanitary permit is obtained them
the county In which the products installed
• The 1OS-500 innocent must be replenished at an Interval s I year
• This product does not replace the need for a regular program of inspection and mmnerrance This Includes
having the tank pumped OUT when the volume of sludge anchor scum occupies one third of the tank'a ATuld
capacity
• FOr mstallemons where the access opening is not directly above the desired product lOwtion within the tank,
a standard installation practice involves The use of a fleiiibie air line between the air suppys rmr entry pant
and product in some material to existing tanks. bade Chronometer may Up needed.
seo 10564E IN riven Ra He 1e01990511
Knight Treatment Systems
Aml 3, 2019
Page 2Of2
Product File No 20180198
If the formulation of the IDS WO moculant is modified , or additional awetions of function or performance are
made, men the approval shall be renderad null and vote unless the change is submitted to this department for
review and the approval reaffirmed
6asea on information supquad by the manufacturer and reviewed by this depadmem, the approval for this
product primanly recognizes these products will not adversely affect the user the bacterial action in septic
systems the bar hydraulic conductivity in soil absorption areas, or groundwater quality. when used in
romance with me manufacturers instrvtlions Additionally mesa products are approved to be installed in
e
accordance
anaew ntreatment tanto introduce bacteria into the wastewater stream that may be benetlaat in
reluvenme failing soil ispersel areas The promid may be Installed In single or two Compartmenttanks an
follows
I. The product may Ce installed in the second companmenl 0f a septic lank, preference is to have the
product placed in the main compartment or Inlet state of a twoCompartmenttank.
2 To pmmole having an area of quiescence and that M sal in a angle Compartment lank, bcffirq
the Pr =Off center-lowands the inlet hder of the tank- is the Preferred persona e
The department is In no way endwvrq this pmym or any adrenning. and is not asseverate for any situation
wfirh may resWl from its use
Sexual
Gen W. Schlueter
Planning Product Reviewer
pmspn of Industry 9ery dsulment of Salety and rofessional Services
Bureau of Trig l Services
(6981267 1401 Phone
(W6) 267 9723 Fax
glan.schlueter@wi gun E-mat
rce.wl.pov
isconsin
o.p.mwnta cwwaaR.
Oclaber 2, NOS
INFEW AND BNLOINOSDIVISION
%myry Rmutl NAwr
PO fwi
u.uwr�v�,�,vro:.assa
m:cwrban..wnw.y
,aaaawa_rw
PkneN J.LrBmMgY,&vWy
IOIIGFR TRPATMENT SYSTEMS
MMIK C NOG& MP
251 COUNTY ROUTE 51A
OSWEGO NY 13IN
Re: Description CHEMICAL OR PHYSICAL RESTORATION FOR POINTS Z
Manufacturer. KNIGHT TREATMENT SYSTEMS 2
Produst Name: WHITE KNIGHT MICROBIAL INOCULATORIGENEWOR 7�
Model Numbems): WK- ANDWK-]B
Product Fb No 20050519
The sawdications wouNitlans be this rJui random have been reuYxed end determined Ee in ama
StatNes and the Wisconsin Adminlstrallve
This approval is os inOenl upon co Ilanm with Me loll ng sNWlaborms1'
• This product must be units lne eriro t memdacturars printetl installation lnstutlOnS and Sees
product approval. If there ii a cmll' menuiachurers msla cation Instructions and the product
approval, the product appric redulre n take pecetlenw.
A copy 0 this approval Wier
WM of this lxaduct
i has this
larger.
A stab Sanitary Permit mat be obtained when this product
The IGS5001noculant must be exchanged at least on an ai
Installation instructions must W supplied to the
most nave inaallM an affluent finer capable
pp xaaeAa
$BNIONWE MtdPl1 FlM PY'. 69051301 OCC ✓�
KNIGHT TREATMENT SYSTEMS
Page 2
October 2, MOB
PRODUCT FILE NO. 20000510
In nursing and new treatment a rejuvenats falling fell dispersal
single or two compartment t
e ndcompadmenlMea Ictonk;preerence Is to have Me produm
cosem en two compemna k
d MYaI eNW Irge compartment tank, ecafing Me
This approval wpemtlea the approvid issued on
This approval after shall nd Incorporated with
product fie number 2003 1.
The department is in no way erxor¢Irg Baia
may reveal upon is use
Dudng Me pond Mat Baia wodua feel is Ina
Commerce m any crowded to Me contact Imorma
address of recers.
Srca ly,
not direcflm a vs Me dealred product edition wlMln Me fiala
at
etlexi Ir tins Between Ms ar euwly¢dserantry point and
eca WIIlcatlonmeyberestled.
under product file number 2000(a .
pr sly approved plans anal predications approved under
Jean M. MadCata n, CST
Engmeenn0 ConwBewR-PlumGnB Pmtlwi ReNewer
Commerce; Barely 8 Buildings My
POBox26B0
201 W Washington Ave.
MadisonW 5870.42258
Final 606-266-0955; Fax6IXr2837456
B-mmt Jesn.MacCubGn@smadonun gov
Eric
and is rat responsible for any dduallon wM1icp
it kMn rM n bly of Me submitting For almorm
anaddrera nee. Renewals will be vamrotlle
Desm,mN,
ATU POW'TS AGREEMENT
Owner name and xYhew
SconM & Holly L Phillipps AUG 19 2020
2N3 g0° Ave I
Woodvslle, WE 54029 L a�Q M tut
Thrsmdenome, mtl by Own ein successs mmA eowna
PTIWTS(Pnvme Onside Wastewater Treannen' System) re'lo' If rzplar
monitoring and maintenance in accordance with the manufxNrtn txommmded
PraNures TWICE um must be pMpmM by a manufacturer wOwlvN
ser,ee provider licere d by the Smle of W,consm to perform these services
Results of these Pmcedus, shall be reputed to We emmig fare Governmental
Unit as Muted by cWe
Locm on ofPOWTS
144
Wee r srraeoaEXEMPr rr m m
Reaturn to,
St CTota Co Land Develapmenl OepI
nol CvmmFeel Rd
Hadwn. WE sam6
Parcel lW 02-1063-70-1
2543 RI Ave W 03 Dloche Na, CSM Vol 20 Pa 5096. Bemg pan of NryNW'/ Mic 26
T29N R 16W Tn Of Deify in, C
10WRDESCRIPr10N
One (1) Wine Knight WK-00 oontaimn6 one (I) Reason ontment unit with tretlud effluent
dhsemarged to seeing mound dtstermi mmpsoent
OWNERSHIP RIGHTS AND RESPONSIBII TY I'OR POWIS
PropeM Owner as desenbed holds suit ownership nights and is temmi for ma,mg
(� ,g �ton, opimmW mamtmance Of PEACE
_was8)
student Indictment
TF« namm Scdt PF01hps& Mon% Phillips. Enron to me to he the exm'u'hngfM foregomg
e SunEN arAswomm Mfare me tFrs any of— 1�p" ,2020
Zxlywgi
✓.1,.,$tme fK'hxonsin
3t .�i
-. J•.Mytotiu�tvithlres Aueus3130�
FOi
gprN ..'IDSo; v..
InsmitheMl iiraflN Ry DmnmK lboywon
PEE 3 of 10
GENEML INFOft MDN
MWAM SEW/GE SYSTEM
INSPECnM NEYOMT
(ATTACH TO PERMIT)
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