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HomeMy WebLinkAbout028-1038-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552336 0 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: Stillin s, Rand Rush River, Town of 028-1038-90-000 CST BM Elev: Insp. BM Elev: BM Descr tion: _ Section/Town/Range/Map No: /00- Z) /Q a ~ 4 p~ S !d r"t' ~ ~ ch-~ 27.28.17.239 TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. II 11 Benchmark Septic t+✓ Pd (o►~5Z lJ z. 25/ OZ Z©o- d Dosing 7 25 Alt. BM vas.g Aeration Bldg. Sewer t 9,2 2 Tit c~~ 00 KICmS Holding 7~ L114 St/ Inlet nz__~ h j !e - X0.37 9i-fop iV~►G ` / TANK SETBACK INFORMATION St/Ht Outlet io TANK TO / WELL BLDG. Vent to Air Intake ROAD Dt Inlet N Septic Ssv ZS / cfvjtll/- I l Dt Bottom / 13.6 S ~f- dos ~5 Z oTsin ~V HeacJa+~lldl'~n~l (~1A 0- D E 17 Aeration Dist. Pipe 2.5 95.-7 Holding Bot. System ~-l ed-Y *'rf s Final Grade / PUMP/SIPHON INFORMATION 477 Manufacturer GF nand St over ' *3•25 O LZI W~01 a Model Number ZO S k*JA_ 2-4, S~ TDH Lift t Friction Loss System H TD lip. S o• v ~r i 2 r q b, r Forcemain Length I Dia. N Dist. to Well I l/ - 20 Z r SOIL ABSORPTION SYSTEM ~S -~f BED/TRENCH Width Length No. Of Trenches DIMENSION No. Of Pi Inside DIMENSIONS 4 •7 6 SETBACK SYSTEM TO P/ BLD WELL LAKE/STREAM LEAPHING Manufacturer: INFORMATION CHA R OR - 1+j Typ Of System: ✓ LIN Model Number: DISTRIBUTION SYSTEM D 0 sed Header/Manifold Distribution i x Hole Size Ix Hole Spacing :nto Air Intake e(s) rj th f Dia~ Spacing 7fZ ZTm_fik fif e L ng Length Clia J 7 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of~~ eeded/6Pde~ d " xx Mulched Bed/Trench Ce Bed/Trench Edges Topsoil /AT~~~~ Yes LASo ❑ Yes L o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1 t Q / Z Inspection #2: / / Location: 101 185th Street Ham ond, WI 5401155 ((SW 11/4^S_E..1/4 27 T28N R17W) meettes,YY& bbu~ndds^Loot Parcel No: 27.28.17.239 " ~ wa 1.) Alt BM Description =T~ P a ► 2.) Bldg sewer length= 0 7 ~ - ZL 4's > -amount of cover =q _ _ / _ GK t~d u (l~~ Plan revision Required? H Yes 50 /No .L Use other side for additional information. Date Insepctor's nature Cert. No. SBD-6710 (R.3/97) ~ o M Lo r" y~ ~ ~ o ry nS 'N" ~ Q b 3 s 4 +1 o M ~~►a~ss~~pa~~a j O 4p try Lj TPV k; o fly a> •s p P •400/ 3 o V f 47 1{ f Z' ~tj f `tom !°sS q u vu Sp ~y d a u r-r dp;..id - County ~r1 Safety and Buildings Division" AIN Q A. 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) p Madison, WI 53707-7162 T q ~p~ S5 z ~ 3 ~ J- Q tJ ft e it Application State Transaction Number In accordance w SPS 383. E mission of this form to the appropriate governmental unit 20-7 ' t3 3 is required prior obtait('d1 t..~ t pplication forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department S~ ervies. Personal information you provide may be used for secondary ur oses in accor e Privac Law, s. 15.04 1)(m), Slats. f tvyyv_ 1. Application Information - Please Print All Information Property Owner's Name t Parcel # &J 'jsttlt'x ~ 02,r- 103S-670 Property Owner's ailing Ad ess Property Location k 1 I Govt. Lot City tate t Zip odde Phone NumberU ' t y, y., Section I UL ( T N; R E o& II. Type of Building (check all that apply) Lot # circle one 71 or 2 Family Dwelling -Number of B rooms Subdivision Name ~P,46S41, Al" Block# ~ ❑ Public/Commercial - Describe Use \ ~J ❑ City of CSM Number ❑ Village of El State Owned -Describe Use III. Type of Permit: (Check only one box ne A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: C t 1 ❑ Non-Pressurized In-Ground ❑ Pressurized In-Grown ~ At-Grade Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil i ❑ Holding Tank El Other Dispersal Component (explain) Of XJ6~~ ❑ Pretreatment Device (explain) r 141 ~Ju V. Dispersal/Treatment Area Information: Design Flow pd) De pplica ' n Rate(gpdsp Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Ele n L 0- 7 sL L~ VI. Tank Info YCapacity in Total # of Manufacturer a .0 Gallons Gallons Units 2 o 2 New Tanks Existing Tanks U U " io 0 2 y~ a` iU v~ ~ rn w C7 G. Septic or Holding Tank Cc /ti t C G Dosing Chamber'1 ( PO, p VII. Responsibility Statement- I, the undersigned, assum responsibility for installation of the POW S shown on the attached plans. Plum er's Name (Print) Plumbe s nature MP/MPRS Number Business Phone Number y 1 JJ Q~? r IQ11 r ~f/ ✓O Plumber's Address (Street, City, tale, Zip Code) VIII/County/Department Use Only Approved ❑ Disapproved Permit Fee Date Issued I5" ing Agent ignat re ` 2 Z ❑ Owner Given Reason for Denial (a2 J ca IX. s(9, FovaI/Reasons for Disapproval ~.z) /1I n /Q cam/ 1 Septic tank, effluent filter and V~!/l Sid- 11 dispersal cell must all be serviced / maintained lM S as per management plan provided by plumber. 2. All setback requirements must be maintained Sps 3 9 3 3 3 OG~~ Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) o~~n1zTME~ Safety and Buildings yet' T°~ 10541N RANCH ROAD o 9 RECEIVED HAYWARD WI 54843 3 I , p s Contact Through Relay www.dsps.wi.gov/sb/ $ www.wisconsin.gov Scott Walker, Governor s1 N CtZ(~IX COUti~ ~I Dave Ross, Secretary I=; P Nt!ING & zk)NING April 12, 2012 CUST ID No. 220673 ATTN. POWTS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER SOIL TESTING & DESIGN ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 04/12/2014 Transaction ID No. 2071753 SITE: Site ID No. 778107 Randy Stillings Please refer to both identification numbers, 101 185TH St above, in all correspondence with the agency. Town of Rush River, 54002 St Croix County SWl/4, SE1/4, S27, T28N, R17W FOR: Description: At grade, 3 bedroom residence p' Object Type: POWTS Component Manual Regulated Object ID No.: 1365932 CoTtc Maintenance required; Replacement system; 450 GPD Flow rate; 38 in Soil minimum depth to limiting factor from original grade; System(s): At-grade Component Manual, Version 2.0, SBD-10854 (N.03/07), Pressure Distribution Component Manual - Version 2.0, SBD-10706-P (N.01101); Effluent Filter V 1 D The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. 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.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • In the event this soil absorption system malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described the At Grade Component Manual are complied with. A copy of this information must be given to the owner upon completion of the project. • The float switch shall be a type that does not contain mercury. 2009 Wisconsin Act 44 prohibits the installation of float switches or relays that contain mercury. • The designer proposes to install an effluent filter to achieve the requirement of wastewater particle size. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the septic tank outlet filter will be required. The outlet filter shall be installed per product approval stipulations. Reminder • The orientation of the at grade system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. I CHARLES L WEBSTER Page 2 4/12/2012 • Limit activities in the area 15' beyond the down slope edge of the at grade per At grade Component Manual. • Surface water drainage shall be diverted away from the system area. I • Materials shall conform to the requirements of SPS 384. SPS 384.10. No fixture, appliance, appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • The existing POWTS must be properly abandoned per s. SPS 383.33 Wis. Adm. Code. 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. 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Patricia ando POWTS Plan viewer tegrated Services W SMART code: 7633 (715) 634-781 715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. b... pat.shandorf@wisconsin.gov cc: Charles L Bratz, POWTS Reviewer II, (608) 789-7893, 7:45 am - 4:30 pm Monday - Friday Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Safety& Buildings will be modified. Code references with prefixes starting with "Comm" will be replaced with "SPS" to recognize the relocation of the Division of Safety & Buildings from the former Dept. of Commerce to the Dept. of Safety & Professional Services. Additionally, all S&B codes will be renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. i RECEIVED ~J~ARE_TY & BUILDINGS Webster Soil Testing Ft Sewer System Design Charlie Et Kris Webster, Owners N5815 770th Street, Ellsworth, WI 54011 Telephone: (715) 273-3430 Fax: (715) 273-4181 WI Licenses: MP220673, ST220673, ST 261669, PEI 8803 POWTS Index Sheet Page 1 of 9 At-Grade System Designed for a 3 Bedroom Residence Property Owner/Project Name: Randy Stillings Parcel ID No. 028-1038-90-000 SW 1/4 SP 1/4 S27 T28 N R17W Town of Rush River, St Croix County, WI Contents Page 1 of 9 Index Sheehy Pate Z of 9 Plot Plan ,tip Page 3 of 9 Plan View Cross Section Pam 4 of 9 Distribution Pi Layout Pate S of 9 Septic Tank Cross Section Page 6 of 9 Pump Chamber Cross Section Pate-8 of 9 Pump Performance Curve ORRESP Pate 8 &9 of 9 Management Plan 10 CHAMLES LL WE13STER J E•18803 O ' FLLSWORT14 r?W % • . WIS. ~ • v~ s . s~ N • • Component manual used: Name: At-Grade Component Manual for POWTS Version: SBD 10854-(N03/07) Name: Pressure Distribution Manual for POWTS Version SBD 10573-P (N.01/01) Pip Line ©14V 7 ~ °s Zn ~ S f0 a y' ~ I ~ W cc►-evt P It a O `pir -F-I' to %ov l s A ON s z~ q D ~ N ~ h w C p n p. 00 o e '~0 O f{f'`6ra 10r / Qr,cry S;~1hy~S'~ 3 6 f q r O~ C, I S CT/ OA/ L r a o T1 I, > s- n Aw J®/ Feet 0_ b Feet 47 L= O Feet Linear Loading Ratem`~0902 GPD/Y M FT Design Loading Rate MGPD/sQ-FT W= 2-~ Feet 'eFobric I: Distribution . Late al Observation----,--,., -Inn u-r- Wet E ~ ,-rc 125!pounrv , • 6 uaF. o,~ 1 sQ0TIL Pwv >5' q X51 p p ~•v a o! co tex t~' ~d dr,`c r ~ .r ~ ~ .n ~o~n,s * v s . c 4,411". CID d e t ' ~h g ~l° / /Q' y Tvy Cth ~7 //r b P7- r~i~olde-o( ~►~i,~- ~•tr~c A c c ess t dA l.~a~ 4.1cs ~.rw+ 4 Frt~ e~ k..l ~ sPa ~~l 4.6 of ~ J'I4CtGY .LAG - Ft X ~ T I.~e.s L-.ift~,s~ Ara,~atty- ~ ~/oZ -~i.c~► Ces fvF ~F,.~la►r ~iiMc ~1 cs. T . ~r l~ I~.r~t ,i 1~` / ~.C ;Irolu ~i o... ev. v~ o~ v~r'1')'r•'jw ~i@~e ct ca.~'f~t Sc~cca e.a(•1.F i~at~e~riAr. 4./c tr ~4 t N C. HAP, A 7 ° 6,-,E- Cie ~~a h ~o Ran Srt ~l b~ S f~ ° + 1 ,.L 7 c,~c«.l S~ ~fs~ IrC ~t.CC r~v7'~~ I a. fo Via. try /t E 1~9P eYtl-7s~iG try ~ ~ #o r ~'N, t ~~Ac ~ at' ca..'1f+ii wJ ~ I ~+1~+' ~ f t J c, e ~'i her f ~ Irt G` e 7 ~ C QoYC'r- i1 c) Ao- 4-4- 0*4 now i Fl. „c k 1 >3i',rC t,ttt. 2.~ t at VJA-,~ 4LIPP~V,*w 71) /i►ave ~ o.:e tf w; i ►+ve ~ t 3 !~'iF- orJy t • bQl ~ toe.r► d v~ ~ kGh le • t TarKK /~lttw.l~de..3`~t..v+s~' yV i`csel- CvHc~-e-~~ k/4 A ,q cX C. £ /9 f raga d e 1a~4n Y a.. /f, b~S PA G I C; F PUMP CHAMBER CRO55 SECTION AND SPECIFICATION5 VEIJT CAP ~P.hf'to GUz'I4h la", t~✓~aW hop e cove). to provo de d ccCSS to P""Vo t" C. I . nl- Sc~ ed ~f O Piar•trrc ik.rn4 a WEATHERPROOF APPROVED LOCKIAIG JUMCTION BOX MAWHOLE COVER JOfr•.FROM DOOR, WIIJDOW OR FRESH I2'MIU. AIR IAITAKE TS- 3 I r GRADE { i" MIFJ. rl - _T COIJDUIT+ PROVIDE I INLET AIRTIGHT SEAL I ' A Q i J/ 1 ALARM J_ jMbR e ~ 1 I. weed h. ~c *APPROVED ( °m JOINTS WITH I ~a ELEV. FT. APPROVED PIPE __j 98. 1 Ar 3' ONTO PUMP--~ OFF D SOLID SOIL CONCRETE ©IOCK RISER EXIT PERMITTED OWLy IF TALIX MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPPEEC~IFICAtlOU DOSE, Carsc r f e TA►JKS MANUFACTURER: Seh S`-- IJLIMBER OF DOSES: PER OAy TAWK SIZE: 7-L0 GALLOWS DOSE VOLUME -sf RA INCLUDING 6ACKFLOW: 1 -GALLONS ALARM MAUUFAGTURCR: / ? MODEL klUMBEK: r` a /l ~c►-t- x CAPACITIES: A= •z`~ INCHES OR GALLOU5 4-t SWITCH TyPC' B IIJCHES OR QLL GAL.LOQ5 PUMP MANUFACTURER:tY G-_~1_IAICHES OR / GALLOUS MODEL NUMBER: 71 r0 + D- 6 1KCHES OR GALLO►JS SWITCH T`JPE: Yte c ®)?4- MOTE: PUAP AMD ALARM ARE TO DL INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE "Z `S GPM. VERTICAL DIFFEKE.ICE DETWEEM PUMP OFF AND 01S~T-R-IDUTIOAJ P E.._ FEET MI►JIMUM NETWORK SUPPLY PRESSURE 3;~. FCET 2~L FEET OF FORCE MAIN X q~ F/pp FtFRICTiO1J FACTOR. 0- 3 0 FEET TOTAL QyAJAMIC, HEAD - ~ FEET IQTERIJAL DIME.WSIONi OF TANK: LEWCsTH ~ ;WIDTH LIQUID DEPTH !7C ~Cs P" rI7 p ~e h °V h e C'cr . y e ~0 7 f • Art ~~t J~ P~gti Ray ~y s,~~i~~~- 3871 EP04 EP05 APPLICATIONS • Fasteners: 300 series • FUIty submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grime rail for for efficient heat transfer, following uses: • Capable of running lubricates and effident strength, and durability. • Effluent systems components. to heat transfer. ■ Motor Cover. Thermoplas- • Homes A1~ for ashiengfic and tic cover with integral handle • Farms mew. now and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP; i I Ed 1 points. • Water transfer R15 or 230 V, erload wit lB and ■ Power Cie: Severe duty • Dewatering RPM, built in overload with automatic reset I at Ie rated oil and water resistant. SPECNqCATil M • EP05 Single phase: 0.5 HP, • IIIIIIIIIIAW Upper and lower 115 V, 60 Hz, 1550 RPM, FEATIM heavy duty ball bearing Pump: EP04 built in overload with ■ 044 'nip Wei - Thermo- construction. • Solids handling capability: automatic reset plc Semi-open design 3/4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTNG • Capacities: up to 55 GPM. standard length, 16J3 SJtO medic l sea protection. • Total heads: up to 24 feet with three prong grounding 41- a ftwM* n • Discharge size: I I/? NPT. plug. Optional 20 foot 0 EPOS M*eftr Thermo- * Mechanical seal: carbon- length, 16/3 SJTW with plastic design for (CSA listed model numbers improved performance. end in "P' or "AC".} rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Cash aM Vie: Rugged • Temperature: thermopic design provides 104°F (400C) continuous superior strength and 140°F (W0 C) intermittent. corrosion ressWara. • Fasteners: 300 series METES FEET stainless steel. 10- * Capable of running { dry without damage to s 30 components. Pump: EP05 8- • Solids handling capability. 25 ° v Y4" maximum. F • Capacities: up to 60 GPM. s I . • Total heads: up to 31 feet PHI • Discharge size: 1lh* NPT. 5 • Mechanical seal: carbon- c 1 rotary/ceramic-stationary, 4 BUNA-N elastomers. i5 • Temperature: 1 3 10 i 104°F (400C) continuous EP '1 140°F (6(rC) intermittent 2- f 5 Dem~+•, C' 1 i I C7. S f~ ny 13.c> IN ° °o 0 20 30 ao 50 GPM 0 2 4 s a I0 12 m'!h C,r ®19% Goulds Pumps, Inc. ErrecOve may, 1995 B3e71 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 'FILE INFORMATION SYSTEM SPECIFICATIONS Owner R 0-„ d s Septic Tank Capacity / b0 (j al ❑ NA Permit # '5c Z 3 Septic Tank Manufacturer wrese i- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Pc,/ /o k ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model ` j a ❑ NA Number of Commercial Units NA Pump Tank Capacity 7,,5--Q al ❑ NA Estimated flow (average) 3 v C;, gaydav Pump Tank Manufacturer V $ese'. ❑ NA Design flow (peak), (Estimated x 1.5) ,5- ® al/da Pump manufacturer 60 -/of ❑ NA Soil Application Rate O J- 9 au /its Pump Model ?87/ _ PO ❑ NA influent/Effluent Quality Monthly average' Pretreatment Unit XNA Fats, Oil & Grease (FOG) S30 mg/L f7 Sand/Czravel Filter ❑ Peat Filter Biochemical Oxygen Demand (13005) 5220 mg/L ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mcj/L ❑ Disinfection ❑ Other. Manufacturer Pretreated Effluent Quality )<NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD5) 530 mg/L ❑ In-ground (gravity) ❑ in-ground (pressurized) Total Suspended Solids (TSS) 530 mg/L VAt-grade ❑ Mound Fecal Coliform (geometric mean) 510` dull00ml ❑ Drip-line ❑ Other Maximum Effluent Particle Size Y. inch diameter values typkal for domestic (non-cornmrctal) wastewater and septic tank. effruent . values typicai for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ,3 ❑ months year(s) (Maximum 3 yrs.) 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 3 ❑ months year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 ❑ months ,year(s) d Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA 4 rA/c e We, Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA / j'V' c dc- CoVer. At least once every ❑ months ❑ year(s) 'XNA other At least once every ,Q ❑'months ❑ year(s) NA ~{F Mf'q LCcoXi.tra.. cif is~J.~.pirp' ~~l~r oh~t V~°ry •yj~5'~6S-WCLCfo~r,Hr~e of t~rt- MAiNTENANCE INSTRUCTIONS yoa.` a/t.rm .FfeVery'P,+!/ to ~V."Ca P-4/•owi dL b4hat -the Inspections of tanks and dispersal cells shall be made by an lndiv ual carrying one of tf% following licenses or certifications: Master Plumber, Master Plumber Read Sewer, POWTS tnspecbor, 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 pondktg 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 stunt In any tank equals one-third (X) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, prebvet4ment components, and any other maintenance or monitoring at intervals of 12 months or less 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. 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. Tt f - (9 /^Q u~ C' / t2 l? ~t~ L. Ran an 0 jv I ! 1 i o ~ S Page ~ of System start up shall not occur when soil conditions are from at the infiltrative surface. ;During power outages pump tanks may fill above normal hWwwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one larp dose, overloading the cell(s) and may result in the backup or surface disc hatrge of effluent. To avoid this short 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; bottom 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 faits and/or is permanently tatken out of service the kftwing std shall be taken to insure that the system is properly and safely abandoned in compliance with ch. Comm 83.33, WisconsIn'Administrative Code: e All piping to tanks and pits shall be disconnected and ilea abandormd pipe openings sealed. e 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 falls 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 uteri for the location of a replacement soil absorption system. The replacement area should be protected from disturbanoe and compaction and should not be infringed upon by required setbacks from existing and proposed moo, lot tines and wells. Failure to protect the replacement area will result In the need for a new &A and alts eva bn to establish a suitable replacement area. Replacement systems must comply with the nags 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 IMAITANER ~ti /e h acr.~ Name ~aYr, Wa L~xc a a, f ' Name Phone Phone SEPTAGE SERVICING OPERATOR PUMPER u!r/~1~ouA LOCAL FREGULATORY AUTHORITY '5-r C R Name Agency ~4 t 6n h Phone Phone 71S This document was drafted by the staffs of the Green Latta, Margaew and Waushara County Zonkp and won agencies. This document meets :he minimum requirements of ch. Comm 83M(2)(b)(1)(d)&Ef) sad 83.54(1). (2) & (3), VYfsconsin Adm&Wtra#m Code. Use of this document does not guarantee the performance of the POWTS_ GMW (2/01) Wi nsin Department of W roe SOIL EVALUATION-BEPORT Divi of Safety8nd(CI Page of n accordance with Comm 85, Wis. Adm._Code _ G0~ F vc County Atta complete } of less than 81/2 x 11 inches in size. Plan must Cko inclu e, but 611. cal and horizontal reference point (BM), direction and Pte' j per t sl~~ dimensions, north arrow, and location and distance to nearest road. p- 00 C1> . 3 t) -P Please print all information.e b Date / 7 _ Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). `~✓1/ YV /v Property Owner / Property Location Rh L✓ ¢h:ory S7i`i f j~ -@e*+. t S W 1/4S 1/4 S a7T & N R/ 7 der)W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# citty~ State Zip Code Phone Number C] # City ❑ Village KTown Nearest Road ❑ New Construction Use jK Residential / Number of bedrooms 3 Code derived design flow rate GPD eplacemen . Public or c mmercial - Dgscribe erial £ Flood Plain elevation if applicable ft. General comments "r- /-If Cd//;1 77 Cry and recommendations: ~`~t ¢ 7` i€QC lje Ql -r ~~C 1`G 07c , > 3 G c2~~'~ Q a Boring # Boring c76, / j Pit Ground surface elev. / ft. Depth to limiting factor V In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E `Eff#t2 f o , /orb 3 - ,~.C J-7 CIL )0 s . 3 7_ s" s Q s / r p 7 Y- 3 *-j o ,PS~ 6 7/f' 7 rl, ,r c 3 c 4 6 o, It S a o- Boring# Boring / IK 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/ff' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 0 - /0 ft R-4 /17 PF q- -r 2 q-6110-6 otp- 0. 24K ev A- q S ) 0-6, 0. FY 3 /8-3/ iaY / - s 2 pai h, Ar a.s 0.6 1-0 V- 43 7. ST4R , f- s OS-2 s c~_ 7 e 6' 3 - S-/o/R tt/6 PAP s)'iC - $ S- c ;Z Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number C h r ~G G><'G s° ~ .4. 06' 72 - Address Date E Conducted Telephone Number e PropertyOwner R 4 y & Sr : o~ S Parcel ID # O .z -/p3 f?- 96- page of 3 OC)O ® Boring # ❑ Boring Pit Ground surface elev. ~ - O ft. Depth to limiting factor 4 2-_ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/iF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 -Eff#2 ~/3 • . 7-s[i~iPs/T - s v s .mss f v t~' 0, 7 7 Z. 17 ❑ 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Ef1#1 "Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appfica Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Etf#2 Effluent #1 = BODS > 30 < 220 mg/L and'rSS >30 < 150 mgrL * Effluent #2 = BOD5 < 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.07/00) 3 pY~ Lr'n e ~fi ti1 c ~p r, Q. s. a0 ~ apC'L the ►s NcQ Q o z d'y:JIA.'6r4rrvvcc// ry ozi- ti o. f r. w W C 11 S' W ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM LO_~ne Buyer h/d t l/l~ Mailing Address / ( c ` Property Address l6l z - d ~~Y- (Verification required from Planning & Zoning Department for new construction.) p City/State Parcel Identification Number LEGAL DESCRIPTION ~j 1 (9~ W Town of l'("14 kl~ Property Location /4 ,Sec. T N R~ Lot # Subdivision Certified Survey Map # , Volume <<ll ~j , Page # Warranty Deed 3 Volume ~l~ l , Page # ~C_• Spec house yes Cam'' Lot lines identifiable es 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, asset by the Department of Commerce and the Departmeut 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms GNAT OF APPLICANT(S) 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) `o 1427PAGE 315 VOL STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED I~ KATHLEEN H. 1iALSH STER STGICROIXOCODEEWI DOCUMENT NO. _ RECEIVED FOR RECORD MalCnlm T Nieiccn an,i Rarhara_yJ Nielson, 05-18-19" 1:30 PH Yyyyyc h a n -i and W i f c i { tpNTY DEED EXEMPT 8 CERT COPY FEE: conveys and warrants to Randy W Stillinc,;s and Marion CORY FF€t J. Stillin s husband and wife TRANSF FEE. 701.70 g RECORDING FEE: 10.90 PAGES: I I :I THIS SPACE RESERVED FOR RECORDING DATA ij NA E AND RETURN AODREe~ the following described real estate in S t. C r o 1 X County, State of Wisconsin:' g' ~;I !p/ ~ ~ d ~YU/s ,i 028-1036-20 000;028 1038 90 000 028-1038-95-000 { ' PARCEL IDENTIFICATION NUMBER West Twenty-two (22) rods of Southwest Quarter (SW1/4) of Southwest Quarter (SW1/4) of Section Twenty-six (26) and South Half (S1/2) of Southeast Quarter (SE1/4) of Section Twenty-seven (27), all in Township Twenty-eight (28) North, Range Seventeen (17) West. I This is homestead property, (is) X~"fi~F Exception to warranties: Easements, restrictions and rights-of-way of record, if any. A.D., 19 g 9. Dated this 17 day of May d (SEAL)S ~1LG~iLG~ ~ EAt) ! Malcolm L. Nielsen Barbara J. Wielsen (SEAL) (SEAL) AUTHENTICATION 4 ACKNOWLEDGMENT M i a Signature(s) State of Wisconsin, ss. St. Croix County authenticated this day of 19 Personally came before me this 17 day of M 199 9, the above named Malc-nlm T., Nit-1--en and Parbara J. nr'oTson hLSband and wife BAR OF WISCONSIN TITLE: MEMBER STATE Breads Poulin i If not authorized by 9706.06, Wis. Stats.) Notary Public to Tkwn be the pe on who executed the foregoing Wtscon State of w ~t~ackno, dge t saint. THIS INSTRUMENT WAS DRAFTED BY L • Attorneyf Kristina Ogland enda Poulin Hudson, WI 54016 Notary Public, sr- CT-nix County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 1 1 f I9/9nnn 19 ) ' • Names of persons signing m any capacity should be typed or printed below their signatures. STATE DAR OF WISCONSIN wi9comn Legal Sw* Co., Inc WARRANTY DEED Form No. 2 - 1982 Mtlwatltee. W'S.