HomeMy WebLinkAbout040-1234-30-000 Wisconsin Qepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
S,fetmhand Building Division
INSPECTION REPORT Sanitary Permit No: 430210 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
W - 7 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:
Gunderson, Kelly I Troy Township 040- 1234 -30 -000
CST BM Elev: Insp. BM Elev: BM Descfiption: Sectionrrown /Range/Map No:
1 00-o / 0 D r /�� Pve, 6 2 �fn cl 6 A4 03.28.19.1169
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
bD
Septic Benchmark
a J o
Dosing V Alt. BM
' (M S(os l b
Aeratiorr Bldg. Sewer C ✓► o V U 5
I
W
Holding Ht Inlet
S GK co th_
TANK SETBACK INFORMATION St/Ht Outle
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / w Dt Bottom vn 0 +75 Z�
Dosing eader/ an.
Aeration Dist. Pipe 2 , lS D Z . S
Holding m
3 . 7, 3 /0/.7
F inal G rade
PUMP /SIPHON INFORMATION .S p y. C
Manufacturer 4r L Demand St Covr i
GPM 3
Model Number
TDH L' d Z � Fricti s System {-le0d TDF], / ry „v
Forcemain Le gth Dia. ,� Diistt.. t f p / l y G �iwry �
I, 2 Y
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Len th, 1 No. 0 Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BI j WELL LAKE /STREAM EACHING Manufacturer:
INFORMATION C OR
Typ f ystem: >20 ) / / /
J c IT Model Number:
DISTRIBUTION SYSTEM
Header/Manifol Distribution / x Hole Size x Hole Spacing V ent to Air In take
P
r ipe's)
/� ? Z
! L —
Length L Dia , Length 41 Dia 2 I 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
Bedfrrench Center 1 Bed/Trench Edges Topsoil j Yes ] No Yes ' No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / If 6 )03 Inspection #2: / 6 1 0 , 3
Location: 499 Trillium Lane Lane Hudson, Wl 54016 (NW 1/4 SE 1/4 3 T28N R19W) Country Addh. I Lot 32 Parcel No: 03. 8.19. 169
1.) Alt BM Description = ✓ `"w �F`' h �9�Cf�r 1 .
2.) Bldg C^Gu� "-X, 02
- amount of cover = >
Plan revision
s [ C�
de for additional information. /No (_ Il y . t�� ril! _ ___ ��
Use other
SBD -6710 (R.3/97) Date Insepctor' Signature Cert. No.
Safety nd Buildings Division County
Y g ( � 1 J
201 W. Washington Ave., P.O. Box 7162 St 1. n
I`-
sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 - 3151 t�3Q 2_1D
► n I.D. Number
Pl a
Sanitary Permit Application State q _
In accord with Conun 83.21, Wis. Adm. Code, personal infort{ati6myou provide 8 -+ ! `7 r 4 e, • / A
may be used for secondary purposes Privacy Law, slo.04(1)(rat Project Address (if different than mailing address)
F
I. Application Information - Please Print All Information p q
( / �ILL(1-lwl VT"�
Property Owner's Na a Parcel # Lot Block #
Property Owner's 94 ailing Ad ss Property Location
) I f Y - -�,� A �
_ -5- (�1 ` � I � �/, 5 ,Section
City, State VLip Code Phone Number
' ( (circ
0,& S )
H. Type of Building (check all that apply) , u- ✓�`� T N; � E r
Subdivision Name- CSM Number
or 2 Family Dwelling - Number of Be rooms
1 s S
❑ Public /Commercial - Describe U _
❑ State Owned - Describe Use 8 M C ❑City_ ❑Village ownship of
Z
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 4 1,0 - ( 3 3 &MD 0 (
A. ew System ❑ Replacement System g p Y g Y
❑ Treatment/ Holding Tank Replacement Only Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
N. Type of POWTS System: (C eck all that apply)
❑ Non - Pressurized In- Ground ound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber Drip Line ❑ Gravel -less Pie ❑ rer (explain)
V. Dispersal/Treatment Area Information: �- - (�D
Design Flow (gpd) Design Soil Application Rate( sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site S•.eel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks I Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
�rs VI I. Responsibility Statement I, the une responsibility for installation of the PO S shown on the attached plans.
Plumber's a me Print Plum- MP /MPR N mber / � B usiness Phone Number
4 / � <�
Plumber's Addre ss (Street, City, State, Zt e) // /► ,
i
VIII. Count /Department Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued s ing Agent Sign e o Stamps)
Surcharge Fee) ?�O
El Owner Given Reason for Denial J
IX. Conditions of Approval /Reasons for Disapproval
�CAOJII a_10
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
OT1Tl Y-IfN0
Ill
r PLOT PLAN
ACT Kellv Gunderson ADDRESS 635 Hillary Farm Rd. Hudson Wi 54016
.- 4W 1/4 SE 1/4s 3 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 7/3/03 BEDROOM 4
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none
BENCHMARK V.R.P. T Of 1.5" pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL IH NW comer of property
SYSTEM ELEVATION 102.8'
Scale = 1 /4 19 = 10'
Property Line
Grading is to be done to divert
run -off away from system
Area 15' below system is to
B.M. 4% remain undisturbed
10 0' ts, Slope
101, 0. --`-
0
101.8 Tank is be properly ry rf(-
bedded and provided / 1
102?. with lockdown covers
with approved g
103'
� S
�j'��
Property Line Well is to meet all setbacks l � \ Huffcutt C; mbo T nk
p rtY found in Comm. 83
Pro 4 At
346' Bedroom
House
Trillium Lane
• Safety and Buildings
4003 N KINNEY COULEE RD
LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
I \
Visconsin www.commerc .wis ons
Department of Commerce www.wisconsin.gov
Jim Doyle, Governor
Cory L. Nettles, S
July 24, 2003
CUST ID No.226900 ATTN: POWTS Inspector
SHAUN R BIRD ZONING OFFICE
BIRD PLUMBING, INC ST CROIX COUNTY SPIA
1008 192 ND AVE 1101 CARMICHAEL RD
NEW RICHMOND WI 54017 HUDSON WI 54016
CONDITIONAL APPROVAL
Identification No 8 879 49 hers
PLAN APPROVAL EXPIRES: 07/24/2005
Transaction ID No. 887949
SITE: Site ID No. 662266
Kelly Gunderson Please refer to both identification numbers, .
Trillium Lane above, in all correspondence with the agency..
Town of Troy
St Croix County
NW1 /4, SE1 /4, S3, T28N, R19W
FOR:
Description: Proposed Four Bedroom Mound System
Object Type: POWT System Regulated Object ID No.: 912676
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01)
and the 'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems
VERSION 2.0" SBD- 10706 -P (N.01 101).
• Limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction,
excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited.
• A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided
per Comm 84 product approval conditions.
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
• Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on -site during
construction and open to inspection by authorized representatives of the Department, which may include local
inspectors.
C ldC ltioIIl lv
SHAUN R BIRD Page 2 7/24/03
Owner Responsibilities:
• Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption
system or any of its component parts malfunctions so as to create a health hazard, the property owner must
follow the contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable
to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the
component(s) utilized in the POWTS.
Note: Per Comm 83.21(2)(c)5, Wis. Adm. Code, if any part of the POWTS management plan specifies servicing or
maintenance at an interval of 12 months or less, the activity must be recorded with the deed for the property. If the
activity has not been recorded, a sanitary permit can not be issued.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions
should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this
review shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the
installation, operation or maintenance of the POWTS.
Sincerely,
Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
Gerard M. Swim
POWTS Plan Reviewer - Integrated Services
(608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm
jswim @commerce.state.wi.us WiSMART`cQde: 7'6,'
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
Cover Page
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017
715- 246 -4516
Date: 7/3/03
Owner:Kelly Gunderson
Location: NW1 /4 SE1 /4 S 3 T28 N,R 119W Troy Lot 32 Country Wood I
System type: Mound System
Manuals Used: Mound Component Manual version 2.0 (01/31)
Pressure Distribution Manual version 2.0 (01/31)
Page#
1. Cover Page
2. Mound PI Pl an
n a
3. Mound Cross Section
4. Pipe Cross Section /Pipe Layout RECEIVED
5. Pump Chamber Cross Section JUL - 9 X003
6. Pump Curve SAFETY & BLOGS DIV.
7 -9. Maintance and Contigency plan
10 -12 Soil test
Signature
License nu er 226900
L) M k
Cat IARTMENI Of COMMERCE
DCVIS�ON OF 5 7Y ND BUILDINGS
SEE CORRESPONDENCE
PLOT PLAN
PROJECT Kellv Gunderson ADDRESS 635 Hillary Farm Rd. Hudson Wi 54016
NW 1/4 SE 1 /4s 3 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 7/3/03 BEDROOM 4
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND )= SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none
BENCHMARK V.R.P. Top of 1.5" pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL #H . R . p_ NW corner of property
SYSTEM ELEVATION 102.8'
Scale = 1/4 = 10'
Property Line
Grading is to be done to divert
run -off away from system
Area 15' below system is to
B.M. 4% remain undisturbed
100 N, Slope
101' B -3
1 01 .8 Tank is be properly
102' bedded and provided
with lockdown covers
B-1 with approved warning
103' labels
B -2
Well is to meet all setbacks Huffcutt Combo Tank
Property Line found in Comm. 83
Pro 4
346' Bedroom
House
Trillium Lane
Perforo!ed Pipe OetOit
Er1d Vies
�Ferforat +.o �
Pvc P-pe
��10 /ODto1'�t Holes L0001ee On $0119"".
Are E4u011y $000e0
5! ` V� r y PvC Force Mead
t , FIRST BOLL ir1><!T TG CartAtC� eC
U
PVC
mcmfold Pipe
, S'FX Q�,f� (iiSt r.OYt�Q"
pipe
4-
<�i- Distribution Pipe Lay out P Ft:
�+ ''�R.
x ° Inches
} I n c hes
rtsr hes
Signed: Dole Diameter 1 ! 5 6d -Inch
Lateral t ; Inch (es)
License Number: Manifold � Inches_
Date' Force Main Inches
# of holes /pipe32
Invert Elevation of Laterals
Designer No'
Date
Non -Woven Filter Fabric
4" Observation Pipe Perforated ,Distribution Pipe
Below Filter Fabric
ASTM C -33 S o n d --� _ G
� 4H
Topsoil "r =' F
E -
Y. Slope . �Fiowed
Bed Of t��- 2 %2 Force Main
From Pump Loyer
Drain Rock ,
Cress Section Of A Mou System Usi F SS
A Bed For The Absorption Area G 1
i
A s Ft.
Ft.
I iZ.n Ft.
Ft.
Ft.
L Ft.
W Ft.
4c
L
4'Observotion Pipe--
i A ' Force Moin
_ ------- - - - - -- ' I
-- �.-_ - -- - - - - -- -- - - - - -- From Pump
c
° Distribution Bed Of 'y — 2 1 2
Q
Pipe Drain Rock
I
4Obs Pipe- LnCATE,p Permanent Marker
�S TH rb T'N B Fxvm Pipe or Rods
fFo
Plan View Of Mound Using A Bed For The Absor ption Arco
PAGE_,,, OF
SEPTIC TANK E FMP CliAM$£R CROSS SECTION AND SPECIF
U
,MIN. ABOVE GRADE � VEATHERPROOF
CI SENT PIPE �I juNCTION BOX APPROVED
> 25 FROM DOOR, I I NDCW OR W I TH CONDUIT MANHOLE COV ER
FRESH AIR INTAKE W/ PADLOCK &
WARNING LABEL
FINISHED GRADE ---- 4" M1:N -
u
INLET
��- GAS— � , t , �
WATER TIGHT' SEALS — T — TIGHT.'_ N APPROVED
A SEAL = jOINTS 1 w1TH
�1LT�R - �� a ;; BALM APPROVED PIPE
APPROVED _T_
: = ON S 0l�tTI1
-- — t 5,[3t.ID SOIL
PIA£ 3' t
ONTO SOL10 (' C Y OFF
SOIL PUMP .OFF ELEN - ��� T - _+ _
D
3 APPROVED BEDDING UNDER TANY'
4- CONCR FAD
S p E C I 1 I C A 1 Y O N S - _• (�
tdii 2S $£R DOSES ? DAL:
SEPTIC / DOSE =�--
TANK MANUFACTIdRER: - v4,}IM£ T�iCLUDZI GAL -
#j� GAL. DOSE £ I,a;„T$ACiC:
TANK SIZES: SEPTIC GAL. 0. L-
DOSE C
CAPACITIES A
ALARM MA�tiJFACT�3R£R : e Z'., fir{'
2 INCHES = -E
MODEL NUMBER: .a '
11. �° vAL
SWITCH TYPE: °' � C = �` � INCHES
� GAL -
-imp MA19JFACgURER : n _ 49— INCHES = ��J- --
MODEL tiuMBER : _ 15.23 WAC LHR
sWTTCH TYPE: £ ALAR f t.�TF I NG AS P£i Z S
GP / P �E
F,zQu!RL'D DTSCF#ARGE RA: . TS'I- gI$i�TiOi+i ?IP£ - =� FEET
AND D�
VERTICAL DIFFERENCE B£TWE.EN PUMP OFF . _ _ _ - - - - -- FED
PRESSURE FRIC TI{)N FACTOR - A_ _ FEET
+ MINIMUM N£'i` IOF >K Si�PF1.1° '..� 'Ti 1Q iI FT. Z)yN ' EAD'
IC H ,
• F LT FC13KI��A II' --- T{f �`R' s�iPLMET£R
#!5)c 3 3= /-7 D
�� scT ntJMF TA NK:
INTERNAL DIME --TONS : LI�i�ID
0-AT E 1
�,IC£t�S� P�L3uBFIi "
�sGPiED= _
?18�
TOTAL DYNAMIC HEAD/CAPACITY
PER MINUTE
HEAD CAPACITY CURVE EFFLUENT AND DEWATERING
a MODEL 152/153 MODEL 152 153
W r
LJ
50 I
I� Feet I Meters Gcl. Liters Gal. Liters
5 1.5 69 261 77 291
153
10 1 3�1 6 i 1 231 70 265
12 40 15 1 4.6 53 201 61 231 1
1 20 . 6.1 44 167 52 197
Q
i 7.6 34 129 42 159
30 25
a S—j 30 9.1 1
23 87 33 2_5
Z 2 85
o 35 10.7 '1 2
-- -
20 4C' 2_.2 -- 1 1 42
a 138.0 Ft. ( 1 .6rn ) 44.0 Ft. (13. m)
Lock Va I
4 _ cusca
10 — --
� I 1
(
0 2 0 7 T , 60 80 100
GALLONS 6 1/4 �
LITERS 0 80 16G 240 320 3 27/32 �_• - --�—c 5/8 -�
FLOW PER MINUTE ° I 3 27/32
e
CONSULT FACTORY FOR SPECIAL APPLICATIONS 1 _ _ _
3 27/32
• Timed dosing panels available.
• ailable and supplied with
Electrical alternators, for duplex systems, are av
an alarm.
• Variable level control switches are available for controlling single phase
systems.
• Double piggyback variable level float switches are available for variable r
I
level long and short cycle controls. 1 1
• Sealed Qwik -Box available for outdoor installations. See FM1420.
• Over 130 °F. (54 °C.) special quotation required
1
12 1/8 I
1571153 Series I II I� 51 — r
1521153 MODELS control Selection 5
Model Volts_Ph Mode Amps Sim lex I Duplex
N152 115 1 Non 8.5 1 2 or 3 —�_ SK206
BN152 115 1 Auto 8.5 Included 2 or 3
E152 230 1 Non 4.3 1 2 or 3
BE152 230 1 Auto 4.3 included 2 or 3
N153 115 1 Non 10.5 1 2 °r3 SELECTION GUIDE
SN153 115 1 Auto 10.5 Included 2 or 3
E153 230 1 Non 5.3 1 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float
BE153 230 1 Auto 5.3 Inc;uded 2 or 3 switch. Refer to FM0477,
o CAUTION 2. See FM0712 for correct model of Electrical Alternator E -Pak.
All installation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -0225 used as a control activator specify duplex (3)
licensed electrician. All electrical and safety codes should be followed including the most or (4) float System.
recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL TO: P.O. BOX 16347 Manufacturersof. .
Louisville, KY 40256 -0347
SNIP is v le, K Care Run Road /� �7O"
Louisville, KY 40211 -1961 Qvvt /TY/—UMPS SNCE ��c/d
Z AM (502) 778 - 2731.1(800) 928 -PUMP
htfp: / /www.zoe/ler, corn
nwo !O. FAX (502) 774 -3624
r, r`nn,trinht 7000 Zoeller Co. All rights reserved.
Maintenance and Contingency Plan for a Mound System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Dose Chamber is to be pumped at the same time as the septic tank.
3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
4. Once every 3 years the mound is to be inspected via the inspections pipes in the at-
grade. The laterals are to be inspected via the cleanouts.
5. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
6. Pump and electrical components are to be checked at the time of the pumping.
7. Owner agrees to leave the area 15' below mound undisturbed.
8. The owner agrees to save this plan.
9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is
not be driven over.
10. Effluent Quality is not to excede the requirements found in Comm. 83
Contingency Plan
1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if
needed, then bypass pump float and try pump without float. If this works, float is bad,
replace float. If pump still does not work, check power at the pump with a electrical device
such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is
power, then pump is bad and needs to be replaced by a plumber.
2. If mound fails, determine cause of failure, test another area or remove pipe and sewer
rock, retill soil, install new mound system.
3. Replace any other failing components as needed.
Important Phone Numbers
Plumber: Shaun Bird 715 - 246 -4516
Pumper: Tom Mondor 715 - 246 -5148
St. Croix County Zoning 715 - 386 -4680
POWTS OWNER'S MANUAL & MANAGEME PLAN Page of
SYSTEM SPECIFICATIONS
FILE INFORMATION septic Tank Capacity ' at ❑ NA
OW1ef t . ^' �'`\ Septic Tank Manufacturer ❑ NA
Permit #_ ❑ NA
Effluent Filter Manufacturer -
DESIGN PARAMETERS
❑ NA Effluent Filter Model ❑ NA
Number of Bedrooms ❑ NA
Number of Commercial Units Pump Tank Capacity at
Estimated flow (average) i al/da
Pump Tank Manufacturer ❑ NA
Manufacturer ❑
Design flow (peak), (Estimated x � .5) Q al/d Pump
S Z ❑ NA
2V.da !ft2 Pump Model r
Soil Apprication Rate NA
Monthly average' Pretreatment Unit
❑Peat Filter
Influent/Effluent Quality ❑ Sand/Gravel Filter
Fats,. OH & Grease (FOG) S30 mg/L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BOD 420 mg/L p Disinfection ❑ Other.
Total Suspended Solids (TSS) 5150 m !L Manufacturer
Pretreated Effluent Quality NA Monthly average" Dispersal Cell(s) ❑ In round (pressurized) S30 mg/L ❑ In -ground (9m vity) - �pA ound
Total Suspended Solids (TSS)
Biochemical Oxygen Demand (GODS) ❑ At -grade
530 mgfL ❑ Other.
Fecal Coliform (geometric mean) s10' cfu /100mf 13 Dri ine
ICaI for domestic (non- cornmercraf) wastewater and
Maximum Effluent Particle Size
Y inch diameter sep� typ ical k e fftuenL
.•* Values typical for Pretreated wastewater.
MAINTENANCE SCHEDULE Service Frequency
Service Event ❑ months Kear(s) (Maximum 3 yrs.)
At least once every
Inspect condition of tank(s) uals one -third (Y,) of tank volume
When combined sludge and scum eq
Pump out contents of tank(s) ❑months e year(s) (Maximum 3 yrs.)
inspect dispersal cell(s) At (east once every
At least once every
❑ months
Clean effluent filter ❑ months -year(s) ❑ NA
controls & alarm At feast once every
Inspect pump, pump ❑ months year(s) ❑ NA
least once every lea
Flush laterals and pressure test At ❑ months ❑ year(s) ❑ NA
Other. At least once every
other.
❑ months ❑ year(s) ❑ NA
At least once every
MAINTENANCE INSTRUCTIONS c one of the following licenses or
Inspections of tanks and dispersal cells shat! be made by an individual VTS Inspector POWTS Maintainer, Septage
certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS fnspe to identify any missing or broken
Servicing Operator. Tank inspections must include a visual inspection of the tank(s) back up and s cum and to check for a ny
hardware, Identify any cracks or leaks, mea t volume of
dispersal ce shall be ly inspected to check the effluent levels
or ponding of effluent on the ground su rface- l round surface. The ponding of effluent on the
in the observation pipes and to check for any ponding of effluent on the g authority.
ground surface may indicate a failing condition and requires the immediate notification o the local regulatory
or more of the tank volume, the
When the combined accumula o f
em by a Septage Servicing OO peratorr atind ddisposed of in accordance with ch. NR
entire contents of the tank shall
113, Wisconsin Administrative Code. retreat ment components, and any
The servicing of effluent filters, mechanical or pressurized POWTS componen�ped by a certifed POWTS Maintainer.
other maintenance or monitoring at intervals of 12 mot or leshall be pe of completion of any service event.
A service report shall be provided to the local regulatory authority within 10 days
st
START UP AND OPERATION if hi h concentrations are
For new construction, prior to use of the POWTS check treatment tank( ,
for the presence of painting products or other
chemicals that may impede the treatment process and/or am a the i erne. o Il pnor to e.
detected have the contents of the tank(s) removed by
'^ Page of
Shall not occur when soil conditions are frozen at the infiltrative surface.
System start up normal highwater levels. When powe r is restored the excess
During power outages pump tanks may fill above
wastewater will be discharged to the dispersal celi(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; oll; painting products; Pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMMENT
When the POWTS falls and/or is permanently. taken out of service the following steps shall be taken to insure that the
system is property and safely abandoned in compliance with ch. 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 property 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 PO
a suitable replacement area. Upon of the POWTS a soil and
_The site has not been evaluated to identify
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.
4 removal of the biomat at
Mound and at -grade soil absorption systems may be reconstructed in place following
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 GAS SES AND /OR INSUFFICIENT OXYGEN.
00 NOT ENTER A SEPTIC PU MP OROM THE INTERIOR OF A TANK MAY E C
OR IMPO SIB DEA TH
RE
RESULT. RESCUE OF A PERS
ADDITIONAL COMMENTS
PO VYTS INSTALLER POWTS MAINTAINER
ENa Name , f 4G r✓ }3J r
Phone �-� -�
SEPTAGE SERVICING OPERATOR PUMPER
LOCAL REGULATORY AUTHORITY
Agency
Name r /
Phone
Phone - - fit .a is document meets
This document
the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies- This
was dratted by e. Use of this document does not
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (Z) 8 (3). Wisconsin Adminlstratl+re Cod Gtr (2/01)
guarantee the performance of the POWTS.
""""-7 wi sconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labof'and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 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, nort'T arrow, and location and distance to nearest road. pe ndin cf
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION E IEWED BY D V
PROPERTY OWNER: PROPERTY LOCATION
Richard Stout GOVT. LOT NW 1/4 36(or) W
PROPERTY OWNERS MAILING ADDRESS LOT* I BLOCK # SUB , OR CSM #�
1353 Awatukee Trl. 32 na C W a'
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE 21 b( R A ROA `.
Hudson WI. 54016 (715)549 -6731 T. Touter R ,1
[x] New Construction Use Residential / Number of bedrooms 3 [ ] Ation to exist, building
(]Replacement [ ] Public or commercial describe
Jt r
Code derived daily flow 450 gpd Recommended design loading rate • 4 0 2 . /-
C ` t.. tr 2
f
Absorption area required 375 bed, ft 375 trench, ft Maximum design loading rate • 4 bed, 1 gpd/ft
Recommended infiltration surface elevation(s) 102.75 ft (as referred to site plan benchmark)
Additional design / site considerations system el. based on contour line of el. 101.75'
Parent material limestone uplands Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE I SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ❑ S ® U I ® S ❑ U ❑ S lR U ❑ S fl U ❑ S CIU ❑ 131
SOIL DESCRIPTION REPORT 0"
Depth Dominant Color Mottles Texture Structure Consistence Roots j e!d D /ft
Boring # Horizon In. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Tre nch
1 0 - 14 TO r4 2 n n
2 14 -27 10yr4 /4 none scl 2msbk mfr qw if .4 .5 .�
Ground 3 27 -37 7.5 r4/4 none sl lcsbk mvfr crw na .4 .5
elev.
102 ft. 4 1 37-55 5 r4 6 c2 7. r '"-
Depth to —
limiting
factor
37"
Remarks:
Boring #
1 0 -10 10 r4 2 none sil 2msbk mfr cs 2f .5 .6
2 10 -40 7.5yr4/4 none sicl 2msbk mfr 9W if .4 .5
3 0 -50 10 r6/4 c2d7.5 r5/6 cl m na na na n .2
Ground
elev.
102 ft.
Depth to
limiting
factor
40�
Remarks:
ST Name:— Please Print Phone:
Gary L . Sf 715-246-
4ress: 54 200th Aije., New Richmon WI. 54017 m02298
lure: Date: CST Number:
5 -16 -96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # pending Lot #32
Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 -13 10 r3 3 none
w, 3 Y
2 3 -30 7.5y 4 none
Ground 3 [ 10-55 10 r6 4 c2d7.5 r5 6
elev. _-
100 ft.
Depth to
limiting
factor
30"
Remarks:
Boring #
Ground
elev.
ft.
" Depth to
limiting
factor
Remarks:
Boring #
.
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
w
STEEL'S SOIL SERVICE
Gary L.-Steel Richard stout 1554 200th Ave.
CSTM2298 WISE S3- T28N -R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246 -6200
'A lot #32- Country Wood
N
1 " =40'
ABM.= top of 12 pvc pipe C el. 100 top of marker stake = 103.2
db ��SlnPE
unc �� s �� e!9—
A/7 oLl- A) � 5
av � t
Gary L. Steel
5 -16 -96
I _
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715- 386 -4680
Pumper Tom Mondor 715 - 246 -5148
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
ANA
OWNERSHIP CERTIFICATION FORM
ll
Owner/Buyer G Cw
Mailing Address - ,
t4 01
Property Address l
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number 0 Y°" 1 auo
LEGAL DESCRIPTION
Property Location 1 /{, �aE 1 /4, Sec. S , T Q� N -R W, Town of I r
Subdivision to - Lot # --�
Certified Survey Map # , Volume , Page #
Warranty Deed ## } 6 3� , Volume Page # 3`? Z
Spec house ❑ yes l no Lot lines identifiable )6—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 function 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
masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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
days the three ear expiration date.
/ / a
SIGNM URE 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
- � xol-�— 2- 11 1 0-3
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** 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
732634
2 3 3 6 P 3 9 2 KATHLEEN H., WALSH
REGISTER OF DEEDS
ST. CROIX CO., BFI
STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD
Document Number WARRANTY DEED 07/29/2003 12:45PK
THIS DEED, made between Cade C. Christiansen and DeAnn M. WARR ANTY EXEW DEED
XQQT Ik
Christiansen, husband and wife, Grantor, and Kelly J. Gunderson and Susan
Gunderson, husband and wife, as Survivorship Marital Property, Grantee. REC FEE: 11.00
Grantor, for a valuable consideration, conveys and warrants to Grantee COPYSFEE: 255.00
the following described real estate in St. Croix County, State of Wisconsin: CC FEE:
PAGES: 1
Lot 32, Country Wood First Addition, Town of Troy
Recording Area
Name and Return Address:
Edina Realty Title, Inc.
400 S. 2 St. — Suite 115
Exceptions to warranties: Hudson, WI 54016
Easements, restrictions and rights -of -way of record, if any. 402511
040- 1234 -30 -000
Parcel Identification Number (PIN)
This is not homestead property.
Dated this 22nd day of July, 2003.
4 � cH�1�frhrk N 1hn ►'rl r✓hrr� rlJ�n
* Cade C. Christiansen * DeAnn M. Christiansen
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
COUNTY. ) ss.
authenticated this 22nd day of July, 2003
Personally came before me this I day of
* L\4 , a0o3 the above named Cade C.
Christiansen and DeAnn M. Christiansen, husband and wife to
TITLE: MEMBER STATE BAR OF WISCONSIN me known to be the person(s) who executed the foregoing
(If not, instrument and ac wled a same.
authorized by § 706.06, Wis. Stats.) `,...
i
THIS INSTRUMENT WAS DRAFTED BY
s ;r
Edina Realty Title — Doug Berg Not ub1iC, tatd is • •'• .
400 South Second Street #115, Hudson, WI 54016 My commission eteRt..f.. Mate expiration date:
IPA )
(Signatures may be authenticated or acknowledged. Both are not necessary.) s, �, ••
*Names of ons signing in an c must be si •• �''• `\
pars gn g y p ty typed or printed below their � � 1.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000
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