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HomeMy WebLinkAbout038-1211-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisio INSPECTION REPORT Sanitary Permit No: 463490 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: Oeverin , Ken I Star Prairie, Town of 038 - 1211 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 13.31.18.1152 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark rbZ•$ Alt. BM .( Aeration Bldg. S wer - �� 1 Holding St/Ht Outlet St/Ht Inlet ,7, 5 �f 3 / `,• o-7 O TANK SETBACK INFORMATION - W-14 w. Co TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet i Septic � r / ,/t i � r • Dt Bottom \ Dosing (O J-- (� Header /Man. Aeration Dist. Pipe g , s 9 Z Holding Bot. System ` 1 ". Z PUMP /SIPHON INFORMATION Final Grade - • C 15! Manufacturer Demand St Cover GPM 3• Model Number T Lift Friction Loss ;;;a d T Ft 13 3 - orcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Tr PIT DIMENSIONS No. Of Pits Insi Dia. Liqui ;3 epth DIMENSIONS �(Z) SETBACK SYSTEM l TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: f r INFORMATION CHAMBER OR f Type Of�Syste � r ,1 / A /� UNIT Model Number: DISTRIBUTION SYSTEM 6 1 3 / �G( 7✓ Z-1 Header /Manifol� �� Distribution x Hole Size x Hole S cing Vent Air I take t Pipe(s) � Length Dia Length_ Di Spacing t� SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over //// Depth Over xx Depth of soil Seeded /Sodded xx Mulched Bed /Trench Center Bed/Trench Edges Topsoil �� I Yes No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1355 212th A New Richmon , W.I ,54017 (NE 1/4 SW 1/4 13 T31 R18 II Lot 62 Parcel No: 13.31.18.1152 1.) Alt BM Description = 6 r d �� i 2.) Bldg sewer length = 'q7 - amount of cover = CJg J 1 Ja t Plan revision Required? Yes X<0 7S Use other side for additional information. L� ��IIJJ Date Insep o s oSigne Cert. No SBD -6710 (R.3/97) A Safety and Buildings Division County 5 ' c I INS N VISConsin 111 201 W. Washington Ave., P.O. Box 7162 er a Madison, WI ��" Sani Permit Number (to be filled in by C (608) 6 -31 v c? 7� 1 Department of Commerce c.J N Sanitary Permit Appli catio ��, State Ian I.D. umbey A- ��,,�� JJy, �� 20 5 In accord with Comm 83.2 1, Wis. Adm. Code, personal information on P Aw may be used for secondary purposes Privacy Law, s15.04(1 m) S7 . CROIX COON V Project ddress (if different than mailing address) I. Application Information - Please Print All Information ZONIN 1355 Z !Z Property Owner's Name Parcel # Lot # k #' Property Owner's Mailing Address ,. nn `` Property Location .1 ) . - 9 Ju `^ /V� V " ' 1 ea je." AJ / ' /,, Section / City, State L d Code Phone Number 1- `, I 5q D I � N; R rcl ne lam/ � W II. ype of Building (check all that apply) r2 Family Dwelling— Number of Bedrooms ak C. po-j-- r ew'.-C) Subdivision Name �j C�SMNumber El Public /Commercial - Describe Use D �--ff ❑Ci ❑Villa shi of �— El State Owned - Describe Use z %64" �-�t � �� � � �^^- �� ty— p III. Typ of Permit: (Check only one box on line A. Complete line B if applicable) _ A. t N7 System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision Change of El Permit Transfer to New List Previous Permit Number and D Issu Before Expiration Pl umber Owner �13D 3 7 6 b IV. Type of POWTS S stem: (Check all that appl on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- round El Holding Tank ❑ Peat Filter El Aerobic Treatment Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter aching qt4p1b a El Drip Li [1Ar Pipe El Other (explain V. Dis ersaVrreatment Area Information: % J Design J Fl�gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal yposed (sf) System le ati _5) (_ 7 1 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site AgIl Fiber Plastic Gallons Gallons of Units A_ Concrete Constructed Glass New Existing Z ,ti e_\ rC Tanks Tanks AA Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber Al VII. Responsibility Statement I, the undersi , assume responsibility for installation of the POWTS shown on the attached plans. Plumber's ame (Print) Plumbe ignature MP/I PRS N be r Business Phone Number ,5'z, �Z �i, : _- Zq6 �- Plumber's Address City, State, Z `/, �J Jj VIII oun /De artment t1se Onl pproved ❑ Disap Sanitary Permit Fee (includes Groundwater Da Issued Issuin A nt Si s) Surcharge Fee) �S El O Given on for �Q� . IX. Conditions of Approval/Reasons for Disapproval 2 SYS OWI,IEIt �J ga t C N�t�b� O t• J Septic tw*, * hunt Nor and � o ✓� � dspw" "N must ON be wykm as per Mwspnwd plan praldad by ptunlbu. I v � - � �,r� 4 v� cSZ_ /� a z AN aoftck tiquMWWft MM be InMltti i inne dt J�- V as par atppAo�eb ood� laldNMrtow. Attach complete plans (to the County only) for the system on paper not less than 91/2 x 11 inches in sire SBD -6398 (R. 01/03) w CN:6 ty111S*t3uiet9 %`n6 ?., " ±w�' y ' . f8 SOWWAM ±Mm imisakra "Qof • PLOT PLAN PROJECT Ken Oeverina ADDRESS 838 Summer Pines Circle Hudson Wi 54016 NW 1/4 SE 1/4S 13 /T 31 /R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5120/05 BEDROOM 3 CONVENTIONAL XXX IN- GROUND ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 BENCHMARK V.R.P. Top of 1" pvc ASSUME ELEVATION 100' Filter Zabel A -100 ❑BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 94.9/95.0 4' below qrade Well is to meet all 338' Property setbacks required by 310' Line WDNR Property Line jL Standard Biodiffuser o 3 Leaching Chamber Bedroom with 3 1. 1 ft2 of Area House Grade at System Elevation 25' " 34 ST 5 ' B -5 B-4 Plans Designed Using Conventional Powts Manual Version 2.0 76' B -3 76' 2 -3' X 69 ` Cells with >3' Spacing 65' B -2 -1 Vents 10' 5 45' 37' 20' Property Line Maintenance and Contingency Plan for a Septic System Maintenance Plan 3 ears. 1. Septic Tank is to be pumped once every y filter is being installed in 2. Effluent filter is to be cleaned once a year. Please note: a larg order to extend the maintenance interval of the filteri in pipes at the ends of 3. Once every 3 years, cells are to be inspected v ia the P the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this pi an. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. p er Comm. 83 8. Discharge into system is not exceed those required as p F ncy Plan f alls cause of failure, use E `:emate ae �d and install new If system a , determine ested replacement area. op tion #2. Install system at a lower elevation, by removing chambers, removing biomat, and install new system. rea is suitable for replacement area, and system elevation O p tion#3. No adequate a cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715 - 246 -45 St. Croix County Zoning 715-386 -4680 Pumper Tom Mondor 715 -246 -51 Shaun Bird #226900 Wisronslh Depa�Lnent of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division t INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 430378 0 GENERAL INFORMATION 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: Oeverin , Ken I Star Prairie Township 038 - 1211 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionlrown /Range /Map No: 13.31.18.1152 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake OAD Dt Inlet Septic Dt Botto Dosing HeIM an. Aeration . Pipe Holding B System PUMP /SIPHON INFORMATION Final N Manufacturer Denrod St Cover G Model Number TDH Lift Friction Loss System Head DH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length . Of Trenches PIT DIMENSIONS No. Of Pits ide Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO If BLDG WELL LAKE /STREAM LEACHING Man acturer: INFORMATION Type Of System: CHAMBER OR UNIT Model mbar: DISTRIBUTION SYSTEM Header /Manifold Distributiorif Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing 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: 1355 212th Avenue New Richmond, WI 54017 (NE 1/4 SW 1/4 13 T31 N R18W) Northgate II Lot 62 Parcel No: 13.31.18.1152 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? L, Yes q,, No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. M, w. wasildwam Ave-, P.O. Bum 7162 j2xCx NV!sct�A4n MsOsam WI 53M7 - 7162 30dWy Pelt Numb (to be Mail b by (o.) De artment of Commerce (6M 266-3151 Sago hu y Parma Appli�ution Soft � In accord wA Comm UM. VIis. Adm. Code, petsoad iefatamiian You p� may be a" for seeoofty pm�pose Prlra s cy Lw. M)w ti<ojeCt rif drIm emt m m � address) L Applicifim hOwn km — Ptessr FIF ARII M II a RECE ✓ ,t' z . Pnqzrtyowaees Na me S E P 16 2003 rsoet o Block propm7owne'sM sitiogAdikess ST. CROIX COUNTY Pt I / ZONING OFFICE l j • 8 Seeuon Zj _ aw, Store Tap Cade Phone Number IL TRW of Baft "Incilt an am CSi Number WI or 2 Famly Dwdrmg - Number of - - Describe use �- /- y� ` O state owned - Die use - E Wrowrabi of WA HL TAw of r+eassi - (C hak off► most boar m A. @q*w Symers ❑ Bit System T'aab pay O Omer ldodiitcadou to Fidsting System B. O Permit Renaud ❑ Permit Revision ❑ of ❑ ' Tiamfe so New list Pte ride Permit Number and Dale Issued tldoce Eapaation PIs NAW )V. Type of YOWTS Sysismic, (Check an duet 2• S — (' / won -Pressurized mdltommd ❑ Nbo d > 24 a of sobible soil O e 24 iu. of sailtbte SON O AtGm& ❑ s5sille Pam seas riper ❑ C70asuuMd Would O Poessreiad bA3M d ❑ ❑ ❑ AeeobicTresnaemt ilsit D Re=cwlmmg sand Filler O Re*cub tug Symhc is Mcfn FfiNer CT■mber - ❑ Ilse Pipe ❑ carer V. A Design Flow (gpQ srA Application Rme bP k CA D4cffwl Mw B Area � � 0 ia i n i 3 4/ C 1 7 3 VL %fe in ? Tiolal Ibmn- 1. l Premb Me Sleel Finer Plastic Cxdkm oruaio � ` Cbnae/e Cloolumad Glass New > Tats Tads scpfic or 4kw"4:4* r Doift AC10biC Tie•�eest Uai ,�,..� VII. R eteittaitraiQsei, asa�e §W iwalsliaa stew row" sbrwa ae attached plies. �� h a ft s g SRS Nambw Business Phone Nmaber #221180 _ a s 7rs— — ' AACKP OWN ON stat� z4 cede) end � S'�" - f 7t) --03 7 (715) m2— ilae oubF AWo,W ❑ SaailBy Permit lire (aeebsdes Caroundwaler Issued lumbis ) ❑ Green Heaton for Dust ReC' �. 9a D ilx. t:o of for D6appaw.'1 YSTEM OWNER: 3 Alf' Septic tank, effluent filter and(,AY/tm0 3 • SZ 4�A � ©d /0S — &M,' dispersal cell must all be serviced / maintained as per management plan provided by plumber. 4b Q 2. II setback requirements must be maintained as per applicable cod 3- e /ordinances. 3, �avc�r au.&c=m0tert= 0 1 13MAY)EWS10 Ostra a■ ppr,.ltea tr.aws z11 i eaesi. aim I I Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, W1 54801 (715) 635 -960, I i I t - �oiuE is ` x a' S7 zor ®° � 3 OW S.T• t./ G7xiz e - I 4(d 7S , i pS: / Y7 c -.z �,txE ltN� i 4I ' e_. , _a y � o -' o AL : ! ' ;•% it _'= rA CD .... IL6 \ � CD rjQ CL RL CD _ ` b 4 O- I• C CD SE � � 0 s u 0 e p t lid G- c N CD 1 A+ 3 0 N - 0 " j V pq 11 II r � coo #o co W X ►-� � Go c� Wcn O9 CD o' 3 /K/. Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, W1 54801 (715) 635 -96 r I , IPWO 4OT 0 6 y N d+1�s = .9LT• 8,�� ,ss� Bt / 'r I/ 9 4. l2 � ��aA/� Lvf �oRAi� �df �� �• 3 car/ ,sntr=cz f'Yr e -� .42 -T / * vs. 6 �o/ Wisconsin Department of .Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 V I L �� ltor and Taman Relations of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 038-1055 - APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION I R VIEWEDBY DATE PROPERTY OWNER: PROPERTY LOCATION Greenwood Enterprises, Inc. GOVT. LOT NW 1/4 SE 1i4,S 13 T 31 N,R 18 IE (or) W PROPERTY OWNERS MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR C 1416 Third St. 62 na NorthGate CITY, STATE ZIP CODE PHONE NUMBER ❑CITY [ [TOWN NEAREST ROAD Hudson, WI. 54016 (715 386 -3674 Star Prairie I 212th Ave. [X] New Construction Use ( ] Residential / Number of bedrooms 4 [ ] Addition to existing building I ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft •8 trench, gpd /ft Recommended infiltration surface elevation(s) 94.90 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND 7RE PR ESAT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem E7 S 1:1 U CA El U FI S ❑ U ® S El ® S ❑ U EIS ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends ................. .................. ................. .................. 1... 1 0-12 10 212 nomm 1 2msbk mfr - w if .5 1.6 2 12 -21 10 r 4/4 none sicl 2msbk mfr °w if Ground 3 21— 2 10 r 5/4 n i elev. 98. ft. 4 32 -84 � -5yr 4/6 n Depth to limiting , factor " +84" � 4'b Remarks: Boring # 1 0 - 10 r 2 2 n n 2msbk mfr QW if .5i .6 >......::> 2 10 -18 10 r 4/4 none sicl 2msbk mfr qW if .4 .5 3 18 -33 10 r 5/4 none sil lmsbk mfr QW na 1 .2 .3 Ground elev. 4 33 -84 7.5 r 4/6 none cos os ml na .7 9 8.9 ft. Depth to limiting > � factor c� ,1 +84 I o Remarks: - .: 4 sT e CST Name: -- Please Print Gary L. Steel Phone: 715 -246 -6200 y ZOfvNVGaF Address: 1554 200th. Av ew Richmond W 54017 _ ... Signature: Date: C tlmbCr tit PROPERTYOWNER Greenwood Enterpris SOIL DESCRIPTION REPORT Page Y2 of '3 PARCEL I.D. # 038 - 1055 -95 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncl3y Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Ttendi 1 0 -10 10 r 2/2 none 1 2 10 -26 10 r 4/4 none sicl I 2msbk mfr of if -4- Ground 3 26 -84 7.5 r 4/6 elev. 98.8 ft. Depth to limiting factor +84" Remarks: Boring # .... 1 0 -11 10 r 2/2 none 2 11 -29 10yr 4/4 none sicl 2msbk mfr qw if .4 .5 Ground 3 29 -84 7.5 r 4/6 none cos os elev. 98.7 ft. — Depth to - limiting factor +84" Remarks: Boring # 1 0 -11 10 r 2/2 5 2 11 -30 1Qyr 4 Ground 3 30 -84 7.5 r 4/6 elev. 98. %. Depth to limiting factor +8 4fe Remarks: Boring # 13 Ground elev. j ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) rrwrcni r vrrtrcn w ==AWVVrA rdjLt=LVilb QVIL. YC3Vrti1' I IVry r1Cr un t 1 Page A al PARCEL ,D, a 038- 1055 -95 Boring # Horizon Depth Dominant Color Mottles Texture Structure Corte 91rrd3y Roots GPDIft in. Munsell Qu. Sz. Copt Color Gr. Sz. Sh. Bed rends 1 0-10 10r22 2 10 -25 10 r 4 Ground 3 26-84 7.5 elm 98.8 ft. 1:4th to liimiling factor +84 Remarks: Boring ,t 1 0 -11 10 r 2/2 2 11 -29 1 r 4/4 none sici 2msbk Mfr if .4 .5 3 r 4/6 Cos osa M1 elev. - 98.7 ft M " limiting facto IX +84 01 Remarks: Boring # 10yr 2Z2, ' r 1 0 -1 2 F — Ground 3 ' Slay. 98 - DWM to lim" factor +8411 Remarks: Boring i► Ground Slev. ft. 0" to Ming (actor I STEEL'S SOIL SERVICE Gary L. Steel Greenwood Enterprises, Inc. 1554 200th Ave. CSTM2298 NW4SE4 S13 T31N - R18W New Richmond, WI 54017 MPRSW -3254 town of Star Prarie (715) 246 -6200 lot #62- NorthGate 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 =40' BM.= top of 1" pvc pipe C el. 100 Alt. BM.= top of 1" pvc pipe C el. 99.90 � o p f1 03 t d� B �► �- 5 ?.o j op S� Gary L. Steel 11 -8 -98 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM �n (/ LAC r 1 .Mailing Address Property Address 3 .f�r_ 2 Al. / Xc (Verification required from PI g Department for new construe 'on) City /State Parcel Identification Number 0 3 8 /.2 // — VO —0 f a LEGAL DESCRIPTION a Property Location A&I '/,, , _ '/,, Sec. /�_, T N R'W, Town of Subdivision Lot # � .� - -- -� _ Certified Survey Map # �- . Volume . Page # - Warranty Deed # 2-1 y' Volume G a , Page # _e e O� Spec house ❑ yes OP o Lot lines identifiable Eryes ❑ no SYSTEM MAINTENANCE Impo pause =dmambeaanoeefyowapfic emCould irsnitindspmmaturefiffhamto handle wastes. Proper maintenance consists of pumping out the septic tank every three years ar soonaa; if needed by a licensed pw i4 m. What you put into the system can affect the function of at septic tank as a treatment stage in the waste disposal sys The propext owner agrees to submit to St. Croix Zoning Department a mast faun, signed by the owner and by a ?' a pl .l r edplaamlaa:rar a lioansedpamsperv_ed ying tLatt(1) the ao-site wadewaterdisposal system _.- ._. - is proper operating _ aa&6i M abiT and pasta w*g Crt'neoessaay), the septic tank is bmi dean 113 full of sludge. Uwe, the undersigned have read the above reslummts and agree to maaintam the private sewage disposal system with the standards set f ink henm, an set by rite Depmbno t of Ca mmace and the DgaanbwW of NaWW Reno wcm stmt of Wisoostsin. Certification U7 has bastmaintained must �rm be caniased and d so the St. C,rok County Toning Office within 30 expiration date SIGNATURE OF APPLI DATE OWNER CERTIFICATION I (we) certify dw all sta - em ents cut this form are true to the best of my (oar) knowledge. I (we) am (are) the ownet( of the descn �by virtue of a warranty deed recorded in Register of Deeds Oiim SIGNAhME OF APPLICAI flK DATE- * * * * ** Any information that its mis- represented may result in the sari t being revoked b the Zoni Y �' l� B Y g Depa�rhttent. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed . • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 'FliE INFOR#OATION SYSTEM SPE�RC/1TIONS - Owner L- — - Septic Tank Capacity D NA Permit O 3-7tF Septic Tank Manufactures DNA DESIGN PARAMETERS Effluent Filter Manufactur4 G ❑ NA Number of Bedrooms 1-7 DNA Effluent filter Model r .md DNA Number of Public Facility Units XJNA Pump Tank Capacity bWA NA Estimated flow leverage) Pump Tank Manufacturer 13 )Design flow (Peak). (Estimated x 1.51 Pump Manufacturer 10 NA g aIAl aY Solt Application Rate _ almd tifz Pump Model !7 NA Standard InfiuenttEffluent Quality Monthly average• Pretre nt atme Unit NA Fats. Oil & Grease (FOG,) X30 mgA- D Sand/Gravel Fitter D Peat Filter Biochemical Oxygen Demand (BOD 5220 mg/L D NA 0 Mechanical Aeration D WetLwW Total Suspended Solids (TSS) 5150 mgA ' E3 Disinfection O Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) DNA Biochernical oxygen Demand (BODJ !30 mgA. ), In- Ground (gravity) D In- Ground (pressurized) Total Suspended Solids (TSS) 530 mgA- NA► E3 At-Grade D Mound _ Fecal Colifonn (geometric mean) 51 cfu/100m1 D Drys -Line D Other: Maximum Effluent Particle Size Y. in die. D NA Other: D NA Otter: D NA Other: D NA 'Values typical for domestic wastewater and wild septic took Othe DNA MAINTENANCE SCHEDULE Service Event Service ftmImiency At least once every: - D months IMa)&nurn 31�) D NA Inspect condition of tank(s) s) Pump out contents of tank(s) When armed sludge and scurn equals one - third (Y of tank volume D NA month s D ( 3 DNA At least once tMar°"" rrt years) cells every: 3 s) Inspect dispersal () year) Q month(s) D NA Clean effluent filter At least once every: — y e s ) O R D month(s)A Inspect pump, pip controls & alarm At least once every: D year(s) ' D month(s) Q NA, Ruslr laterals and pressure test At least once every: D "Nis) Other At least once every: © NA Other. ANA MADTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or mss: Master Plumber, Master Plumber Restricted Sewer: POWTS Inspector, POWTS Maintakw. Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks) to identity any missirig 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 adlis) shall be visually inspected to check the effluent levels in the observation Pipes and to check for any pond'mg of effluent on the ground surface. The pond'mg of effluent on the ground surface may indicate a falfirng 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 JY 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. piing prwucls: PCTS abmvly y —4--, ..� ..................�� �.� — — — 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 kmatiorh of a replacement sod absorption system. The replacement area should be protected from disturbance and faction and should riot be infringed upon by required setbacks from existing and proposed structure, lot lines and walk. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacernerit systems must comply with the rulers 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. s not �tsd=�a��tat� t U and site ha v umu nt area._ If no replacement area is a holding tank may be installed O Mound and at -grade soil absorption syste ms may be "nstructed 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. < <WARNNNG> > SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR OXYGEN. DO NOT ENTER A SEIPTIC. PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUIUSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE 011144CULT OR LE- #221180 81199M. W (715) 63 POWTS INSTALLER POWTS MAM Name t ft� --�/ Name Phone S'.- ) !o PFarie — D STAGE SERVICING OPERATOR [PUMPER) LOCAL REGULATORY AUTHORITY Name Nam CA ( -)( - C&UJlf Phone Phone s' ?b li b This document was dratted in compriance with chapter Comm 83.22121(b)OHO &M aid 83.54111. (2) & (3). Wisconsin A&nkisuative fie• 724105 ?j U 2 �2�6 0 P. 3 0 j STATE BAR OF WISCONSIN FORM I - 1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI Document Number RECEIVED FOR RECORD H This Deed, made between Gl"eenPD00d $YiterprlSeS a Inc. , a 66/02/2003 10:15A)1 Wisconsin Corporation i; WARRANTY DEED ! EXEMPT 1 _ Grantor, REC FEE: 11.00 an d Kenneth J Oevering TRANS FEE: 70.50 COPY FEE: 2.00 CC FEE: PAGES: L Grantee. !I Grantor, for a valuable consideration, conveys to Grantee the following Ij j • described real estate in St. Croix _ County, State of Wisconsin (the "Property "): He6o Are, Name and Return Address Lot 62 of the Plat of NorthGate II, recorded in the ice of s or St. Croix County, I Edina Realty Title �I Wisconsin, on June 20, 2001, in Volume 8 of Plats, 400 S. 2nd St., #115 at Page 55, as Document Number 648882. Hudson, WI 5401 6 - -_ - -- 038- 1211 -40 -000 Parcel Identification Number (PIN) This is riot homestead property. i' (is) (is not) 1 !I !r f I !I I' I! 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 easements, restrictions, and reservations, if any, of record. Dated this AA day of Mai 2D03 �D ENPERPR ES �� (SEAL) (SEAL) r (SEAL) (SEAL) .Ma R sch, Sec /Treas AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, SS. St. Croix Count . I authenticated this day of Personally came before me this day of MRIE 2Q03 the above named TIC ?- Rtrcrh, its President aru3 Mar= R_ Rust , i tc . pr re R !� TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the persons _ who execuigd t e authorized by §706.06, Wis. Stats.) instru n and acknowledge the e. r t' THIS INSTRUMENT WAS DRAFTED BY r 7 Ma ry R. Rusch Sandra Gehrke / • Notary Public, State of Wisconsin New Richmond, WI 54017 My commission is permanent. (If not, a iratiot) bate (Signatures may be authenticated or acknowledged. Both are not SeDtembeP•;. 1 2603 ) necessary) ' Narnes of persons signing in any capanry must be typed or printed below their signawre STATE BAR OF WISCONSIN Wisconsin Legal Blank Go Inc. WARRANTY DEED FORM No. 1 - 1998 Milwaukee, Wis. .} -- s t d • t t cn CD � ON 1 OD 416 I W N -�' W o ( � N 0 E 1339.70' lu • ' }-.• i o iwv ru N 0 E 248.63' 1 cn 1 � !v ro o cn w .a 1 1 pp• °- o� l k v N Z 'I I08 � ro s _j U W OD 00 ' ry -O ( N 0 E 311.54' O N im OD o ° o ! ' �� rx) I a •-- 1 U% I N g ro 1 ,� 49 ! N 052 E 284.26' c� �Nro ( WOE E \ $ t U1 4 ° OD 4 R) •,� \ "" w c f C O'S F S6 O O A V U� {{ z I t- 3 �O �O� 3 , � p •o .0 o I Ul CJ l 8. ( a f �so .�� p� •W� S 0 to .... ♦ .r 1 x w f H it A (1j w � ii Z .�