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HomeMy WebLinkAbout004-1034-90-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488277 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: I Personal . informat on you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Ht Name: City Village X Township Parcel Tax No: Montbriand, Daniel Cady, Town of 004 - 1034 -90 -200 CST BM Elev: Insp. BM Elev: Description: Section/Town /Range /Map No: BM /pd 6 ' I CST 15.28.15.233A20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER 9 41 , AIS CAPACITY STATION BS HI I FS ELEV. Septic T^ 6 / Benchmark . g / Z 5 0 0'. co /00. ( goo Dosing Alt. BM Go,�t�o v, 50 cow 7. 72- 7 z . gs Aeration Bldg. Sewer 11 o ding V St/Ht Inlet TANK SETBACK INFORMATION S t/Ht Outlet TANK TO P/L WELL BLDG. V ent o it Intake ROAD D Inl et ep is �A 15 J / 'k 6 , B ottom 76—sing /6j ea er an. era U on D ist. Pipe o mg Bo t. System Z. - 17 4 17, g3 F inal ur a a � .�ca � � 9 Z I sp PUMP /SIPHON INFORMATION CYC 04 1 m anufacturer ` D emand over &� G 7 7 9 -S l� Gov w o e um er 41.s I UM 11-In I�� 1 9Z nc lon o s ys em ea Z5 75 J r 5 I n - I Le ngi n � � I . Z N J U151 . DIMENSIONS /a (06 Qc INFORMATION CHAMBER OR 7S " IJ UNIT O ' L V } -- it i Jj /, Length 7 / Dia i L Length 6 " 7 Dia t ' Z Spacing x Pressure Systems Only xx Mound Or At - Grade Systems Only Bed/Trench Center Bed/Trench Edges Topsoil Yes I; j No Yes l_ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /b / n Inspection #2: / Location: 3027 County Road N Unknown (SW 1/4 NW 1/4 15 T28N R15W) NA Lot 3 Gk Parcel No: 15.28.15.233A20 PlMpbC 1.) Alt BM Description= � r 1 2.) Bldg sewer length = 4, - amount of cover Plan revision Required? I Yes No Use other side for additional Information. -- Insepcto gnature - -- - SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ST. CROIX consin Madison, W1 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 'y" 277 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you p i e TRANS. ID # 1188552 may be used for secondary purposes Privacy Law, s15.04(lX Project Address (if di dif than mailing add � ( I. Application Information — Please nt All Information A Z C Property Owner's Name Parcel # Lot # 3 Block # DANIEL P. MONTBRIAND 004- 1034 -90 -200 Property Owner's Mailing Address Property Location 1086 SCOTT ROAD TY S W NW 15 City, State Zip ode Phone Number ' /a, ' / <, Section q HUDSON WI 54 - 02 28 159 1circleone) II. Type of Building (check all that apply) T N; R r f Q 1 or 2 Family Dwelling - Number of Bedrooms /f ay .yQ 101 C,..`, Subdivision Name CSM Number Public/Commercial - Describe Use 806543 ❑ State Owned - Desc //I Au ( []City ❑Village Orownship of CADY III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. 0 New System ys ❑Replacement System ❑ Treatment/Holding Tank Replacement Only 11 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) (� ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil 0 Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground El Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line Q Gravel -less Pipe ❑ Other (explain) 4 ,� ; •r 9 V. I is ersaVTreatment Area Information: Design Flow (gpd) Design Soi7Appfi cat' ate(gpdsf) Dispersal Area R aired (sf) Dispersal Area Pr osed (sf) System Elevation 600 1 t� 600 ZpC) 600 o0 98.13 •� VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing aJ n /"6 �1 Tanks Tanks A✓ 14 �ac+L. . /"6 Septic or Holding Tank 1250 1250 1 Wieser Concrete x Aerobic Treatment Unit Dosing Chamber 750 1 750 1 1 1 Wieser Concrete X VII. Responsibility Statement- I, the undersigned, assume responsi ility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum s Signature I MP/MPRS Number Business Phone Number Bennie Helgeson 0292 715/772 -3278 Plumber's Address (Street, City, State, Zip Code) W1229 770th Avenue, Spring Valley, WI 54767 VIII. Coun /De artment Use Onl Approved ❑ Sanitary Permit Fee (includes Groundwater Date Issu Issuin gent Si to (No Sts s) ❑ Z Surcharge Fee) O ` �� �' / bfp Iff Reason or ial ' IX. Conditions of Approval/Reasons for Disapproval fYS<TEII{O�NIfIEIl: 1. Septic tank, effluent finer and dispersal cell must all be services / maintained as per management plan provided by plumber. 2. AN seback requirements must be maintained as pK appiic" nods / ordirWnces. Attach complete plans (to the County only) for the system on paper not less than 81R x 11 inches in size SBD -6398 (R. 01/03) �I(,a.w\ �enE, 'Pif14� l k, At cl G \ o /� b ,sef�(c pi(,) - Plat,— i a F � To AF io d �/ 14 '�} f3ecx F1d�n� l7Qha Safety and Buildings RECEIVED 4003 N KINNEY COULEE RD cornmerce.wi.gov LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 It lsconsin JUL 1 2 2006 www.commerce.wi.gov /sb/ epartment of Commerce www.wisconsin.gov ST. CROIX COUNTY Jim Doyle, Governor Mary P. Burke, Secretary August 25, 2005 CUST ID No. 220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/25/2007 Identificat Numbers Transaction ID No. 1188552 SITE: i 1 Site ID No. 703503 Wifim Seiffm 1: ay1 e� fwe� ►? r t a K d Please refer to both identification numbers, Town of Cady 1, above,; in all corres ondence with the agenc St Croix County SWIA, NW1 /4,, S15, T28N, R15W Lot: 3, FOR: Description: Four Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1035646 Maintenance required; 450 GPD Flow rate; 17 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual, SBD- 10572 -P (R.6/99), Pressure Distribution Component Manual, SBD - 10573 -P (R.6/99); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 14 5.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD- 10572 -P (8.6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" SBD - 10573 -P (R.6/99). • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. Condit • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c A D ARTMENTI • A Sanitary Permit must be obtained from the county where this project is located in accordance with the N OF FT) requirements of Sec. 145.135 and 145.19, Wis. Stats.�� SEE CORRE� • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat w BENNIE W HELGESON Page 2 8/25/2005 • Comm 83.22(7) A copy of the approved plans specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00. Charles L Bratz J POWTS Reviewer II, Integrated Services WiSMART code: 7633 (608)789-7893, 7:45 am - 4:30 pm Monday - Friday cbratz@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 INDEX SHEET PROPERTY OWNER: WILLARD SEIFFERT 508 BAUER ROAD HUDSON, WI 54016 PROJECT NAME: WILLARD SEUTERT PROJECT LOCATION: PART OF THE SW 1/4, NW 1/4, AND PART OF SE 1/4, NW 1/4, S 15,T28N,R15 W MUNICIPALITY: TOWN OF CADY COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD- 10573- P(R/99) MOUND COMPONENT MANUAL SBD - 10572 -P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section and Specifications Page 5: W1250 /750 -MR Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Sign Address: W1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: August 16, 2005 ? %F Cc y" CE LDINGS 3PO,NQEWC rage 12U Synthetic Covering Distribution Pipe ASTN? C 33 Medium Sand - N G - - - - --- ��-- F Topsoil o 10 E 3 d Conk V. �• S 7 % Slope Plowed C EA-1-G f z "_ 2 2 Force Main From Pump Loyer Aggregate D 1 ,58 Ft. E Ft. Cross Section Of A Mound F s � Ft. G , S Ft . A j_�L Ft. H l Ft. Signed: a Ft. K �t. License Number: L Ft. Date: j •7.3 Ft. T /S' Ft. W 3 Ft. L — _- Observation Pipe � K FA g )/ - -�'- ------------------- - - - - -- j Distribution Et_>r Of i — 2 2 Pipe Aggregate I 1500 Observation Pipe (3a-sc, Arec,- Plan View Of Mound PerforoleQ P lp• pnloll P, I End Vlaw Porloroito (' ' PVC Pipt lvCtlll ru � Holes Located on Bottom are Equally Spaced R oiclrlbullon..• Plpr I Distribution Pipe Layout P .� 9" x -YIL� S 7_ Y — Hole Diameter Inch Signed: •• Lateral " Inch (es) License Number: Manifold ",,, Inches Date: Force Main " Inches �ML�E t �teo. 9 9 T67�-/ 14ol -s �b� Page ( 4 0f 8 SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" .PUC_VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHERPROOF JUNCTION BOX APPROVED >_ 25' FROM DOOR, WINDOW OR FRESH AIR INTAKE WITH CONDUIT wl PpADLLOCKV6R WARNING LABEL MIN. 18" IN. INLET WATER TIGHT SEALS GAS- T TIGHT i �� VAPPROVED FILTER — A SEAL t JOINTS WITH � $�� _}__ ALM APPROVED PIPE Z APPROVED a -1- B pN 3' ONTO PIPE 3' I �— SOLID SOIL ONTO SOLID C ' SOIL PUMP OFF ELEV . g�j, . D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS 1 SEPTIC / DOSE I / (c X 5- — g (5-a TANK MANUFACTURER: rd)l�� r TANK SIZES: SEPTIC 1 SO GAL. DO /�. %3 &I ` BACKG X7,93 GAL. DOSE ALARM MANUFACTURER: 'sec- rte CAPACITIES: A = aS INCHES = Ya 3 GAL. MODEL NUMBER: LL B = 2 INCHES = Ja.D Y GAL. SWITCH TYPE: oc1 PUMP MANUFACTURER: C = INCHES = GAL. I C �• o I MODEL NUMBER: O �(_ D =, INCHES = GAL. SWITCH TYPE: 'r 1 REQUIRED DISCHARGE RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE q Q F EET FEET + FEET FORCEMAIN X 3.7 _ FTl100 FT. FEET INTERNAL DIMENSIONS OF PUMP TANK: L ENGTH WIDTH DIAMETER LIQUID 6��'F� _--5L2ZL- - f � f1eo5 -e- 5e-.e_ c Sties SIGNED: LICENSE NUMBER: DATE: 1/88 a � � I rulA p Z (LR ' U V) LLJ N U- w° _� ��` v w �� O I �c�a � F= Y a- M p �a LLJ F= V) Q I-- w� w <N oa\ I V m a Q _z z_ d l \\ a. p Y ° dN (n QQ CO = Nwx V °. m ° I -joN 0c� D l-J �, 3Wo af L=J O 0 U)t- �Q L 0,,7 O 0<p W A U) � N 0 F- _J r Q Q N� 1� 3 0 Q N '`� ,o..(or -i?� J w U JAN } Y N .. J co ao co — J .. F- o ff F Z w '� U Z ciiJ��mx� - omy o°i Q �I FA z - - WZ �ZpJ = p: Q coo d p pQOOaWW —wD Zdc9 co U c� N3mc�� =-�3mw a a z w z J J Q Q p OJ z Z J „£S w J = Z r-KV N I 1 •1 1 1 1 I 1 _ I I � I 5 I w S\ 1 ' ao w F N c N .9 1 I Z i aLCJ w J F— O N 98 OS „99 I X w TOTAL DYNAMIC HEAD /CAPACITY I • a HEAD CAPACITY CURVE 3 7/8 I 6 1/4 W 4 PER MINUTE I I L MODELS "140/4140" EFFLUENT AND DEWATERING 4 s/a Ft. Meters Gal. Ltrs. 14 5 1.52 91 344 ° ° 3 7/8 45 _� 10 3.05 84 318 + 0 15 4.57 76 288 0 12 40 40, 1 20 6.10 68 257 1 1/2 - It 1/2 NM 35 25 7.62 59 223 1Q 30 9.14 49 185 30 5 10.67 38 144 40 12.19 21 79 25 45 13.72 5 19 12 5/8 qy Lock Volve: 46' = 6 20 U 4 5/16 Q > 15 SK1524A O 4 _ a r o 10 2 3 7/8 I 8 1/4 5 .i 4 5/8 0 0 3 7 U.S. GALLONS 10 2OF 30 40 50 60 70 80 1 90 100 110 ° -L + LITERS 80 160 240 320 400 0 FLOW PER MINUTE 010904 ° 1 1/2 - II 1/2 NVT CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and supplied with 1613/32 an alarm. • Mechanical alternators, for duplex systems, are available with or without —� alarms. 4 5/16 • Control alarm systems are available for 1 phase pumps used in simplex —1 SK15248 system. See FM0732. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long cycle controls. SELECTION GUIDE • Sealed Qwik - Box available for outdoor installations. See FM1420. 1. Single piggyback variable level float switch or double piggyback variable level float • Over 130 °F. (54 °C.) special quotation required. switch. Refer to FM0477. • Refer to FM0806 for 200 F. applications. 2. Mechanical alternator M -Pak 10 -0072 or 10 -0075. 3. See FM0712 for correct model of Electrical Altemator E -Pak. 4. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) 140 Series - 53 lbs. 4140 Series - 73 lbs. or (4) float system. 14014140"" MODELS Control Selection Model Model Volts -Ph Mode Amps Simplex Duplex N140 N4140 115 1 Non 15.0 1 or 1 &5 2 or 3 & 4 E140 E4140 230 1 Non 7.5 1 or 1 & 5 2 or 3 & 4 A CAUTION BN140 BN41401 115 1 Non 15.5 1 art &5 2 or 3 & 4 All installation of controls, protection devices and wiring should be done by a qualified BE140 BE4140 1 230 1 Non 7.5 1 or 1 & 5 2 or 3 & 4 licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO. P.O. BOX 16347 Louisville, KY 40256-0347 Manufectums of. . SHIP TO. 3649 Cane Run Road o ® jj Louisville, KY 40211.1961 ) 9 11M, 4 9 S NCE �ffl http //www.zoeller.com P1/MP (502) 7 (502) 7 0 Copyright 2001 Zoeller Co. All rights reserved. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 FILE INFORMATION SYSTEM SPECIFICATIONS Owner S Septic Tank Capacity al O NA Permit # Septic Tank Manufactu(erWIESER CONCRETE O NA DESIGN PARAMETERS Effluent Filter ManufacturerZABEL O NA Number of Bedrooms 4 ❑ NA Effluent Filter ModelA -100 12" x 20" O NA Number of Public Facility Units CR NA Pump Tank Capacity 750 ga l O NA Estimated flow (average) 400 gal/day Pump Tank Manufacturer WIESER CONCRETE P NA Design flow (peak), (Estimated x 1.5) 600 gal/day Pump Manufacturer ZOELLER PU1IP CO O NA Soil Application Rate 0,5 gal/day/ft 2 Pump Model 140 O NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit EX NA Fats, Oil & Grease (FOG) 530 mg /L O Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L Ex NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L O Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) O NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L C NA ❑ At -Grade M Mound Fecal Coliform (geometric mean) 510` cfu /100ml O Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. O NA Other: O NA Other: O NA Other: 0 NA "Values typical for domestic wastewater and septic tank effluent. Other: O NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) O NA Inspect condition of tank(s) At least once every: 2 (2 ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume O NA O month(s) (Maximum 3 years) O NA Inspect dispersal cell(s) At least once every: 2 13 year(s) 13 month(s) 0 NA Clean effluent filter At least once every: 13 ❑ year(s) 12 month(s) O NA Inspect pump, pump controls & alarm At least once every: 13 O year(s) ❑ month(s) O NA Flush laterals and pressure test At least once every: 3 ER year(s) ❑ month(s) O NA Other: At least once every: ❑ year(s) Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal 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 Servicing Operator. 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 combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4 /Ot) f OWNER: WILLARD SEIFFERT Page 8 of 8 START UP AND OPERATION 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 ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space Filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code Compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by requ 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. ❑ The site has not been evaluated to identify a suitable replacement 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 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 Namej IiELGESON EXCAVATION INC Name JOHNSON SANITATION I Phone 1 715/772 -3278 -Phone 715/273 -5811 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name JOHNSON SANITATION Agency PIERCE COU Ty ZONING Phone 1 715 /273 -5811 Phone 715 /273 -6747 This document was drafted by the staffs of the Goan lake, Marquette and Waushara County Zoning and Saribil n ayenclo& Thy wmb the minimum requirements of eh. Comm 63.22(2)(b)(1)(d)d(0 and 83.54(1), (2) 6 (3). Wisconsin Adminlsliallm Code. Ua of Ihy doalaaeltdM ad guarantee the performance of" POWTS. "move /Ir w ©L'ri'�.l� .�►"i : C__ Imo►- ��11����r'�ii�� ' if MME M �® 28M M .. �. _ 1-. �. r Parcel io Page cc �Z - .3 Teetu�e Bav>�7f Routs Jim Haimon Depth SL Qr. Sz Sh 't�1 'E11�2 in .7 .d �d `✓ rd El Bof" $ 9 fr oep�t► to 9 � Pit c�rouwdsuf weiaw. 8mmfty Rotft Hamon t)ePw oanir�ant ttedoor Desaipion TO&" Sfn� Ca me 'r -EW a gin. , sz Cm* Color Gr. SL WL Bow* D Wks GW „ nam xleceeiev. _ L oepmbrofadw soll c Rate o„ fiools TetUUe 1 'E1fN2 Haixon Depth o� d Q. Sz Sh in. • EHktent q1 = BAD, > 30 < 220 m9n- and TSS >30 _< 150 mglt. • E15uem #2 =00[% < 30 mgA. and TSS < 30 rrglL ice provider and the The Department of Commerce is an equal opportunity sery enma`o311 e& t 8� services or need material in an alternate format. please Contact - seo -a�w�r Z Arf APO A pit A f z Fogerty Phsm6ing #221180 28288 McKenzie Rd. \ B _ Spconer, Wl 54802 x (715) .35 -9609 1� r� A op NprE : R -s ss L 33 ` A 0/ y . • /wei0 ,6th/ � X�-• i 9j'. /� lot bwe . Lm r- rK L�►T '� GoT 3 Lot" ti Jt K TN Fo ' gorty Plumbing & rerk Testing 28288 McKenzie Rd. Spooner, WI 54801 • � ..,.,mow., yr .,o.w� ................y.. RF/ � / in acco 85, Ms. Adm. Code County . Attach complete s plan on per of �}a 1/2x 11 in s in size. Plan must include. but not limi d a 'cal and horizo7ltrrE poi (BM), direction and Parcel I.D. �y 10 3 ��0 percent slope, scale Abm( T and lion nd distance to nearest road. @3S 2 ( co j do R ed b Date Personal infonnaffion you provide may be used for r (Privacy Lax'. s. 15.04 (1) (m))_ Property Owner p� Property Location Govt Lot 114 *W 114 S,_ T N R E (ot Property Owner's Matfiing Address i of # Stark # Subd. Name or CS4 A# 3 — city State . Zip Code Phone Number ❑ city ❑ Village RToxm Nearest Road (1i New Construction use: Residential / Number of bedrooms Code derived design flow rate 45',20 GPD [] Replacement ❑ Public or commercial - Describe: Parent material �ZG LD/�'� + Flood Plain elevation if applicable ft. General comments n r r V&v ,� 4 Yom° and recommendations: sera 7s. s r 7 &.0 ' ❑ ❑✓ pit Ground suffaoe elev. /� & Depth to uniting facts —=`-a— in' soil Applieaiion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E[f>f1 1 0#2 •/ l0 Vz — r S 2 L 3 " 1 , * - .7 _ 4 — i Borim # ❑ t3o Rtl © Pit Ground surface elev. 4 fL Depth lo Gnlift facto in. Snit Appliptiorr Rate ��Hororizort�� Depth Dominant Color Redox Description Textrae St ruc t ure Consistence Boundary Rots GPD/ft� in. Munsell . Qu. Sz. Cont. Color Gr. Sz. Sh. •Etf#1 'Etf#2 L AS M 2 O— •S 2 o S- 3 AM G AL ° Effluent #1 = BOD, > 30 < 220 mg/L and YSS >30 < 150 mglL vent #2 = BOD < 30 mg1L and TSS < 30 mg/L:" - 'Number • {Please Print) 4 2 ' to Evaluation Conducted Telephone Number Address Fogerty Plumbing & Perk Z sting 28288 McKenzie S P of S �+ - E��" Parcel ID # - Property Owner [� Boring Sod ication Rate ® 1 7 Boring # Pit Ground surfa 9 ft. Depth to limi6n9 factor ce elev. _ _— Roots GPDIfE Redox D Texture Strad •EW •Eff#2 Horizon Depth parpnant Gr. Sz Sh. in. Munsell Qu. Sz Cont. Color Ac A af , _7 Z .7 t O — a ..� —y M ❑ ALL— Boring # __ ft. Depth to lin ting factor — in. Soil Rate Pit Ground surface elev. _ Cortsf� Roots GPO/fg Redox DescrfPtrar Texture Strrtctttre •Elf #1 'Etf #2 Horizon Depth Dominant Color Gr. Sz. Sh- in. Munsell Qu. Sz. Cont. Color Boring # ❑ Bones Ground surface elev. Depth to limiting factor — in. Soft 'nation Rate ,y ______ -- ft• },C) Pit Boiyxlary Roots GPDIt� Texime String Cow 'Eff#1 'E Horizon Depth Dominant Color Redox Gr. Sz Sh. in. Munsell Qu• Sz. Cont- Color ' Effluent 91 = BOD > 30 `_ 220 m9I and •TSS >30 < 150 mgll ' Effluent #2 =• BOD < 30 mglL and TSS �5 3 m9n- 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 contac t c de at 608�6Cr3131 or TT1� 608 - 264 - 8 777 . SOD- 97701R -61M) s do R /tie ICI �o,J,✓Ar loT �/ Fogerty Plumbing , \ d A 2- #221180 28288 McKenzie Rd. x s- Spooner, Wt 54802 11 (715) 535 -9609 fe I' -lee /oo 0 Q 7.s s ^/pTE = A ss IC -1 IzA*4MV, MAO LsT 3 0' ��✓� of L,T �/ y ' /I10�0 • X- fir y . pe aP 44t Awe N , 1mT ' LdT '� Z Gor 3 IP7"d �e Us P C X par Tl� Fc ;�.^rty Plumbing & ,Perk Testing 25288 McKenzie Rd. C IA,pT Td ftlts��� = test .ALT Spooner, WI 54801 ST. CROIX COUNTY RECEIVED SEPTIC TANK MAINTENANCE AGREEMENT JUL 12 2006 AND -- OWNERSHIP CERTIFICATION FORM ST. CROIX COUNTY Owner/Buyer 11c� �l rnDn-t try a Mailing Address 102 Ck 5 Go++ L 0_0 PLJ L,- y Property Address /V (Verification required om &ning & Zoning Department for new construction.) City /State Parcel Identification Number o p LEGAL DESCRIPTION F Ar 4 o f 5� 112 - 1 A Property Location Sl< 1 /4 , AJ40 1 /4 , Sec. f , T _,g_ N R / '5 W, Town of Subdivision UTA , Lot # 3 Certified Survey Map # `j Lf ?, , Volume A , Page # S_ 0 7 l2� Warranty Deed # 1 5 Volume , Page # Spec house yes <0 Lot lines identifiable (E) 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 is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County 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. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNATURE 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. 08105) o� PREPARED FOR: SURVEYOR CERTIFIED SURVEY MAP LEGEND r. •c z BILL SOFFERT do J AR LOCATED IN PART OF THE SWt 4 OF THE FOUND 1 OUTSIDE ° 508 SAUER RD. S N LAND SURVEYING, INC. DIAMETER IRON PIPE 3 w �� HUDSON, WI 540 / 16 2920 ENLOE STREET NWI /4 AND IN PART OF THE SE1 /4 OF THE x w e :°�: a HUDSON, Wl 54016 NWI /4, PART OF THE NE1 /4 OF THE NW SET 1' OUTSIDE DIAMETER BY 1 /4 N E• C4 8 •�•►� t��ri AND PART OF THE NWI /4 OF NWI /4 OF 0 18' LONG IRON PIPE, WEIGHING z r NW COR. SEC. 15 1.13 LBS. PER LINEAR FOOT W gw c .. SECTION 15, T26N, R15W, TOWN OF CADY, ST, w zN CROIX COUNTY N WITNESS MONUMENTS , WISCONSIN. ........... ROADWAY SETBACK LINE W l- N M U N h w c,, �`' " OF RECORD Z (100' FROM RIGHT - OF - WAY) � � x z .7F . �' �'� FOUND 1/2' DIAMETER im�� C M 4 0 . u �d IRON REBAR ��� C.T. a �� " LAT�'ED LANDS ® soll BoRINC � U PROPOSED DRIVEWAY Fbz I $ ,� 1 • �`` , » '— — — 12' WAS UTILITY EASEMENT rX 2188.42' —*— FENCE _� LOT 5....... , N8414'54`W o 04.77' " I I 13.649 ACRES '' ................ . = i (603,267 SO. FT.) LOT 4 N00'07'S9 E INC. R/W 10.000 ACRES LOT � .... ............ » ....... ... 13.410 ACRES ® LOT 2 � (4W,605 SO. FT) 10.000 ACRES • .... t 0) I H (5 I N 84,140 SQ. FT) INC. R/W (435,605 SO. FT.) A I ( EXC. R 10.000 ACRES i p I ° (418,959 SQ FT 9.593 ACRES (435,805 SO. FT.) � EXC. R/W ) 3 (,. F. � INC. R W ) 9.564 A C 417893 SOT �' E L'c�v EXC. R/1M a (416,603 SQ. FT.) z • ,»tea EXC. R/W o ---'j I vARtaB fn I 1 ® S 0 ® ®® �Z O D ,01 r a� >I z , 63.1 " W 3 52 09' .32 574.68' 11.4 t S89'59'39 "E 2272.93' 46.28' - - - - -- $ S89439 - E SOUTH LINE OF THE N1 /2 OF m d THE St /2 OF THE NWI /4 Mn 4 CSR. SEC. 15 WLA'TTED LANDS / _ _ — — — — _ — — — _ _ SCALE IN FEET 1 " = 250' ESTABLISHED FROM WITNESS v MONUMENTS OF RECORD 250 0 250 THIS INSTRUMENT DRAFIM BY: WILLIAM KANE JOB NO. 6527 -01 DATE: 06/27/2005 REVISED 08/03/2005 SHEET 1 OF 2 SHEETS f/ RECEIVED 26E3�9 WARRANTY DEE JUL 1 LISTER OF DEEDS 2 2006 THLEEN H. WALSH . DOCUMENT No. R S CROIR CO., WI ST. CROIX COUNTY R CEIVED FOR RECORD This Deed made between WILLARD A. 07/05/2006 11:00AM SEIFFERT, WARRANTY DEED Grantor, and DANIEL P. MONTBRIAND, EXEWT # Grantee REC FEE: 11.00 TRANS FEE: 210.00 COPY FEE: Witnesseth, That the said Grantor conveys to Grantee CC FEE the following described real estate in St. Croix County, State PAGES: 1 of Wisconsin: A parcel of land located in part of SW'/ of the NW 1 /4, part of SE '/4 of the NW '/4, part of the NE '/4 of the NW '/4 and part of the NW '/4 of the NW '/4 of Section 15, Township 28 Tax Parcel No 004-3.034-90-200 North, Range 15 West, Town of Cady, St. Croix County, RETURN TO: Wisconsin, described as follows: Lot 3 of Certified Survey River Valley Abstrac! Map recorded September 15, 2005 in Vol. 20, Page 5070, 1200 Hosford St. : y� Doc. No. 806543. P.O. Box 14 Hudson Wl 5540 -01 7—o 4, This is not homestead property. Together with all and singular the hereditarnents and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated thi day of June, 2006 (SEAL) Wil ar ei ert STATE OF WISCONSIN )SS ST. CROIX COUNTY Personally came before me th' y of June, 6 the o n Wi . Seiffert to me known to be the person who execut the foregoing ins c o g the sam . -L-9 Notary Public, State Wisconsin My Co ission (expires): THIS INSTRUMENT DRAFTED BY: Attorney Barry C. Lundeen MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street, P.O. Box 469 Tracy L. Turner Hudson, Wisconsin 54016 Notary Public State Of Wisconsin I Of 1 Parcel #: 004 - 1034 -90 -200 07/14/2006 08:20 AM PAGE 1 OF 1 Alt. Parcel #: 15.28.15.233A -20 004 - TOWN OF CADY current 'k ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 01/23/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner DANIEL P MONTBRIAND O - MONTBRIAND, DANIEL P 1086 SCOTT RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 3027 CTY RD N SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 10.000 Plat: 5070 -CSM 20 -5070 SEC 15 T28N R15W SW NW & SE NW CSM Block/Condo Bldg: LOT 03 20 -5070 LOT 03 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 15- 28N -15W Notes: Parcel History: Date Doc # Vol /Page Type 07/05/2006 828859 WD 09/15/2005 806543 20/5070 CSM 07/13/2005 800215 2842/462 LC 07/13/2005 800212 2842/457 TI more... 2006 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/17/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 10.000 1,600 0 1,600 NO Totals for 2006: General Property 10.000 1,600 0 1,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00