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HomeMy WebLinkAbout040-1306-21-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515062 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: Thao, Chaying I Troy, Town of 040- 1306 -21 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /00 9 tM 1 G - S> - r 08.28.19.1848 TANK INFORMATION 1 1 ELEVATION DATA TYPE MANUFACTURER , CAPACITY STATION BS HI FS ELEV. Septic �j� Benchmark QQQLW f I b Z AI� � g .1 /01 05 Aeration Bldg. Sewer 3 l lG�o Holding St/Ht Inlet /o. y5.3Z TANK SETBACK INFORMATION St/Ht Outlet A I S ` -Y - %1 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet X 1 1 Septic ' / z3 Z3 Dt Bottom Dosing Header /Man. % �� /• Z� Aeration Dist. Pipe 7 .P aF Goa X1.83 9�• 3Z Holding Bot. tystern 12 • �� q 3 • gC PUMP /SIPHON INFORMATION Final Grade G 30 c 79 7 Manufacturer Demand St Cover + L GP �, Q --�� S • I /dI� Model Number � TDH Lift Friction Loss System Head I TDH t Forcemain Lengt Dist, to well SOIL ABSORPTION SYSTEM BED /TRENCH Width Z3 Length / No. Of Tre nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 90 Z 1 f'etiv"-�j I SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer � , / / INFORMATION CHAMBER OR 9 -� 1� UNIT Model Number. -F:/� / �l 4 . Type Of System: " © ✓,, / DISTRIBUTI YSTEM ! abj41,, Header /Manifold f/ Distribution I x Hole Size I x Hole Spacing Vent to r Inta Pipes) _ � I- Length O Dia r Length \ Dia \ Spacing \ 3 Q �. 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 /_ 55 Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 447 Jordyn Lane Hudson, WI �55TT•`�� 6 (SE 1/4 NW 1/4 8 T28N R19W) Sunset View Lot 21 Parcel No: 08.28.19.1848 1.) Alt BM Description = 5f�• 2.) Bldg sewer length = Z � amount of cover 1 Plan revision Required? "Lf Yes )(No y Use other side for additional information. Date Insepctor Sign u Cert. No. SBD -6710 (R.3/97) IL to 11 Safety and Buildings Division County N y% ilconsh* hingt on Ave., P.O. Box 7162 Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 56 10 (P _Z_ Sanitary Permit Applieat* CEIVED State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informs ion you provide Y A may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if di erent than mailing address) 11 IN y� I. Application Information — Pleas rl t All Information �` o W q * C%FtOIX NTY ml 0.1 T Property Owner's Name PI,pNNINCa &ZONING Parcel # ham. �,` o o . 06 - • o ®� � Block # Property Owne s Ma k dress �• , $ �, S \ Property Location � 8 J LLFF Q % NUIIA , Section CJ City, State Zip Code Phone Number Q q (circle ope?� T 2 —e N; R�E org1/ IT Type of Buil ing (check all that apply) 1 or 2 Family Dwelling - Number of Bedrooms 4 Subdivision Name CSM Number El Public/Commercial - Describe Use 11 t�iLy S u Sd�0 &44) 13 State Owned - Describe Use j y AAVD l i ❑City_ ❑Village Township of T� y III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System y ❑Replacement System ❑ 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 IV. Type of POWTS System: Check all that apply) - D; jr ca I l 2 z- - o on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil. . ❑ At -Grade Stng ter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter 0 Aerobib Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter XLeaching Chamber II Drip Line ❑ Gravel -less Pie ❑ Other (explain) V. Dis ersaVTreat ent Area Information: Design Flow (gpd) Design Soil Application e(gpdst) Dispersal Area R uired (s Di�ersalA opos ed ( f) System Elevation on - 7 �S? j - 43 . o0 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks W �✓ Septic or Holding Tank X ' ZSd 11 0 0 'e- a F,' •fao�/ / Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone.Number i At'k zZS>o -3 6�Z Sys =l9 7 Plumber's Address (Street, City, State, Zip Code) VIII. Countv /De artment Use Onl proved ❑O=nReas.n Sanitary Permit Fee (includes Groundwater Date I sued Issuing Signatu (N tam Surcharge Fee) 00 �/ / "/ ❑ Deni al IX. Conditions of Approval/Reasons fpr Disapproval t rte. 3) SYSTEM OWNER: 1. Septic tank, effluent fifter and ,q G • t dispersal cell must all be servicas/ maintained as per management plan provided by plumber. 2. AN setback requirements must be maintained as per applicable code I ordires. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in sixe SBD -6398 (R. 01/03) (, -7 kap T X ; aa "":>a-' X 1 Q w � 1117 T r�cl 44 �--0> NEW Sysfom E,v. -F3.00 its ► P� S z Z So 3 si soh. PV c- /Yla ; n r Ely, Lj 0 i \ D p 00 S7` w /F�t�✓ �(E Safl.Tcs� Ulf- 00 if lecopy � ` ,,`` �l2 f o� �.G.L. \l�fd'IQ(J1C.� ,f►� �` � r �, i 1 i 1 1sP � NEW Ev. _ l Ac¢s;7� 6o�v A LTL TE - N 3� a -D;s eal.ls C haw. 5 �P - I IG t T,Ek M (T- Z.. P V 'For t"e. p4a n r � ff Y, q o \ I �J4 W L OD O D ��:� � � `p4 �/� � IVD 5 ` O V ✓ `. KEW X9e' a v t 2159 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations unty Attach complete site plan on paper not less than 8%= x 11 inches in size. Plan %st PA L St. Croix include, but not limited to: vertical and horizontal reference point (BM), directio road. percent slope, scale or dimensions, north arrow, and location and distance t rcel L D. 040 - 1306 -21 -000 Please print all information. viewed B Date Personal information you provide may be u MRivacy taw, s. 15.04 (1) (m)). ` �9 Property Owner L Property Location Chaying Thao Govt. Lot SE 1/4 NW 1/4 S 8 T 28 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1658 E. 7th Street 21 Sunset View City State NtIYBiWf tCE _j City _j Village 0 Town Nearest Road Saint Paul I MN 1 551061 Troy 1 447 Jordyn Lane 1/ New Construction Use: 0 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD -I Replacement J Public or commercial - Describe: Parent material Glacial RuMash Flood elevation, if apRlicable Na- I General comments " ""A- ' and recommendations: Site suitable for onv. POWTS u ng 0.7 gpd /sq.ft. soil application rate. Recommend system elevation to be between = 93.00'- 94.00'. Boring # — I Boring Pit Ground Surface elev. 99.67 ft. >121" in. Soil e Depth to limiting factor Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDr in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 ff#2 1 0 -12 10yr3/2 none sil 2fsbk dsh cs 2f,1m 0.6 0.8 2 12 -20 10yr3/6 none sl 1 csbk mfr cw 2f,1m 0.4 0.7 3 20 -31 7.5yr4/6 none Is 0 sg dl gw if 0.7 1.6 4 31 -38 10yr4/6 none s 0 sg dl cw - 0.7 1.6 5 38 -121 10yr5/4 none strat. s Osg dl - - 0.7 1.6 it Boring # I Boring r✓A Pit Ground Surface elev. 99.33 ft. Depth to limiting factor >118" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *Eff#2 1 0 -18 10yr3/2 none sit 2fsbk dsh cs 2f,1m 0.6 0.8 2 18 -24 10yr3/4 none sl 1 csbk mfr cw 2f,1m 0.4 0.7 3 24 -32 7.5yr4/6 none Is 0 sg dl gw if 0.7 1.6 4 32 -39 10yr4/6 none s 0 sg dl cw - 0.7 1.6 5 39 -118 10yr5/4 none strat. s Osg dl - - 0.7 1.6 * Effluent #1 = BOD 5 > 30 < 220 mg /L an TSS >30 < 150 g/L luent #2 = BOD <30 mg /L and TSS < 30 mg/L CST Name (Please Print) nature: CST Number James K. Thompson s 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 6/2/2009 715- 248 -7767 t Property Owner Chaying Thao Parcel ID # 040 - 1306 -21 -000 Page 2 of 3 3] Boring # Boring 1/ Pit Ground Surface elev. 99.43 ft. Depth to limiting factor >119" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -16 10yr3/2 none sil 2fsbk dsh cs 2f,1m 0.6 0.8 2 16 -31 10yr3/4 none sl 1 csbk mfr cw 2f,1 m 0.4 0.7 3 31 -39 7.5yr4/6 none Is 0 sg dl gw if 0.7 1.6 4 39 -46 10yr4/6 none s 0 sg dl cw - 0.7 1.6 5 46 -119 10yr5/4 none strat. s Osg dl - - 0.7 1.6 1 F J Boring # J Boring _Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # I Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD s.30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD -8330 (8.07/00) A.C.E. Soil & Site Evaluations • So. /e da/u a� o � P• ♦ EX�'s�fir� elev` 0 Ck 7X 4 o Srdyn / 0 / 419 -5,0 -5,0 � 4Wy¢ Sep 8, 6&. cro;g co., ,AD OIZ- 1306 - ,V -� ^i 99.75' 110 J l ope tkr'o axeo- P, o pose.c/ re5,2t cft. E/c v` o f bdv` o+ Z` J 4 • 63 6 .ScsV t'. /�. A Tgoe� /off 3 38' did C 7 w[ // Serving Pi . 3 0�3 NgNKASr r531 X l 611[=4 101t 7-507 515041 SECTION w OA6 _� =-I -O F SUNSET VIEW - - - - --- I s x. 1700 Alu1INUN NOWfEtlr ,I UNP A TED LANDS _ - - -- ------ ----- --------- 1S7S)C�- 06061= - - - -- ' �---- - - - - -- I g______ DEVELOPMENT x2121 4[91 Maw4F4 - - - fC THRD x 895110% t 102110' N 6651'161605.06' w LOCATED w x 5W I/4 Or K NE 1/4, THE SE I/4 Or THE ow I /4, \ 121168' / •° THE NN11 IJl a T1( SE I/4 AND a TNE N[ 1/4 OF THE SE I/4 OF VISION rfi4M SESM a rAK, wt", TOM OF W9, SS.CAQ[ COW, wRN14a. IRJ401E ATA TA \IrT' �irlJif _l_aJ'r--- --- --- -- -- -- -\ a�+w U" am ow 2911, - ' / � - - -- 4'A' 75021' 1711'11 1 n l X03 . x " I I1 I I IMY . - - - - - -- 1.2 31100' 211.10' n / 101) 711 w' 71.61 '10f 9191 Na71y'I I N \ (T 4 3112 21777 VVIf 20191' N 9371' F S7' u 6 6N,w LOT 20 \ '4 5. PAGE 1211 S \ ]-1 167 Imx )11rN' 1 X7914'3' ( u) . 911111 n 111171 .X1' [ ♦ 0 0 [136721 {11 1N1(' r' }I Jam' 151.4 67171{ 1491 04 X 170JW r n ! • + Y JI•Ir 11 • X wxw f 1 _.._. -1x 00 91091 296568 3f. 7.1 9191 2191' ma'Ir 1132' N Irxw r U 1 • x 0x'01' [ 41 . N x9lr r Dr2 I 5 LOT l9 I $° A0 (2121 ; s` " E 50 q 1-1 919' n/.lr 27" 149 S"I'S 1 1 • X xmr 4 s. s504.11 , r v 4 Y �' to k. I to J low I'm 2121'06 w X x3115' It 256210 S.F. I ! Z." Y I 911 1olY 17U7' w1(x ;a T1 N 1{911{( s.5s k. j /'gib; 3 A t 1(i Ke Insr it l ap iin i 1 50 411 9191 147Y ma'4 Ili 4 Y $ 1%v l 1 41. S 50m lr 1 4 11. s 3r4r [ w 1 11. 11 -3 10' 19111' 671676 1017 S 11914{ A7 . w3ID' N A 11 . f Jr4 I , i 1 X - ' 101 16791 wr x21 919 1 191 19193' ( --- - - - - -- -- - - - - -- $W - NE SC 9a6o' I P; i L_ - _ J 'I ` Q I III Inw I /a' 1,371, I4a' Y X475' [ 'yi 1 S w1Ar [ 71 I }u 'W.w 106191 109111' 1y9 XIrma]'( nq.X1{171I'( u4.JnN'3'[ 1011 1J1m Ia.w X3'tl' air Nwmllr( 'LOT 16 a s u1ar x4 1ra1r slaw N 9067{ [ 415 • f 11742r E 4 16 1 (721'3' F N 66504 4 15210 241.0 w7YSr ran' S 911791 [ 11� L- - - - --- N - -- -- - -J ' O 0 L 10 0 .47 IrAw Iw1r 5 41ArI y 1 ., 1 249106 s.1, •. x91 67 X34' 11.11' � r g CN ,10U ,�''''` 1 6213 k. �--------------- - -- - -� 1 � IT 11 1 17 41.91 I 919191 mu s 911{21• [ n n . s 991x' [ 4 4. X 9377 F �I 7t 11 '� ' a 19.74 isw 7w.u' lu4x wit x 9JAr ( 4 I$ . X wJrJr F u Ia. x II41r x 1 1 A 71 -a 71191 Ia.10' 103'0' 191$ X 11'$.71,1411 • r 4lAr 1 n 3. X 41VIVF 1 1 511 1 }3 1670' 13. 52' 41" 1331, 7 I lPa71, 0 IS I allow 1 21 . 141(91 [ I I I`A I B-11 755%' w1.A' 1)n17r 'AX 7 9951' r n 3 • S 4Ifw ( 4 II • S 9xx X '` - -- - - -- 1 LOT 21 w' D w u IAw' 101.91 99111 nnw s 11'44 c -- T - - - - - -- l A u Iuw 1nx 10721 19191 =911(4•[ [ AI, - LOT !0 w •law "'8 „� I \ 957 a1, Y w 3 mw Iwv Xxw 9121' s I? r 211 LOT 8.1, I s'qv,. I I I SE -NW \ 74 k. w 21 mw 1 0 a mov 121.6{ x44 Inx s 421.4' 1 +' J I H 3.11, Xw III.w $ Xm'w 1 310 E391' 10.91' 917917' 31x N wl qr 1 u ll. S w7rx 1, u n• N 17o{'a' la 2 2391 Iww 1!x11' 213' x X2171 1 r•, - - A, \ , / I \ \ 0 LT x 2391 l w xxX lax N WA71' 1 q1, '" , t (3 \ • I 1 101 JI ma 11.1/' 111(4 2121 N n4JA' 1 ;' d+i •;)' , I 5, I \ I a 3 -x lam 4110' ax3 lost x wx A' 1 n3 •X167'x' r 43.xn42C 1 11 2111x21 1 la awANCt <�� 4 4u�J7 1, . 1 1 © \ JI - Inw nlw MIT! 11431 S 771rar r 4 A . x won' r 4 3 • S 52U7 r i I DO W l O,g1(n / ' 1 \ N '� Z34 73.00' 171.11' J111,jf 1457 S X1(7r r n 3 • S 51411• X 411 . f m17'A' r 41.41 O 1441711 90, 1 �f� 1.... 9213' 14 T Ai V g6' -- ORDYN {ANE J 96.I3' ... ! / LOT 11 V I¢,6T \ 43600 9F. V 1 45' 45' 1 ('----� LOT 34 = 1 \ 1 . J ✓21'60 �I ,'u. d ' LOT 17 j 66676 sY LOT 33 \ �. " /� 56874 s1, \ ; LOT 22 I � r 151 k. ° 11915 91. ` ,1 s / LOT 12 11 13 k. \> 1ti 7 , ` / 46217 31 4 0 = 168 �h z' w9osr o Sk. q p 1 ._ 6, J n p a g 125 k. J N L__ 6{36'111 - 502.91 - _ -J O `___ U 1kn11mmjNk4AdopkxilNWeHA V ;Ia•4oa' /o I� $ / 16YZ6 14.65 ( \ \ sp 2sals.2lwJaUa20mJ276z1SUmdm --- ^- \ 5 6x24 a 13067 w43m 0/.9mg i u / / 1 V. 1 V,'p5'N I '� I dl \ I I-' -_ ^, 0 A LOT 141^ LOT 151 g 161 LOT 23 P Z caosd�", LOT I3WI s 51191 / 1 �5M99 31.1 i EASJ Ito D T) 199 - ifJ -� AOTal' I. 49ro Sr j SECTION B, f 431W a1,. . ' � 8 1(5363 9.t I n, 123 k. l I la k. � � / F01 (9191 s. � loo � , : a. , ° 1 064 k I 1 ;8 1 La k src . I " / `.\ � r68J D T) 1 / 7 "I - p , `.\ kIMIN.a MpIAAENI � 1.02 it. I J' -- -� p 0 0_ 79 I 156.92' 19 LOT 24 \�' � % \ 1 N allr3t 47157 / \ a, -- -- - -- --� O n \ 69606 31. LOT 31 / / s IT32 1 491 140" i mix / \ 3 \ x9 k. p ro I h tl TG619P y' ' \\ - / \J \ I O\ 119 k, /,t, w D 41',0' 100.66' 49.79' O i / \ \ a \ w INDIA 4 66ot1lttll� O 2 0 0 ( \� \ i, wE \ 91191167. 6F.0�OawL Nw -SE LOT 30 /i / '�Y I�----- - - - -18 f l l- I I LOT 25 + y 68668 61. /�' % Iw 1 LOT 28 a LOT 27 aox LOT 291 LOT 26 I v 1 175 k'n,� / 43521 s.1,. 1 45214 31, (X91 S.L 1 ono .-N lA. = 105 k. IN k. - 1 1 106 1 I I \\ \\ 9 N N" 19121' 245.60' 26111 200.10 1E7�1 I s WWII 421 XASCS 0619191121310 m R X06 NE -SE UNPLATTED LANDS 191[ or in 9 t/1, M.463 wwm '•8 n l 0 100 300 no SWTHEASJ COW, ��• SECTION 6, FO.AO am r- FEET SHEET 2 OF 3 AL a P ENT THIS INSTW WED If JAMEY N NE6Ea Safety and Buildings Divisi County N *6consin 201 W. Washington Ave. 0 0 2 Madison, Sanitary Permit Number (to be filled in by Co.) Department of Commerce ( 2 Sanitary Permit Appliea on State Plan I.D�mber inform" accord with Comm 83.21, Wis. Adm. Code, personal inform e^ N maybe used for secondary purposes Privacy Law, s15.K1,,., ��{ � Project Address (if different than mailing address) I. Application Information — Please Print All Information �T 7 ':J 1 2009 Lae. MAY 2 w r 5 Property Owner's Name ST CR011<t%U�N t'r Parcel # Lo Block # e� C� G & ZONING OFFICE ow I f f 1 Property 0 er's Mailing Address Property Location O O _ / b( _ 2 _ ry 'Pau 14 a , �J�`D S V, P02A Section �-lJ City, State Zip Code Phone Number �/ ' 7 � �rrcle C v J S ( G (0 � q T z 8 N; II. Type of Building (check all that apply) SC I or 2 Family Dwelling — Nu e f Bedroo s / Subdivision Name CSM Number ❑ Public/Commercial — Descri U .1S V t(, i 4 - w C1 State Owned — Describe Use v<< S 5 -$ Ai f ❑City_ ❑Village �Tovmship of III. Type of Permit: (Check only one box on line A. Complete line B if applic#ble)':P-( ® ' t, A. )(New System ❑ Replacement System ❑ Treatment/Holding Tank Repl` ment Only ❑ Other Modification to Existing System B. ❑ Permit Renewal E3 Permit Revision ❑ Change of ❑ erm' nsfer to New List Previous Permit Number and Date Issued Before Expiration Plumber er IV. Type of POWTS System: Check all that appl ;Non — Pressurized In- Ground ❑ Mound > 24 in, of suitable soil Mourul'< 24 in. of suitable soil. • ❑ At -Grade ❑ Single Pass Sand Filter El Constructed Wetland ❑ Holding nk Filter Aerobia; Treatment U Recirculating Sand Filter Recirculating Synthetic Media Filter chin Chamber Dri in Gravel -less Pipe ❑ Oth r (e la ) V. Dis ersaVTreatment Ar atio : 1sf • %L, lI s C Jq^1 ors 1P_4te at E�ID s Design Flow (gpd) Desi Soil Applic Rate(gpdso I Area Required ( Dispersal Area Propo (sf) System Elevation (o 00 •7 S � O 94• w VI. Tank Info Cap i in Tocal, I Numbe1w Manufacturer Prefa vi /,US ite Steel Fiber Plastic Gal Gallon of nits `h/ Concre 'Constructed Glass EA Now Tanks T u �{ I $ -rL V Septic or Holding Tank , ' dO I r 20 "Q /�� /O +/ Aerobic Treatment Unit !� l B /\ 1 0� yak, T.( Z5" Dosing Chamber © (�? L P t 200 boo MR �c VII. Responsibility Statement- I, the undersigned, assume responsibility for ins allatlon of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's S MP/MPRS Number Business Phone.Number z z.So 3 !o GIz - (:f(os /9 Z 7 Plumber's Address (Street, City, State, Zip Code) VII[I.County /De artment Use Onl pproved ❑ sappro�VenReason Sanitary Permit Fee (includes Groundwater Date Issued Issuing t Signat S ps Surcharge Fee) $ 4 -75 , t0 5/ 21. �/ I J IX. Conditions of Approval/Reasons for Disapproval 3' $/221 De] SYSTEM OWNER: Y 1. Septic tank, effluent filter and I M Tp * /oAw, Q, c1RA C",,..6crs ki; U dispersal cell must all be services / maintained t)'!lX w: tl he,. 4!'opoea 0. "0� as per management plan provided by plumber. �I 11 2. All setback requirements must be maintained Is per epplioable Code / oi'di W Ices. J Attach complete plans (to the County only) for the system on paper n less th an 81/2 x 11 inches in size i/�cl`e.a5e� g. Zoe�(a.` `)� d'e Go,�. pex" SBD -6398 (R. 01/03) et e�dt� t�1 �G��*�e.� -Q- �� A �"- l - k4tm4m— � `4- ' - f A �aj A,(tAj elY - 7 Y,5 ' 9)C) NATO' e 5q' *M Z oo Pve- :ForcAt p4a,", Ely, Ar 0 rT �4A IS \, _ .- may,' - F] CO py kA t �Tc Tc-.e, M47C 444 }a 44C- C 6? VT os) A5 T�erL`ts Wisconsin Departmen of Co �t V ' F-Q SOIL EVALUATION REPORT Di" ion of Safety and uildings Page of 2inrdanc with Comm 85, Wis. Adm. Code Attach complete site an on County per not less t 411� ,B 1/2 1 r 1 inches in size. Plan must include, but not limited to: vert T refere ce point (BM), direction and Parcel I.D. percent slope, scale o imert4(� 41 t1G�i3 ocation and distance to nearest road. F04' 1 ease print al/ information. Revi ed by "Date �- Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). � � Property Owner ZZ Property Location s� 1 /4 NE 1/4�S �• T Z-8 N R �Q � Property Owner's Mailing Address f E (d) W Lot # Block # Subd. Name or CSM# P • o. f ox 3 3 (- ) -- SUrvs� City State Zip Code Phone Number ❑ City [] Village .� Town Nearest Road t3f \,SaM 1N12E L 5 �l$ZO (�IS) I TZO`1' New Construction Use: ® Residential / Number of bedrooms 3= Code derived design flow rate � S Q — �j 00- ❑ GPD Replacement ❑ Public or commercial - Describe: Parent material G Lie) R L QJ'jA y } t Flood Plain elevation if applicable (� ft General comments and recommendations: 1Z g���►� p e� w C�eta CMf�i3 s , V-1 P Boring # ❑ Boring PE$ za ® pit Ground surface elev. I0� Z ft. Depth to limiting factor in Horizon Depth Dominant Color Redox Description Texture Soil Application Rate Structure Consistence Bcundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 ___. 'Eft #1 'Eff #2 w-m 317 si I Z'Fsbi� rn Cw Z 0 3o to�2 3 l — 3 fz-VA — S Osq �I t I r { a Boring # ❑ Boring C� Pit Ground surface elev. ) � � ft. Depth to limiting factor ? a 7 in. Soil Application Rate I Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh, •Eff#1 •Eff#2 I D -l4 1O`1CZ3 — I 1 Z'fS m` r cu'u Z� •S •� 2 1D 3$ l — JL 1 Z S b'r VYI i r CCS l'C + S -8 Effluent #1 = BOD, > 30'< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 CST Name (Please Print) - s _ m9/L and TSS < 30 mglL ... ignature CST Number Arthur L } lie gerer 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation conducted Telephone Number 421 N. Iiain St. d iver calls, UI 54022 1Z _lq_d3 715 -425 -0165 s Property Owner ` y �� ( h/) �1�/`1 -- Parcel ID Cj Page Z ; of Boring # ❑ Boring ® Pit Ground surface elev. �� • S ft. Depth to limiting factor 7 C t S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure . Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 °E(f#2 � -1� 1 0'� R 3 i Z �-- S 1( 7- �S�t -L �Y1`�y- CLJ Z `� • S •� . t'p Z 10- ► Dy 2 316 S l ( 7LV4 S 3 3 _as ►o�� y�� — S C) sg tl ' b ❑ Boring # ❑ Boring ❑ pit Ground surface eiev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff #2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. °Eff#1 •Eff#2 Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L Tlie Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 264 -8777. S B V -8330 (k6/00) - Property Owne 1- ��VJ(� -1 Parcel ID # il/ Cj Page ' Of 3 Boring # Boring Group s d� ❑ ® Pit d s elev. � S fl. Depth to limiting (actor in. Soil Application Rate Horizon Depth, Dominant Color Redox Description Texture Structure . Consistence Boundary Roots GPD /fl In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 �1 -10 1 vi 2 3 / z 1 ( Z- (zSbl� m`� cw Z `� • S • f3 . (P 103 I D`t2 31 6 Sl ( 7Lr1 Sbk h� CS 3 .-t_ - z l! b F] Boring # Boring ❑ ❑ Pit Ground surface elev. fl. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2 'Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftx In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 • Eff#2 Effluent #1 = BOD, > 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD, < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.6/00) PLOT PLAiT Paae of -� Scale 1'= 50' LoT zp ! u3 O,4 6 )b 5 1O OS 5-3 5. — )00 - I v 3 I l00' I to �UtB� E '�`A wQ- 1►`1 1T t 14 L 0 v� \�- $irk �-1 LSL 100 0 Uri G�cOVrJt� S1� e f�T LpT L'J1Z� 1 13w14_Z LrL It 6' ory Z ` ILL ��� �I A �V e C'( P� w / (_J�'(�? iC a . \Z - LQ -03 715- 425 -0165 220254 _ � Zls_zr CST Signature Date Telephone No. CST No. Job NO. 910. LOT 20 296583 S.F. Z r , I 150' ,,�''�yo" I 6.81 Ac. o :h, I 0 150' I N Ch . S. w Top of I.P. u 910.62 7 O N 89'58 48 "W I I Q 4 LOT 21 I so' \\ 322743 S.F. \ 7.41 Ac. 21 \ I Cs \ I N I CJ� c s � \ LOT 17 .5 co 56874 S.F. \ �tK, !�� LOT 22 I r 1.31 Ac. <� CD '5� o,� > >R . 25 \ 48947 S.F. C tK i I "E 2.91 �� '`�/� ��'` 20 D 1.12 Ac. 30 J .O 140.65' ( \ 4 (- - -� I S 85'24_44 "W 320.87' N I I ° LOT 16 I LOT W I LOT 15 I � 1 I 23 o ' ;F. 51986 S.F. 1 145252 S.F. P. S n r 1 1.23 Ac. 0 1.04 Ac. 1.19 Ac. 0 o I I JI Z - - - - -� 1_% Q 3 , �/ \� 29.813� 1p �� 05/19/2009 08:21 7156475181 WIESER CONCRETE PAGE 02/02 vw -oo aozlcnM:31U 8002 'Ndf 'A3?1 aooz AHvnwr !sLva o9j" m •muoa K3aror+ - o"m sn 9LLEM x \ ° Ins -As wvaa La 31311111 � ���'��m - ten Nb'YV �u d 35 \ !3LVa SON AMI t _ .i/031V09 Hri —OOB o0zkrm ~ fJf W f cr LU Z W Z F W X J V 0 ¢ O O a F J U w Lij O a: a J W O z a Fd N 0 a. N N O O �,� � p H U W N U f H J W O O z fn 9! I 0: p M op w O r U w o f o m z �C a p w x D p OW wFw �� Z H a Z O d O U a o N o m�n�ww � c �z U w [� fj Q M tri W 4 W N •F N 7 0 O W W 00 LL- - O p R W V) O w W Q d fy U _ o p r (X sn� aoww �+ic�i o En U Y0R� Q F -J1-7 ~ I ¢ �NQ MN O ¢ W O 1 o W R L11 Oi Z W m O F- yI in ~ G7 J \ a O CA N L o~ —�~ O¢w Oo ¢ 'n z w to w w l- LJ w m P 0 rv, p -jv! ==Z -Z�o5g ze C) U CL ❑ Y�Q awl �m :1 IL Y Z m( -) :2 m � d d C7 <*— C z G 4 < V) Z O W W ~W O Q ~ Y � ❑ 7 C31 7 p Z z J O Z Q ❑ cc $ ~ Nz p d N V) U 'Q Q W a a n n _6£ cn 11 11 � z H II f I I W o I I a P •, I in pr (xw I o o- LL I iLi u w J z x 96 a „6ti „£S COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of cover, Access Opening, not top of cover, must mdend to a point no greater must e)dend at least than 6 "Below Finished Grade 4" Above finishedGl ade Covervuith VJ A7NEK CDF �( NT� •� Locking Device � 61SE?9X PP'► a` +P (typical) I Finished Grade �UILW�� Min. 23" 3b FT-. �Q2 h Access Opening ►lJ5U Min. 23" Access Opening t FBI � I Z ��G R �G�2 CE/h Outet Effluent Filter W /TH 1f �'�✓C S( E • A ( `� . Union plo,2oYEp /P� 3 Fr Inlet Baffle N �/it ON`Ta SOS- /D SO /L i it Pump 3�� d ary��( ,n ur?der u j4-A oah-lei e 2 "/al�r�hav� �dSPs Two Compartment Septic/Pump Tank (-/.D l ( ' keV ale n 0 6'1 i5 . � J SPECIFICATIONS TANK MFR: IS E A DOSES PER DAY: TANK SIZE: SEPTIC r 2 GAL. DOSE VOLUME: GAL. DOSE _ .'AL. (INCLUDES FLOWBACK & <20% OF DWF) ALARM MFR: CAPACITIES: A = INCHES MODEL # (© Switch type: F' B'= �?-'- _INCHES _iy �' N$ GAL. PUMP MFR: Z (� r C = � INCHES = . CUSGAL. MODEL #: R N — --S� 3 Z,i - . I q SWITCH TYPE: o� D = 7i INCHES = ?bG REQUIRED DISCHARGE RATE. GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE.BETWEEN PUMP OFF•& DISTRIBUTION PIPE (LIFT) _ +�" FT. MIN NETWORK SUPPLY PREJ�URE (DISTAL & NETWORK PRESSURE)'= + FT. FT. OF FORCEMAIN x hr FT. /10Q FT. FRICTION FACTOR ...... _ + / FT. &v ate_ . j `` TOTAL DYNAMIC HEAD (TD ) _ �� 0 I FT. INTERNAL TANK DIMENSIONS: LENGTH__ , WIDTH LIQUID DEPTH_ MP/MPRS SIGNATURE: -� M I�, LICENSE NUMBER: 2 2 SO 3�p R' }f PUMP PERFORMANCE CURVE PUMP PERFORM ., •- I im A a gill] 4', 1 IS to 1 S O LI D PASSING CAPACITY ■� ■■■■ 0 ®emm0 ° emm ° e °O ° ■ ° e ° °mm�0 \HEE1��� ■ ■ ■ ■ ■ ■ ■■ MEMEME oS\ \111\ ■SOME■■■ m ®� ®m ®e ■°©�mo0 0 ®0 ®m ® °ao�0m® ®mom ME\MI� ■I ■E►►\■■■ ■■ ■ ■ 1=\1111 \ ■ ■5\ \ ■ ■ ■■ a° ®mom ® ®oam�m ®mom a °° °0o°am�■00 ®�m� M \E \11 \IIO \E■► \■■■ ° ° ° ° ° °° ° ®�■ ©000 \II I \S■EME LINE \ \ \11m101 \LN ■■■\■ MO11 ►!31,000, 00 ■ ■ ■O\ F�� 185/4185 should not be subjected to less than 30 feet TCH. umn explosion proof pump, see FMO219. SEWAGEAND DEWATERING Model 293/4293 should not be subjected to less than 15 feet TIDIH. ■ / rM Quick4 STANDARD CHAMBER 52" — -- I Quick4 Standard Chamber 48 " (EFFECTIVE LENGTH) I I, ' I f e 12 Mimi MEN EM IBM MM 2 ME M A M — 34" SIDE VIEW SECTION VIEW MultiPort End Cap__ - -- �r �- j 16" - 12 - - -� I _ -- - - -- - - - -- 34" -I SIDE VIEW TOP VIEW FRONT VIEW .�x L� y 3'. r. ; F. w Quick4 Standard Chamber Nominal Speciflcations � nom- ""Ant ort end Ca Nominal S ecifications Size (W x LLx 34.' x 16' X:12 kh Y 6 ;f 'f. "' Effective Length fi ' . ;;48 "`� invert Height x �` ".. 8 or 1 25 Invert Height 24� fit. S �fi� m i .�' q ,". ,�� INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY r Inc str'L�ctural rhognty oI each chamber, old plate. wedge and other accessory manufactured by Infiltrator ( "Units "), when installed and operated ieac o cl an onsite septic system in accordance with Infiltrator'S instructions, is warranted to the onginal purchaser ( "Holder ") against detective natanais and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units', provided, however, rol a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences . e cs it warranty tights, Holder must notify Infiltrator In writing at Its Corporate Headquarters In Old Saybrook Connecticut within within fifteen 11 5) c 3lc,i .d defect. Inf'Itrator we supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. f I ciiu, s i.ao Tty sperifically excludes the cost of removal and /or installation of the Units. O p THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT SYSTEMS INC TO TI UNII "S, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. ;c 1nls united Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not exend to .ncidra tal, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of Environmental Onsite Wastewater Solutions' production and profits, labor and materials, overhead costs, or other losses or expenses Incurred by the Holder or any third party. Specifically - chided from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of :1 e Units, the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation Instructions', failure to maintain the 6 Business Park Road • P.O. Box 768 In -ire— ground covers set forth in the installation instructions; the placement of improper materials into the system containing the Units; failure of c Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or Old Saybrook, CT 06475 any offer event not caused by Infiltrabr. This Limited Warranty shall be void if the Holder fails to comply with all of the terms set lone in this Limited Narranp 860- 577 -7000 •FAX 860 - 577 -7001 runnei. in no event shall Infiltrator (,a responsible for any loss or damage to the Holder, the Units, or any third party resulting from inslallalion or ship - 800-22 Irani, or from air procuc:t liabil claim s of Holder or any third party. For 1, Its Limited Warranty to apply. the Units must be installed in accordance ,lT all site conditions 2qu.md fly state and local codes; all other applicable laws, and Infiltrators installation Instructions. Ic7 No:apresentarve of rittolo, has the authonty to change dr extend Ihls Limited Warranty- No wananly applies to any party other Ihan the ongi- iai fH,ridei 1'he auove represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty require - nents Any purchaser of Units should contact Infiltrator 's Corporate Headquarters in Old Saybrook, ConnBCticul, prior to Such purchase.. to obtain a ::opy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. U.S- Patents: 4,759,661; 5,017,041; 5,156,488', 5,336,017; 5.401,116; 5,401,459, 5,511,903; 5,711 63i 5,588,778; 5,839,844 :anadian Patents. 1,329,959, 2,004,564 Other patents pending. nfittralor, Equalizer and SIdeWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. s registered trademark In Mexico. Contour, Contour Swivel Connection, Mlcrol-eaching, PolyT'uff, SnapLock, CharnberSpaeer, PosTock, QuickCut, QulckPlay RECYCLED PAPER aria Ou,ck4 are trademarks of Infiltrator Systems Inc. © 2003 Infiltrator Systems Inc. Printed in U.S.A. 001 12U'.3HP -2 ® Filters PL -525 EFFLUENT FILTER( ) Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters.The PL -525 is rated for over 10,000 GPD k t Alarm �N ��— Accepts PVC igallons per day) making It one Of accessibility 1111 extension handle the largest commercial filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL -122, the new Polylok PL -525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots Rated for over float up and temporarily shut off 10,000 GPD the system so the effluent won't , leave the tank. No other filter on the market can make that claim! Accepts 4" & 6" �r SCHD. 40 Pipe \ PL -525 Maintenance: ,' O The PL -525 Effluent Filter should operate efficiently for several years under normal conditions before 1 requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be � Gas deflector done by a certified septic tank Automatic shut - off pumper or installer. t i �� ball when filter is removed 1. Locate the outlet of the U.S. Patent No# 6,015,488 I septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover ana 4. Pull PL -525 out of the housing, mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to tree 4" or 6" outlet pipe. If the tank. Make sure all solids fall filter is not centered under [n, back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL -525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cove,. t 4chnica1 Specifications PL- -525 EFFLUENT FILTER (COmmERbAL) EXCEPTS 6'SH010 1 FOR INLET EXIENTION 11,57 14.35 ✓: OUTLET I BUSHIN GEXCEPTS V SCH 1086'SCN40 � 8.10 p I L - -- 1 -.I `r � -10.68 - n i y i 5M L%CTv2 _j S 33.02 I I i i PL-525 FILTER HOUSING 1fl31 -- ^' PART NO. - 30142 -525 � t �� MATERIAL: HOUSING - POLYPROPYLENE OUTLET BUSHING - PVC I. 6.5 BALL -HDPE - SOCKET EXCEPTS FLOAT SNITCH 1 y 'r -„ - - - -� 1 ar 10.23 1 1 I -- EXCEPTS 1' SCH 40 .98 FOR HANDLE EXTENTION 10.81 _ -. ii -`� S30CF1n6'SLOTS 6.21 - - -- SOCKET EXCEPTS BO4 BILL PUSH ROD r__ -_ OPENING 'I i j � 7.09 OPENING 20.71 O i 19.02 2244 I O o POLYLOK PL -525 FILTER CARTRIDGE PART NO. - 30141 -525 M ATERI AL - POLYPROP YLENE T Polylok PL -525 Support Stand Should you feel it necessary to add additional support to the PL- 525,filter, use a six -inch Schedule 40 or SDR 35 pipe to extend from the base of the filter to the bottom of the tank. The extention pipe needs to be anchored to the filter housing with one or two #1AX 112" SS screws. �-- Anchor 1 -2 Stainless steel screws through housing and into pipe. Use #10 X 112" 6" Schedule 40 Pipe Pipe rests on bottom of tank IL POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page FILE INFORMATION SYSTEM SPECIFICATIONS Owner � � 7 �t� 1(J, �l �� / Q� Septic Tank Capacity Z (� a l C N Permit n f Septic Tank Manufacturer � ❑ N.� 'I DESIGN PARAMETERS Effluent Filter Manufacturer ,j �c ' N l' 1 Number of Bedrooms ❑ NA Effluent Filter Model $Z 5 ❑ "�� Number of Public Facility Units ❑ NA Pump Tank Capacity 900 al Fj N` Estimated flow (average) g al/day Pump Tank Manufacturer Gam, Design flow (peak), (Estimated x 1.5) (P OC"� g al/day Pump Manufacturer e—r Soi! Application Rate z Pump Model g '� g al/day/ft' /ft _ Standard Influent /Effluent Quality Monthly average' Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) N j Biochemical Oxygen Demand (BOD 530 mg /L YIn- Ground (gravity) n- Ground (pressurizeei Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: Omer. ❑ NA Other: 'values typical for domestic wastewater and septic tank effluent. Other: MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ JZy ear(s) onth (Maximum 3 years) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume Inspect dispersal cell(s) At least once every: Cl month(s) ❑ year(s) (Maximum 3 years) Clean effluent fitter A4,least once every: I ❑ month(s) C years) ❑ month(s) ❑ t Inspect pump, pump controls & alarm At least once every: ❑ ear(s) _ ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) Other. ❑ At least once every: O month(s) ) Other: MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certiflcatro Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. T�: inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or :ea measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surf3_ The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pone of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires cu immediate notification of the local regulatory authority, When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the ect r contents of the tank shall be removed by a Septage Servicing Operator and dispo$ed of in accordance with chapter NR Wisconsin Administrative Code. Ad other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretrea 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. D OP Pa Z Z OPERATION 9e _ 01 For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s), If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil: painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: >c suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption ystem, The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T alua ' bUlLable re place ... Milt al b ai e �FR1)4/113 , Ft)1Q - A/>� CotjSrRLlC71pu ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name M k - F_ t4 15 " Name Phone 6 1 L . � S. 1 11 91 1 I Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S Phone b 20�l �Cl Phone - 7 / G 3e' - fo and 93.54(1), (2) & (31, Wisconsin Administrative Code. This document was drafted in compliance with Chapter Comm 83.22(2)(b)(1)(d) &(f) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM I- V Owner W •� �0� , �4�k x t Or g, _ �,t. w ) �b t h gt � ' f I tjl ' S �( Uowv ?h,c�l Mailing Address � � � � b Property Address 4- A Lat (Verification required from Plannind & Zoning Department for new constructio r��_ b 3S— 1 16 - ,0 6 . 0 h 0.rT ,f : 6q - /D 35" 1 D�coo� City /State 1 S Parcel Identification Number &(0 - f o 3 7 - 210 . 100i D y - /03 7 - 36 - o 00 LEGAL DESCRIPTION Property Location s 1 /a , 14 If 1 /a , Sec. 8 , T om- ° N R tV W own of !r" !I Subdivision n V 1 Certified Survey Map # NA , Volume , Page # Warranty Deed # 70 6 q3 S ,,Volume Z 7 / // , Page # `1 Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber', restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system i p s i n proper operating condition and/or (2) after inspection 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 stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 4MA���_ - / 19� GNATURE OF APPLICANTS) DATE * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 76 C 43S k U 2 7 4 1 P 4 7 0 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., wi RECEIVED FOR RECORD Document Number Document Name 02/02/2005 06: 30AN WARRANTY DEED EXEMPT tl THIS DEED, made between Maichue L. Thao and Meng V. Thao, wife and husband REC FEE: 11.00 ( "Grantor," whether one or more), TRANS FEE: 450.00 and Chaving W. Thao and Yer Xione COPY FEE: ( "Grantee," whether one or more). CC FEE: PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Recording Area interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space is needed, please attach addendum): Name and Return Address Lot 21, Plat of Sunset View Development in the Town of Troy, St. Croix County, Wisconsin. FG is Part of. 040- 1035 -10 -000; 040 - 103540 -000; 040 - 1037 -20- 100 :040- 1037 - 30-000 Parcel Identification Number (PIN) This is not homestead property. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. (is) (is not) Dated r — 3 (SEAL) (SEAL) * * aic L a . Thao (SEAL) (SEAL) * * eng V. T ao AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF W i' Cz Nj f'n ) ) ss. S f C �� r' COUNTY ) TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on (If not, the above -named Maichue L. Thao and Meng V. Thao, wife authorized by Wis. Stat. § 706.06) ..��`"` "���ht husband V,B . ..ptlir t known to be the person(s) who executed the foregoing THIS INSTRUMENT DRAFTED BY: ? NO nt and acknowledged the same. ' I Attorney Kristine Sland Hudson WI 54016 5 J Vtee4, t •+ ary Public, State of �Oi�S� '••.......•••''i _ ommission (is permanent) (expires: "� ) t qTE OF (Signatures may be ueZfor acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. 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