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HomeMy WebLinkAbout040-1312-04-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: 1 INSPECTION REPORT 479424 d t ATTACH TO PERMIT) ( eJ `� 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: Delta Construction Troy, Town of 131J-o CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: G GS 1 04.28.19.20.3 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 3 V--. Benchmark l`cSZc_ , 1Z(a 1, 76 i6j. 76 1146 Dosing Alt. BM F ;t a F lL— o, l•`MCP /00•Z Aeration Bldg. Sewer 5 . e� 9L • bB Holding St/Ht Inlet S $.7 95. s 3 TANK SETBACK INFORMATION St/Ht Outlet to • 03 9 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � U � / /5" / / _ Dt Bottom Dosing Header /Man. Aeration Dist. Pipe j6 • � 0 1 3 .3 Holding Bot. System -72,3? 9 .33 br PUMP /SIPHON INFORMATION Final Grade 1 3- 1 44'8 Manufacturer Demand St Cover // r / 2. GPM t-,•I l-I & I �d �o �[Yj Model Number TDH Friction Loss Syste ad Ft Forcema la. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Lengtq INo.OfTrenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS �g �- C12- SETBACK SYSTEM TO I P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer. INFORMATION Type Of System: 7 7 CHAMB T OR Model Number. DISTRIBUTION SYSTEM 22.4 -Z Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ' 1 If Pipe(s) \ \ \ ` 2 41 Length Dia T Length Dia Spacing > e SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulch d Bed/Trench Center ' I Bed/Trench Edges Topsoil ` �} Yes L No as (] No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 519 Edie Court Hudson, WI 54016 (SW 1/4 SW 1/4 4 T2I-8N- R1 9W) Cottage Meadows Lot 4 Parcel No: 04.28.19. 1.) Alt BM Description = (; � 4 Coo C� 2.) Bldg sewer length = 1 - amount of cover = 7 ,4L it Plan revision Required? Yes No Use other side for additional information. - - - - -- — Date Insepct s Signa re Cert. No. SBD -6710 (R.3/97) and Buildings Division County Ifir or IN 01 gton Ave., P.O. Box 7162 ,sCon .sln 2 Sanitary Permit Number (to be filled in by Co.) ' ., Department of Commerce 8) EIV 9qz Sanitary Permit AA! 'o Plan ID. Numb� i In accord with Comm 8321, Wis. Adm. Code, inf 4 may W used for secondary purposes Pw, s xm) ject Address (if diflexent than mailing address) ' � I. Application Information — Please Print All Information ZONING OFFICE fN �.�/� C� , Property Owner's Name Pgkbel # Lot # ) Block # Pro rty Owner's Mailing Address Property Location 2v r`- 7 Section City, state Zi ' A /w/ T � N; R� E p Cade Phone Number cle 7` 7` 8i' / / � i � O crrone) ,II. Type of Building (check all that apply) 'J &I or 2 Family Dwelling - Number of Bedrooms 7 10C Subdivision Name � ❑PublidCommmxcial- Describe Use ❑ State Owned- Describe J e use Z g CLV \S v �22- }7.� G� o L (� E lcit) D Village Eafownship of�r III. Type of Permit; (Check only one boa on line A. Complete line B if applicable) / A. flew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal El- Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Numher and Date Issued Before Expiration Plumber Owner IV. Type of POWYS System: Check all that a pply) T lion - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Momad < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wedand ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Fitter ❑ Leaching Chamber ❑ Drip Lane ❑ Gravel -less Pipe ❑ Other (explain) V. DispersaVl7reatment Area Information: Design Flow (gpd) Design Soil Application Raw(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (st) System Elevation 4(04,0 ✓ I . 7 ./ ,/' ✓ r • s ./ 1 OPz, VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Sted Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass Now Tanta Talcs Z 94C Z ^!d0' ' Septic orik"ingfin v v Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement - 1, the undersigned, assume responsib' ' fdr installation of the POWTS shown on the attached plans Plumber's Name (Print) Pl s *1P/1PRS Number Business Phone Number Plumber's Address (Street, City, S Zip Code) ,Zr"P z, rg K" 174P VIII. on" /De artment Use On (pProved ❑ D Sanitary Permit Fee (includes Groundwater Issuin gent Signs tZ ps) Surcharge Fee) 6t, ❑ Giv n for Denial .J IX. Conditions ofApprov easo for Disapproval n SYSTEM OWNER: 3 �Jr ��G ` t, 5 L) aw 1. Septic tbatk, effluent tiger and �/► CL} AeLc ) dispersal cell must all be services / rribirttWm d / ► to A �� as per management plan provided by pNlnibs'. 6VtA. e 0 LJ �� Y 2. AN setback requirements must be maintained I V as w aoolic" code / ordinances. Attach complete plans (to the County only) for dine system on paper not less Wan 8112 :11 inches in sae SBD -6398 (R. 01/03) Fogerty Plumbing #221180 / 28288 McKenzie Rd. Spooner, WI 54801 - (715) 635 -9609 - OA AM9,e E �► = �;�►s srcat Ed�DK o '- LoT to'.rivr�t ISO G�f �, S• wl 9s.y 9�.Z Y agc�n � x f�E � 7� - 2 Py• 7 Y 11 Fogerty Plumbing #221180 2823 McKenzie Rd. Spooner. WI 54801 (715) - 635-9� V. 7. i 7� _ pl. 7 r jot o O o g a• ' a � j . ° -_ r � ` . � . •`�,\ � are n - ts � � a -• •. V -" '-- -� \ CA :t 'L3 a s_ �; (ant . LY t3. . ! l l ID C i }� O SD it p m nmsuv ON 0 00:0 OZSZ6V£SILT Was umt I1 1 TAU ui iQ ui iii I wy 5 U 1 71 wQ WT WE99:9 SOOZ IT 13O 98Z99£99TLI DNIE[W l'Id Ik.L -daooa iauuv3S /iaido j /xvd /iajuud ICuosiad io3 uodag AJOIS!H -xv3 S8O SOROS J 1 3 MUJO dH a< a=n3ance wur %-I o;;. wp. "N' minty . Attach complete site plan on pager not Mess than 8112 x 11 tnagm in sim ter rruSt include. but not rsrdted Im vertical and hari mtd rekirenee paint MM). &emn and Parcel 11?. � percent slope. sea* a �. r� ="'• and bcahon and drstartte to n scat, pate ,printam awn. /i dS Personal WwTaakw you pwode way Ne users nor secoofttr pwPom 1► taws ism (1)( Property Owner Property E�CaAiGft I& Govt Lot W10 114 114 'S T Z� _ N R E f III ASS , ! �# Block # Subd. Name of Property Owners � �c' 7 taty State Zip Code Phone Number ❑ Cdy ❑ �e (VOM Nearest Road I kit -1 o �� r. - Nunn ConstnrctiM use: @'�ale+� r Morn rer of bedrooms [] Replacement Code dedwed - flow rate GPt Public o r comatercial - Describe: el /f Rood Plai0013110211100 it - n Pa c3eilerat comments �oNV��L y x • y '1� 9.2. B iA Z Fro,,, ar' Bari' --ZZ f B Sad D �9 "' Appinea�n Rau Q P t C surbm e1w. IL Depth to W KM WWI` Texture Struc� eat 'toms .... GPDJW Horizon Depth Dorm rant Color Rsdox Des •�1 & M in_ t CkL Sr_ Cry cow Gr. Sr- Sh JP 4 -27 G _ 2- - _ — T7 - m 0 t /moo — �] # [a p s �_ R 1 AD � — RaM Textiue f3orarda!Y Rook GPO/Ri Horizon Depth DomararttCo[or Redox Desaiplion •EW1 1 002 in_ Munsell CAL Sz_ CCIFIL Color — xG zsrc F G — .3 Sdr z 5' 401 02 = gQp, <30 nVL amd TSS c 30 UWA: - • tit till = Boos:. < - ash TSS >3t1 < 15asngll- CST Number Nrr<nber TdePW Amass Fogerty FlWmbing & [lie Evatuaion 7l 28288 rte s <;rmfler -f Fogerty Plumbing #221180 28283 McKenzie Rd. Spooner, WI 54801 (715) X35 -96� 17� ,0,T "" y //Ale i X � ,BBRsN/ �- cr•,�c�E 1 7 A #1 MA , f Buildings Division County � ` 1 n Ave., P.O. Box 7162 S - Cl isconsin Sari Permit Number be filled in by Co.) Department of Commerce 315RECEIVE 7� Z Sanitary Permit Applicatio t n 5 tape I.D. N In accord with Comm 83.21, Wis. Adm. Code, personal information ou pro I G may be used for secondary purposes Privacy Law, s15.04(1 ) ST. CROIX COUN fr A ddress (if different than mailing address) C�f � I. Application Information - Please Print All Information Z ONINO (f-4 I Property Owner's Na me / Parcel # a Lot # BleektiY f 0 � — lel 464 o ­WKe z Property Owner's M Miag Address Property L n 20 ST ,;1ti..Setxion _ City, State Zip Code Phone Number (circle one) II. Tpe y of Bu1i1 g (check all tha pply) T Z� N; R1 _E o& a� 5t,�m �' ,� o k Subdivision Name CSM Number LH'1 or 2 Family Dwelling - Number of ms i L . _ _ bl 1''` ❑ Public/Commercial - Describe Use G�OI`7` Ow ❑ State Owned - Describe Use + f _ 3 - []Village 5kownship of III. Type of Permit: (Check only one box on a A. Complete line B if appli!!�le) A- RNew System ❑ Replacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ ge of Q Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration PWMIV .6wner - s4 a rV Type of POWTS System: (Check all that apply) L►d Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter 11 Constructed Wetland 11 Pressurized In- Ground ❑ Holding Taut Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber Drip Lice ❑ Gravel4ess Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) I Design Sal Application R�te(gpdsf) Dspersal Area Requ sf) Dispersal Area Proposed System Elevation C/f 1 ✓/ a VI. Tank Info Capacity in Total Number Manufactu Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing - Tanks Tanks �O Septic or NeWhig-9F Aerobic Treatment Unit Dosing Chamber j VII. Responsibility Statement- I, the'un ' "ed, =some respondbi4 f installation of the POI sho on the attached plans. Plum(ter's Na me (Print) Ptu 's Si gnature �— �H'/MPRS Number Business Phone Number Fogerty Plumbing 1 - Plumt>eA t late 'p _s 4 FWX Spooner, WI 54801 � r.ar VIII.-Cohfi tseft - el 7, 7X7 3 7 eAe Approved ❑ D roved Sanitary Permit Fee (includes Groundwater Da Issued Iss ' gen ignatu Surcharge Fee) ^^ zlo �S ❑ caner G' 3� � $ IX. Conditions of ApprovalMeasons for Disapproval SYSTEM OWNER: � 1. , 'Septic tank, effluent filter and 4,cC +t-)w dispersal cell must all be services / maintained t as per management plan provided by plumber. 2. AN setback requirements must be maintained as per applicable code / ordinances. Attach complete plans (to the County only) for the system on paper not less than 81r2 x 11 inches in size Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635 -9609 d fF I = AAI '0 /=oumo ter catlixR O _ /�� 6W. r. 7 w��LrE/L w LE.vGrN GP•D � p� s�7'jwCl , D i1� a 3 aAkm . 3 b4V,W-E w Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635 -9609 4 #i .¢�T lrr, 99 ss j}E[ r,4 Coif/S% = fONA�O (Or CORN/xI s'c�src -.rs: C�zt� I � i CvaltT tE',v�rN GP•0 `' rtf �6•y fps - � g p' s �7-tnt�c / 19 b of A 3 aARM 3 w L- A �,y Plsd RECEIVED Wisconsin Department of commerce S EV LUATION REPORT Page of 3 Division of Safety and Buildings J 9 j 9W5 Ir accordance with Comm AOI. Code Attach complete site plan on paper 1 C °� X ' t)'u iJl� in siz � musY� Coun r include, but not limited to: vertical and Parcel I.D. percent slope, scale or dimensions, north arrow. and location and distance to nearest Please print a►► information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). Property Owner Property Location ?o 3> 5 0 Govt Lot N E 114 5111114 S 4 T Z+$ N RICY E (me PoWerty Owner's Making Address Lot # I Block # Surd. Name or CSM# 5 OM 14A C"r 1 COTTA Ca f MeR t>&WS State Zip Code Phone Number ❑ M ❑ village E9 Town Nearest Road I- I'WD50d WI I 6*1 ( "i Roy I SoLaf Z Cg New Construction Use: ® Residential I Number of bedrooms 3 - 5 Code defined desire flow rate 4 5 0 - -7 GPD ❑ Replacement ❑ Pubic or commercial - Describe: Parent material L Dam 3 0 EK- V Wr"�S Hr Flood Plain elevation if applicable General comments and Area,, Spot Tested s AWW 1v a conventional Inground system (P.O.W.T.S.) O �# ° Boring 9Q.� face elev. R Depth to kn&V fac ® Pit Ground surtor 7 9 2 rat. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW In. Munsell Qu. Sz Cart. Color Gr. Sz. Sh. 'Eff#1 'EB#2 0 -14 10 V R 2 V 2 — 2 r l» -Fr 5 3 �-t' • (o . 8 Z P4 - �9 I o Yi2 `th - S i Cl 2-C Sb1C Pr FI Q W d -F 3 29 -121 10 Ye, S /s - s © s ci d - - . 7 1 -(o Filte# ° B°� 0 Pit Ground surface elev. l ft. Doh to li &V factor( rat. so0 Application Rate Horimn Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff In. Munsell Qtr. Sz Coat Color Gr. Sz. StL •Ef#11 •EtT#2 1 p - IZ 10'rP, 21z - 3 cab m-Fr •8 2 112-25 t o YR ` 1( C l 2 mSbk I m fr Q W 2 v4 --e+ - 3 25-9 I DYoL - S O s d 1 - I ✓f ,-7 1. (a • Et11uaM #t = BOD > W 22o "W& and M:--W 1 1.% ffQ& • Mkwnt #2 = BOD 130 mgiL and TSS 5 30 nV& CST Qlaese Pft L es 9 Address Date eisluation Conducted Telephone Nummber 281 !o eve Sp2 V t:� Y, wl A4A a - Zoo s (� /s� 77 - For issuance of permits and designing Ulbricht & Associates Contact; Ulbricht & Associates Private Sewage Consultants Registered private wastewater consultant and plumbers 2812 1 Oth Ave. 2812 10th Ave. Spring Valley, VVI 54767 Spring Valley, WI 54767 715- 772 -3442 O RIGINAL I- v T `f Property Owner Pant w # d9 b / b l - 1 o —oo ao P,�P Z of 3 F-31 Bod # ❑ Bas ® Pit Ground srrfaos elev. 9 8" 58 ft. Dept, to WmTvV factor > 9 Z in sea Application Rate Hodmn Depth DmkmdCokm Redox Desaipton Texture Structure C Wistanoe Boundary. Roots GPDN in. Munsell Qu. SL Cont. Color Gr. Sz Sh. 'Eff#t 'EM2 l 0-91 bK mom' S 3 4 /0 8 2 3) 1 v b m -ft i a w Z 4 . -* /O 3 SI JvYOZ S D s d L I F-1 B ❑ ❑ pit Gnxrnd sudaoe dev. IL Depth to bn is factor, im sett Application Rats Horhmn Depth DM*WtCokm Redwc Desaipton Texture SkUckft Cmddw oe Boundary Rods GPOW AM Nonuse♦ OLL SL ConL Color er. SL Sh. • ❑ Berm # ❑ ❑ pit Gtoutd srrfaoe dev. R Depth lo factor in. Sol Application Rate Hodson Depth Dorrinard CAkx Redooc Description. Texture Structure Con toe Boundary Roots GPDfE in. Mutsu tlu. SL ConL Color Gr. Sz. St> •Effin 'EM2 F-1 Bodre # ❑ BorkV ❑ pit Ground strisoe elev. R Depth to irrtitrg farior in. Sot Apallosibn Rate Horiaon Depth DwkwtCdor Redtat Dasuxi dm. Tetmrre Sbuctue Corsidernce Boundary Rods GPM h Mu>sd Ou. SL Conn Color Gr Sr Sh 'Bf#1 •E>M2 • Eomtt #1= BOD, > 30 = 220 ng& and TSS >30 <_ 150 ffQL • Effluent 92 = BOD, _< 30 not and M 30 ffQ& The D%m m a of Commerce a an equal opportunity service provider and employer. If you need assistance to access services or need material in an altanate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. snwawopLMM mm E MI.: wig w ■mmr M��Mmmm mm� M� ®Mmmom "1 I ) ST,EAT C O ft Ur MEADOWS PAS - 3 or 3 LoT ej o BC>Ri ae i = fa+FN�.ttn�Ri For issuance of permits and designing Fo p 9 g 1� C p t-N - rou p. Contact: Ulbricht & Associates Registered private wastewater consultant aW OUMbW 5 4 A L Cr 2812 10th Ave, 1'' = 3 o' Spring Valley, Wl 54767 715. 772.3442 t..11brscht & Asso ciates e Consultants private S 2612 'i Mh Ave. S p ring Malley, V41 54767 a' �i q .5E p Rip L1 N n a ., M I y P SE r 2 " A 80✓C Or R0019 U = 0141 M N g3_ �$5f tool �. g q. 5s' Q� I t3M Z _ gq.-79 2 - rt 8t»i E V C� FZf�cI� i 5O Vt'rli PROP L`R LTY L IIV 6 ! 3'7' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ /,� L Tim CDiySi v Mailing Address Property Address 5 CV I L® ut r l (Verification required from Planning Department for new construction) �� City/State / -�� �-�' � Parcel Identification Number �f�O LEGAL DESCRIPTION Property Location y,, � y,, Sec. c� T -R _W, Town of 2 - 1201V - Subdivision _ C 1 IACI '071z,,o-'p0 Lot # �. Certified Survey Map # Y03o 9 Volume , Page # Warranty Deed # _ ro 3 5-191 Volume _ Page # G Spec house O yes 2 no Lot lines identifiable [dyes O no SYSTEM MAI NTENANCE consi Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance sts 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, lumber, journeym plumber signed by the owner and by a master P ►J yman plumber, restricted lumber or a hcensedpumper verifying that (1) the on -site wastewaterdisposal system is it' proper operating condition and%r 2 after O rnspect9on and pumping (if necessary), the septic tank is less 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 standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification statiiVthat your septic system has been maintained must be completed and returned to the St. Croix County Zoning office within 30 jdaysthe thre expiration te. .a SIGNA APPLICANT DATE OWNER CERTIFICATION gp�erty 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 scn above, b y virtue of a warranty deed recorded in Register of Deeds Office. SIGOF APPLICANT / DATE- * * * * ** Arty inforrnation that is mis represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** i ** Inelutle 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 u. e b b b r u 4 1 C=s ka .st�9a KATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., WI DOCUMENT NO. RECEIVED FOR RECORD 08/16/2005 02:00PH WARRANTY DEED This Deed made between CORNERSTONE FX0 PT # PARTNERS, a Minnesota limited liability company, REC FEE: 11.00 Grantor, and DELTA CONSTRUCTION, INC., a TRANS FEE: 3120.00 COPY FEE: Wisconsin corporation, PAGES : 1 Witnesseth, That the said Grantor conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: RETURN TO: TYAT P, L0a3 q,D Lots 1 -13, inclusive, Plat of Cottage Meadows in the Town of Troy, St. Croix County, Wisconsin. This is not homestead property. Tax ID# 040 - 1014 -20 -000; Together with all and sing the hereditamentnd 040-1014-50-000 and g� s a 040 - 1015 -80 -000. appurtenances thereunto belonging; and Cornerstone Partners, LLC warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations, if any, of record. Dat th day of August , 2005. CO TONE P CRS, LLC (SEAL) Its: AUTHENTICATION ACKNOWLEDGMENT signature of as STATE OF WISCONSIN ) of �ariners, ) SS LLC authenticated this day of August OU GU f � COUNTY OF ST. CROIX ) ���` w - �• �S Sr i • O' +� Personally came before me this 15 t bay of August, 2005, the TITLE: MEMBER STATE BAR OF sD y •. Z % above named ` O : . ' ' * t of Cornerstone Partners, LLC, to me W (Signatures maybe authenticated or acic. Btiarc not known to die person who executed the foregoing instrument and n�a0 •• � adrnow the same_ THIS INSTRUMENT DRAFTEII::tk - • • • • - & h-AL D. Peter Seguin 'i" 4 S OF 1N� ����� MUDGE, PORTER, LUNDEEN & SEG>N;!L. ' 110 Second Street, Post Office Box 469 Notary uni P ub lic, state fires): . My Commission (expires): 1 2 - 11 - 2005 Hudson, Wisconsin 54016 UNPLATTED LANDS OUTLOT 2 N n W TIONS B.M. TOP OF 23686 S.F. N Not � 3/4" IRON PIN - 0.54 Ac. o l C EL = 906.14 � T U 1 U) I VOL ZM Pc. 227 I va. 2"7 m 2w N 88'33'44" W 287.00' 119.67' Z VARIES 48.10 238.90 \ Z \ LOT 1 W cn I Z a En I ,y \ 43572 S.F. z 1.00 Ac. N I \ ���� HK = 90.03 N Z cA o C A� LBO - 908.03 W (� a W A O LO T \- a N UND AS NOTED i�"_ 43667 S ��' '0 3fl 1 c° i s c0 i I � 1.00 Ac. / jo cn WT. 4.173 l BS./FT. j I \ _ _ 23! 15' N � I S 2 ' , / M > "5;9 to LOT 3� � 298" i �O co 1 43560 S.F. ! r� I ' n N / �� / o, I 91U 3:: N I 1.0o Ac. / �� _lp I 0'i 5 0' CN co I o gap 00 CN 'pul C) I L'C' N X05 �� _W // Qldolp W to 3 o i E OF EDM pI ® / C)�Q Q HK - SM84 M rn ( N 1 0) w� ,ER I LOT 4 � � LeO - 910.84 �� ° o I O I S cH wA70 of io 43582 S.F. .h c� �, %S, i Z , o o I 1.0o Ac. / �,� f LOT 5 LESS <1 N ry / I I Cl a I � 43614 S.F. 7MIED BY j ( ! / 1.00 Ac. I 100' 'VATM I oc _ J _ �nar 136.57 ---- _.__ _ _ -� 311.81' i 27. VOL -= 448.38' -- 1 I P LA N I I ION UN TED DS i - - - i N RDS: I i I a o p - o QQ to �. . AL O _� ' V ' i 1 f' O CD Go CD co CL OD 1 • � J �♦ - C) r .l j GQ i o o - -` o 1 114 n a a V o 0o as O 00 !4 a • C ��N 0 0 0 3 s FILE INIM111MATION -- SYSTEM ►Tp _ Septic Tank Capacity / d ��_a NA Owner _ _ _ _!- Permit t - - Septic Tank Manufacturer a NA Effluent F ter Manufacturer 0 NA �N PARAtI� a NA Number of Bedrooms ,Z a NA Effluent Filter Model O Number of Public Facility Units 1YJNA Pump Tank Capacity �1 IVA Peep Tank Manufacturer NA Estimated flow leverage) C) . NA Design flow (peak(. ( x 1.5) 6 Purnp Manufa Pump Model }� NA Soil Application Rate -- aUd ne Q NA Monthly average• Unit standard Influ�t qty a Sand/Gravel Filter [3 Peat Filter - Fats. Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand ( BODJ 5220 mg/L ❑ NA 13 Mechanical Aeration a Wetland 5150 mglL a D'ISnfection a odner: _ Total Suspended Solids lTSSi � ❑ NA Monthly average Dispersal Cel(s) Pretreated Effluent Oxygen D 530 r�L )q (gravity) o kWoo and (pressurized) Biochemical Oxygen Demand tBODs1 o Noland Total Suspended Solids (TSS1 QO- a NA a At - Grade a Other: <70' cfiu /1001N a Drip-Line -ne _ -Fecal Cofufocm lgeometnc mean) - o NA t Effluent Particle Size )'s in dua. o NA a NA E3 NA Other. a NA *Vak,s typical for donestnc vraswwaex and seplic tank effkueat. MAINTENANCE SCHEDULE service Frequency Service Evert ❑ rnoath(s) Inspect condition of tank(s) At least once every: s) lMaxlnwm 3 years) a NA Pump out contents of tank(s) When combined sludge and scum equals one-d" When of tank volume 13 NA a rrnonth(s) 3 yam) a NA inspect dispersal cells) At least once every: 3 Yeats') ' a Inonth(s) •a NA At least once even: year(s) L. Clean effluent filter A a nnonth(s) - AJdA Inspect pump, PUMP controls &atom At leant once every: a yearns) a month(s) C2 NA Flustr laterals and pressure test At least once every: a year(s) ❑ rnonth(s) _ rL NA Other:- At least once every : a yearns) Q.NA Other: MAINTENANCE INSTRUCTKM one of the following a �tificat ens: Inspections of tanks and dlspaI cogs shad a made by S individual carrying Maintainer: Servicing Operator. Tank WTS leaks Master Flambe: Master Plumber Restricted Sewer; PO Igor � broken hardware, id any cracks or inspections must include a visual inspection of the tankts) m identify any mksing of effluent on the ground surface. of combined sludge and sde I n and to check for any back up a porndun9 and to check for any p�log measure the volume levels in the obsevation fa The dispersal cents) shag be visually inspected to check the effluent may indicate a fang con diti on and requires the surface of effluent on the ground surface- The ponding of effluent on the ground immediate notification of the local regulatory authority- When the combined accumulation of sludge and scum in any tank equals one-third )o f aacce Banc �� an c hapt NR113 contents of the tank shell be r emoved by a Septage Serv o and disposed Wisconsin Administrative Code. pressurized Components, pretreatment Ali other services, including but not Umited to t h e servicing of of filters PODS Maintainer. units, and any servicing at intervals of 512 months, shag be Performed of any service event. A service report shall be provided to the local regulatory authority withirr 1 O days of completion .Ala UP AND.OPBI AMON o f products or other chemicals For new constnoction, prior to use of the POWTS check treatment tank(s) for the presence adorn detected have the contents that may impede tW o a ment process and/or damage the dispersal ceil(s). If high concentrations of the tank(s) removed by a septage servicing operator Pdor 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 highwatsr levels. When Pourer 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 Pknvdm or POWTS Maintlimm to assist _m manually ioperatingI the Pump Controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal Celts. Do not drive or park ov er, or otherwise disturb or compact, the an within 15 feet down slope of any mound or et -grade sod absorption area. the p � i and prolong the We of the Reduction or elimination of the following from the wastewater stream may ; dental floss: d'capers; disinfectants: fat: POWTS: antibiotics: baby wipes. cigarette butts: Condoms: cotton swabs: deg medications; oil; painting fruit and vegetable peeings: gasol'me: grease: herbicides: meat scraps: foundation drain (sump pump) _ 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 safety 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 sort, 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 comp cant replacement system: ennemt area has been evaluated and may be utilized for the location of a re pl a cement soil absorption ❑ A suitable replac . system. The leC ace�rrrent area should be protected from dcsdxbance and compaction and should not be infringed upon by , lot Ines and webs. Failure to protect the replacement area will required setbacks from exam* and proposed structure r� area � systems must oil result in the need for a new s and site evaluation to establish a - 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. 13, The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site area. If no replacement area is evaluation must be perfored to locate a suitable replacement available a holding tank m 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> > AND)OR INSUFFICIENT OXYGEN. - DO NOT SEpTIC. PUMP AND OTHER TREATM TANKS MAY CONTAIN LET GASSES AMMSTAMM DEA TH MAY RESULT. RESCUE OF A PU NI P OR O TH ER PERSON FROM THE INTEINOROOF AA TANKBE DIFFICULT OR WPOSSWLE• , #221180 (715) 6358609 j t?OWTS WSTALLER POWTS NIABIITAW� �` -� -Name Name 1 Phone - Phone "�' /�- �.3 = - 09 - SEPTAGE SERVICING OPERATOR (PUMPI-RL LOCAL REGULATORY AUK I Name Name �� Phone Phone w I. Administrative Code. This document was drafted in compliance with chapter Comm 83.22(2)(b)(1ltdl &(f) and 83.5411), (2) & 131. 08/22/05 YON 07:11 FAX 715 386 4686 Q001 EV UATION REPORT p of 3 py�atgolotyandt3Nftdinpa ,�Irl�� ?': � f li •' In aooadr�cawNhcomm Mm Code c=MY 54 • C Rt>/X Alloch toorpteM ells pteo an pope► Ia s 4 to r`;; wade.bwtndaer.dtat PEW LD bgb'ID /4 — 1p-baao parowtaiope. anchor north mmw and loewan anddktanatoneaisat++aad �1s ptemm print as khtmaallim Revieaed by wnt.rrama.aon � v�••r e.o..aror.monewr w.vo�(� �.••. • iao+ftld+0►• PrpettyOMW TO D D• FJ m 5IV Dom Gmt Lot N C 114 .SY4 S 28 N R I R E 00 FoR .Vo .F.MaDVAftmes Ld8 8 S[bdNmmores O S 2 O M �-"r 4 Go ?TA ci rr MCR L>D "JS O � ❑ ~e Town Naa Road HvIDSoAI wl 5'Ml ► TROY S ►� Ig NewCa WUcL n UMW RaatdentWINumbardbaermnw 3^ _ CodadwbeddaNOtwowtale So - 75� CaPC ORepletwnat ❑ pubkoroatniweid-Dem1w. 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SY Sh 1 *eW2 2 12-2 Iolrlopt , - C I 2MSAk m Fr p W Zv4 4 6 3 25-9 i DYI. s D s d l - J ✓f '7 f to •S •E>itwt8l� >30:220mplandl> �3D <100tndL •Hlow,td2• �9Dt�yILrd7SS130WOL csr Ntntbw t Lelp w�lY 59�I3�� Adftw DYtaEnahYfanCadaied Td hmaNtaabsr 2SIy /oTH >c SPR /.+tT I�r41.4t%'/, Wl /Nd /b 20of ( 772 3'M-Z For issuance 01 perr* and designing Ulbricht & Associates Contact: Ulbricht &Associates Private Sewage Consultants 2812 1 Qth Ave. Registered private wastewater consultant and pi►ebers Spring Valley, VV 1 54767 2812 10th Ave. Spring Valley, Wl 54767 715 -772 -3442 ORIGINAL AIR Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 08/22/05 HON 07:12 FAX 715 386 4086 IM002 Rq�lyp�s Paa1DA �'Pb -lal�l �c� °°° �,� d 3 - oo*v El ® pit Gwxldswfwodw 9 858 i< Domrbewrawto. 19 2. Sd ttodaom Dwo DOMWodcdol Rd=DoKdolm Tidwe �Yna.. a WMAMO S R-ft .Pare bL wwwe Qe.a- CmLcd r O am UL •�, �Ba1t2 ► I oYa - fr- v4 8 2 1 - 51 ►urR Cl mfg C L ZuF. 4 6 3 31 -92 lorieVe 5 0 sci d ► - ► 7fl 3 3 Q e°°"°' 0 p QoWdWt Wdw r: ;9k :. ,.., - eevFdt�erwa iti '.. No*= 010 am I 'Cdw ftftDwoWm Tiwo a wkw tiauidny Roas MR K I no" Q%at COOLC*r Or. lb- I& � asoftf Q � trrawdeuboedw ! D.pll.awryfador in Bat Rrb ttadawr Ows mm*mmcdm Red=Deem"w Tmam eta3m tioed< kL sow" Q L SL Cad. cur Or. ttz ah low Q Badn0* Q Qiwe "ftmdwr t DaptrbieMigtmyar Reee tbYoll Oath mwmwcft Rnto TOMOM SbUINM t:DFAIMWM 0 11 Roo* IL ha=lt Q L tz Omr.O*r ®r ft. SL • 8iwittf�BOD�a3p��agl .ardYSS�CtO_19Dapll • f�tlwttd2�80D��3D11dLaadTSS�3D�a�L TM Depa[t M GfCa U=w is re► .gal oppormiry aenice P�idar and �PbYR Ifyoo used shoe b.Dams ewvioas or mead =.Dahl in me aNemate fommW ple=a Do=le. me depntmoat a t 606- M&al5t or T[Y WS-26"M. AIR Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 I 08/22/05 HON 07:13 FAX 715 386 4688 0003 Cerr -rA6W MCADVV PA em 30p3 O ea SbRl ate o fbgFp3 AOk t1ZK For issuar►ce of permits and aes+cffirg e Q.J Tou R Contact UIMCht & Associates Registarw private wastewater Corr m# and OAM 2812 10th Ave. Spring Valley, W1 54767 715 -7724W Uibdcht & Ass Consultants private Sewage 28V 1W Ave. Spring VaIIGY. "til 54757 �8a PR ��>r ��� 9q•So q 8.5E A N �Ml = too-00 y 2 P SET z d h BOJ& a p pdM p ,�, �io� ti �� Qt = 9 9• SO a ' AM ys x. 770 t- N 7 gq toy Q� �E fit- is ut' ,� 7 t3n1 z_ R9. 9 y LO-r 5) . gl+� 3 1 �z ~ T P s£ Nl� SowrK PROP vwry 4►/JE ! 3 ?' z Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 I