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. Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552377 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: 024-1020-40-000 Case , William "Bill" Pleasant Valley, Town of CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: t CS 16.28.17.112C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER I jA CAPACITY STATION `BS / MI . ZFS E LIiV. Septic j 3 Benchmark 3 Z /45,Z_ i c. F'l /Z56 Dosing Alt. BM 3•Z, ~Q3.3 4fO ,boa J 3 7506 J Bldg. Sewer 5• yZ /01 , Z 1d k, ~ •n A Holding St/Ht Inlet 17Z3 St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 1 Dt Bottom /~I q JC , 7 /ad 1 1 `7 42 Dosing / Z / Header/Man. , Z /6 Z- cl( /4' 1 'i~Z Aeration Dist. Pipe 4.2- /d2T ~ ~ Z. Holding Bot. System _ /6 /r PUMP/SIPHON INFORMATION Final Grade 3•7-/63• Manufacturer Demand aand / St Co~,,ver ,3 •Z /63.3% (fin ~ J Model Number G 3 77, $9 J o vv~'o ~ T TDH Lift , RR Friction L s System H d5 T~H-!• t r `f Forcemain Length Dia. / I Dist. to Well 11-7 SOIL ABSORPTION SYSTEM ILd Depth BED/TRENCH Width Length No. O Trenc a PIT DIMENSIONS No. Of Pits Inside Dia. DIMENSIONS O 7S e SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CLEA HIR OR Manufacturer: ` INFORMATION Ty y J m :5-Y ) 1 -7 /JUNIT Model Number: 179' 1 1 - DISTRIBUTION SYSTEM A f Header/Ma ifg[d Distribution / x Hole Size / x Hole Spacing / Ven Air Int II .f . 7 44 Length Dia Z Pipe(sLength) Dia Spacing Zv T ? 32 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/S dded xx Mulc ed Bed/Trench Center Bed/Trench Edges ` Topsoil I Yes [E No Yes f-01 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: G / Z' / Inspection #2: W NA L t 2 -A,'5& Parcel No: 16.28.17.1120 Location. 1790 30th Ave. Ham ond, WI 54015 (SE 1/4 SE 1/4 16 28N 17 I~_ r 1.) Alt BM Description = r I CO J~- '0(a 4 2.) Bldg sewer length - amount of cover rl a I~ 'qZ. o Plan revision Required? Yes No ~ Use other side for,additionat information. Date Insepct s Sign re Cert. No. SBCi-6710 (R.3/97) PIS ' Safety and Buildings ivision Co Q ' 201 W. Was gto,~ Ave., P.O. Box 7162 , Viscoinsin Made, V►~T 33707 - 7162 Sanitary Permit Number (to beilled in by Co.) 8) 266-3151 5~/2 Department of Commerce State Plan I.D.Numb- Sanitary Permit Applicat~. In accord with Comm 83.21, Wis. Adm. Code, per~onal inform atiitiaye~a Project Address (if different than mailing address) may be used for secondary purposes Privacy Law, s15.lk1(1)(m) 1. Application Information - Please Print All Information t' s / fir:: Pareel Lot # Block # Property Owner's Name P( t iJ., .LI , n r ,1 Property Location Property Owner's Mailing Address 1 ® l/ S 4- 5ijE' Section /Z. City, State Zip Code Phone Number T N; RE o h/at kip H. Type of Building (check all that apply) Subdivision ame CSM Number 1 or 2 Family Dwelling -Number of Bedrooms ~ /S~N ~ ~ P ❑ Public/Commercial - Describe Use ❑City_❑VillageNTownship of El State Owned -Describe Use L III. Type of Permit (Chec We A. Complete line B if applicable) A. El New System eplacement System ❑ TreatmentlHolding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner / I Q V IV. T e of POWTS S st heck all that a 1 El El Non -Pressurized In-Grotmd Mound 24 in. of suitable soil otmd < 24 in. of suitable soil At-Grade El Single Pass Sand Filter Constructed Wetland ❑ Pressurized In-Group o ing Tank El Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line Grave less Pipe ❑ Other (explain) -V 1 V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application e(gpdsf) Dispersal Area Regt}ired (sf) Dispersal Area Prupped (sf) System Elevation DD yr ,t.~~ o -i /f O g //Ot~ CG D /!0 5a VI. Tank Info Capacity in Total Number / Manufacturer / Prefab site Steel Fiber Plastic Gallons Gallons of Units oncrete Constructed Glass New Existing VV Q L !i'~e 71) Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit D Dosing Chamber Ci !J VII. Responsibility Statement- I, the undersigned, assume res onsibili for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum s Sign a MP/MPRS Number Business Phone Number 1 Plumber's Address (Street, City, State, Zi de) U . S cam/t 6z I oun /De artment Use Only Sanitary Permit Fee (inc udes Groundwater Date Issued ing Agent ps) c Approved ❑ Disapproved Surcharge Fee) y~ 7 6-,m /3/ Al ❑ Owner Given Reason for Denial "T IX. Conditions of Approval/Reasons for Disapproval Cif` (/l^ ~`flrtti-e La v ,'C, " - SYSTEM OWNER: 1 Septic tank, effluent filter and l~ dispersal cell must all be serviced / maintained l) V~yi fA~ a as per management plan provided by plumber. 2. All setback requirements must be maintained s 1's 3 9 3 as per applicable code/ordinances. c j ZN; t,,;., Q t v~ Irrt s~ Attach complete plans (to the County y) for the system papeOr not less than Sles In size Q „ / ) SBD-6398 01/03) -rVl(~~ ~l e o ~ 00 w ° d~ v ON V z o 00 a cn o cn o+ o d. d ~ h rq I ~ L1 a- y v m Tt 0.. y 00 00 m Op ti 0.a o h F u 00 It IN, .moo °a a K 2 ~ r" ~ ~ Er o o~ J I~ O = 0.o W o ~ 3 z • c W o~ S x o t o ~ o .0 9 W h aw o y ~ ~ GL w ti ~ o R sue. ~ a 00 3 ~ II O p N Q a, 0.U q oa .y U w ~ 0 ~L °O O b ~ ~ ~ II b ~ y 'r pp h ; ~•O Wk ~ U d F a£a O ~ A II Go 14 ~ a ~ oo~o•~ m m $ Go II II it 0 N W 1 .-r N M VI 14 WPG~~E~ o a, Safety and f PART ~T 141 NW BARSTOW STBFL 4TH WAUKESHA WI 53188-3789 3 p Contact Through Relay P www.dsps.wi.gov/sb/ S www.wisconsin.gov ~o S Scott Walker, Governor ADO SSIONP~'S Dave Ross, Secretary June 06, 2012 CUST ID No. 648443 ATTIC- POWTS Inspector ZONING OFFICE KEITH E KNUDTSON ST CROIX COUNTY SPIA 927 150TH ST 1101 CARMICHAEL RD ROBERTS WI 54023 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 06/06/2014 Transaction ID No. 2093879 Site ID No. 780238 SITE: Please refer to both identification numbers, Bill Casey above, in all correspondence with the agency. 1790 30TH Ave Town of Pleasant Valley St Croix County SETA, SETA, S16, T28N, R17W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1375707 Maintenance required; Replacement system; 600 GPD Flow rate; System(s): Mound Component Manual - Version 2.0, SBD-10691-P (N.01/01); Effluent Filter 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. Conditions: The following conditions shall be met during construction or installation and prior to occupancy or use: • The existing POWTS must be properly abandoned per s. Comm 83.33 Wis. Adm. Code. • The building sewer shall be protected from frost per s. Comm 82.30(1 l)(c) Reminders: • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD-10691-P(N.01/01) and the SBD-10706-P(NO1/O1) "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems - Version 2.0. The building sewer shall be protected from frost per s. Comm 82.30(1 l)(c) 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. KEITH E KNIIDTSON Pale 2 6/6r2O12 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 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 ACr 0 Ross J Fu 11 W SMART code: 7633 Wastewater specialist, integrated Services (920)360-6140, ross.fugill@wisconsin.gov cc: Charles L Bratz, pOWTS Reviewer II, (608) 789-7893 St. Croix County Zoning Note: Effective January 1, 2012, A codes under the judsdicfim of the D'vWon of Safety & Buildings iWN be modified. Code references with prefixes starting with "Comm' will be replaced with "SPS' tD recognize the rebcation of the Nvis of Safety & Buildings from the fomhet Dept. of Commerce to the Dept of Safety & Professional Services. AdditionaNy, al SO codes will be renumbered and addressed in a'300' series. For future reference, the Wisconsin CommercW Buing Code A be addressed by SPS Chapters 360-366. MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Bill Casey Replacement Mound Owner's Name: Bill Casey Owner's Address: 1790 30th Ave. Hammond WI 54015 715-796-5252 Legal Description: SE1/4 - SE1/4 Sec. 16 T28N-R17W Township: Pleasant Valley County: St. Croix Subdivision Name: CSM Vol. 14 Pg. 3894 Lot Number: 2 Block Number: Na Parcel I.D. Number: Plan Transaction No.: Page 1 Index and title P O.W.T. S. Page 2 Data entry Page 3 Mound drawings Conditionally Page 4 Lateral and dose tank APPROVED Page 5 System maintenance specifications Page 6 Management and contingency plan DEPARTMENT OF COMMERCE Page 7 Pump curve and specifications DIVISION OF S F€T~Y A ILDINGS Page 8 Plot Plan ~f, SEE OR ES NDENCE Designer: Keith Knudtson License Number: MPRS# 648443 Date: 05/2 12 Phone Number: 651-470-1737 Signature: Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/01), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01) Version 5.1 (R. 06/06) Page 1 of 8 Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) R Residential or Commercial Design Note: Sand fill (D) calculations assume a 400.00 Estimated Wastewater Flow (gpd) Table 83-44-3 in-situ soil treatment for fecal colifomt of 38 inches. 1.50 Peaking Factor (e.g. 1.5 = 150%) 600.00 Design Flow (gpd) 7.00 Site Slope 99.80 Contour Line Elevation (ft) 14.00 Depth to Limiting Factor (in) 0.60 In-situ Soil Application Rate (gpd/fl) Distribution Cell Information 75.00 Dispersal Cell Length Along Contour (ft) = 8.00 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/ft) 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest oint in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) E Center or End Manifold 4.00 Lateral Spacing (ft) If N above, enter the elevation ft 2 Number of Laterals of the highest point. 0.156 Orifice Diameter (in) 2.33 Estimated Orifice Spacing (ft) = 9.38 ftz/orifice 1.50 Forcemain Diameter (in) 25.00 Forcemain Length (ft) Does the forcemain drain back? 92.00 Pump Tank Elevation (ft) Enter Y or N 4.55 System Head (ft) x 1.3 2.29 Forcemain Drainback (gal) 9.13 Vertical Lift (ft) 67.41 5x Void Volume (gal) 2.54 Friction Loss (ft) 69.70 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 34.46 System Demand (gpm) 16.22 Total Dynamic Head (ft) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 x x 1.25 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/Inch Calculator (optional) Treatment Tank Information Total Tank Capacity (gal) 1250.00 Septic Tank Capacity (gal) Total Working Liquid Depth (in) Wieser Concrete Manufacturer gal/in (enter result in cell B49) Dose Tank Information Effluent Filter Information 773.76 Dose Tank Capacity (gal) Pol -Lok Filter Manufacturer 16.12 Dose Tank Volume (gal/in) PL-525 Filter Model Number Wieser Concrete Manufacturer Project: Bill Casey Replacement Mound Page 2 of 8 Mound Plan and Cross Section Views '1/10 B ; • ; ' ' ' Observation Pipe . • :4u : : : - A •5 W r.- :B z . L Mound Component Dimensions ft A 8.00 ft E 28.72 in H 1.00 ft K [Aft B 75.00 ft F 9.50 in 1 13.99 ft L ft D 22.00 in G ft J 7.75 ft W 600.00 (fe) Dispersal Cell Area 1649.53 (ftz) Basal Area Available 8.00 (gpd/ft) Linear Loading Rate 7.50 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 103.43 (ft) ♦ H G j (ft) Lateral I F Dispersal Cell 102.13 101.63 (ft)-► - Invert Dispersal Cell: Elevation E- ~ 99.80 (ft) Contour Elevation 7.0 % Site Slope # Geotextile Fabric Cover Shading Key Dispersal Cell See lateral details on 1❑ _ Topsoil Cap o C 1.5 ft Page 4 for number, size, Subsoil Cap o and spacing of laterals. Laterals are equally © ASTM C33 Sand F spaced from the Typical Lateral Tilled Layer c 0 ft distribution cell's Aggregate o centerline in the * A _ distribution cell (AxB). Project: Bill Casey Replacement Mound Page 3 of 8 End Connection Lateral Layout Diagram Laterals centered over the A T. 8 dimension ♦ = Turn-up vdball valve or cleanoutplu g P .I All taterals are edent.cal I<- X )I Moles drilled on the bottom of the taterat S equaly spaced Force main connwion via ter or aoss to manifold at arq point. Laterals force main of PVC Sch 40 (per COMM Table 84.30-5) Number of Laterals 2 Orifice Diameter 0.156 in 5/3L Lateral Diameter 1.50 in Orifice Spacing (X) 2.37 ft Lateral Length (P) 73.47 ft Orifices per Lateral 32 Lateral Spacing (S) 4.00 ft Orifice Density 9.38 ft2/orifice Lateral Flow Rate 17.23 gpm Manifold Length 4.00 ft System Flow Rate 34.46 gpm Manifold Diameter 1.50 in Total Dynamic Head 16.22 ft Forcemain Velocity 6.26 ft/sec Dose Tank Information Locking cover with warning label and locking device and 'G/ sealed watertight Electrical as per NEC 300 and -0 Comm 16.28 WAC 4 in. min. Disconnect Tank component is properly vented Alternate outlet location Forcemain diameter Wieser Concrete Manufacturer _ fi 1.5 in. Capacity 773.76 Gallons Volume 16.12 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 29.68 478.38 B 2.00 32.24 C Pump off elevation (ft) C 4.32 69.70 93.00 rr D 12.00 193.44 D rNaft% Puin ee~~h Star, Total 48.00 773.76/ I_ Do♦ se tank elevation (ft) C~ e [X{T . 3" Bedding under tank. 92.00 ~J A D;m n~ r✓s GaIIa ~r Alarm Manuafacturer S.J. Electro Alarm Model Number Tank Alert S-0 .5U S ,00 a.a Pump Manufacturer Goulds C ( 6_b /U 78 Pump Model Number EP05 D /,2, 06 193. Pump Must Deliver 34.46 gpm at 16.22 ftTDH - /All o it 773 74 Project: Bill Casey Replacement Mound Page 4 of 8 • Mound System Maintenance and Operation Specifications Service Provider's Name Powers Sanitation Phone [2:1:5:-:2::4§6-57~~8 POWTS Regulator's Name St. Croix County Zoning Office Phone 715-386-4680 System Flow and Load Parameters Design Flow - Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 400 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1250 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600 ftz Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once eve 3 ears Effluent Filter Should inspect and clean at least once eve 3 ears Pump and Controls Test once eve 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Inspect for pondin and seepage once eve 3 ears Other Miscellaneous Construction and Materials Standards S P5 1. Observation pipes are slotted and materials conform to Table Eom484.30-1, have a watertight cap, and are secured in as shown in the mou mponent manual. 2. Dispersal cell aggregate conforms to G X4.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished • • • • • . . . . . . . . . . . . . . • • • • • • • • • • • • • • • Grade vl 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Bill Casey Replacement Mound Page 5 of 8 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01/01), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BODS, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BODS, 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically cogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Pretreatment Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project: Page 6 of 8 Page 7 of 8 HGOULDS PUMPS Submersible Effluent Pump 3871 EP04 t EP05 0 APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower grade turbine oil for tic enclosed design for heavy duty ball bearing Specifically designed for 0 e lubrication and efficient improved performance. construction. following uses: heat transfer. • Effluent systems ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms manual operation. Auto- superior strength and corrosion Cwmdianstandards Awociation • Heavy duty sump matic models include resistance. _ • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron (CSA listed model numbers end • Dewatering assembled and preset at the for efficient heat transfer, in "C" or "I"'.) factory. strength, and durability. SPECIFICATIONS ■ Motor Cover. Thermoplastic Gotlds Pimps is ISO 9001 Rwjswed. FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. 1/4" maximum. ■ EP04 Impeller: Thermoplas- E Power Cable: Severe duty • Capacities: up to 60 GPM. tic Semi-open design with rated oil and water resistant. • Total heads: up to 31 (Let. pump out vanes for mechanical • Discharge size: 11/2" NFr. seal protection. • Mechanical seal: carborr- rotary/cera m i c-s td b o n a ry , BUNA-N elastomers. • Temperature: 104°F (40°C) continuous 1401F (60`C) intermits ru. METERS FEET 10 i • Fasteners: 300 series _ stainless steel. • Capable of running 9 30 5 GPM dry without damage to $ 2.5 Fr components. 25 0 7 Motor: _ • EP04 Single phase: 0.~ HP, v_ 6 zo 115 or 230 V, 60 Hz, 1550 a - RPM, built in overload 41th r s automatic reset. a a 1 s • EP05 Single phase: 0.5 HP, o EP05 115 V or 230V, 60 Hz, 1550 3 10 - - RPM, built in overioau with EpOq automatic reset. z • Power cord: 10 foot s standard length, i 1 S1TOW with three prong o o grounding plug. Optional 20 0 1o zo 3o ao So GPM foot length, 16/3 S1ihl ~^Jth three prong groundi;-~. 1, lu g o z a s a 10 12 m3i11 (standard on EP05). CAPACITY Goulds Pumps ® 2001 Goulds Pumps ITT Industries Effective May, 2001 B3871 o 00 a t) II ra, o W 3 0 0 r, U - v 13 o 00 p ~ to a Q, Ld Vj ~1 Col M 7 y 7 1' 1 M M rn V ~i ^ v 1~ 01 13 VN, ~ N N h y ~ O p 0 U `ti^' y V .oM F4 I N O ~ ~ ~ ~ ~ ~ ~ O Q' M ~ Q M rrww ~0 0~ O ~ Qp ~ O oxi J W a W y ~ d of o y M L n ~ O ~ .y ae w n \ GL ~ ti Y( ~ O y O Op V U o y Op. i evl N y a ~ d b ~ y ~ C N A •t3 ,a ~ O y -0 h r ry U a o q ~r ~ o e o 0. o6 o ~ u h y U F a A I a~ A o o ~o v, w S o o w z A°,, ~ u u u o Ia CIA en 06 4t 4~ 4t o 'y , ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ! L L Mailing Address 1220 ~n Property Address / ) !5~z> z d y (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number I ~/Z 7 ld 2 0 ~~0 0.44 LEGAL DESCRIPTION Property Location_ -W, Town of i/4 '/4 Sec. T Subdivision Plat: Lot Certified Survey Map # & 2-b V ~ , Volume l , Page # Q Uhl- CLAWLA W,aF~ty Deed # 3 g (D X (before 2007)Volume , Page # Spec house ❑ yes 7-fio Lot lines identifiable L?yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §C,e 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. 5P5 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. 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 \j 4 tyw%~_ rj( SIGNATURE OF ANT(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. 09/07) Y ~ Wbwndn DapMWW t of Ca Mww SOIL EVALUATION _REPORf Page / of t9ivi~ionof wand 8uian~ vmComm 85. Wis. 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Paroel K) # page Z of # oo*v e ®Pk (,~ratsrdarsfaosalsv 7 LL # Deptl' b lini+8 tec+or Sol ~Bdarr Deacdpkn Tardare Shuahse Bourdwy boots ta'P0W Horizon Dq* Don*wt or. SL Sh AEWI OEM2 in. kkmm CkL SL Capt. Color e- or. sG Z M c sr `r cwt ~ . Q F% Gmwda.taoedsv- oep6rbis e r sot P-m. # O Horimn Dop& Dom%"Culm Re*K Dasaipl m Team Saudrae cm*wnoe 8aadsy Roots GPD kL t CkL Sz Cad Cdor or. Sr- Sk 'ESL II ' I - F-I # ° mov ❑ PR pioutdsut<soeoleir. R Depr►b feanr in SdAnkaWn l~ Hot= Dwft- Danirnnt iiYertorrDesaiption. Te&e SY XWD cmalm m Bourdoy Roans GPDR im Mulled err. Sz Cori. Color tar. SL SIL 'Ew a" ~ •dttu.nt#tt.9Ops!3pS12oIrpllaldTSS>30<_150n1011. 'tftwt#2=OW,_S30nWLandTSS<_WwA& MW Dept of Comet= is= cqW anortnnity service Provider and pgrl"w If ym noed a fm access services" _ aced msWW m an alb mft I'omaa1. Please = pct tine depmtma t at Mg-266-3151 or TIT 60&M-8777. \ 1 `J l 1 4 \ ~ ~ p N •V w~ ~ry i \ ~a so g i a ® Y a S 8 w ~ x h c r q_ y w It It 11 A In A - IR- y \ N IL f] State Bar of Wisconsin Form 3-2003 8 0 3 0 6 3 5 QUIT CLAIM DEED Tx:4021672 Document Number Document Name 937868 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between William D. Casey and Barbara H. Casey, husband and 06/21/2011 11.51 AM wife. EXEMPT#; 16 ("Grantor," whether one or more), REC FEE: 30.00 and William and Barbara Casey Joint Revocable Trust dated June 8. 2011 PAGES: 2 ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Recording Area Wisconsin ("Property") (if more space is needed, please attach addendum): a Name and Return Address Jennifer A. O'Neill SEE ATTACHED ADDENDUM O'Neill Elder Law, LLC 900 Crest View Drive, Suite 220 Hudson, W154016 024-1020-40-000:024-1019-80-200:024-1019-80-100 Parcel Identification Number (PIN) This is homestead property. (is) (ismot) Dated June 8. 2011 I r-] I l~s s (SEAL) (SEAL) *-William D. Casey G (SEAL) (SEAL) *-Barbara H. Case AUTHENTICATION ACKNOWLEDGMENT Signature(s) William D. Casey and Barbara H. Case husband and wife. STATE OF WISCONSIN ) ) ss. authenticated on June 8 2011 COUNTY ) Personally came before me on , the above-named * J ifer A. O' 111 Attme at Law TITLE: ME R STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Notary Public, State of Wisconsin Tiffany A. Petersen, O'Neill Elder Law, LLC My Commission (is permanent) (expires: 900 Crest View Drive, #220, Hudson. Wisconsin (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003 * Type name below signatures. 1 of 2 ADDENDUM TO QUIT CLAIM DEED GRANTOR: WILLIAM D. CASEY AND BARBARA H. CASEY, HUSBAND AND WIFE GRANTEE: WILLIAM AND BARBARA CASEY JOINT REVOCABLE TRUST DATED JUNE 8, 2011 PIN: 024-1020-40-000 024-1019-80-200 024-1019-80-100 LEGAL DESCRIPTION: Lot 2 of the Certified Survey Map recorded in Volume 14, Page 3894, being part of the Southeast Quarter of the Southeast Quarter (SE 1/4 of SE 1/4) of Section Sixteen (16), Township Twenty-eight (28) North, Range Seventeen (17) West; AND Outlot 1 of the Certified Survey Map recorded in Volume 19, page 4946, being part of the East half (E 1/2) of the Southwest Quarter of the Southeast Quarter (SW 1/4 of SE 1/4) of Section Sixteen (16), Township Twenty-eight (28) North, Range Seventeen (17) West; AND Lot 4 of the Certified Survey Map recorded in Volume 19, Page 4946, being part of the East half (E 1/2) of the Southwest Quarter of the Southeast Quarter (SW 1/4 of SE 1/4) of Section Sixteen (16), Township Twenty-eight (28) North, Range Seventeen (17) West; All in the Town of Pleasant Valley, St. Croix County, Wisconsin. 2of2 r FILED JUL 1 4 2000 f 62d~~ KATHLEEN H. wAtSH 1p 8e~ster oI Deeds CERTIFIED SURVEY-MAP N fNILLIAM AND BARBARA CASEY Part of the Southeast 114 of the Southeast 114 of Section 16, Township 28 North, Range 17 We&, Town of Pleasant Valley, St. Croix County, Wisconsin. APPROVED ST. CROIX COUNTY Planning Zoning and Parks Committee h UNPLATTED LANDS g I N 9v-00'00" E 498:32' JUL 14 2000 ° If ° not faCOlded Within 30 days of t" ° approval dale approval shag be w nPN and ~ ° ° 1nOid r FENCE I TYPICAL) g 2 r O - z 3 E 114 CORNER SEC. !6, r 28 N, R 17 W S 90' 00'00" W 64.27' (P.K. NAIL FO[/NO} o LOT Z . iH 8.643 ACRES $ N VPLATFEO LANDS a 376 30G SO. Ff. ~ a 4 6.313 ACRES EXC. RDAD R.O.W. W m 4i N 2 1. 363.414 SQ. FT. N 90' 00' 00" E 660.65 U ar C~ to w ,?S ttl ~ "'3 it X10.65' 100= ° LOT 2 zI o ro SEPTI'C 5.909 ACRES I tl1 sl Q O 2 257.23850 _ FT. j Z Z . 9001 ACRESEXG. ROADRO. w In SHED I a _ a ~ W ~f ~ f 217.052 SQ. FT a O 1 I 0: z I, in a - r - - _ - _ _ - - _ _ - - wELL- _ ROAD SETBACK LINE WWWA CL 1540.53' N 89.54' 35" E 103U92' °f g a1 & z so' y i 414.06' 6!6.86' 414.05' 1081.46' 667.41' -IMT _ SOU LINE SE 1 4 CENTERLINE N 90 OOVO"N/ 2621.99' 40' 1.~ - S 114 CORNER SEC. 16, T 28 N, R 17W ! 41.23' UNPLATTED LANDS (P. K NAIL FOUND] SE CORNER SEC, t 6, T 28 Nl, R }T 16L (BERNTSEN CAP FOlJI1fD) 1*14 SCALE • $00, O 100' 200'- 300' 400' 600' d00' All bearings referenced to the South Into of the Southeast 114 of Section 16, LEGEND Township 28 AbM, Range 17 West, assumed N 90 00100"W • .Indicates 1"x 24" iron pipe weighing 1.13lbs.1lin. R set. o Indicates sod boring for proposed septic sde. This instrument drah`ed by Laurence W. Murphy LA W. Dated. April 24, 2000 "Revised this 12th day of July, 2000." Owner's Address: 1790 30Th Ave. LAND Hammond, W/ 54015 Vol. 14 Page 3894 SKEET 1 OF 2 id ` - 9 D C SEP 6 2000 (t.1 FILE - 626406 U L 1 4 2000 ► ATHLEENH.WALSIi 18 ST. Cla01X COitNT`( Register of ?eeds SURVEyo NPAD CERTIFIED SURREY MAP v WILLIAM AND-BARBARA CASEY Part of the Southeast 114 of the Southeast 114 of Section 16, Township 28 North, Range 17 Westin Town of Pteasant. Valley, St Croix County, Wisconsin. APPROVED ST. CROIX COUNTY Planning Zoning and Parks Committee cn UNPLATTED LANDS N 90' 00'00* E 498.32' J U L 14 2000 IN N If not recorded within 30 days of ALI to approval date approval shall be a o null and void .J N h ~t Q. FENCE f TYPICAL Q g W E 114 CORNER SEC. 16, T 28 N, R 17 W S 90' 00'00" W 84:27' `von a (P.K. NAIL FOUND) o j w . LOT 1 p N 8.643 ACRES amo N UNPLATTED LANDS ~ a I Z) co 8.343ACRES EXC. R AD R.O.W. W wM ~ N 'on 363,414 SQ. FT N 90 00'00" E 660.65 U N 1.2 W w DI tg iv o O fi10.85' l~ l ' I e SEPTIC LOT. i Ui j v c~i J 1 (L a 2 N 257,238 SO. FT 1 Cn W I Z 2 SHED 5.001 ACRES EXC. ROADR O. I 2 r 217,852 SQ. FT. I lit .1 = I ~ d A KNELL ROAD SETBACK LINE N ' o - - - -0_ DNS{ LM1G 1540.53' - $ N 89' 54' 5"E 1030.92' °i g et 5 j I 41 .06' cy 616.66' g 50' } y _ 4 - 414.05' 081.46' 667.41 ' SOUTH LINE SE 114 CENTERLINE - N 90°00'00 1t/ 2621.99' 40141.110 S 114 CORNER SEC. 16, T 28 N, R 17 W UNPLATTED LANDS t 8125' (P.K. NAIL FOUND) SE CORNER SEC. 16, T28 N, R f7 W (SERNTSEN CAP FOUND) SCALE 11'r 200' o 100' 200' 300' 400' 600' 600' All bearings referenced to the South line of the Southeast 114 of Section 16, Township 28 North, Range 17 West, LEGEND assumed N 90 00'00"W • -Indicates 1" x 24" iron pipe weighing 1.13 lbs.llin. ~~tlr ft. set. Indicates soil boring for proposed septic site. CQ This instrument drafted by Laurence W. Murphy LAU {Y W. Dated: April24, 2000 1 N j "Revised this 12th day of July, 2000." Owner's Address: 00 1790 30Th Ave. LAND ` Hammond, W/ 54015 manna Vol. 14 Page 3894 SHEET I I~ RECEIVED • 7 8 9 9 3 6 APR q O yV1C VOL 7 9 PAGE 4946 Tip L LVW REGIS~R pF DEEDS ST. CT ER MI 66' x cn a w n~ L 'nW t Z RECEIVED FOR RECORD ► X W. CRUX (mil )NW K m 03/18/2"5 12 :15PH ran) BtJRV YOH'8 RECORD X CERTIFIED SURVEY MAP v cn z z z z g F, REC FEE : 13.00 co' Cn z A a r $ $ ° $ COPY FEE : 3.00 m z q; T m: o ° mK can a vm, PAGES Z. 2 < m-' T E G) A O 8 O g m m z z O ti°p OR o Z~ Z m p m m 4 OoNi v s `b" $ N ovZmN J~O 0 N 0, 9 c= mm 23 m m tn>e -q~ p r zz m ° kT O~ rn to &7 ~1 I w cn g n 3 m r IC I A A , z o Z Z N do4 c°aom_ON I " a MO[~° ~2 PCo X349 CU I "p m ~mm - - - - - M_G]_PL 144f D r A m p -i 00°03' 2"W 13 3.0 I--~1--~°-~ O 28;93' 1284.10 z Z 166I z -4 O2Zm z = M co I(~~ m arm- Z M C p 17~ I O 1+ m m m 0) 40 T -n > Q ! a Ya O j O a Eg I- "n cn C . cn fn T I+ w M M NY/ v ° m. O I~ ^ I~ A Q m o A M N - - - - _ m: EAST LINE OF THE SWIM OF THE SE1/4 i' A y ~Q m WEST LINE OF THE SE1/4 OF THE SE1/4 j~ O O Q m d I s 0 °41'oo, M n _ 29.59 635.68' 202.ao' co c m I~ s00°41'00"w 668.27' x m ij m ao W o I ° W Z N -A m,A z o I 63 IQ j jC C3 id m N m O (n 3 lig z i P I i I m o o NOO°40'89"E m Q m N o I~ 122.10' \ z -4 D c_ m D ¢-T v) I rr= o T Z O nOI m I~ IQ I IPIO m ~~S~F ► ► r"' Z- m m N00°1%57"W m my 1~ I ° t~ Ip I~ rn n ' 178. T p ~z m m I~ IO 1 I / II°O I~ mm~m r ► ► ma m 10 66 'Bib 1° O O z I+ 1 C) cn 4G**7 3 33 33' d' I ;di~ A %S~o m$8' cf) 66' ~ 0 'S7"E 567.28' w ~T- ~ EAST LINE O THE SE1 4 aQ_ w p - - - - - - - r ' S00°18'57'E 745.9T $00°18,57"E gT.2~- S0(r18'57"E 1313.25-~ m m m 1 MG`IJp[~QS L D (~l~l_Mn_QS~ 2 c° M~ S vy 0:0 z I On _z z m rn~I BEARINGS ARE REFERENCED TO THE ST. CROIX COUNTY GPS NETWORK \ NAD 1983/91 VOI.19 Page 4946 4*4 i t Parcel 024-1020-40-000 08/01/2006 05:32 PM PAGE 1 Alt. Parcel 16.28.17.112C 024 - TOWN OF PLEASANT VALLEY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner WM D & BARBARA CASEY O - CASEY, WM D & BARBARA Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1790 30TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 5.905 Plat: 3894-CSM 14/3894 SEC 16 T28N R17W SE SE LOT 2 CSM 14/3894 lock/Condo Bldg: LOT 2 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 16-28N-17W SE SE Notes: Parcel History: Date Doc # Vol/Page Type 12/20/2004 782935 2718/230 EZ-U 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/10/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 15,000 68,400 83,400 NO AGRICULTURAL G4 3.905 500 0 500 NO Totals for 2006: General Property 5.905 15,500 68,400 83,900 Woodland 0.000 0 0 Totals for 2005: General Property 5.905 15,500 68,400 83,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 139 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1 , ° ~ 3v0 d L1 > > ° o CD (D _ r4.O1 0 0 O v ai O N N rn A ~ =r 3 3 CCD FD V CD w N rl m y U) 00 A a l~D Z z O r.y 41 C = m J W= N C 0~`D C\ A m fll o N N Q i"S j O O = N m w N O O N co to 3 ° o n 00 O,r O 0 c O v co D co n, 0 o. S o, C W A CD OD cin C a I rv NO Na 3 N L j O f0° O m O C1 CD co N 0 0 3 y S°► Q O 3 !r M O O O a CO) CA CO) a n' D 'D N ~ Aye' CT A c CD .r W co N I ca =r "m. C N Z CD C ~ d ~ O 7 N j 1 CL c A z m N m •U p O 0 I CD m m OD CD CD g z cn - A m 4 y Z m A A ~ I w CO a O D ` m > > n v, N c D m o a 0-0 N 7 O 7C < 0 d -4v z CO y VC 4Z CL 1 0 co w O I N y o o. N o m a°ro <n O A I ~ ~ o y °O i_ ti AS BUILT SANITARY SYSTEM REPORT 'OWNER TOWN S H C. T R W ADDRESS • ST. CR fij X C UNTY WI ONSIN . ` j-7 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I . jf di ate North Arrow S CAL SEPTIC TANK(S) / -MFGR. kp, CONCRETE A-~ STEEL . o rings on cover Dpnth PUMPING CHAMBER SIZE r Uri!' i-L Get MODEL GALLONS er Cycle , TRENCHES NO. of width length area ,BED NO. of lines 4 3,1 width % length Z area+~yg dept to top o pipe NUMBER OF SEEPAGE PITS outside diameter total pit area AGGREGATE PERK RATE RE REQUIRED AREA AS BUILT Disclaimer: The inspection of this system by St. (Croix County does not imply complete compliance with. State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR, DATED O PLUMBER ON JOB LICENSE NUMBER r j job ~r 7SO , l3` 8 3 9 l Al?-3 9'~. o 4 I RI, PORT'01 INSPECTION INDIVIDUAL SEWAGE SYSTEM . San ta,gy Pc.nm4 t w2 yx State, S e p -t.(. c__V_q~ _ SAME Towne hip --St. Cno,i"x County' „ca.t-c.orl _S6--Iq~ Sec".tio r _ot Subdi vibi on 1 I' _IC TANK S4, ze ga Iona Numbe.n aA eompa4tme.nts i ancV Ajhorn: Wo.t 8uifdi ng_,Oepi 1.20 5tope - Htigh.waten _ LIMPING CHAMBER S"+ ze 7~e~ gakk-are Pump Manu6actune.4 Cif Mode-x Numbe4 ~L~INc, iANI~ " S.i"ze gaffo N mb n ompantmenth Pumper- - A i rS4m ra.tance {nom: Wett Building 12% 6tope H.Eghwaxe.n IitiORPT"ION SITE lied T~Le.nch i-Stance Ano I. Well Bu-i ding___ r2a e~ope- Highwaten I,;tiORPTION SITE DIMENSIONS W i d"th o 6 ,tne neh -At Re..q u.tn-ed anea_ --_-~,t_ 1_vnlth oA each tone Z 4t Depth o6 rock betow -ti e~__ - cn Number, o6 k.4'4qe,6 _.3 Depth oA rock uve-n .tik"e_~ A _ c.n 7'o tae I'eng.th 06 tine.,s _ 1LL--- 6t Depth o A tite bekow gnude___ ~-n D.ietan'ce be"tween einea 6•t S.Eope oA .tn.eneh kn. pe.n- 100 6t ~ Totat abaon.ption an.e.a~-- At Type oA Cove. n.: ap on 6V aw 17 D I ME_NS I ONS. Numbch u{ p4 is G&avek- around p~ 4 yee_---_--na Outside diameteh- - Jt De.p#h bekuw tinfex _--~•t Iotae abi,uit pt•i.on cne.a b"t Area aecfu,0Lcd At CIA NS III CTI O fSY TITLE 111) ROVED DATE 19 ore ww- 'f. Jf CTrD DATE 198 It ASON FOR REJECTION ` State Permit # PLB67 State and County Permit Application County Permi # ~ y7 for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER F PROPERTY Mailing Address: B. LOC TION:'/a ction N, RJ7 E (or) W Lot# City_ Subdivision Name, nearest o , lake or landmark Blk# Village 7 Townshi CC/ ~ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family __A!!~jDuplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher _/YES NO Food Waste Grinder YES y # of Bathrooms Automatic Washer S(ES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement Prefab Concrete L~ *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1►.30 2) 3) Total Absorb Area sq. ft. New Addition Replacement *Fill System eeprage ench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ ed: Length Width r Depth It Tile Depth /8 a No. of Lines ~J Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Di ance from c slopeT I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Ce i ed Soil Teste , NAME C.S.T. # and other information obtained f m (owner/builder). #Z Plumber's Signature .IW~'/MP #-Phone Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). Do Not Write in Space low FOR DEPARTMENT USE ONLY Date of Application D Fees Paid: State County Day sa d _Issuing Agent Permit Issued/fkjeeted (ate) / d Nam Inspection Yes-No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, W 2. state (pink copy) 4. plumber (canary copy) Ravi 13762 . REPORT ON INSPECTION OF SANITARY PERMIT (1 Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Time of Inspection ame, ress, icense o. o s a ing Plumber (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepa a Bed ❑ Holding Tank ❑ Fill System ermanen reference Point) escri e: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO 8 HOLDING TANK: Manufacturer o ga ons ; construction ; depth to the cover ft; If septic tank is being used are baffles removed? YES ❑ N0; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE R N . Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? E]YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.05/8 Signature of Inspector: PLB 108 4/80 WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH O CT 13 1980 P. 0. BOX 309, MADISON, WISCONSIN 53701 Q C APPLICATION FOR THE USE OF A MOUND SYSTEM 8005044 i• i• •i i4 i~ i• i• 1 i• i• i• i. ii i• V i4 I Location 1/4 S 1/4 S T N, R 1 E (or) W Town or Municipality ~1C~SJSc~,, VQA e)Y Street Address I Lot No. Block Subdivision County vo• ' .Y Landowner's Name: I ~,,.t vL Mailing Address: eT atM1M0tA LIC~oLASiIn S~`ldl t .i i~ i. i. i4 i• 4 V .•4• i• iC V it ~ •i i4 a I (We), the undersigned, hereby make application for permission to install a mound system on the above-described premises. I recognize that the above premises are not suited for a conventional septic tank-soil absorption field. If permission is granted, I agree to have the system installed in conformance with the Division's approval of plans and specifications. I further understand that the alternate system is more complex in nature than a conventional septic tank system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Division employees or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspecting the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system.. r I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Division will send the applicant a Letter Authorizing the Construction of a Mound System. I agree to give notice to any subsequent buyer that an application for an alternate system has been made and if installed, that the premises are served by an alternate system and further agree to give that buyer a copy of this application. The Division receives this application-subject to this understanding and subject to all the conditions and obYigations set out in t a "Cation. (or, I) ~ VV Date' Signature of Ap licant STATE OF WISCONSIN) Subscribed and sworn to before me t~ s s . County of.,s~ ) this 13- day of 19 i~f) . Notary Public, State of Wisconsin My Commission expires: I~tS - EH, 115.Rey. 9/78 t REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES OCT 13 1980 P.O. BOX 309, MADISON, WISCONSIN 53701 8 0 0 5 0 4 4 t V~ LOCATION: ~ %,.iE%, Section NO ,TKkN,Rt? @46N W, Township kil"Ifty Lot No. , Block No. County 4"C, cft tyL ,-1 ub rvlsion Name Owner's/Buyers Name: y`tM ,1 e; Y Mailing Address: & LT N9tV6 CeRh &1M/ CEO 54o 1 S TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT~ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS Q---- SO PERCOLATION TESTS 4-gAi4i L5 -so SOIL MAP SHEET 8S NAME OF SOIL MAP UNIT SO-CZ- PERCOLATION Saw c S 4 ~.°a.u.~• PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD I PERIOD 2 PERIOD 3 P- Z4- 5eir 1~61L+>j4 tr-k DA-M ZZ J'A nLr, 3o I I 30 P- z 24 z 9A7% Z, Z, mosid 30 7/6 "7/i 3 P- 3 3 t7. wm zz ONE 30 1 I 1 3d~- 4_0 P- P- LT n~ ~rw 3es rx-M (.'O!4.1 M L o ¢-p P SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST Q IF OBSERVED IN INCHES B- .,7D.% IJO A~ /r 70" 614 1/t7, L z.Z+n IS l' -Zo it `s Gr GS ~ Gv -W B- $ l Oovd. 7050 L c i -.11 " 1 Z N Nt S to" Cr. B- 3 No uE 54", - 13% L In" 17. i s cs Zoe sst4 644 B- 5 73 IVot3L a~3 Qr+ L It~.`° sl ~d~" 1 ZS" w►acl 5 B_ PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. *`Tv eA iA-Il on7si"I iZCQubQ (oot7 ,~i~~Z. FoL ¢ $QAtM fiDa- 611 ~LC~L~'1~M'OYi~ CIO CZ. V~t'~►S 10 AA 00 40 1 _ 9 9 , to ~ ~ o~ I 9°I = dal° .,4,~. Pz w S ~aaQN dQ3 134 i .P , a6, r i : tiw LOT 9I4_0 A, 8 fJ p I L d-tv~S ~Of1. ~ tt _ W Ear- ~ ~ - ~ - CL07~ 160.77 S ' l/ x F c t € e L4( boo T I ii LS 4k, R- ►`I W M G ~,8 D w► - j too. 00 I, the~under~s'igend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. ` Nl ~ aQt~Y Name (print)er t.._ Certification No. Address 31 . ~+aA G~-z , ~~~►erL-Act~S , Wt S~IrD2~ .Name of installer if known L. CAJ Dn Copy A -Local Authority CST Signatu PAGtier 4 r~ t-vl 0 4 4 O CT 13 1980 Ste. b(~,'CZ~ th1► 21~ w 1i/zi ressurc Distribution Pipes r, QLx-A-S -r JM•t-t='t' ~ Mani f' 3~ V Pipe ~!f V4 "VIAM, Holes Located 3 Downward ~ + ' Mtya +1 %01:7. SPlatt;4 r~-r 3 (too rr Force. Main • qu.i~p thR try ,t~►2~•A j N S-CA 6Z p1S`C12t 6J'~.~~ s-Sre Wk AS 01 \3 I=LCVA+ltant aF Ila \ p~-S~. PeQtivlt BS boo 43 I>v- F~ Mama B5 = `t b Cl $OTtoM o(= DtS-C t tit SYoiL'e 1►J4rAL~C- *%6 IN s1 CJ 4WWI.& G. t. i LDL4 Ta S v.n Z%C_. ) ►E i 4~ ,~1 (s, RCur,7p SU"tit. Z'Z, fir " lll-t a- A.-t lputUp LoAmeu ~ 3 t N StA tom. L Z,O U Ca M,l.c o..l A-r l.~V q Z~ S P!? l,-AT (;v&4l+tSrRS) Sc V'ttir ANA -to Sip TAM v-- out'i.F_~t' t_UtV= q?-.O fa►?ou,vo AT `750 CnM. Fv2C.t,: MRtu, CIk t ~1nt~l S~QS~ Paz P~ ~n.p c~~ntig 6AS(, C~i.~r A~ova TABAn L ss ~3 /post-, _y_ _ ~ ` GASSY 0 Yll 8005044 OCT 13 1980 OW Z x U 1 n/ CI- a% W CL W40 a w q o 0.10 02 x If) CC < 4 Cv W w W Q 7 E- a S f~ v d` '0 a ~ (r iL w a, z V,-[ m 0 CL OW> ql-a a. ° a s z a t~ W CIL tl. CL ins W a w (L t r rJ in Q 4 > O J . U Z ix a 2 w a tiA 2 ° CL a CL m _J z rr 0W ~ a W J W ~A a r z a \1 ~ . .9 \ 11 w)J V wT c i - OCT 198~ Boo of4 - V4 PAC's-c V\A C R S lsY S~z~ ~-a c. 4-r► o Motp+-r- %6)'Tzs A% 1ZnW a~nrlouo~ lei . S4-ntS u~ ~ •~0 L5Q ~S~rv~► t i (z. ~ -bkS-CR~C3v~~~ti1 CPC wL-T" sPa(-Lo o A-c 3' 11~~~~~~ l3. 5 x ~ E3 ~ ~ P ti~ A N ►cw ~ o ~ 1vc►--~~a ~ 1 Z.' 40 + Z,S To-t (u MP 1-~AcD = 1,3-rcS -c. 1~• 1 To i A-L t7 ! S^~'. ~ moo- G A~ VCT 13 1960 • 50e , 8005,044 3 MAKE USE OF YOUR BASEMENT, INSTALL A MYERS WASTE HANDLING SYSTEM. Many homes have a basement area below the level of sewer or septic tank lines where it is desirable to install bathroom fixt4res and other appliances necessitating the use of a pump to deliver the waste water to the sewer or septic tank line. Typical installation is illustrated. The Myers "SR series packaged waste i handling system is designed especially { for this service. The pump is a 4/10 horsepower sewage f pump with special. "Tornado" impeller that passes solids up to 2 inch diameter `i and other waste material normally found in household sewage. Pump is installed in 18" x 30" corrosion resistant lightweight basin: Cover seals p sump gas tight and allows pump to be - removed without disturbing vent pipe. The sump level is controlled by a sealed i a switch mounted on basin cover. Separate cords on pump and switch allow pump to be plugged directly into grounded receptacle for manual oper- ation or to be plugged into series plug of switch cord for automatic operation. F 2-Year Limited Warranty-The reliability of the separate pump and Y = 1 R, switch units and the heavy, duty. pump with the (Tornado) impeller allows 2 Myers to offer a two year warranty. If 1 the pump or switch fails within two 4r*' years from date of purchase because of k~ w firs: I defective material or workmanship they will be repaired or replaced f ree of charge. The warranty does not cover labor to remove or re-install the pump and does not cover freight or consequential damage. Abuse or mis- use of the equipment is not covered by the warranty. BASEMENT INSTALLATION Y t j/ j VENT PIPE VENT PIPE - - GLEAN OUT --VENT PIPE ' - WASHER DRAIN. v 4 _-3" VENT PIPE DRYER WASHER } k.- LAVATORY 2' DISCHARGE PIPE QSs7 E:= LAUNDRY TUBS SHOWER a t y WATER 2" FREE FLOW CLOSET Z CHECK VALVE SEALED SUMP COVER WITH SEPAR4 FLOOR DRAIN PUMP COVE" a _ • T O CT 1 3 1980 L 0®5®44 500 i ~ a$ 3 i7 d -m r CONSTRUCTION FEATURES "I - POWER CORD-10feetlongalsoavailablein20footlength.CSA IMPELLER-Special (Tornado) impeller made of high impact % 14and UL approved. Has grounding type plug for plugging into any glass filled Valox plastic. Has bronze insert for threading to pump s standard 115 volt grounded receptacle for manual operation or shaft. Impeller is non-clogging and will pass 2 inch dia. solids. for plugging into series plug of switch for automatic operation. Has pump outvanes on backs roud to keep.trash from seal and MOTOR HOUSING-Heavy cast iron coated inside and out with to reduce end thrust. baked on epoxy paint for corrosion resistance. Motor stator is VOLUTE CASE-Cast iron coated inside and out with baked on pressed into housing for perfect alignment and best heat epoxy paint. Support legs provide proper clearance for solids to transfer, enter pump. MOTOR-Powerful 4/10 horsepower 1700 RPM motor. Has no PUMP OUTLET-2 inch pipe thread, can be used with steel or starting switch or relay to cause trouble. Has built-in overload plastic pipe. Strong case allows pump to be handled with protector to prevent damage to motor due to any excessive discharge pipe for installing or removing from sump. overload. Motor oil transfers heat and lubricates bearings. BEARINGS-Bearings are sleeve type for low friction quiet PUMP SHAFT-Stainless steel ground to exact size and heat operation and are lubricated by oil in motor housing. shru pumpkmpeller or for permanent drive. Has thread to receive THRUST WASHERS-Thrust washers are used top and bottom to MECHANICAL SEAL- Rotaryshaftseal has carbon and ceramic take thrust ineithetdirection. Washers areteflonimpregnated for faces forpositive seal. Seal body lsstationarytoprevent string or low wear, smooth operation. trash from winding on seat. All seal parts corrosion resistant. FASTENERS-All screws and bolts are 18-8 stainless steel. Easily MOTOR BOTTOM PLATE-Cast iron coated inside and out with removed after years in sewage water. baked on epoxy paint. Plate mounts to motor housing to make a CORD SEAL BUSHING-Cord is potted into plastic bushing with complete motor assembly. Plate supports lower sleeve bearing polyurethane resin for leak proof high strength seal. Eliminates ` and shaft seal. Complete assembly including; impeller mounts to possibility of grounds due to live wire touching housing as plastic volute case with flange, bushing acts as insulator. PERFORMANCE CURVE PERFORMANCE TABLE a.~ortrunw~ wn iwnu w ~o s+c bo iep aw W NQ ago aeu as sac TOTAL HEAD h i•.. - . IN FEET 2 4 fi 8 1-0 12 14 16 18 20 j CAPACITY GALLONS PER HOUR 8000 55DD 4000 4300 3800 2898 2X00 iz6tl 420 4 it la TI^ + ' l3 TOTAL fi z HEAD IN METERS 1.0 t.5 2.9 2.5 3.0 3,5 4.0' 4.3 5.0 ' 5,6 4- t CAPACITY ' i.. LITER$ A: OD 0D ° PER HOUR 21600 191100 18000 15600 13800 11400 MON 6600 4200 180 CAPP* Y 01H1.010 "l ""M i / D.I.L.H.R. Mb. RA' WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Leroy .Jahsky O.W.S. Division of Health 13 E. Spruce Street Section of Plumbing & Fire Protection Systems Chippewer Falls, WI 54729 y 15),723-8786 . ON-SITE WASTE 'DISPOSAL. INSPECTION REPOd - Name. of Premises . - qq Street City County Address rf.1 4 Master Plumber f b.-. 1 F R, Vi , Owner Address. ❑ County Permits Appropriate State Permits i Type of Building: . ❑ Public ❑ Single Family OF11-u- ex - , . CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM ❑ Building Sewer R ❑ Conventional Soil Absorption System ❑ Septic Tank ❑ Conventional System-in-fill JAN 6 1981 ❑ Holding Tank Alternate MMMtI'System ❑ Seepage Bed ❑ Holding Tank ❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System BRIEF, FACTUAL COMMENTS AND SKETCH: --T 7 gy 3 : 4,rf _ I Z tP f t , 3 ~4 1 - / - !VIA ( j{)) TT / ' f r Y •(-,.f s7"8"t.,, - ,.J t l' . ,may-i' r f } r 3 C . ^F Y - rs f w.. r , - { 1 3 _ ~ 6 tv tr F 1 F r f E 1 -4-t- _Litt_ - ❑ SEE ATTACHED DISCUSSED WITH PLUMBER. C 4 Yes. ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION. ; Signature of Inspector " White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party R State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION Bureau of Plumbing, Platting & Fire Protection P.O. Box 7969 TO:~ Madison, WI 53707 h II Plan Identification No. i Gentlemen: Re: r The Bureau of Plumbing, Platting and Fire otection has reviewed plans, site survey information and installation details for the construction of an alternative private sewage system to be installed at the above-mentioned location. The plans and specifications were prepared by and received for approval on The so i 1 and site evaluation was conducted by The site meets the soil an site requ rements spec ed In c h. H , Wis. Adm. Code, for the us of The proposed system is fora - Wastes from the building will discharge to a gallon capacity septic tank which will discharge to a '7d-!1*:~ gallon capacity pump chamber from which a pump having a capacity of gallons per.minute against a total dynamic head of 'i, r feet will disc' a ge through a inch diameter pipe to the soil absorpt o-i system. It is of utmost importance that the system be installed in complete accord with the plans and installation details and the conditions of approval con- tained in this letter. The licensed plumber responsible for the installation shall notify the county inspector when the installation of the system will commence so that the county inspector shall be able to inspect this instal- lation. The installer shall not deviate from this approval and shall follow the directions or orders issued by the appropriate local or state authorities. DILRIi-M-6159 (N.7/80) r In accord with ch. 145, Stats., and ch. M 63, Wis. Adm. Code, the plans and specifications are approved contingent upon compliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep one set of plans bearing the stamp of approval of this department at the construction site. If the installation of this system has not commenced within two years from the date of this letter, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination oversight, construction or any damage that may result in or after installation and reserves the right to order changes or additions should con- ditions arise making this necessary. This approval is based on ch. H 63, Wis. Adm. Code, requirements. It shall be necessary to obtain and fulfill the permit requirements of the county in which this installation is to be constructed. Failure to obtain county permits will automatically void this acceptance. Sincerely, wree~v Ja is Sargent Bureau Director JS:JP:kas enclosures cc: OWS County f DILHR-SBD-:6227 (R.9/80) (PLB.106) Plan Identification No. S~- O l 7 Construction Inspection of Alternate Design Sewage Disposal Systems .Wisconsin Department of Industry, Labor and Human Relations Bureau of Pl.umbing. Platting and Fire Protection Owner's Name Mailing Address A. Site Investigation at onset of construction 1. Name of Installer 2. County Inspector Date 3. Package # 4. Preliminary onsite made by Date _ 5. Depth to limiting factor (50% unconsolidated rock or estimated ground water level) 6. Percolation rate 7. County installation.permit number 8. Are percolation and soil boring holes evident? Yes No 9. Is system located in area of soil tests? Yes No 10. Is system located in area shown on state approved plans? Yes No 11. Ground slope in area of system 12. Site data is correct as presented by C.S.T. and system designer? Yes _ No B. Inspection of Construction l: Disposal site plowed and properly prepared? Yes No 2. Disposal site conditions wet or damp? Wet Damp Dry 3. Type of fill material 4. Depth of fill (1' Minimum) 5. Is a crawler type tractor used? Yes No a. Blade Bucket 6. Has site been driven on by any vehicles? Yes___No If yes, explain _ _ - 7% Trench width as indicated on approved plans? Yes No 8. Trench spacing as indicated on'approved plans? Yes No 9. Have 'trench bottoms been properly leveled? Yes No 10. Trench length and number as shown on approved plans? Yes No 11. Distribution piping proper diameter? Yes No 12. Holes in distribution piping properly sized? Yes No 13. Holes in distribution piping properly spaced? Yes No 14. Holes in distribution piping in a straight line? Yes No 15. Distribut.ion.holes drilled straight into piping? Yes No 16. Depth of gravel below distribution piping 17. Depth of gravel above distribution piping 18. Thickness of marsh hay covering 19. Permanent marker at end of each trench I 20. Depth of fill over center of system 21. Depth of fill over outer trenches 22. Side slopes 23. Type of fill used above trenches 24. Depth of top soil 25. Seeded? Yes No If no, has mulch been placed over mound? Yes No C. Pumping Chamber 1. Diameter of inlet 2. Diameter of outlet 3. Head 4. Size of pump tank gallons 5. Draw down or gallons pumped per cycle 6. Manufacturer and type of pump same as that indicated on approved plans? Yes No If no, indicate Mfg. and. Model f of pump used. 7. Quick disconnect provided? Yes No 2 8. Diameter of manhole 9. Height of manhole above finished grade 10. Diameter of vent 11. Height of vent above finished grade 12. Pump tank located as shown on approved plans? Yes No D. Septic Tank 1. Properly installed? Yes No COMMENTS I, the undersigned, hereby certify that the questions were answered on the basis of my personal inspection or knowledge of the construction of this alternate system and further that all data and answers recorded on this form are correct and to the best of my knowledge and belief. Name: Signature: Title: WE HAVE INCLUDED TWO COPIES OF THIS FORM FOR COMPLETION BY YOUR OFFICE. WHEN INSPECTION OF CONSTRUCTION IS COMPLETE, ONE COMPLETED FORM SHALL BE RETURNED TO THIS OFFICE WITHIN TEN (10) DAYS AFTER YOUR FINAL INSPECTION OF THIS ALTERNATE SYSTEM. Date received by Bureau of Plumbing, Platting and Fire Protection 3 77, t F ~ --~k. `~i 1. ,i a 4W +*bA And DATE: PFOJECT- 41- .i Cc i(:AN its. c r s, DETACH H9RE 1: ~.i~11F~►-»-'~r--~+•'~+tip-F"...'~^+.-~_-~*+r~•~t-~!"<•--^y~"-='?~-..3,a-r•.~.o,.,,.~._._..._.~.v.....-•r'•`---•------+°- ~ a lk V 4 F".'~Y~V~' a; r~a'R ~ t~ii.1~1'RR.1, 'S ~~r t'•, ~F~ 'tt., r r { F y n,e+' r't~Vieiv i diCat4a ti a e1 #$a regft9 l i x a~ ik { nil ~ =o1c "4- Fee ~f Fee is bei4 tel I'M ed^bea f pv aymen 'tl r t i PtoYiding.o*i of th tf + Ste i : ► k~s4; f~dr ®nt. § `,>f k k ei~ a .t` to►elf F ^ a.,. - ee bed C. d YY`t3'?@ l~i~tpattGe: •r. 11 a~ Ift i Plans b4ir9g r8turned Additional infoa»atrOt BLOW ,,4 1. Pfau St itissi D iaar~a li ►f` 4tca# t~ 1 subm ttod spEa w noted. 1 ~f J Plans not clear,''ieg#fa pecrlganent. r i tltk d f i ?h D All infor'mation,sp ittet# sfsW"bo signed, apted or stamped in ac with Section -l# 62.2501 D A€ffdaait.en'closed.' i i E • Gt. Alternate sewage D*oW Syxt& s'(Mound Systems) x M ;1; t jwt y D PL8 108`JApplicatitsn_for use-of •analternate system). County.onaite.rogtturedjl woya" D Design'caleulatipns for pressurized distribution DCram xai[►rr of OP lateral layout C3f4sp view of atterna#e. 111. Private Sewage pis (Sysroems 0", ~ t * } l" ❑ Ground s1upE withar2E cgntaars irr-entire' aree of soil alawrption system extending 25' on aflisidts k} i i D E%vation'ef per~t fefernc4:point (6et~rharkj r xt r i D Locati'omdf aria sdkWe* fbrOplacement•system - provide soil test data. • y D Plot plan showing lot siz% and lijatersl distances.fra tj sewage disposal system or holdirlg.t"a4•tr4,l>ti i, 0Construatioa d4aif of seppe, t olding or lift pump tank if site constructed'or-tank manufactwrer if pre~4 ! DConstruction detW,*t Mn of soiC4bs r do system. C1Soil taoring a+Rd PWC6hKi>+M'kt iifieoail tESter 0 copy) . r~ t! gt~ Q~i "eF#fiB"4f1 r5t1CfQ98d. nw~ ,~1 ilk D GontpleYa &tr "tied h#* Rion°(# 90RY'l. t }E`I § q, IV. Holding ~+3t?k$ _ ~ ~ ~ ~ ri ' CaPrgfj# ttij J c s'+r ' ai Ho ..tan C s ~ gr +byr owner aed-locat unitlof govereimgnt (sample enclosed). a Rfm son, for it it it t 4 $oil test dt state f from coisIly O "copYl: a ~t L ftmp r. r y ~1sJ 1 a , t t r y D Cal4gations for- total ft pump dischargeR head a "k p r jW100s um eF ff'cYcle. ;1e & dstlciain.~ Q o#'ai44ote; o*jXM of aut tic siphr itScfYrt#ihp *z@, pump cuntea, draWdown and average fi r4.a ln, pua*`ts* .:sf10WIr►g pul t~$~.lt~'Stpf~nES). ~ rs~ ~ " r °fortopterts66missioni 14 e,"d Au 4 } `iof !!t- 2Q" beyond, 446p of :trench befnra sktls laegin l ' is x d ;,gt on t-by( potrrtygr district¢pktMb4V.6upervisor k" ;l,gr of tirr e'fMtt& ewr in ice. 11, tiq ~_~.,a,_,_~._ t.~1_' at ..~..C..'. ~ ~ s .a z«_ _au:'•. .i__ ._.~.x ,.._.a..~_.~_ y.:~su, ,.,X...e.~.- '_.a:.~.. r - - - - - - - - - - - - - - - - - - - - - - - l ~ L r R 1 7 . 6 o at CA, . NT 0 H! 01Z P, d q /l7 D 1 , r_ ,r i ' r - I` r s .1~~ DTI `~l t _ ice. - 3 - - r• `f.1 r L