Loading...
HomeMy WebLinkAbout030-2127-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 499286 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: Amelsbur , David & Valerie I St. Joseph, Town of 030 - 2127 -50 -000 CST BM Elev: Insp. BM Elev: BM Description: Section[Town /Range /Map No: OZ .,o tilY� ' Z LS 25.30.20.1039 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER , CAPACITY STATION BS HI FS ELEV. - Jn_ 4r Septic , 1 j:�, '11,., 4. c Benchmark r O , ob /62 /a 2 . a Dosing Alt. BM r . `1 12 .53 19.s t*r� n Bldg. Sewer cut hw /0 9 / I N F% 45 i5 . $6.53 Holding St/Ht Inlet S'4- X13 ZS TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 561 (off / g l *7 /8 / Dt Bottom Dosing '7d56# �� Header /Man. (o,9 i3 Aeration Dist. Pipe `ys ii•4 a. 93• 3 Holding Bot. System j4 M io q q 3 PUM /SIPHO INFORMATION Final Grade Low g 4L 93• (,I Manufacturer / GPM nd St Cover Model Number b fe / -5G T " TDH Lift Friction Loss System Head TDH 1 Ft /3.9 Z 4 4o I N Ar (p , 0Co Forcemain Leng, Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width i Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / ��. 6( 3 Qom'U"46 SETBACK SYSTEM TO ,E P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION T Of S ste CHAMBER OR yp y Z Q 7/ ,f� UNIT Model Number: OJeef� �+ a �/ r DISTRIBUTION SYSTEM o (' �� d` m Header /Manifold �� Distribution x Hole Size x Hole Spacing Vent to Air Inrrtake e PIPe(s) o n, G Length /3 Dia Length \ Dia ` Spacing ` ` d— SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over ` Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed /Trench Edges , Topsoil `Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1365 Birch Park Circle Houlton, WI 54082 (SW 1/4 NW 1/4 25 T30N R20W) Birch Park Lot 35 Parcel No: 25.30.20.1039 Cb �� 1.) Alt BM Description �� `aJ th / s u 2.) Bldg sewer length = /� 7rJ o O o dwv,. Cq - amount of cover = >f a.QJL 3 /� aS yv�y 3 2, ° v► Plan revision Required? Yes ,}� No Use other side for additional information. Date Insepctor' ignatur Cert. No. SBD -6710 (R.3197) RECEIVED A- FEB 0 7 2007 commerce.vvi. ov Safety a d Buildings Division County „ ST. C OIX O�UW . Washi gton Ave., P.O. Box 7162 C V t s V on s Madi n, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) D o ■ f Commerce /Y q Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary p urposes in accordance with the Privacy Law, s. 15.04(I)(m), Slats. L Application Information - Please Print All Information N ►C t� I 1 �(1`t7� Ct Property Owner's Name I Parcel # AW O 4-- Uadnf A 41f�Z ® 30 -- --5 —0 Property V O Mailing Address �? j Property Location / q Z �V d 0 J T Govt. Lot City, State Zip Code Phone Number � y,, - Alk /., Section Z 5 / ) S 117 (circle one y� l � /V ` • I U II. Type of Building (check all that apply) pk Lot # T JQ N; R � E 01( iL or 2 Family Dwelling - Number of Bedrooms 3 __ ; � Subdivision_ Natne_ I �jar✓prH.r'(�.•t, nn// Bock # J I�C,� ❑Public /Commercial - Describe Use 96- A ❑ City of ` CSM Number Village of ❑ �+ ❑State Owned - Describe Use t �0 04 Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. $'New System p y g p y ❑ Re S Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain) *- I B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that appi A Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersalfrreatment Area Information: Design low (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (st) System Elevation 0 7 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U New Tanks Existing Tanks /� , ^ c g U Septic or Holding Tank 7 Dosing Chamber C� t7 V1I. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ignature MP/ umber Business Phone Number mmx C� o / � 7 1 22 Plum er's dress (Street, City, State, Zip Code) VIII. ount /De artment Use Only Fee Date ssued Issuing Approved [I d Permit ent Signatur S 110 11 rven Reason r Denial / 0 IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNEW 3, IeLca 1. Septic tank, emuent futer and J dispersal cell must all be services / maintained as per management plan provided by plumber. 2 All satbim* requirements must be maintained IS per a system and submit to the County only on paper not less than 8 1/2 x I1 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 i P�o A C '` moo' N T �2 � flz,3 i b o n� P z ~,c,K mot+ 374 �` • ��x D + C 0 (, L P�o 4- NA- V D AV ID '- yAC A�I�L `� 40' N T AA 14-K �DZ,3 V N Z P p � gov LIU Ott""' w �v� Z D ` 3 �Z 1 oCt• 1. 2(10b 3 :3,gpM Jason Garman Team Na•316 P. 9 c G H t33,25,3 sq. ft. 1 j 0 acres . 1 3.08 ocres � LOT 3 LET - �� \1spv; LOT 34 n . p 7.. 15,633 sq,ft. ;w ' 1 � � , J 55 ones ,.lk Q� A0 co LOT 3' �. ,r `�,�, ,lak• 1100 40,180 sq, ft, l.a 3.22 S17 9" �; 3.{,• 3S Vo T AM B5: t4 x ✓t 'a., TTBlififl VVJ W&r T%T,r nnn 'Y /inin OCT 07,2005 16:23 651 379 5264 Page, 9 1 N 'o BIRCH PARK ✓i I W d 4 he SW I/e 0 Ne NE 1/1, and UY NW 1/4 of The SE I /1, Ord the N[ 1/4 of the SE I /1, and The SE I/1 of RIWmINh6 u xe Sf 1 /4, end the SW 1/e of the SE 1 /1, rd [be SE 1/4 0l he SW I /N, rd the N[ 1/I of the SW 1 /4, o,d w SE Ve r�r E�y 4 I of The NW 1 /4, 01 b Secle 75, Iorehip 30 North. hinge IO Well, Iorn of St JmQW, Sf. G61 Eantg, W"mo N W.e4I NYY 'j 10 bW VM `! - -` \ _ r -- 1.X0 A FIF IIEfF r(xI NO 1 i . I RNWHS HI 3/4'er FHI Ww WK 0 iN a 1 ... .... ..... . ew us NW uWw rm1 MAN I \ I � \ I 1 DMTES FOX KM 011NIY MC11M ® \pj CS f aMAYatINlx I i r \ A �� I,IN 1' • .. HNOHS wavoHO antrr lHA WX CWSex FM ue Ok " , \ % WGUtlW RU[A7CF wnnY4 4 nol n4«eYih 1 \ \ The so d 64 of W 1 /4NkA ,\ T . woe-,W b04h0 S« NN MO .. \ ? \ / 1 0*w x 50 too «e�0«0Y M si« . M 4« —ate Nuso.15 N« til p • \tl \ r C 0 •{'4 \ � SCYf N fIIl �� O' PN«k 4tl k> Nnrm 0 ,8j '4 `, \ emfl to twit Nw4 MM NW S � � Sf p \ I Q W 6. eX11 � �W n r. 1 \ I yN�g r� i r AUTUn x� rs 106 LOT 35 \8 �o l R ✓y� ; u uStNan N[ - , u LT -_ - -- LOT 36 �\ + p ,} RN I\ r, k \�l 4 \ Q p 4a A \ q Hp 1 HNC N INN XM WWWWWH �A N WIM., AWK WaI-a-WFY uys •\ f i fi. y P`. 1 . p l AS W IN IN Net. h >b h LOT I 34 -- W �oJ v ✓ S i i ^ x , A Op q1` fop' fop' e \ 0 ® S R or I\ ^ i LOT 37 �•� `\ ' 'j Of t , �u 1 Q ; ' 1 w W 6 J •5s I I Q' � •R� \ ne� NMI LOT X33 i da r« I LOT 19 • "+ ► ��`"° =.. «.Y... \, NuxNf ° �Nn i.W NY« I 144 Yw1M 0 \ p` \ vqy ° ,W NWID NW \ N1A \.emw NN4� �` \\ A \ ` \ � tt,, ���' j w - +e �+ I'� 1nrN �f'ILOT 32 ;.' iqf I \ ; •.\ 'err', C�"�1°00,1„ .rr.r�w V^ A �.'th. I I '' YW M,.YIMneYwPY «Yk �YMYA "� LOT 18 \ I \ -.s :J� 35$'1 ° � q \ YMh1me \,•• \ ,\ 2 Nti/�wIWI YI r W yi / � LOT138..- eFYN_ - -' � I •p � � "'�IRCN p � wIWWV ., YNYeIw/YMwYYl. wre.1' rti IE y 1x a« y IL n �1 ' Ibb �\� .1 I 0 ` / -•�; 1 ' 2I rr M+ w� Y 1 500N+� h tp s i°+ ', `\ `f LOT 17 � k a g' WWII A y aa Y�r ny.br as LOT 20,`�1�;r. -.>;; MYR«wYr�ww � 4640 Nfdll NW \ 61.1pu ' I W I Nuxu _.� UNPLATTED LANDS I a u e/1.N' I MCCOO RKR003A880QAMINC (SEE SHEET 2) ,� yb.aw.•� - - MATCH LINE A----- ---- - 9fRE1IOP4 Wisconsin Department of Commerce SOIL EVALUATION REPORT page I of 2 Division of Safety and Buildings in accordance with Comm 85, Ws. Adm. Code County ST. CROIX Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.Q. 030 - 2127 - 50 -000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re by Date Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). Properly Owner Property Location DAVID J. & VALERIE R AMELSBURG Govt Lot - -- SNI 1/4 NW 1/4 S 25 T 30 N R 20 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1424 Avon Street North 35 — Birch Park City State Zip Code Phone Number ity ® Village • own Nearest Road St. Paul, MN 1 55117 1 ( 651 489-0986 Birch Park Circle Q New Construction UseE) Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Q Replacement Q Public or commercial - Describe: Parent material loess over outwash sands Flood Plain elevation if applicable ft. General 0omments Conventional In- ground trenches -- 0.7 loading rate and recommendations: ADDITIONAL BORING REQUIRED TO EXTEND ORIGINAL SYSTEM AREA. SEE ATTACHED REPORT DATED 10/10/01. El Boring Pit Ground surface elev. U5 ft. Depth to limiting factor >90 in. Sod 6ge ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 I *Eff#2 1 0 -10 10YR2/2 -- 1 3fsbk mvfr cb 3vf-co 0.6 0.8 2 10 -26 10YR4 /3 — sil 2f -msbk mfr as 2vf-co 0.6 0.8 3 26 -90 10YR4 /6 — s Osg dl __ -- 0.7 1.6 Boring 9 # 0 Boring F [3 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 Effluent #1 ■ BOD > 30:! 220 ffKA and TSS 40 < 150 mg& ` Effluent 92 ■ BOD < 30 mg& and T88 < 30 mg& CST Name (Please Print) A �natujre CST Number Mary Jo Hollister 224832 Address 4E Telephone Number W9875 690th Avenue, River Falls, WI 54022 11-22-06 (715) 426 - 1775 Plot Plan for Site and Soil Evaluation Page 2 0f.� M • Property Owner 1» =.giOft. Legal Description tom- ill P---ARcm vas.. v z9z (except where noted) 2 go, sw % /q oFMjkk WW� SEC ZS� T3DIu ,,oV� Backhoe pit ^s ST. Msp?t+ North 45 S 4 O V 0 spa J . te r•• - _ Site Location: �• c.T Zs• �' - 2 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 � , Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County St. Croix 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. d�r� Q G . percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 7 Please print all information. Review by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Quest Development, Inc. Govt. Lot E 1/2 1/4 SW 1/4 S 25 T 30 N R 2 0 E Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# Suite 150 10700 Old C ounty Road 15 35 Birch Park City State Zip Code Phone Number aity E]vllage ■ Town Nearest Road Plymouth MN 1 55441 ( 7¢3 -595 -9512 County Road E St loseph New Construction Use[D Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Loess over ont wash sands Flood Plain elevation if applicable t 9, 1 n ft. General comments 1 TQ and recommendations: This site is suitable as a below grade conventional stem: �.� X0 Boring # Boring >96 FT ] Q pit Ground surface elev. ft. Depth to limiting factor ar oil Awfibabyin Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bou avji pool in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ty 1 *E *Eff#2 1 0 -11 IOyr2 /1 sil 2msbk mfr cs 2f .5 .8 2 11 -38 10 r4/3 sil 2msbl mfr cs 1f .5 .8 3 38 -96 7.5yr5/6 s Osg ml _ - .7 1.2 2 Boring # Fi Boring >98 ❑ 0 Pit Ground surface elev. y� ' 4 ft. Depth to limiting factor in. it plication 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#2 1 0 -9 10yr2/1 I 2msb1 mfr es 2f 5 .8 2 9 -28 10 r4/3 sil 2msbk mfr cs if .5 .8 3 28-98 7.5yr5/6 s Osg ml _ _ .7 1.2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L * Efflue - D < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, WI 10 /10 /01 715- 246 -2454 j L 1 } i Quest Development.Inc P 2 o f 3 Prdpert y Owner Parcel ID # 9e g �- 3 Borin # Boring 0 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 -10 10yr211 - 1 2msbk mfr cs 2f .5 .8 2 10 -29 10 r4/3 - sil 2msbk mfr cs If .5 .8 3 2 9 -100 7.5yr5/6 - s Osg ml - - .7 1.2 ❑ Boring # lJ Boring a pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i I Boring a Boring # Ground surface elev. ft. Depth to limiting factor in. Pit 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 * 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- 8330Test (R.07 /00) 3 of 3 �V� S 1rC G.r g 1 Al �'1G m o I 1 Q1 i q � 0 r 1 �n 0 P11s> too C 1, qL TO l3 E 1+SS 6 PIN NG Cd.v rte- 7 69 30 2.03 • Zo o3D • 2.0 7 Ulbricht & Associates O 30 Z 0 3,-69 • 70 � private Sewage Consultants 6s5 O'Neil Rd. 0 d Hudson, Wis. 54018 - 715 , 3 SI G ` 9/8 S 7i 5 - 77:t.• 3 yel--- Kav 21 06 10:00a Mary Jo 7154264827 P.1 f Hol list er's Soil Testing & design Mary Jo Hollister W9875 690 Avenue River Falls, WI 54022 (715) 426 -1775 (715) 426 -4827 (FAX) Send to- Z13/V 1 lV� From: Mary Jo Attention: Date: ZZ AI ()A. D (o Office Location: I Office Location: Fax Number_ -y (p g (o Phone Number_ ❑ Urgent ❑ Reply ASAP ❑ Please comment ❑ Please Review ❑ For your Information Total es including cover.� Pa9 9 JQ Comments: t� Case Cic t n — a Y CAA �j &rxd ~J de /I Owe. -"� 11 121 .. 4-z � 1 1 7'3 5 � • 1 9 9 2 6 P 2 9 0 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI DOCUMENT TITLE RECEIVED FOR RECORD 11/10/2005 10:30AX WARRANTY DEED EXEMPT I REC FEE: 13.00 TRANS FEE: 330.00 COPY FEE: CC FEE: PAGES: 2 Rewrding Area Name and ReMm Address Wilkerson & Hegna, P.L.L.P. 7300 Metro Boulevard, Suite. 300 Edina, Minnesota 55439 -2302 5ZJ -000 Parcel Identification Number (PIN) Premier Title THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE Thin information mast be aomptaed by subraw and EW (U►ePkea)• Odor k*modon such as due gmndng Baum. legal &wripdom etc nary be placed on this.*st page of #he doeaamig or awy be placed on adfiUnd pagrs af dw document J?(4$;. Use of this cover page adds one page to yow document and S2.00 b the rwo dim fy- Wtrcnastn SJWW&t 39.43 (2n0 WRDd ?N9 r 4i 99 291 STATE BAR OF WISCONSIN FORM 1 - 1998 I WARRANTY DEED Document Number ,I i i -, Birch Park, L.L.C. I! This Deed, made between _. _ it a limi li company under the laws of the �{ state of Minnesot _ _ Grantor, and _ David J. Amelsberg and Valerie R. Amelsberg, h usb an d and wife, a survivorship marit p roperty if — i Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate In —_ S Croix County. State of Wisconsin i` (the "Property "): I RP outing A ea Name and Return Address s iy Lot 35, Birch Park s Premier Title 7300 Metro Blvd., #300 i I Edina, MN 55439 30- 2127 -50 -000 i4 Parcel Identification Number (PIN) !i This is not homestead property. i1 (is) (is not) i a if II f , I� it Together with all appurtenant rights, title and interests. !� Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except all easements, reservations and restrictions of record, if any. Dated this __ L__ day of November 2005 � I i (SEAL) BIRCH PARK, L.L.C. (SEAL) l j By: Ja s aters, Its Chief Manager I' (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT �j i Signature(s) State of Vk{19dWM.M1nnesota Il rl ss. 1' Hennepin County 1111 �1 authenticated this _ — day of _ !J� iJ ZS Personally came before me this day of November, 2005 the above named Tame M Waters the Chief Manager of f _. Birch Park. L.L.C.. a Minnesota limited li company an behalf of the LLC TITLE: MEMBER STATE BAR OF WISCONSIN (If not, me kn(*%q. 10d the foregoing I authorized by §706.06, Wis. Slats.) instrutT - nt,a*dlc A owl a�A1�eF +t AUDI vl {QV Ii {I THIS INSTRUMENT WAS DRAFTED BY Wilkerson & He gna, PLLP e3 0 Metro Blvd. 1, 7311 Me 311 Notary Public, State of Wisconsin Edina, MN 55439 _ My commission is permanent. (If not, state expiration date: j . (Signatures may be authenticated or acknowledged. Both are not __Ti •) it necessary.) it I �• `Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. �' WARRANTY DEED FORM No. 1 - 1998 Milwaukee. Wis. Ij ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer i Mir L X24, Mailing Address ` ,� 4 A y o A0 ST � � � f �i�� �`� � � l � • 7 Property Address (Verification required from Plaiming Department for new construction) 1 City /State Parcel Identification Number o 30 - Z Id - 7 — 50 — aob LEGAL DESCRIPTION Property Location u1 4 , _AL y Sec. aS, T,30 _N -R a0 _W, Town of 5� Subdivision 13 Rc� partk , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # _ / ( — ,Volume 2 Pa 2 �, e # l; Spec house ❑ yes 9 no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE 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 ftuiction 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 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 Zoning Office within 30 ;GNATURE s 9 e thr aea ' date. s 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 pr y describ bove, y virtu of a warranty deed recorded in Register of Deeds Office. A U OF APPLICANT DATE + * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Inclatde 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page L of L FILE INFORMATION SYSTEM SPECIFICATIONS Owner �v L � E Rf -t Septic Tank Capacity 26 a l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 'Z 6�-L ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model / III ❑ NA Number of Public Facility Units ----- ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) U v g al/day Pump Tank Manufacturer (� 1 �r; �/� ❑ NA Design flow (peak), (Estimated x 1.5) g al/da y Pump Manufacturer Lk ❑ NA Soil Application Rate 7 al /da /ft2 Pump Model ° t' ❑ 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 VkIn- Ground (gravity) ❑ 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. ❑ NA Other: ❑ NA Other: ❑ 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: ❑ month(s) (Maximum 3 years) ❑ NA ® ear(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: ❑ month(s) (Maximum 3 years) ❑ NA d year(s) Clean effluent filter At least once every: 13 month($) ❑ NA ® year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA M year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: p years) ❑ NA 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 of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) I Page 2 of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) 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. 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; Y P 9 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 N SLA 0 L Name Phone — — Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name R, b 14 Phone Phone �`j' •-3 �j^' �� This document was drafted in compliance with chapter Comm 83.22(2)(b)0►(d) &(f) and 83.540►, (2) & (3), Wisconsin Administrative Code. APR -12 -2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 [IGOULDS PUMPS Submersible v19 J- VAL lE Effluent Pump fog PE EVENT PUMP SPECIFICATIONS MOTOR FEATURES Pump — General; General: ■ Corrosion resistant • Discharge: 1'h" 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: 1 /2" tecdon with automatic reset ■ Upper sleeve and lower maximum sphere. • class B insulation. heavy duty ball bearing j APPLICATIONS • Automatic models include a • Oil -filled design. construction. float switch. • High strength carbon steel ■ Motor is permanently Specially designed for the • Manual models available. shaft. lubricated for extended following uses: • Pumping range: see PE31 Motor service life. Mound performance chart or cu � p rve. ■Powered for c Systems .33 HP, 3000 RPM ontlnuous • Effluent/Dosing Systems PE31 Pump: • 115 volts operation. • Low Pressure Pipe Systems • Maximum Capacity: 53 GPM • Shaded pole design ■ All ratings are within the f • Basement Draining • Maximum head: 25' TDH PE41 Motor working limits of the motor. \� .. • Heavy Duty Sump/ PE41 Pump: • .40 HP, 3400 RPM ■ Quick disconnect power I Dewatenn g •Maximum capacity: 61 GPM • 11 S and 230 volts cord, 20' Standard length, • Maximum head: 29' TDH • PSC design 115 or duty volt grounding PE 51 Pump: PE51 Motor. lu . Maxi • pg • mum capaaty:70 GPM • .50 HP, 3400 RPM ■Complete unit is heavy duty, Maximum head: 37 'TDH 115 and 230 volts portable and compact. METERS FEET • PSC design ■ Mechanical seal is carbon, 40 ^_ ceramic, BUNA and stainless I MODELS: PE51� PE31, mat �s1 i steel. ss � ! I I ! I I ! I I I I HR .ss..ao..so ■Stainless steel fasteners. 10 i , 3o E4 ` I I - . " + ., I AGENCY USTINGS I �' i 1 Fr i j' �i I I I •� I. ` 25 I I I I r I I• I i i I �c k us c 20 Tested to UL 778 and I I_ I_I CSA 222108 Standards 15 I I , I _ I BY Cana" Stan&W& File #1A36 AodaOOn I i , I I 1 10 T" 1 ' ' ` I Gourds Amps is 150 9001 Regiqwcd 5 o L 0 0 ICI 10 20 3 0 0 0 6 70 GPM 80 0 $ 10 15 m Goulds Pumps ® CAPACITY 2004 ITT water Technology, Inc BPR.3 June, Zoos <& ITT Industries B!'E31 I COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of cover, Access Opening, not top of cover, must eidend to a point no greater must erdend at least than 6" Below Finished Grade 4" Above Finished gl . p ' pt2e�D CAS Z1'L Locking Device Xl 6 '64Y (typical) Finished Grade t Sew& Min. 23" > 30 ifi > Access Opening 0e- 1NSUL Min. 23" Access Opening N PI � i 2 �yG �o�c�iyigi�/ Ouh:t Effluent Filter j /.�/ /TH if �'o✓� S 'E Union Aoppeo P 1 PC 31 Inlet Baffle � 121'1 ON`1a SOL /a S'0/C_ C f Pump I So, b 3 ",Sand ar raml bedd un d er VJJA c+eh-Aer 2" /aver s4 ah e d ges Two tomparTment Septic/Pump Tank (h * �� oh 00"irae waI SPECIFICATIONS TANK MFR: �/1��i �'I� DOSES PER DAY: TANK SIZE: SEPTIC I GAL. DOSE VOLUME: _ 7 q Z GAL. DOSE n GAL. (INCLUDES FLOWBACK & <20% OF DWF) ALARM MFR: : pc A) 1 At66 CAPACITIES: A = - V 11fCHES = GAL. MODEL # l-} 1N /6 J Switch type: B = — 2 — INCHES -� GAL. PUMP MFR: © � C = 7 INCHES= /Y q, 2 GAL. MODEL M R 15- _ -� / H PE: D = INCHES - GAL. SWITCH TYPE: J �_ REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) _ `S FT. MIN MUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) _ + _ — FT. _ 0 FT. OF FORCEMAIN x FT. /100 FT. FRICTION FACTOR ...... _ + — �e6 — FT. q, I/ TOTAL DYNAMIC HEAD (TDH) _ � FT. INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH MP/MPRS SIGNATURE: AA O il I tm LICENSE NUMBER: Z 9 //,41. A44 � L sCs> (A rZ3 ie *4 y 1 1,5 r /A/r/ STANDARD CHAMBER 52" Quick4 Standard Chamber 48 " (EFFECTIVE LENGTH) e 12 " Z 8" I � I 34" SIDE VIEW SECTION VIEW MultiPort End Cap A 16" 12" 34" SIDE VIEW TOP VIEW FRONT VIEW INFILTRATOR SYSTEMS. INC. STANDARD LIMITED WARRANTY (al The st ucturat Integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ("unksi, when installed and operated In a leachfield of an onshe septic system in accordance with Infiltrator's Instruction, is warranted to the original purchaser rHoW against defective materiels 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 riot required by applicable law. he warranty period will begin upon the date that Installation of the septic system commences. To exercise its warranty rights, Holler 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 deter lined by Infiltrator to be covered by this Limited Warenty. . • Infltrator's fiab4ty spedtcely excludes the cost of removal and/or Installation of the Units. (ic) THE UNITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE [TY OR FITNESS THERE ARE OTHER RITANTIFB WITH RESPECT SYSTEMS INC '^` I V C TO THE UNITS, INCLUDING NO IMPLiF� WARRANTIES OF MERTA81L1TY OR FITNESS FOR A PARTICULAR PU ICULAR PURPOuE. (c) This Limited Warranty shag be void t any part of he charnber system Is manufactured by anyone other than Infiltrator. The Limed Warranty does not extend to ncuente , consequent e, special a ndreot damages. Infiltrator shag not be liable for penaitlas or liquidated dama Including loss of Environmental Onsite Wastewater Solutions°" production and p ofits, Tabor aro materiels, ova head cos4s, or oft err losses or expenses barred by the Holder or any hid party. Specifically excluded from Lim lied Warranty coverage are damage to the Units due to ordinary wear and tear, attention, accident, misuse, abuse or neglect of the links: me Units being sabfacted to vehicle traffic or other conditions which are not permitted b the instamtion ihst Icnoma; failure to maintain the 6 Business Park Road • R O. BOX 768 minimum ground towers set forth in the Installation Instruoti"; the placement of Improper materials Into the system containing the Units: failure of the Units or the septic system due to InYxoper siting or imnproper sizing, excessive water usage, Improper grease disposal, or Improper operation; or Old Saybrook, CT 06475 an otI-xx event not caused by Int rata: This Uaded Warranty shaft be Vold t he Holder fags to comply e tams set roa n This with all of the Limited Warranty. 860 - 577 -7000 •FAX 860 - 577 -7001 Further, In no event shell Infiltrator be responsible for any loss a damage to the Holder, the Units, or arty third parry resulting from installation a ship- S -221 -4436 meet, o tom any product habdty claims of Hoiden or any "d party. rot tea Linked Warranty to apply, the Units must be Installed in accordance with all site oDnditlons required by state and local codes; all other applicable laws; and Infitrata$ Installation Instructions. (d) No representative of Infiltrator has the authority to change or extend this Linked Warranty No warranty applies to arty party other than the origl- nal Holdar. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties he. different warranty require. ' ments. any purchaser of Units should contact Intgo-etor's corporate Headquarters in Old Saybrook, Connect prlor to such purchase, to obtain a copy of the applicable warranty, end shcu ld carefully reed 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 SldeWinder are registered trademark$ of Infiltrator Systems Inc. Infiltrator Is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark In Mexico. Contour, Contour Swivel Connection, MicroLeaching, PolyTuff, SnapLock, ChamberSpacer, Posil QuickCut, QuickPlay RECYCLED PAPER and Quick4 are trademarks of Infiltrator Systems Inc. ® 2003 Infiltrator Systems Inc. Printed in U.S.A. 0011203HP -