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HomeMy WebLinkAbout032-2136-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division -- INSPECTION REPORT Sanitary Permit No 506127 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: Ko el, Christopher & Alanna I Somerset, Town of 032 - 2136 -50 -000 CST BM Elev: Insp. BM Elev: BM Descri lion: Section/Town /Range /Map No: /19 b,6 / 0 �� /� - �'� r A &a- 13.30.19.1207 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY . STATION BS HI FS ELEV. Septic / •t ov Benchmark -7 . oc ion -9 goo. a Dosing Alt. BM �+ / ��� o� MUvnh Aeration /C� Bldg. Sewer � V 1�e /a1. o Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO WELL BLDG. Vent to Air Inta e ROAD Dt Inlet �[l �f Septic �^ /'- �i� , gl Dt Botto S �/ — _ A- 7 Dosing c � v eader an. - Aeration Dis Pipe -7.3 Holding Bot, System Z /% 3 � J 7 Final Grade '��,,,, LL PUMP /SIPH N INFORMATION /C3 �7�(ti�►� 2 • '7 Manufacturer Demand St Cover i GPM al T.7 /O 2,/ S Model Number , q<, & ,C) TDH Lift Frictio i LS}s System e d TI, 2 �Ft Forcemain Length D / Dist. to well v' 20 SOIL ABSORPTION SYSTEM 0 &Aste, BED /TRENCH Width Length No. Of Trenches PI DIMENSIONS No Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1 /M ;I/ SETBACK SYSTEM TO P/LN BLDG WE INFORMATION LAKE /STREAM G Manufactu /' /� I � CHAMBER o, n f i7T>f+L Type f System: x ^ f S / UNIT Model Number: �_ / DISTRIBUTION SYSTEM /1 - YrWPA eader anif [ p FL stribution J� �,�,p� x Hole Size x Hole Spacing Vent to Air Intake f 7 pe V Length___, Dia ngth Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over De th Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 3� t � ��� Bed /Trench Edges Topsoil Yes No Yes'i No COMMENTS: ( include code discrepencies, persons present, etc.) Inspection #1: & ! 2-2 !_ Inspection #2: / f Location: 1571 84th Street So rset, WI 54 (SE 1/4 NW 1/4 13 T30N R19W) Stonewoodo Ldt 5 L ' Parcel No: 13.30.19.1207 y 1 °2 y�/t-'1Lst.c.Q�✓ 1.) Alt BM Description = o 2.) Bldg sewer length - amount of cover = // Ip f Plan revision Required? Yes �, Use other side for additional information. T r \ Date Insepctor's Signat e C SBO -6710 (R.3/97) ]AI commerce.vvil.gov Safety and unty 201 W. Washin on AvR VED C sco Madison, WI 5 S nitary Permit Number (to be filled in by Co.) Department o ■ f Commerce 5 a �y z APR 1 Sanitary Permit Applicat on S te Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this for to theggprQgtt(3 ®h►fiCfitbl unit is required prior to obtaining a sanitary permit. Note: Application fo s for state -owned POWTS are P ject Address (if different than mailing address) submitted to the Department of Commerce. Personal information you prov p urposes in accordance with the Privacy Law, s. 15.04(1 )(m), Slats. �� (�( 4 1.4 L 1. Application Information — Ple Print All In formation t / / ( ! T Property Owner's Name n Parcel # 12 `7 O �t i2 (� PEL d- AVF Property Owner's Mailing Address Property Location (S�'Z LAnr6 ---- C Govt. Lot City, State Zip Code Phone Number W y., Section (Z / z Al 19 —5—L� T�_N; R� O / 7 (circle one) / / II. Type of Building (check all that apply) pr Lot # I& I or 2 Family Dwelling— Number of Bedrooms Subdivision Name _Eor� _ 'Sub tw: 4e _ Block # _ T A J 6— L E> U P ❑ Public/Commercial — Describe Use P 1 4 J` ❑ City Of ❑ State Owned n — Describe Use CSM Number ❑ Village of 3 �1t7f l� �iG I �'� Vlwv►n *Town of 111. Type of Permit: (Check only onJ box on line A. Complete line B if applicable) A. New System El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System /Component/Device: Check all that appl &on- 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: /Occ� + S Design Flow (gpd) esign Soil Applica Rate(gpdst) Dispersal Area Required (st) Dis r System Elevation (� 9 1600 -50 V1. Tank Info Capacity in Total # of Gallons Gallons Units c New Tanks Existing Tanks C y ° a wU A rn wC7 a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP /NfPR'SNumber Business Phone Number el� grk- 1 j � I �_ 2- 73 � Plumber' Address (Street, City, State, Zip Code) VIII. County/ e artment Use Onl Approved ❑ Di roved Permit Fee Date Issuing nt Signature ❑ ter en R for Denial �P V ' / � C IX. Conditiqw9 f WWeasons for Disapproval 3� �I ✓ I �^b eil 1� 1. Septic tank, effluent finer and ` ,nnJ/1ei dispersal cell must all be services / maintained ' L D • as per management plan provided by plumber. 2. All setbwk requirements must be maintained Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches 'n size n r , , -o c 4-6 SBD -6398 (R. 01/07) Valid thru 01/09 G6 .5 a r l �j 0-Y\ / �• 6 c-�t ivl.�j O J E L D L A-�✓ q4 z26Y q A y1 iy B 1 25 ( 5 �� P o 7 r ���L H P L Z 1, �A gz 63 5D , z " vV 421�`� < J� P � v a rr � / C nO��S C 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 extend to a point no greater must extend at least than 6" Below Finished Grade 4" Above Finished G ade . Cover with WiTA114 V ,�,. ,,� _ r Locking Device T X/ brJ '89x �PPt2e�rfrD lHf� �1'�'I�t� -- ( typical) Finished Grade r ?V I l.p /ti1i6r r SEW fly r Min. 23" 3 Pr ) .4 2 1, Access Opening 1 5()L Min. 23" Access Opening i ,2 „^6 Oul dt Effluent Filter f r,�//TH if "P✓e S! '� X11 r Union peoYEA Pl 3 Pr, r � 01 SoL.ia Soi� Inlet Baffle r r Pu p �- 3,. d or raw- an � yy ur?der- . wj� AA een'er 2.. Aaw er shah �d�es Two Compartment SepticlPumpTank ( 4o eep we hA SPECIFICATIONS F : �� D OSES PER DAY: TANK M R. 1 �� �� O TANK SIZE: SEPTIC GAL. DOSE VOLUME: I �r �- GAL. DOSE GAL. (INCLUDES FLOWBACK �20% OF DW�F,�) ALARM MFR: �/ (� �LE '�`� CAPACITIES: A = z 3 INCHES = C ` ( l / GAL. MODEL # l "b l Switch type: B = — 2 — INCHES = GAL. PUMP MFR: u t-D C= 7 INCHES = lkZ GAL. MODEL M '42 b INCHES= Z GAL. SWITCH TYPE: D= REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION FIFE (LIFT) _ 7, S FT. MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) = + d FT. A FT. OF FORCEMAIN x ql t FT. /100 FT. FRICTION FACTOR ...... = + p Z FT. TOTAL DYNAMIC HEAD (TDH) FT. INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH MP/MPRS SIGNATURE: LICENSE NUMBER; /� 2 c APR -12 -2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 HGOULDS PUMPS Submersible C �2,s +nPrf �oP Effluent Pump PE Hi" , 4,L uAt PuMp a� SPECIFICATIONS MOTOR FEATURES Pump — General; General: ■ Corrosion resistant • Discharge: 1'A" NPT a 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 h" tection with automatic reset. ■ Upper sleeve and lower maximum sphere. • Class 0 insulation. heavy duty ball bearing • Automatic models include a • Oil -filled design, construction. APPLICATIONS 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 Systems performance chart or curve. • .33 HP, 3000 RPM ■ Powered for continuous • 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 Dewatering • Maximum capacity: 61 GPM • 115 and 230 volts cord, 20` standard length, • Maximum head: 29' TDH • PSC design heavy duty 16/3 M with PE51 Pump; PE51 Motor: 115 or 230 volt grounding plug. • Maximum capacity: 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, 4o r. ,— ceramic, BUNA and stainless . . PE511 I I j i I - I moD; s: K31, PFa1, mss, steel. 35 _ I I j I I I I ^ HR .33, .ao, .so ■ Stainless steel fasteners. 10 I C i i I� - -1• !• , I 2 GPM I - I Iii 'AGENCY LISTINGS 30 ••FE4 u I �c us Zo Tested to UL 778 and C5A 221108 Standards 1, By tanUNan Star&rds Assocaoon file ftla" 10 �--i ; I I ' ' , i_ ? L !_ ' , I A ; I . j - i Goulth run,Es I's iso 90M ReyLqerea. 1 I I , j 11 � Ili I! I I li I I 0 O 0 10 20 30 40 50 60 70 GPM 8o 0 5 1 0 15 m Gou P ® 2004 ITT Water Technology, one- CAPACITY Effe June, une, Zoos " ITT Industries E37/41 C+K t 574 - P4C d P L nw Q iek4 w / 0/ co N -f o , �� STANDARD CHAMBER 52" Quick4 Standard Chamber W - -48" (EFFECTIVE LENGTH) (� e B B 98.5 34' SIDE VIEW SECTION VIEW 9 Ct7�/ lD� Mulffort End Cap A 16" 12" nn 34" SIDE VIEW TOP VIEW FRONT VIEW IN I Mill 1111 r INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Unitsj, when Installed and operated In a leachfield of an mslte septic system In accordance with Infiltrator's Instructions, is warranted to the original purchaser rHolde j against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that I a septic permit is not required by applicable law, the warranty period will begin upon the date that inslallatlon of the septic system commences. To exercise its warranty rights. Holder must notify Infiltrator In writing at its Corporate Headquarters In Old Saybrook. Connecticut within fifteen (15) days of the alleged defect. Infiltrator wig supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. / • Infiltrator's liability sPecfically exclWdes the cost of removal andro installation of the Units. "k wig THE UMITED W AND REMEDIES IN SUBPARAGRAPH HARE FITN THERE ARE PA RT I CULAR PU RPOSE. W ARRANTIES WfTli RESPECT T SYSTEMS INC TO THE UNITS, INCLUDING LUDING NO IMPLIED WARRANTIES OF MERCHA TY OR OR FITNESS FOR A PARTICULAR PURPOSE. (c) This Umded Warmly shall be void lt any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, Including loss of Environmental Onsite Wastewater Solutions" production and profits, labor and malmais, overhead costs, or other losses or expenses n red by the Holder or y third party. Specifically excluded from Limited Warranty coverage era damage to the Units due to ordinary wear and leer, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the Installation Instructions; failure to maintain the 6 Business Park Road • P.O. Box 768 minimum ground covers set forth In the Installation Instructions; the placement of improper materials Into the system containing the Units; failure of Old Saybr CT 06475 the Units or the septic system due to Improper siting o' Improper sizing, excessive water usage. Improper grease disposal, l, or Improper operation; any other event not Caused by Infiltrate This Limited Warranty stag be void if the Holder fails to comply with all of the terms set forth In this Limited Warranty. 860- 577 -7000 •FAX 860- 577 -7001 O �fA Further, in no event alai Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third parry resualg from kstallatbn o sh ip• 800 -22't - 4436 mmt, o, from any product liability im clas of Holder or any third parry. For this Limited Warranty to apply, the Units must be kstalled In accordarhce with all site conditions required by state and local codes; all other applicable laws; and Infiltrators Installation Instrucilons. (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty apples to any party other then the origl- . net Hader. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty require- ments. Any purchaser of Units should contact Infltrator's Corporate Headquarters In Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 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 SideWinder 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, Snapl ock, ChamberSpacer, PosiLock, QuickOut, QuickPlay RECYCLED PAPER and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed In U.S.A. Q011203HP -0 r s Wisconsin Department ofCom $OIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings ccordance 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. 032 - 2136 - 50 - 000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all i n rm CEIVED Revi by 7 7 / 67 Personal information you provide may be used for se dary purposes (Privacy Law, s. 15.04 ( ) (m)). Property Owner �� � 3 20 Rroperty Location CHRISTOPHER T. KOPEL & ALA M. / /��. L - - -- SE 1/4 NW 1/4 13 T 30 N R 19 E (or) W Property Owners Mailing Address . CROIX COU # Block # Subd Na mfor CSM# 11011C Oak Groove Circl 5 1 -- Stonewood City State Zip Code Phone MurnOW ity []Village ■ Town Nearest Road Woodbury, MN 1 55129 ( ) NK 160th Avenue Somerset a New Construction UseEl Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 0 Replacement Public or commercial - Describe: Parent material glacial outwash Flood Plain elevation if applicable lug General comments Conventional In- ground trenches -- 0.7 loading rate -- to be designed by Roger Nelson and recommendations: (New test cond d due to location of propos 7dwelling- use initial report for re la ement area � L ouJf.�. lx, t*C,9tofc .0 U , FT] Boring # Boring ✓ " l a f.Qa. of u�, 4-o Q Pit Ground surface elev. 100.27 ft. Depth to limiting factor 118 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -12 10YR2 /2 - sil 2fabk mvfr as 3vf -m 0.6 0.8 2 12 -20 10YR4/4 sil 2f -mabk mfr cw 2vf -m 0.6 0.8 3 20 -5 10YR4 /6 sil 2fabk mfr cw 2vf -m 0.6 0.8 4 51 -118 7.5YR4/4 - s Osg ml __ -- 0,7 1.6 Horizon 4 has some gr; few cobs. / r1 1 r l6 .rS 2 Boring # Boring 98.$2 126 Q Pit Ground surface elev. ft. Depth to limiting factor in. 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 I *Eff#2 1 0 -4 10YR2/2 sil 3fgr mvfr cb 3vf -m 0.6 0.8 2 4 -10 10YR2 /2 - sil 3fgr &sbk mvfr as 2vf -m 0.6 0.8 3 0 -24 7.5YR4/4 is lmsbk mvfr cs 1 of -f 0.7 1.6 4 24 -100 7.5YR4/3 9 f s Osg ml cs -- 0.7 1.6 5 100 -126 7.5YR4/4 s Osg dl -- -- 0.7 1.6 Horizons 3 & 4 have some gr; few cobs. * Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BQD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si a CST Number Ma Jo Hollister Hollister's Soil Testing & Desi n 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 03-27-07 (715) 426 - 1775 Property Owner KOPEL & BEANE Parcel ID # 032 - 2136 -50 -000 Page 2 of 3 [-3 Borin # Boring J g 0 Pit Ground surface elev. 98.22 ft. Depth to limiting factor 76 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 -4 IOYR2 /2 -- 1 3fgr mvfr cb 3vf -m 0.6 1.0 2 4 -12 1 IOYR2 /2 1 1 3fgr&sbk I mvfr as 2vf-m 0.6 1.0 3 12-25 1 7.5YR4/4 2fabk mfr c`W lvf -f 0.6 0.8 4 25 -49 7.5YR4/6 -- a (/ is Osg ml cw lvf -m 0.7 1.6 5 49 -76 7.5YR3/4 -- '� s Osg dl ab -- 0.7 1.6 6 6- 2 7.SYR4/4 fl 7.5YR4/6 is Impl mvfr -- -- 0.2 0.6 Horizon 4 has some gr; few cobs; one stone. F-1 Boring # C1 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 ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. g Pit 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. *Ef1#1 I *Eff#2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/- 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- 8330Te t (8.07/00) Plot Plan for Site and Soil .Evaluation Page 3 of 3 Property Owner c (f gIsroI?AEg T xo be 1 " = 40 ft Legal Description t , 5 N,y nom - t oc TE0 %4_ (except where noted) -WE OF T N w�l4 5 EC {3� � y N R1� U1� Q = Backhoe pit CROW, C0%A 1All6eAW North ,3,C6 , s 4 1 W �X ZW �. (� E ; �- too. Idp.Ot3 bo FLI Site Location: Ibo'ch qvr�.� Q) G J y { .............. ma c, a y Cb Ae f ........... f#3 00 `' l ? r i- t 7 y • 0,9 ^' 1 37tR' .T z lz 732, 9 5J SO FT � co 137 0 ACRES lVt18`2 '4 c OD 7i 5�. tit MINIMUM FF .F =942 .�' co j L 0 T 4 ` rn s . �, ' w ..J �J�J A CRE.S 1.JC� MINIM T. * "' �'y£ � ,'i S7 " MINIMUM F.F.E 43. *� U LELEVAT f , ACRE RED �* " _ E c� F F I=. =922.8 y . " 427.8?' s 22 4 "'iw 2 TH- -SOUTH QUARTER LINE _ _ ..... 1889.7l'-, s 'k {�0'{}7'33'�W 2621.64— _—�._..�.�..__ OVERALL. "TH- - SO UTH 1 � 4 LIN /4 CORNER --------- a00*07`,,3;5 ")N 5241.26 --- ` L.�� Y � D A t.3� --. 13-30-19 - _ .• _.M. ALUMINUM MONUMENT .. ..TA HrjM BEA J40 TAN '' =t�T" A m "— W�SCOrtisin Departrnant.0# Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 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. # APPLICANT INFORMATION - Please p �� ♦ t! Re vie by Date Personal information you provide may be used for se purpo I .(Pf lc Law,�`s,�3.0 (1) (m)). �y �Z 7 Property Owner L1 r erty Location . Lot 1/4 1/ ,S T N,R E (010 Property Owner's Mailing Address let Block# Subd. Name or CSM# ST CROIX COUNT`/ 1 1 City Stat Zip Code JP'}io IjFICE City ❑ Village Town Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow e�,-V gpd Recommended design loading rate bed, gpd/ft -L-2- trench, gpd/ft Absorption area required 2:"� bed, ft .�90 trench, ft 2 Maximum design loading rate �? bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) ,��� ft (as referred to site plan benchmark) Additional design /site considerations Parent material — '222 Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S MU � S El ❑ S 10 U I ❑ S O U I ❑ S MU ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots ... Bed ,Trench `� 1 UUm, � _ Ground 3 7 elev. Depth to limiting factor Remarks: Boring # 13 11� Z_ a. 7 Z " P. I ` ' Ground zs- elev. Depth to limiting factor ✓ gamin. Remarks: CST Name (PI a Pri t) Signatur Telephone No. r - -> Address Date CST Number r PROPERTY OWNER ;,� SOIL DESCRY TON REPORT e ' page � of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench K � Ground iev. Depth to limiting factor ; n. Remarks: Boring # z I Ground elev. ft. ' Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting ; factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) I tL 00 a IN O w p g ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer ��� �d ��Vl!/ /S e✓ b Mailing ddress / � en, ji e- / bt j Rc 4 mo ,, � g �� - C�1 � �1 l `.� �U7 9'�foZ Property Address 15 7 l l " B I Aky W �no ki d , (U/ S'YO/ 7 (Verification required from Planning & Zoning Department for new construction.) ;ity /State l'j R(' 4wi-QA � W 1 Parcel Identification Number 032' (o - - 00 O ? .,EG- AL DESCRIPTION Property Location _,:�e ' /a ,J � ' /a , Sec. -a, T 30N R W, Town of � L Subdivision Aowezw © ,6 Lot # S . Certified Survey Map # 2 , Volume , Page # Warranty Deed # � 3 � �Z- , Volume � - ,Page # Cow Spec house yes no Lot lines identifiable yes no •'S`l`I:IVY MAINTENANCE AND OWNER CERTIFICATION ,r Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper .aintenance 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 rt.s,wnsibilities 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 ..,caner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site t.; zstewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is toss 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 ste..ndards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. ., stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & ur iug Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the 1roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office. �_a7ber o bedrooms -- ./Vl1l l SIGNATURE OF APP T(S) DATE " *.Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** nciude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if r ( is made in the warranty deed. ,Z E V. 08/05) i t POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa / of Z FILE INFORMATION SYSTEM SPECIFICATIONS Owner C 4(2 ( 4 P � �� — 6 Pe Septic Tank Capacity � 2 D a al ❑ NA Permit # Septic Tank Manufacturer f ES ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer z Lc L ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ld 0 ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity 60 a l ❑ NA Estimated flow (average) 0-0 gal/day Pump Tank Manufacturer (A�)JC_ -jj L ❑ NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer �� L ❑ NA Soil Application Rate 0 al /da /ft2 Pump Model /O � ❑ 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 ® In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu /100ml ❑ 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: 3 ❑ monthis) (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 y ears) ❑ NA ® year(s) Clean effluent filter At least once every: ❑ month(s) ® ea ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA 19 ear(s) Flush laterals and pressure test At least once eve ❑ month(s) ❑ NA every: V year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: O 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) ti. Page Z 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 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; 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 C— L S p� Name Phone S_ Z 7 3 _ T T Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S' CAP D Zo -_J !� Phone Phone Z �z _ b 8 v 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. • 8037 1 ;a � STATE BAR OF $ ISCONSIN FORM I - 1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO.. WI Document Number RECEIVED FOR RECORD This Deed, made between 14 EAM!E +- NYEi2PA1X -C3 0 Z-LC 08/17/2005 11:41BAR _ _ WARRANTY DEED /S C.,.uS in/ �1 M i TFr D /� B/L ! EXEMPT # _ Grantor, REC FEE: 11.00 and /� / STn /� T. _mod f��L 1,g� - e 114_N. _ TRANS F 170.90 E CC FEE /t PAGES: 1 "S01N'T ��� ✓V A l�I TS __ Grantee. Grantor, for a valuable / c�onssideration, conveys to Grantee the following described real estate in S% ` -,<O I County. State of Wisconsin (the 'Property "): Recording Area Name and Return Address �L. c, T S, � 7'oNC f.✓oD D, To t�c/n/ o F /S/�R/�f � E F'M TE: RJ L L C �•it-rE 7- Si. C'.QoiX (?4V"rY - 72 7 -7 T-4 hl v I�so�, �,✓2 SyDi� - / � � Parcel Identification Number (PIN) This T homestead property. (is not) 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 It= ASF/vYE/�/ �, C U�/YA ANA �E'- s'Tie /C T�a�tIS °F ��C ORD� /F Dated this / TN day of /YV �i Ut T Zee (SEAL) (SEAL) . 09A A , V4-- (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, ss. St. Croix Court t authenticated this day of Personally came before me this 1 b day of Augus the above named Barbara A. Geving 0-, TITLE: MEMBER STATE BAR OF WISCONSIN X22 �� AR y x'= to (If not, Z ;e know o be the person who executed a foregoing authorized by §706.06. Wis. Stats.) C� I CJ : y strum t nd acknowledge the same. k P Ut \, •Z _ THIS INSTRUMENT WAS DRAFTED BY '���'.rr'9T • ' �c��+��` A E/QO/�RR �1. G �/ /ic/4 OF _f'.nnni P _M- 6111 7 i XSCIn Notary Public, State of Wisconsin _'7 es 5 O14- o s permanent. (If not, state expit 727 TN T �vDte L✓ '� / 7// My com i -`i i �i8s date: (Signatures may be authenticated or ackn wledged. Both are not .) necessary.) • Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank co., Inc. MIWrwawr;Wis Y I Jrr— t-f — G ti j M, 6 .. 'sonvi w►ivriws — 1-- .- _�"L� "- �"ur�° -`= =-- - -'-- -- -- -- � �.(�� • I' .� q„9i.O6Wi f _t_�•- - -^_ __ _ __ .._ 7i1�d/Wro lft�ltrf ` .Qr ^ 1N j .N � (ays m SMI eoMeaTJ t t +a�mw ammr o nrsw 6 si r es OM 1 If gg 3s .n i lia & _- TAM i - + \ ,s o y: ''a" y � �' ► � � Z;Z ^y . , , - ` Z. 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