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HomeMy WebLinkAbout008-1008-40-000Wisconsin Department of Commerce Safety and Building Div~on PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 'ermit Holder's Name: City Village X Township Jensen, Steve Eau Galle, Town of :ST BM Elev: , r Insp. BM Elev: BM Description: ~ TANK INFORMATION TYPE MANUFACTURER `'' ~ ~a~.~e-Q 1~ -1 t~ Ez CAPACITY Septic (~Sf~2.. -s85 a Dosing t ~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ' l ~ f ~, 3 r Dosing l t `t ~ ~~ Aeration Holding PUMP/SIPHON INFORMQT[bN..,o~''~ ~-°~~~ ~ 3S (~ ~ ~~ Manufacturer Demand tit=; GPM b M d l N " ~ um er e o ~ ~ ~ ~ 5 j - DH Lift Friction Loss System Head TDH Ft 2 (~•S z.39 .~° ~S• 1 Forcemain Lengt ~. Dian _r' Dist. to Well ti S :L.., ELEVATION DATA County: St. CCDIX Sanitary Permit No: 488052 0 State Plan ID No: arcel Tax No: 008-1008-40-000 Section/Town/Range/Map No: 03.28.16.386 STATION BS HI FS ELEV. Benchmark ~, ~ . S3 0~. s3 ~ d17 . ~ Alt. BM Bidg. Sewer ~- ~~ ~ 4 p~ ~ St/Ht Inlet ~ ~~ ~ • t]~ r St/Ht Outlet Dt Inlet Dt Bottom ll•sb r q~.a3 Header/Man. ~, rS ~~ 3g Dist. Pipe . / ~ ~ .jQd O Bot. System c f ~ ~~- r ~ • ~ al Grade U ~~l~l~ ~- (Z~~ ~ -- ae t Cov r D r- ` 5 2 i-l ~ 5~- .8~a. o Z .c~! '~ SOIL ABSORPTION SYSTEM ED DIMENSIONS Width t O Length ~ S No. Of~reneHee 3\ ~ ~~S PIT DIMENSIONS No. f Pits Insid Liquid Depth SETBACK INFORMATION SYST M TO Type OfflSystem~ P/L ~'~ BLDG ~ ~O 3, WELL ~ LAKE/STREAM ~ LEAC~Ii CHA(yUI~N T oR Manufacturer: Model Number. nICTRIRI1Tl[1N SYRTFM Header/Manifo'd r p Length ~'~ Dia ~ ~Z" Diserisution r ~ rr pc) " ~ Lengkh ~Z 2 Dia ~ ~- Spacing x Hole Size ~~ I g x Hole Spaf ing r ~ ZI l~' Vent to Air Intake CPfll C(~VFR v Drc~m~rn s..~Inme nni~ YY 11(inund nr At-Grade Systems OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil r i~j Yes ICI No I', Yes ! No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~n~~/~~Q Inspection #2: l ~ Location: 2409 60th Avenue Woodville, WI 54028 (NW 1/4 NW 1/4 3 T28N R16W) NA Lot P rcel No: 03.28.16~~ S.T u..o.-~.~~eRa.. cs~-ws `~) C~.~~~,,re~-Ce„ .~ ter"-e+~~ 1.) Alt BM Description = 2.) Bldg sewer length = .. ~ ~ ~ b'td~-(~-~t~ ~ ) S'E-~~ w r ~- S . -amount of cover = ~ Z " S~ ~~ ~r ~ VV Plan revision Required? Yes No ~~ ~qr ~• ~. 2 Use other side for additional information. / ~o Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division ounty 1 ~ ~~ ~ 201 W. Washi ~ '•~ Madis WI C t b f ll d i b P N b i i I~~O~~~~ o e o.) o e i n y erm um er ( tary t Department of Commerce ~' ( 8)266-3151 JeZ Sanitary Permit ~p lica ion'"'' S to Plan I.D. N°mber ' RANS. I D # 1229225 Tn accord with Comm 83.21, Wis. Adm. Code, pert'Iinf tion you rovid~ -` CU Y s15 4(lx~i~ CRCiIX C be used for seconda ma ur oses Ptivac w p t A~i address) {~f ~]fferent than mailin y ry p p , g ~ ~ A~IVUt i hi I. Application Information -Please Print All Information ~ 7~0 Property Owner's Name ~ Pareel # of # Block # STEVE JENSEN 008-1008-40-000 ~- '~ Property Owner's Mailing Address Property Location 1070 11TH AVENUE NW NW Section 3 Yy '/. City, State Zip Code Phone Number , BALDWIN, WI 54002 715/684-4211 T 2$ N; R ,~G(cirolione) / /~,$~ V II. Type of Building (check all that apply) ~ ~ ~ `' , jv yvt: ' Ott 4S CSM N b S bdi i N i ~ 5 d 1 or 2 Family Dwelling -Number of Bedrooms ~ ~ ~ _ _ um er ame u v s on '- ' Public/Commercial -Describe Use N/A _ ~ ^ State Owned -Describe Use ~~,~, ~i2 ~' /Q ~ ~~J OCity ^Village ^I'ownship of EAU GALLS III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) A' Q New System ~~ ep y ^ R htcement S stem Treatment/Holdin Tank Re lacement Onl ^ g p y ^ Other Modification to Existin S rem g ys B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a 1 ^ Non -Pressurized In-Ground 0 Mound> 24 in. of s itable soil ^ Mound <24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ~ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculatin S thetic Media Filter g ^ Drip Line pe ( p ) ' g yn ^ Leachin Chamber ~ Gravel-less Pi ^ Other ex lain ~/ V. Dis ersal/Treatment Area Information: Design Flow pd) Design Soil Applicati Rate(gpdsf) Dispersal Area Re ui (sf) Dispersal Area Deed (sf) System Elevation 750 ~ 1 ~,Ej ty,'~~ 750 , lZSC 750 Zp 99.5 VI. Tank Info Capactty in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constntcted Glass New Existing ~t (l ~ Tanks Tanks 1ppJL, septi°orxoldingTank 1585 1585 1 WIESER CONCRETE X Aerobic Treatment Unit Dosing Chamber 850 950 1 WIESER CONCRETE X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu 's Signature MP/MPRS Number Business Phone Number BENNIE HELGESON 0292 715/772-3278 Plumber's Address (Street, City, State, tp de) W1229 770TH AVENUE, SPRING VALLEY, WI 54767 VIII. our /De artment Use Onl pproved ^ sa Sanitary Permit Fee (includes Groundwater Da Issued Issu' Agent Signatu o S s) ^ Surcharge Fee) `~ ~ ~ ~ ~~ ~ ~6 D er en Reason for IX. Conditions of ApprovaUReasons for Disapproval e R ^ J t. ~ i-I a~t.~ i SYSTEM OWNER: ,3, (,o n ~a.de. ~gpfav ~G : ~. tt '' n f ~ i, $raptlc tank, e[Iklent r~t.f and e~ec~-- ~./ / ~ ~ I~ / di~efsal eed must sH be taervicea / mai>~ait~ ss per management plan provided by plumber. 2. Aq selbaek regtllfemer-ts must be maintait-ed a paf applir~bla ode / ordinances. Attach complete plans (to rho County only) for the system on paper not less roan iflll z 11 modes m size ~L~- SBD-6398 (R. 01/03) -1'l0~" 1'~a~ • Ftnc ~ ~ ..~. • ~~ t ----s - -- .~ -~ ~y o' -~- ----- 01.`'10 a .~ ~-0or^- er~ n~~ ~ ~~~`. ~~G~P~ ti .~ i ~~~~C~ O~~~SQD S`~`~C Gh ~..~,.R E k ~. r 05.3 Pr o~pOS~ •-~ Ga~~~~ s B~Q I-l~w.`. ~ ~ ,ems.. e, ~; ~~. r` ,,,3 S```<,r r S'SS/qso Gtil, "~Z~.-ire( ~~ loU ~ 700' t~o ~ o f cT ~ ;~Q~„ Top o~ ~ ~~ 1°~~( B~r~.e _/~ ~ / ~ ~ v mt ,60Ta. ,~V~ i ~,Ni. ~6 . o S' Top ~~f y'' D~~ JV ,, o, .S~al~ 1 = ~ ~. M. I OCR. ego Top c~F 1 '' pU~ P ~~ -c. ~7.ov ~_\ ~ ~ 3 ~ ~ ~ 1 i 'rr Q~j ~' ( o ~- ~ ~ y o' - ~-- __ .--------~ Tod, c,~f y'' D~~ t'eKC-~ ~os'~" ~ orJ. R.~~ca.~ T~vc//SCyc •c r l ~~yti ~laGe'~fa~ ' ~~ ~D~~G~ ~~~5~~ GM c..~,.R E k ~. ~r05"•3 ~'_ t ect•. e. '~ ( C c ~~ ~1 3 s~ /V ri r ~O ~ ~ccc~~. %~t.Uc ~_ I `` ~,r rsgS/yso Gtil, ~ `. Pr oppOS~ ~Q G0.~~~~ ~ s B~~ No 700' fio cL Q ~ c~ H `'Qg" _----- - ___~__ _ _ - -- _ _ _ _ _- -----, f`- - _-------- -------- -- _ ---- y 70~ ~f ~ « RUC Opr~p.E . ~. M. 1 O(~. nv Top c~ t'' PUS P ~~ -c ~ 7, o ~~ Q j oo ~ -.. .~ "~ a-ti3\ f !~ ~~a ~ j l ~ ^~' y~ l r S (np~` ~ o /~ // p Qa/ commerce.wi.gov i ~ ~scansin Department of Commerce January 04, 2006 OUST 1D No. 220292 ATTN.• POWTS Inspector Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www.commerce.wi.gov/sb! www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA. W 1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPII2ES: 01/04/2008 Identification Numbers Transaction ID No. 1229225 SITE: Site ID No. 708585 Steve Jensen Please refer t~ both identification numbers, 60th Avenue above, in all corres ordence with the a ene . Town of Eau Galle St Croix County . NWl/4, NWl/4, S3, T28N, R16W FOR: Description: Proposed Five Bedroom Mound System Object Type: POWTS Component Manual Regulated Object.ID No.: 1056994, Maintenance required; 750 GPD Flow rate; 30 in Soil minimum depth to limiting factor from original Bade System(s): Mound. Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (8.6/94); 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 requirement:,. 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: • This system is to be constructed and located in accordance with the approved plans and with the component manuals listed above. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • 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. Stats„ • The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular tra:flic or soil compaction in this area is prohibited. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. • The proposed well shall be located a min. 25' from the treatment tank and a min. 50' from the dispersal cell. • Comm 83.22(7) - A copy of the approved plans specifications and this letter shall be on site cfurin~ construction and open to inspection by authorized representatives of the Department which m~iy include local ms ectors. P.O.~a'V.T.S. Conditionally BENNIE W HELGESON Owner Responsibilities: Page 2 1/4/2006 • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • Comm 83.52(1)(x) -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. Ln the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • 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 EOWTS. 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 maybe 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, Gerard M. Swim POWTS Plan Reviewer -Integrated Services (608}789-7892, Mon. -Fri. 7:30 am to 4:15 pm jswim@commerce.state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART`code 7633' cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 e INDEX SHEET PROPERTY OWNER: STEVE JENSEN 1070 11TH AVENUE BALDWIN, WI 54002 PROJECT NAME: STEVE JENSEN PROJECT LOCATION: NW 1/4, NW 1/4, S 3, T 28 N, R 16 W MUNICIPALITY: TOWN OF EAU GALLE 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: WLP1585/950 Tank Specifications Page 6 RECEIVED Page 7 DEC 3 0 2005 Page 8 SAFETY & BUILDINGS Pump Specifications POWTS Owner's Manual & Management Plan - Pg. 1 POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 ~~/ Signed Date: December 28, 2005 DEPARTMtN~ ur t,w~u.~~~.~~ IV15~ON 4 F Y AND SOILDINGS c 5EE GOR NDENCE Synthetic Covering ~, ,'.STN? C 3 3 Medium Sand -~ ~,~,r Topso(I y % Slope Page ~ Of 8 Pipe . ~~ ~k~. 99.0 Plowe d Layer D . ~ Ft. E `f Ft . F .8a Ft. G .vim Ft. H / Ft. 'J' ti_ 3 :_ {- t~~.0 f z - 2 z g99regote _ Cross Section Uf A P~~ound Distribution D/, 3.? _ ~G %=_- F ' D ~, „~ i ~ON~ r Force Moin From Pump ~ ~~d Ft. Signed: a 7S" Ft. K 7.~ Ft. License Number: ~ 9` Ft r Date: !_ ~ ~/.9 Ft. _____- T ..Z_.(c~ F t . F o i-c..~ /~'1 ~ ~ .. W ~~ F t . .~/ Fr o w. ~c...~• ~ -_ - -- ---- L. _______--- Ii II Observation Pipe __.:.. T---------- LL p f 2 .. _ 2 L, Distribution Pipe Aggregate ~} a ~ ~~a3a ~ ff rLc~. _ /Sao Observotion Pipe Plan View Of Mound C ) eo,~.o~-f frc.~`'S`~! . .'~ ~ I~•l P~D~ Perloroleri r'Ip• Oe~oU / ~ / End Vlcw Porlu+ui~J j t.... Distribution Pipe Layout Signed: License Number: Dace: Holes Located on Bottom are Equally Spaced f-~~~cc-- Nsa_in rr' R 7' S ~~ 'i 1 it X ~~ ~ " ~ 11 Y _~ S Hole Diameter - Inch Lateral " ~ Incn (es) Manifold " ~ Inches ~~ ~. Force Main - Inches , .i ~~~ ~~E ~`~ ~ I~e~. /oo, o a ~urlper o~~,a~e~~s ' k 3 ~~n~eX", ~~~ ~QiY1~lQ~n Page-,Of~ SEPTIC TANK b PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" ~U~C_VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF JUNCTION BOX APPROVED > 25' FROM DOOR, WINDOW OR WITH CONDUIT MANHOLE COVER FRESH AIR INTAKE W / PADLOCK E C~v~o~~ ~~W, -WARNING LABEL f p0.Oa +_____- 4 " MIN . 2y a 18" IN . ~ S.D. ~ ~l 18 MIN• , INLET ~ ~ ~, I , WATER TIGHT SEALS GAS- ~ ~ TIGHT ~ ~, \ , ~/APPROVEO F~~TER - A , SEAL ~ JOINTS WITH zA$~~ ,Q_~oo ...1_ ~ ALM APPROYEO PIPE ' APPROYEO ' is"xll,'' B ` ` ' pN ONTO 3 PIPE 3 ~ ~ SOLID SOIL ONTO SOlIO C I ' SOIL PUMP OFF ELEV . ,SIFT. -~- OFF D 3" APPROVED BEDDING UNDER TANK CONCF;ETE PAD SPECIFICATIONS _Yet~l rY~,.l s T dt~ n.t~S SEPTIC I DOSE ~q, ~~ x .~ ~ ~1~_ ~~~. TANK MANUFACTURER: jiL~/eS~r TANK SIZES: SEPTIC $~ GAL. DOSE VOLUME INCLUDING DOSE ~O GAL. (o,.S~.~ 6a~,..FLOWBACK: ~~(o./a? GAL. ALARM MANUFACTURER: ~S'J, ,E/<<~--o .~S~,,,,sAPACITIES: A = ~O INCHES = Sr00 GAL• MODEL NUMBER: /o/ ~ g = 2 INCHES = ~_GAL. SWITCH TYPE: _,/~•Prc~..vt, X164 PUMP MANUFACTURER: 7rs•~~cr C = ~_ INCHES = 1~C~ GAL. MODEL NUMBER : D = ~ INCHES = aso GAL. SwiTCH TYPE: ~,.Y~, ~/obi REQUIRED DISCHARGE RATESI~ 6~ GPM PUMP ~ ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF ANA DISTRIBUTION PIPE ~ FEET + MINIMUM NETWORK SUPPLY PRESSURE ~~ FEET + ~l~_ FEET FORCEMAIN X ~~FT1100 FT. FRICTION FACTOR . - . ~? • i~ FEET TOTAL DYNAMIC HEAD FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID 6Ep'Y`A- ~$~~ ( o?S~¢.~. ~etr ~~ c ~~ /'"Pas .e ~$'e c T-+~~ .~Oe ~. 5f1 e SIGNED: LICENSE NUMBER: DATE: 1/88 OS6 S85ldlM~3ll~ g~trg-S~~-008 soot xavnNVr ~3ivo ~ 'ovi no oNO.~ /un '3oviaod/w+ 'H~oa N3aron - iMS~xe w~nvao 313d~U0~ ~3S~im ~31V4 'ON ~3a ,L=.,4/t ~3~V~5 _J ,^ V/ Q __ O N Z ~ ~ Ua ° Q cy ~ a ~ w a O ~ ~ Q ` ~+ Opp OO O o m o do WI-W Ca.~U ~ W Z ~ ~ . Gov ° ~ o (~ ~ ~ \ io M ao M of a a w in tD. ~ ° ¢ cv a r ~ ~ Y Nij00 ~ W WQOW ¢ JZ~ }: N N U / ~ ~~ ~// ~ VI _ MiO .. to ~'pJWF-U~.J-r W Z ~-(nN p ~ ~ ~ ~ d J .. O (n M~ pw~= ri-0¢ ~ Z~ OOw U ¢ w W m U W ~ cn Y ==~~o°O~~QU z~° oz ovU,~ z- a ° z a w o' Q ww°wj z: ~ao Q d~~¢~ s ~2 Jy ] N3 o ¢~..~ U U Z U g o Q J 0DU Z f' ~- ° _ O Y ~ J J ~ ¢ O Z Q ~ Z Z J V\ ~ ' ~/. ~ ~~~ w ~JN W LWi p~~U ~Om 4¢ ~ O~ ~~ „~lOl 3 ~~ W ~. S~ ~ w O J F-- ~ t L boot ~Ner ~n3a ~dnNdw oild~s oss~~ses ~d~nn ..~£S w r- W d' U Z O U W N W_ U Q z 0 U ° W N_ 0 F- N U w N m Y ¢z¢ ~ U ~ N W Y N_ Z ~ ~" O F- N U 3 ~~ w~ . 5 W w _0 a N ~ ~~ o Z o W \ W ~ N Z W f W 7 t7 W n N N I U Q W W U x w O r W W O O W ~ I U ¢' w Z Q g w N Y Z H ~• ~ •' HEAD CAPACITY CURVE NIODEL8 137n39 ~- MO DELS 137/1 39 FL Meters Gal ttrs . . 5 1.52 93 352 6 2s 10 3.05 79 298 15 4.57 64 242 s 20 20 8.10 36 136 25 7.62 8 30 Valve: l c Z8 R 1 s k o 4 10 S 0 -'-I- S. GALLONS 10 20 30 40 50 60 70 80 90 100 I 0 rERS 80 160 240 320 400 p FLOW PER MINUTE ooaes~ CONSULT FACTORY FOR SPECIAL APPLICATIONS • Three phase pumps are available in 200/208V, 230V or 460V. • Electrical attemators, for duplex systems, are available and supplied with an alarm. • Mechanical aliemators, for duplex systems, are available with or without alarm switches. • Simplex Panels are available for 3 phase pumps. • Control alarm systems are available for 1 phase pumps. , ~ t37 Series - 47 lbs. 139 Series - 51 lbs. SI Sesl Control Sa Netlorl Lb ModM Yohs-Ph Mode Am Slm CSA UL M13T1139 115 1 Auto 10.7 1 or 13 B Y Y N137I739 115 1 Non 10.7 2or267 3or536 Y Y ' BNt37 17 1 Auto 70.7 - Y Y D1371139 230 1 flub 5.8 1 or 13 8 - Y Y E13T/139 230 1 Non 5.8 a23T 3or568 Y Y • H13711 200.208 1 Auto 62 16 Y N • 1137/139 200.2(18 1 Non 6.2 2 6 7 3 or 5 6 8 Y N • J13711~ 200.208 3 Nm 2.8 4 334 or 568 Y Y • F1371139 230 3 Non 2.8 4 364 or568 Y Y • G137 460 3 Non 1.4 4 334 a 568 N N • 6139 480 3 Non 1.4 4 384 or 538 N N • No molded plug "Single PIA9Y~ switch included. Pumps krrlst be operated in upright position. Trine phase units require a control ae6tdl to operate an external magnetic contactor. For irkkrrnation an additional Zoeller prokhx:b roar b catalog on Piggyback Variable Level Float Swifdlra, FM0477; Ek~ctrkal AMerrlabr, FM0488; Metiwkicd Alterrlabr. FM0495; Alarm Padkape, FM0732; and Surrkp/Sewage Basiru, FM0487. SK373 • Variable level control switches are awlilable for controlling single and th phase systems. . Double piggyback variable level floel switches are available for vari~- level kxtg cycle controls. • 1Jver 130°F. (54°C.) fjpeciel 9uotatari required. • Refer to FMQ80t3 for Z00' F. applk;afNms. SELECTICIN GUIDE 1. Integral float operated 2-pole mechank~l switch, r1o external control require 2. S'rrlgte piggyback variable level float srritdl a double piggyback variable le that switch. Rater to FMO4n. 3. Mechanical alternator M-Pak 10-0072 or 10-0075. Refer to FM0495 4. Simplex three phase control panel. Refer to FM1228. 5. See FM0712 for kxxTect model of Electrical Attemator. ti. Variable level corltrof switch 10-0225 uteri as a control activator, speafy dupe (3) a (4) float system. CAUTION Ail installation of controls, protection drvicea and wiring should be done t a quallfisd licensed eNctrician. All ehrctrical and safety cods should t followed ineludinp fM most scent Natdlonal FJectric Cods (NEC) snd tt Occupational s+ah acrd Hullh Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. BOX 18317 LouavrNe, KY 10258-01311 Merwla~kaersd.. L•Q, ~~ SHIP T0: 3848 Cana Run Road • loulsvie, KY 10211-1961 j~i4tnT'P S.~' /939 • f5o2) na273f • 1(800) 928•PUAIP htrpJhvww.zoollsrcom PUMP !O. FAx(5o2) n43821 ® Copyright 2001 Zoeller Co. All rights reserved. 4 13/16 _ _~ i 1/2' - 11 1/2 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Paga 5 of ti FILE INFORMATION Owner STEV1 J~f5EN Permit ft LESION PARAMETERS Number of Bedrooms 5 ^ NA Number of Public Facility Units Q NA Estimated flow (average) 5U0 alJda Design flow (peak), (Estimated x 1.5) 75 al/da Soli Application Rate , ~P al/da /ft2 Standard Influent/Effluent Quality Monthly average ' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mglL ®NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD6i 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA 'rValues typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity 155 al ^ NA Septic Tank Manufacturer i,,-I~;SEK (;UNCl:1:1'~'~ ^ NA Effluent Filter Manufacturer ~Ai51JL ^ NA Effluent Filter Model A-1U~J 1L" XlU" ^ NA Pump Tank Capacity y5i~ al ^ NA Pump Tank Manufacturer `~;- ,; - .., :. ; ^ NA Pump Manufacturer ,. • , T';k 'Pii,.yj~ ('Q ^ NA Pump Model 137 ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: ®NA Dispersal Cellls) ^ NA ^ In-Ground {gravity- 17 In-Ground (pressurized! ^ At-Grade l~l Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: l ^ month(s) (Maximum 3 years) earls) ^ NA Pump out contents of tanks) When combined sludg e and scum equals one-third (Y,1 of tank volume ^ NA inspect dispersal cellls) At least once every: 1 ^ month(s) (Maximum 3 years) ~ year(s) ^ NA ® monthls) ^ NA Clean effluent filter At least once every: 13 ^ year(s) ® month(s) ^ NA Inspect pump, pump controls & alarm At least once every: 13 ^ year(s) ^ month(s) ^ NA Flush laterals and pressure test At least once every: 3 yearls) ^monthls) ^ NA Other. At least once every: ^yearls) Other. ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the follovring 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 tanklsl to identify any missing or broken hardwanj, 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. Tha dispersa{ cellls) 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 IY31 or more o the tank volume, the entire Cohtents of the tank shall be removed by a Septage Servicing Operator and disposed of in acconjance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressuriz~3d 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 an~J service event. r Page _~_ of `'_ TART UP AND OtSERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other Chemicals chat may impede the treatment process and/or damage the dispersal ce(lls). If high concentrations are detected have the contents of the tankts) 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 ceI11s) in one large dose, overloading the cell(s) and may'resuh in the backup or surface dischafp~i,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 Ito restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ^ 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 required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement. area"will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systerps 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. #c~ 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. --w.....wu .. AA11~~1C~IT@ _ . nnWTC IruCTAI I FR POWTS MAINTAINER Name ii:,LliI:;SUi\ L`nGAVA1'lUi`~ INC Phone 71~/ 7 71-327b Name JUH ' Phone 715/273-5811 ~EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name JUi-iiVSGi~ SANITAT ti Name . , Phone 715 'L73-5ts11 Phone 71- his document was drafted in compliance with chapter Comm 83.22(2-Ib-(t Ildl&If) and 83.5411), 121 & (31, Wisconsin Administrative Code. + . ,. Wisconsin Department f Commerce ~ ION REPORT Division of Safety and B 'Idings ,.,a ,, fl Pry Page ~ of JUG ~ iwoaacbrvance w r ~,ornm oa, vvis. twrn. .oar; 1 County S ~ /~ ® / ( Attach com lete site pl non a ~{~ 112 x 1 inches in size Plan must ~ p p , ~ . i l d b t li it d di ti t ~ f i t BM d nc u no m : ver on an u e, e eren po n ( ), rec percent slope, scale or imensi~, on and distance to nearest road. Paroel I.D. (~ $ ~" ~ ~ - ~ ~ Q Please prinf all information, Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ 3 Q Property Owner Property Location ~lju~ ~~S~h , ~ 11 Govt. Lot ~~ 1/4 W1/4 S~ T~~ N R ~ ~o E(o W Properly Owner's Mailing Address Lot # Block # Subd. Narrre or CSM# s6 9 c. r. ~. .~~ _ ,-- City State Zip Code Phone Number j ~~ Q " / ~ ' ^ City ^ Village own Nearest Road l ! ~ ~l Ut oc~c yLL~~ (7 Z ~ r6~ -a l Q IL h s~~l-e, O > e. ~a.c.~ C L~ rvew Construction Use: l.~" Kesidential / Number of bedrooms ~_ Code derived design flow rate ~d ©~ GPD ^ Replacement / ^ Public or commercial -Describe: Parent material L O ~ SS ©cJ 2 ~- ~~~ Fiood~iPlain elevation if applicable Air ~- ft. and ecommendations: ~5~ ~ 7 `~ / Y () / ~ e l ~ l%vl ~~ /o ~ ~ ~lc ~ b u ~ A GC rr ~ e,- ~p~ e ~ ~C~ G O~ C o ~t fain- 99 a0 r Boring # ~~ Bonng ( L~ Pit Ground surface elev.- ~~ ft. Depth to limiting factor .3aZ in. Sal lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 ®`I 3 `-- L ~r S ~ ~ ~ -~0 ~ ~ ~ CL vc b ~~ ~ a . 3 Boring # ~ Boring Q ~~ pit Ground surface elev. 7 ~~ r ft. Depth to limiting factor 3 ~ in. Sal lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EfF#2 I C~'~~' - 3 ----, S i L ~~ c S l ~ ~~ P~ ~ o~lt2 s L -K t. + u 1 u . ~' b5d - ~' .sy ~ o ~' S C ~I- '~ ~ * Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TS5 < 30 mg/L CST me (Please Print) Si re CST Number er1 n r~ e~ ~S~r., `_ ~ ~~~a 9~ Address ate nation Conducted Telephone Number -~la~y 77c~~-~. , ~4~~ ~ r ~,~ . Cl~ 1 ~e 1,~r ~ -3o.-a ~- 7 7 ~ - 3~ 7 g Property Owner ~~~~~~ ~~~~~ ParcellD# Page ~ of Boring # ^ Boring Ground surface elev. g 7, ~' ft. Depth to limiting factor _~Q in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DifP in. Munsell Qu. Sz. Cont. Cdor Gr. Sz Sh. *Eff#1 *Eff#2 I a - l~ 1Z ~ --- ~ .~ sb hit-t^~- cS r~ ~ F ~ ~ . ~ a ~, ~ -- ~ h,, s~~ t - ~~ ~~ ~, o ~ - ~ loy~ -- ~'~L~ ~1k u~~ ~ r~ ~, c~ 7Syk ~ ~- <S C~ uc s6 wt~'~ I' ~ ~ ----_. ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil licalion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fY in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. *Eff#1 *Eff#2 * Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL 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) ~cncL t- ~iQ t~ ~ o{ ~ ~ ~ ,.~8,, 't3•M ~ 4~~C~S . -r-o~, a-f ~~~ ~~~ ~ehc-e l~osf c~~b~~. R,bl~d~, Pa~~ 3 o f 3 (' ~ S . T'.' .~e v~ n ~ -c ~1 ~-~ ~ e s'~'~ ~~ ~ 9~ ~~OS. 3 ~ro c~~ ~I ~ ~~~~ 9~q °-o ICL~~ ~ ~- /,/ .~ ~. ~,.Nt ~ ~ (. ~' / ~ ~j-~,~~ a ~f ~'' ~U c ~, ~-e ~------~ ~Kce~°+ ~s ~how~ ~. on ~ ~,M- lo©.ob Td~ of ~"puc -~,~p e \ ~ ~ 83 1 1 y~e Sio~O '~ ~ I °~" ~ yo ,~ ~ ~ ~, ~ ~ ~~~ .~~ ~ ~~ i \ / II~ ~ OwnerBuyer Mailing Address Property Address ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ~Zo Ce~.~,r ~~'~.e~l- ~ ~-. ~ - S2 fit, ~ ~n~C a4o~ ~~~ (Verification required from Planning Department for new construction)- S~koDZ-- City/State N~ 0 ~~_ Parcel Identification Number ~G ~ " ~ d0 g' ~~ - O ~~ LEGAL DESCRIPTION c5~02g Property Location ~~ `/., ~.i~1._ `/4, Sec. ~ , TAN-R ~ ~ W, Town of ~.k ~ 11 ~ _ Subdivision Lot # ~ ~ Certified Survey Map # ~ ~ ,Volume ~f ~ ,Page # ~ ~ Warranty Deed # ` 0~ l9 ~. ,Volume ,Page # 3 Spec house ~ yes ~ no Lot lines identifiable ~ yes O 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 plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposalsysrem is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fuU of sludge. Uwe, the undersigned have read the above iequiremeuts and agree to maintain the pr'vate 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 da s of the three year expiration date. ~a /a /D5 SIGNATURE APPLICANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Offtce. ~~- Sa , a9~ 05 SIGNATURE OF PPI;ICANT 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 U, 2879 P Say State Bar of Wisconsin Form 7-2003 TRUSTEE'S DEED Document Number ~ Document Nam THIS DEED, made between Arthur D. Jensen, Trustee or successors Trustee as Trustee of the Arthur D. Jensen Trust, Dated July 6, 1999 ("Grantor," whether one or more), and Steven D. Jensen and Robin R. Jensen, Husband and Wife ("Grantee," whether one or more). Grantor conveys to Grantee, without warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): NW '/< of NW '/, of Section 3, Township 28 North, Range 16 West, St. Croix County, Wisconsin except the follawing: Commencing $i the NW corner of said Section 3; thence South 595.09 feet; thence East 50 feet to the pint of beginning; thence South 27.91 feet; thence West 17 feet; thence South 393.48 feet; thence East 275.41 feet; thence North 421.39 feet; thence West 259.41 feet to the point of beginning. Corrective Trustee's Deed, correcting the legal description of Quit Claim Deed dated July 11, 2005, recorded July 11, 2005 in Vol. 2840, page 520, Doc. No. 799983. Dated S ~ rp T~ nc t3 it >2 !, ~t~. 8r~s 1 ''~~ KATHLEEN H. wALSH REGISTER OF DEEDS sT. cROIx Co. , wI RECEIVED FOR RECORD 09/01/2005 11:45A?f TRUSTEES DEED EltEp~T 103 REC FEE: 11.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address Arthur A. Jeosar 569 Cty IZd BB wooa~;Il~, wI saoza 00&i008-AO-000 Parcel Identification Number (PIl~ * Arthur D. Jensen -Trustee (SEAL) (SEAL) AUTHENTICATION Signature(s) suthetrticated on ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St. Cmix COUNTY ) s Personally came before me on ~~? ~~ 6~ /, ?~S , TITLE: MEMBER STATE BAR OF WISCONSIN the above-named Arthur D. Jensen (If not, authorized by Wis. Stet. § 705.06) THIS INSTRUMENT DRAFTED BY: to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. L ~ ~~.---.----- JOfcl. KRAEMlKR * 3o~Kraemer o... Joel Kraemer Notary Public, State of Wisconsin My Commission {is permanent) (expires: June 14, 2009 tsi~u~ may he authenticated er aelmowkdged. Bo{h at+c nst raeoessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIF[CATION3 TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. TRUSTEE'S DEER ~ 2003 STATE BAR OF WISCONSIN FORM NQ 7-2663 • Type name below signatures.