Loading...
HomeMy WebLinkAbout042-1012-80-370 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Buildigg Division INSPECTION REPORT Sanitary Permit No: 453060 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information °pou provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Hold&'s N. =me: City Village X Township Parcel Tax No: McKenzie, Allen I Warren Township 042 - 1012 -80 -370 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /cue.. � SST t4 / >V 05.29.18.77C30 TANK INFORMATION ELEVATION DATA k i . 32, / -i" — 7 i ) G .`. TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ` Benchmark l J Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet �- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ Septic i v — � —3o _- _ Dt Bottom :21. - 2 Dosing _ Header /Man. 4 4 Ly Aeration �,, Dfst'Pi0e 5 5•I Holding eef�stem PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM - Model Number f / L, 4 t' ~ - 974 TDH Lift Friction Loss .j System Head TDH Ft 7, Forcemain Length Dia. Dist. to Well a SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 G� 3 SETBACK SYSTEM TO O P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: �. s. A) /A UNIT Model Number: r Cvl %✓l� 1c. C - Z DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) — >75' Length ' l Dia y Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed(rrench Center ? 7 BedlTrench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: 1C'V 1C' Inspection #2: Location: 1135 109th Street Roberts, WI 54023 (NE 1/4 SE 1/4 5 T29N R18W)kNAA Lot 8 / Parcel No: 05.29.18.77C30 1.) Alt BM Description = TO P ot rc, in. c ' 6%')6� J 2.) Bldg sewer length = L 3o J - amount of cover = >7 9 Informat' n. No Plan revision Required? i Yes Use other side for additional ' SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. I��I.e✓� S, fY1` �nZ ;e L �, t �' Gs�� ?�%ti�?3Y v�•{ (b y �3� "' 4 V z s / 7'c 'n' x SC. ,{`t h ST • ; ,ANN SSc�`75 �n �JJ `J sp, Goo/ � (� I i 1 3> i `�� / 0 G ,c � 1� ,s N pr �M 'top low_ �d 3 p v 1 l `r IC? IN � NJI `7s G 1 - • • � �e�osed �1b� �� �.� ti E y SIC y s T XY N P i b° Sri �`t ►� ST • �Q.0 l , A) N Ssc >7 s �Jct r (` VA f S 3 Qer nJJ � � s7 i"fl e^ UAL S��s•V /LtJc�SFis /�i� 'It 1000 C rll .tv 3 Tr�eu.c m g0 �� -� S 7s , i � by v A tit l Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 V i $consn Madison, WI 53707 - 7162 Sanitary Permit Number (to be fill in by Co.) Department of Commerce (6D8) 266 -3151 44 5 3CD(pC) Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21. Wis. Adm. Code, personal information you provide ©S c � , 7 _ 2 L 3 Q may be used for secondary purposes Privacy Law, s15.04(1Xm) Project Address (if different than mailing address) I. Application Information - Please Print All Information °' *" 'Fh S ) 0 Urns w Property owner's Na me Parcel # r Lot r g Bloc le lr\ I1 �, m� , Property Owner's M ailing Address Property Location 1 !qJ4 2 10* �' . S � %, S< %,Section 5 City, State o \ ^ Zip Code Phone Number sY - C ae+.� m IV �SC.�75 (circle U. Type of Building (chock all that apply) T oZ, 7- N; R E ort or 2 Family Dwelling - Number of Bedrooms � ��� Sub d0 � Name � q q 3, ymber 11 Pubiic /Commer - Describe Use y Ll ❑ State Owned -Describe Use (,� �� ❑City ❑village Afownship of i�,� kN III. Type of Permit: (Check only one box on line A. Complete tine B if applicable) A. %New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B, ❑ Permit Renewal Permit Revision ❑ Change of ❑ Permit Transfer to New 3� Before Expiration Plumber Owner O IV. of POWTS System: (Check all that a 1 ) Non -Pressurized In- Ground El Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil 11 At-Grade El Single Pass Sand Filter Constructed Wedand ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter i ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑ Drip ine Grav -less Pi . ❑ O (explain) V. reatment Area Information: Design Flow (gpd) Design Sail Application Rate() Di 1 Area Required (sf) Dispersal I Area Pr e (st) System Elevation ) r ' a - S I of ✓ 97� VI. Tan Info Capacity in T Number Manufacturer Prefab Site Sleet Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks is _ 00 Holding Tank ��7 r AcrO* Treatment Unit - Dosing Cbwftr c G 'rS VII. Statement 1, the respiin ibility for 4=5009 of the POWTS shown on the attached plans. s Na nNt (Print I Plumber's S1 gnature / PRS umber Business Phone Number �,V t)6 - 7 3s Plu 's Addre ss (Street, City, State, Zip Code) Soh L N.l J o Use Onl pproved ❑ Disapproved Sanitary Permit Fee incl udes Ground water Issued ing igna e ( ps) Surcharge Fee) r ❑ Owner Given Reason for Denial IX. Conditions of ApprovsWReasons for Disapproval SYSTEM OWNER: S �Q 6 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained Atmeh a mph" t (m an Comity 9 "W for tM syMin on paper not less than 81/2 x It hicbes in size , ---- -. �SEPT?.0 TANK &; PUMP COMBER CR05� E� +' MIN. ABOVE GRADE & WEATHER PROOF • APPROVED Cl CI VENT PIPE ON BO � JUNCTIO + R WINDOW OR JUN MANHOLE .COVER ? OM D00 IT FR � U 2 S H CONDUIT FRESH AIR INTAKE WIT W/ PADLOCK £ WARNING LABEL 4 MIN 18" IN INLET 1 ` WATER TIGHT SEALS GAS- ` TIGHTi + A SEAL + APPROVED 4 11 d ream' _� ; ALM JOINTS W/ CI r�g't0 ly g ' PIPE 3 ' ONTO CI PIPE 3' ONTO -B ON SOLID SOIL SOLID C 1 ' RISER EXIT SOIL PUMP OFF EGEV • SS FT. —&- "- - O PERMITTED ONLY D IF.TANK MANUFACTURER HAS APPROVAL 3++ APPROVED BEDDING UNDER TANK CONCRETE PAD SPE CIFI CAT IONS SEPTIC 1 DOSE nn��� , TANK MANUFACTURER: lV NUMBER 'DOSES PER DAY: S _ TANK SIZES: SEPTIC oo GAL. DOSE VOLUME FLOWHACK 9� GAL. DOSE - Cam-° GAL. . p7, GAL. ALARM MANUFACTURER: CAPACITIES: A = Id,3� INCHES MODEL NUMBER: B 2 INCHES = 33.1 GAL. SWITCH TYPE: ' � C = ( i INCHES = �a� GAL PUMP MANUFACTURER: MODEL NUMBER: D = INCHES GAL SWITCH TYPE: REQUIRED DISCHARGE RATE -53 GPM PUMP & ALARM WIRING AS PER ILHR 16.23 WAS /U•1 FEET VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE _-- -5 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . • • • . ' 't ' •_ FEET + �_ FEET FORCEMAIN X /�9 FT/ FACTOR FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH + DIAMETER LIQUID DEPTH .36 �10 , ?6 d �-a 0 S3 e• a f: . + . 44J 1 11' Y •r. .t .I• ..e - 1 1 i t+ +. ;.• ! 1 't !. it '. 't . e \ � . i.,'. 't �'" 1 Y 1 : i � 1 1'.' all .. /..: \• 1/ rt e, a yr t I; rWOMEN Jwallows #ww #isi #i #i!liii •a ;,a #iiii ## laia�fl��7i I, Via. ir�i # #i� ii •!� : w �:::::::::� ■ :::::: no #sisww si w r:•w##www�rl ■ss �ww■ wwwi�r► ss �.i�■rwww#!!#swlsai ' N ►!Mxb"wii #iNilir■ I+ Ch i #iii�►ilir #� #►!! # #iiiliii! Zl . �arCisQq i #i�ra i ,sswliss##siw# on aaimom####isws! L -: \�#ii��ili ►�islwii:�iiwi#iwiii "iNai;\!w#ia""vokRazow l il►ii #i!w #! ►, ii ■. ■..awi.;i �•�i ##wwaiiar#iw iylMEown #il�i'.�riiifi. ili►!�swi► #isii t" �IwNiZ"l !wwi "O iww" ii ! ►qiiwiw! ' '" ' ��rw ## .�iiCw��liir• = #il►isia�iiili r . " P* -'s �` "����►`�,�. iiilifi \►�i� iiiwqo! #•iws! ii i��ir���� '�l►iiii�.7i�i!!i \! ►tiiAw 1 z t #il ii lw #wi�.���� #ii►�i�;liw #li�iiii • , .a , is #i #s # #ii #!�i#i#i�wliQ#!!wi #ss#w • a � Safety and Buildings Division County '}� 201 W. Washington Ave., P.O. Box 7162 i seonsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 2 S3'0G0 Sanitary Permit Applicatio tale I D umber In accord with Comm 83.21, Wis. Adm. Code, personal information ou provide may be used for secondary purposes Privacy Law, s15.04(1 m) MAR 2 � n , Prof dress ( different than mailing address) 1. Application Information - Please Print All Information ✓ l 0 R Prope Owner's Na me - _- _,_ _ ;; # Lot # Block /( r _ , AJ Pr operty Pro Owner's M ailing Address gym' Location l T � u - J C' u, - S - E �'A,Section S City, S e Zip Code Phone Number � � �.) � (circle 5 "'ti, ST - t� T � N; RE or U. Type of Building (check all that apply) 5 Subdivision Name CSM umber X1 or 2 Family Dwelling - Number of Bedrooms s `j 0 Y 13 of El Public/Commercial - Describe Use ! ` ( 3 A. El State Owned - Describe Use ❑City_ ❑Village gTownship of r� 1 Pv M. Type of Permit: (Check only one box on line Coffqlete line B if app ' ble) A. New System ❑ Replacement System ❑ Treatme olding Tank R lacement Only ❑ O odification to Existing B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Per 't Transfer to New Lis rev us Permit u ate Issued Before Expiration Plumber Owne IV. Type of P OWTS System: (Check all that a 1 ) Non - Pressurized In- Ground El Mound > 24 in. of suitable soil ❑ Mou 24 in. of suitable soil At- Grade El Single Pass Sand Filter Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ t Fi r ❑ Aerobic reatment iL it El Recirculating Sand Filter E eMr ❑ Recirculating Synthetic Media Filter 11 Leaching Chamber El Drip Line G vel-less Pipe U Other (expla n) V. Dispe rsall'IYeatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) I Dispersal Area uired (sf) ispersal Area Proposed (sf) System Elevation L go !� 9S JO wo $7 VI. Tank Info Capacity in Total Number anu icturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units 601 to QC�I Concrete Constructed Glass New Existing 1 / Tanks Tanks Septi r Holding Tank _ co (� � _ �rS Aerobic Treatment Unit C► Dosing Chamber VII. Responsibility Statement- I, the undersigned, responsibitit for ' n of the POWTS shown on the attached plans. ( 'nt) Plumber's Si lure MP Number Business Phone Number � tier's Na 7 IS a (Q Si3.S Plumber's Addre ss (Street, City, State, Zip Code) L s - f� N' S 4 VIII. County/Department Use Onl Approved Disapproved Sanitary Permit Ft ludes Groundwater Date Issued I sui Agent Signatur o Stamps) Surcharge Fee) 2 r -g1 O3/ p ❑ Owner iven Reason for Denial IX. Conditions pprovag val SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All 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 81/2 x 11 inches in size l�TT I/1Itf1 /T I1� Il�1♦ A) IE Y-� ssi P,�- v e. S LOT � 8' C S w�, 70 k( 2 3 y %i- t, S't L"-k ,I) N Ss07 r r -e /S 7'C ' %X IV aSt S.�:C, /(.cJi`PSF�s�i� -tom. It �gd��`f 3 , e v� �. s to z�- 7 et�yr`e -'eC� Cl�'3C� C� ID Cft O P I 3' h S)' . ZIA ,11'1 N SS I `� may_ // {.� �ne�i- �rQ O � —lca+ � _,� L� _ • 3 , r��: {VO fi C S C, /(�(1�'e-s 3 T S: t 0 °rr • 's' F-\ toe A 4 1562 F Wisconsin Department of Commerce SOIL EVALUATION REPORT page t of 4 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code AC.E. Sal & Site Evaluations • Attach complete site plan on paper not less than 8' %x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 042 - 1012 -80 -300 Please print all information. B D Personal information you provide may be for sr® 5.04 (1) (m)). 3/ 0 Property Owner F � roperty Location White Pine, Inc. - H. Fo elber ovt. Lot NE 1/4 SE 114 S 5 T 29 N R 18 W Property Owner's Mailing Address ` of # Block # Subd. Name or CSM# P.O. Box 504 "A Proos 4 Lot CSM City State Cod�Qe City Village Town Nearest Road Hudson WI 1 54016 7 - Warren 115Th Ave. New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 2j Replacement Public or commercial - Describe: Parent material Glacial Till _ Flood plain elevation, 9 applicable na General comments and recommendations: Evaluation completed to facilitate creation of 4 lot CSM from existing lot 5, CSM vol. 13, Pg. 3768. Install 3 trenches using 49 leaching chambers at elev. = 95.10'. q F Boring # A Boring Pit Ground Surface elm 98.66 ft. Depth to limiting factor >93" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' *Eff#1 *Eff#2 1 0 -16 10yr4/2 none sl 2fcr mvfr as 2fm,lc 0.5 0.9 ,& 2 16 -23 10yr5/4 none sil 2msbk mvfr cs 2fm 0.5 0.8 3 23 -39 7.5yr4/6 none sl 2msbk mfr cw 1f 0.5 0.9 , (P 4 3949 7.5yr4/6 none Is 1 msbk mvfr cw 1 f 0.7 1.2 , } 5 49 -93 7.5yr4/4 none sl 2msbk mfr - - 0.5 0.9 ( F-1 Boring # ,,A Boring Pit Ground Surface elev. 99.71 ft. Depth to limiting factor _ >92" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKP *Eff#1 *Eff#2 1 0 -9 10yr4/2 none sit 2fcr mvfr as 2fm,1c 0.5 0.8 , ( 2 9 -21 10yr5/4 none sl 2msbk mvfr cs 2fm 0.5 0.9 3 2140 7.5yr4/4 none sl 1 &2msbk mfr cw 1f,vf 0.4 0.6 4 40 -92 10yr5/4 none Ifs 1 msbk mvfr - - 0.4 0.6 , sS3z 9l 3Z Horizon #4 " bands of 7.5yr4/4 1msbk sl at 8" - 20" intervals. * Effluent #1 = BOD 5 > 30 < 220 mg/L and TS >30 < 150 #2 = BOD -S mg/L and TSS <30 mg/L CST Name (Please Print) S nature: CST Number James K. Thompson 3602 Address A.C.E. Sal & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceda, WI 20 6/14/02 715- 248 -7767 Property Owner White Pine, Inc. - H. Fogelberg Parcel ID # 042 - 1012 -80 -300 Page 2 of 4 3 Boring # Boring a� Pit Ground Surface elev. 97.41 ft. Depth to limiting factor 68" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM *Eff#1 *Eff#2 1 0 -16 10yr3/3 none Ifs 1 msbk mvfr cs 2fm,1 c 0.4 0.6 , S 2 16 -28 1Oyr4/4 none sl 2msbk mvfr gw 2fm 0.5 0.9 3 28-40 10yr4/6 none sl 2msbk mfr cw 1f 0.5 0.9 •� 4 40-68 1Oyr5 /6 none Ifs 1msbk mvfr cw 1f,vf 0.4 0.6 rj 5 68 -76 10yr5 /6 m2d 7.5yr5/8 ffs 1 msbk mvfr cw 1 f,vf 0.4 0.6 -- 6 76 -85 7.5yr4/4 f2d 7.5yr5/8 scl 1 csbk mfi - - 0.2 0.3 4] Boring # Boring Pit Ground Surface elev. _ 97.13 ft. Depth to limiting factor >95" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 2 - *Eff#1 *Eff#2 1 0 -10 1Oyr4/2 none sil 2fcr mvfr as 2fm,1c 0.5 0.8 �e 2 10 -36 7.5yr4/4 none scl 2msbk mvfr cs 2fm 0.4 0.6 3 36 -50 7.5yr4 /6 n sl 1 &2msbk mfr cw if 0.4 0.6 • 4 4 50 -95 7.5yr4/4 none sl 1 msbk mfi - - 0.4 0.6 `f F -sl Boring # Boring 9 Pit Ground Surface elev. 96.96 ft. Depth to limiting factor 72" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW *Eff#1 *Eff#2 1 0 -20 1 Oyr4 /2 none sil 2fcr mvfr as 2fm,1 c 0.5 0.8 , tp 2 20 -28 1Oyr5 /4 none sil 2msbk mvfr cs 2fm 0.5 0.8 , to 3 28-45 1Oyr4/4 none sl 2msbk mfr cw If 0.5 0.9 b 4 45 -72 7.5yr4/6 none Is 1 msb mv fr cw 1 f 0.7 1.2 , 5 72 -97 7.5yr4/6 f2d 7.5yr5/8 Ifs 1 msbk mvfr - - 0.4 0.6 Horizon #4 contains 1" - 2" bands of I Oyr4 /4 Om Ifs at 6" -16" intervals. Effluent #1 = BOD 5 > 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. SOIL AND SITE EVALUATION 1562 Page 4 / of 4 PROPERTY OWNER: white Pine, Inc. - H. Fogelberg PARCEL I.D.# 042 - 1012 -80 -300 A.C.E. Soil & Site Evaluations REPORT MEMO Lot lines not established at time of soil evaluation. Additional soil testing may be required after parcel creation to accomodate lot line locations. Dense tree cover limits ability to explore soil conditions throughout parcel. Further exploration after lot lines, building site, driveway, etc. are established may reveal more suitable system area. t C /edQo� Cki�s;6•n 4emce1;tc QpPr�• � mop• /; �e /,o 'A "o�prcpeserl // C SF St . S T CrpiX head;ly W�d�d 5;tc rla; I n Box t) le• &ee . o y 97.0 ConL�occ / o� � SyxI ■ Sl got ■ B3 ry `'!'� q4. AssumtJ a Ie&� _ /OO. Co re p penc Ld e 8.2- I eas'i / cJQkle d Al ckr� n Z; ► EZ1203H • r ! f r. sir S `, �/ \�F + + � � r +► 1 2 1 !! r r y RR ! T• •mi +��E, • +•R 112 Cam. a 18.84.. fr !! 1 f�lw!! !!! r•�f RRf - -24^ 36 U.Q.0(4- PrY ter R • a r a - } : 31-±� SMk% ft (2 Ifla d$ a >c (2S ,ncges B ottom reaya c?E a 3.r1. a�tsa Tow Sk � Iwter(ae+c A _'.ttLl p J �. r—:;.� }' 1. �r. t mm ar6n�ay,. t ,,� 4 1 z.,t� 422 W S. #4 Coo, f j Area t3 ; • . a r. _ 401 Fr °1�ttei! 7 x tyeera { kcal „Vium. a S' S►it( � ►ore cran.sers :ewe 12 m..3 Z Sa f 4 psa ' t.12*, 6 1 ` p.. s rr 36 rR } QA $ F Tow, �esn "°�"� !!!f F rslaried Trg E �wnc Area •. � 6 17 r 0.42X . 4 "➢Q 1 ,. &215 . bawcew LY�cesl Y_Z w s�.FL vcr It - 1.763 0, too = r ' h f k f i t X r© �-C, T're c h 9 S re9 Qr Ys tem E71203H f -- -- 060 ! f RX ,"'fin Gti�t r POWTS OWNER'S MANUAL & MANAGEMENT PLAN page —L of SYSTEIIII sPEdf�cATaas Owner y 1 Q i `� Tank Manufa+cturer W . -, S ❑ NA Permit # 4. Septic 0 Dose ❑ HoWina vol. 10 gal DESM PARAMETERS Tank Man ufau tum NA Nub of Bedrooms 0 NA 0 Septic 0 Dose O Holfing vol. gal Number of Public FacW" Units NA Effluent Filter Manufacturer 0 t v et 0 NA Esrdnted (average) flow 300 Effluent Fier Model * f Design (peak) flow a (Estimated x 1.5) 41 S Z M Pump Manufacturer 1j8 NA Say Application Rate „ Pump Modal Standatcd Qty Monthly awe' Pretreatment Unit CIA Fats. 00 lk Grease (FOG) 530 mg/L O SwKVGmvel Filter 0 Pest F:Rtw &ochernical Oxygen Demand (SOD 5220 mgA. ❑ NA ❑ Mechanical Aeration O wetland Total Suspended Solids (TSS) st 6 0 nmg/L © Disinfection 0 Other l3istreated Mused Quality Monthly average Manufacturer Biocherr" oxygen Demand (SOD !r.30 mg/L Dispersal cents) ❑ NA Total Suspended Solids 17=1 530 mg/L 0 NA pCin- Ground ( y) o In-Ground Wessurized) Fecal Coutorm (geometric mean) 510 cfu/1OOrrml 0 At- Grade ❑ Mound Maximum Effluent Particle Size Y in dia. ❑ NA 0 Drip -Lipe 0 Other: Other 0 NA Other. ❑ NA *values typical for dorrmastic wastewater and septic tank effluent. Other. O NA MAfNTENANCE SCHEDULE Sage Event Service FrequemY 7 is) � 3 years) ❑ NA Inspect condition of tarmk(s) At feast once every: s) �� Pump out contents of tankts) corrmblmed sludge and scum eons one -third (V of tank volume 0 NA 0 When the high water alarm is activated Inspect dispersal Ceuta) At least once every: morth(s) (illlatouhrnrrtn 3 years) ❑ NA j Clean effluent filter At (east once aw am�extit (s} ❑ Na every- e 11 mcorrth(s) ❑ NA Inspect purr, pump controls & alarm At West once every: 0 } Flush laterals and pressure test At least once every, 13 ❑ NA Other: O manth(s) 0 NA At least once every: 0 vear{a} DNA MANTENANCE VASTRIXTIONS Inspections of tanks and dspersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer, Septage sarvic ing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of cwmtAned sludge and scum and a check for any back user or parnckng of effluent on the ground surface. The dispersal cag(s1 shall be visually meted to check the effluent levels in the observation pipes and to check for any ponding of effluent on the Wound surface_ The pond`mg of effluent on the ground surface may indicate a falling condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scrum in any treatment tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Saptage servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of affluent filters, mechanical or pressurized components, pretreatmen units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (21G2) R START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the Presence of painting produce, solvents or other cteet"icals that may impede the treatment prom andlor have tha contents of the tankts} removed by a damag the sod o to us l call( If } concentrations are detected a�vicir>e operator prior' to use. System start UP shall not occur when soil conditions aria Munn at the infiltrative surface. During extended power Outages pump tar" may fdl above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispargat ells) to one laMe dose and may overload them resulting in the age of efflient. To avoid this situation have the contents of the pump tank removed by a discharge or surfae to restoring Power to the affluent intg Operator prior controls to restore normal levels within the pump tanks Plsatrbst or POWTS Maintainer to assist Sept S"c in manually operating the pump Do not drive or park vehicles over tanks and dispersal Oafs. Do, not drive or park over, or otherwise disturb or compact, the area within 16 feet down slope of any mound or at -grade sod absorption area. Reduction or elimination i s; cigarette from the wastewater stream "my may improve the Performance and Prolong the rife of the foundation tins: baby y wipes; wtta butts (sump p�Pl discharge; fruit and ; condortaa; cotton swabs: degreasers; dental floss; diapers disinfectants; tat; Painting / Products, Pesticides: sanitary napkins; tampons; and water e. herbicides; unrest scraps: medications; oil; ABANDONMENT When the S few and/or is Permanently taken out of service the following steps shad be taken to insure that the system is property and safety abandoned in conwhauce with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shad be disconnected and the abandoned pipe openings seated_ • The contents of an tanks and pits shad be removed and properly disposed of by a Septage Servicing Operator. • After pumping ad tanks and pits shad be excavated and removed or their covers removed and the void space filled with sod, graved or anther inert solid material. CONTINGENCY PLAN N the POWTS fails and cannot be repaired the fodowaeg measures have been, or must be takers, to provide a code compliant anent system: A suitable replacement area has been evaluated and may be utilized for the location of a sy stem. The replacermant area should be protected from disturbance and replacement be soil absorption axiatlng and proPosed Structure, 10 &M and wells. cornupactioe, and shoed not 6s infringed upon by refit in Oe need for a new and evaluation tom a suitable FORM to Protect the replacement area will area. Replacement systems must comply with the ndes in effect at that time. ❑ A suitable replacement area Is not available due to setback anchor soil !imitations. Baring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a Suitable mPWc wrmM area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soli absorption systems may be reconstructed in place fallowing removal of the biomat at the infiltrative surface. Reed of such systems must comply with the rules in effect at that time. < < WARNING > > SBMC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC. PUNT' OR OTHER TREATMENT TANK UNDER ANY CNKM'STANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY 13E DIFFICULT OR MWOSSMLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS NEAI Noma Name Phi t s Sl. Phone . SEPTAGE SERVICING OPERATOR {PUMPER! LOCAL REGULATORY AUTHORITY Name Name S`� C_ro ; n ; h Prom 7 i S 3 Phone This docurseent was drafted by ire staffs of the Green Lake. Marquette and Wauallare CountV Zeroing and Sanitation ages in compliance with meter Comm 83 . 22 t211bit11ldl &tfI and 83. 540). t2i & (3 ), Wisconsin Administrative Code. ti ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L -% N A-- kc" 71l c Mailing Address 14, f" A v;z - . S. 5 73 .. rAu L; A6.1 5 507E' Property Address Xkk 1 O S7^ 46tz'VI-S W (Verification required from Planning Department for new construction) City /State _x3 9 W/ Parcel Identification Number ®��- �o C Z LEGAL DESCRIPTION Property Location A/C'- %4, 5 f '/4, Sec. . T l N -R /8" W, Town of d Subdivision C— S M Lot # Certified Survey Map # �� , Volume ` (° , Page # . Warranty Deed # �� I q-7 -L, . Volume 215 7 . Page # Q Spec house ❑ yes Xno Lot lines identifiable )Kyes ❑ 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 master plumber, journeyman pl*nber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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. 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 Zoning Office within 30 days of the three year eispiration date. SIGNATURE OF APPLICANT Cy 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 p escribe ve, y virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLIC 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 J 2 15 7 P 0 1 7 - 7 1 1 4 -7 2 STATE BAR OF WISCONSIN FORM 2 - 1999 REGIST O DEEDS • Document Number WARRANTY DEED ST. CROIXCO. , WI RECEIVED FOR RECORD This Deed, made between White Pine, Inc., a Wisconsin 02/27/2003 103:00P11 Corporation -- _ -_- — EXEMPT # Grantor, and Allen S. McKenzie and Lori L. McKenzie, husband and REC FEE: 11.00 TRANS FEE: 189.00 wife - — COPY FEE: CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area g f Certified Survey Map filed January 7, 2003 in Volume 16 of Name and Return Address Survey Maps, Page 443 8, as Document No. 704934 located in the Edina Realty Title Northeast '/4 of the Southeast '/4 of the Southeast '/4 of Section 5, Township 400 S. 2nd St., #115 29 North, Range 18 West, Town of Warren, being also a part of Lot 5 of that Hudson, WI 54016 Certified Survey Map filed in Volume 13, Page 3768, St. Croix County, Wisconsin. Metro Legal Services EDIRET 382817 A 042- 1012 -80 -300 242922 L\`D 17i X033 Parcel Identification Number (PIN) This is n homestead property. (9) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this 1 q * day of February 2003 White Pine, Inc. fir, AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) p ) ss. j County ) authenticated this day of _ ,A� - •�+"''"" ^"` .::_uOFlA Personalty came before me this _ day of Notary Public February 2003 the above named :ilatn o f WiSCOnsn White Pine, Inc., a Wisconsin Corporation by TITLE: MEMBER STATE BAR OF WISCONSIN its (If not, to me known to be the person(s) who executed the foregoing instrum nt and acknowledged the s e. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY A ttorney Kristina Ogland Notary Public, State of isco in Hudson, WI 54016 My Commiss'on 's maner . (I t, stat expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) * Names of persons signing in any capacity must be typed or printed below their signature. Inrormation ?roresslonais company, Fond du Lac, vm STATE BAR OF WISCONSIN 800655 -2021 WARRANTY DEED FORM No. 2 - 1999 CONCEPT PLAN FOR HANK I LOCATED IN THE NE 1/4 OF THE' SF 1/4 OF SECTION 5, T29N,R 18W, TOWN OF WARRE ST. CROIX COUNTY, WISCONSIN, BEING PART OF LOT 5 OF CERTIFIED SURVEY MAP FILED IN VOLUME; 13, PAGE 3768. ( LANDS ARE OWNED BY LOUIE ROLF AS OF 06 /04/02 ). --------- - - - - -- I I I �y` vq I - I I � I I I I I � doe , q 2.090 ACRES 2.126 ACRES (- 2.613 ACRF9 J -i _ -- -- 2.269 A 1 C � 2.579 ACREt J 2.001 A(Tf.9 2.219 ACRES APPRO V 70 4934 :;T. 0101•. Ci r VOLA-6 PAGE 4438 Plirro•,n 7— RE. H. ISTER DEE _ ST. CROIX CO. WI IAN U 7 2001 RECEIVED FOR ECORD 01/07/2003 02:00PH REC FEE: 17.00 COPY FEE: 5.00 CERTIFIED SURVEY MAP z LOCATED IN THE NE1 /4 OF THE SEI /4 OF SECTION 5. T29N.R18W, TOWN OF �+ WARREN, ST. CROIX COUNTY. WISCONSIN. ALSO BEING PART OF LOT 5 OF w i T HAT CERTIFIED SURVEY MAP FILED IN VOLUME 13. PAGE 3768 IN THE ina ST. CROIX TY COUN REGISTER OF DEEDS. cn LEGEND M / SUBDIVIDER ° - INDICATES SECTION CORNER MONUMENT HANK FOGELBERG ~ ( AS NOTED) 308 MIDDLE PINE COURT tU - INDICATES i' OUTSIDE DIAMETER IRON STAR PRAIRIE. WI. 54026 PIPE FOUND. nn I¢ - INDICATES I X IS ( OUTSIDE DIAMETER ) IRON w J P IPE WEIGHING 1.13 LBS. / LINEAR FOOT SET. (R) - INDICATES PREVIOUSLY RECORDED INFORMATION. _N_ icnp T CORNWE 0 . �'• - INDICATES 50' BUILDING SETBACK LINE FROM ,+p RIGHT -OF -WAY. E1/4 CORNER SECTION 5 C u o o D LANDS EAST -WEST 114 SECTION LINE ( 1' IRON P FOUND ) I 8, m (OUTSIDE IAMETER ) °�^ z 7 .00' _ R._ N90 00 '00 E 5 Lu oW 00 L15THAVENUE cr tn° i R ) LOT 1 OF I �'"° WS /4 TION 5 om I CERTIFIED I z � (ESTABLISHED FROM 40' mg ) 5vuu) TIES OF RECORD ) S97° . w ) SUTt�/EY MAP I I m - ZA . iv to 7.OJ • I TVOL 8, PG. 232_4.1 I� I 33' u i TOWELLING I CO) ° � I L 1 IO o . pp _ �Iwl °. o e PARCEL DESCRIBED 0 i 1 oQ.1 w I >�' LLI 101 V, m IN VOLUME 1908 f- c�I I �'- O Q PAGE 85 -86. I Olw'w Q I °'� a — - -- I — o c9 �I I o 4i. LL m I w 0 b' OL ; 2 - A I V >I I WCK) J OWELLD G 9 N ° 7 4 0OI \ 2 155.17' w I vat 1E NOTE FOR CURVE , ° 2 m fn =� a.+y INFORMATION SEE o SHEET 3 OF 4. r, $o i o�w6 N89 720.00' ORIVERAY: N w , to (R N89 °59'47 E) I 9 "w n � oruvEWA 1489° 59'4�'E •j z ¢ a 560.00' 60.00 �I 220.61' in `IT0- LOT 7 W � S CO N N o$ r- y 92.609 SQUARE FEET LOT 4 : z 33 ( 2.126 ACRES ) u 111 F r ' 605 SQUARE FEET 90. * If l HJi * o N GA, s ('2.080 ACRES ) S7 ° 04 pLW fp :Hb'iO:JU [ co 7 22'12 E m �1I 37 4.77• L] I IV N e U z 3 S s 7 °zB'oi w �O LOT vI In NOTE THE LOTS SHOWN OX 5 -a 98� 2265 ACRES T § al HEREON ARE SUBJECT TO (n A 1Y' WIDE UTILITY 5 -8 $ jl EASEMENT ADJACENT TO ry AND PARALLEL TO THE RIGHT- OF -WAY Ta LINES OF 109tH STREET. QAL, LOT 10 0 ( SEE SHEET 2 OF 4 1 PREPARED BY: g o SCALE IN FEET 1" ,150' FiRANBER6 51,RVEYIN6 ° n 1239 C.T.H. "E' O 75' 150 300' NEW RICHMOND. WI. 54017 PHONE ( 715 ) 246 -7529 THIS INSTRUMENT DRAFTED BY: JOSEPH W. GRANBERG JOB NO. 02 -030 SHEET 1 OF 4 Vol. 16 Page 4438 I