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HomeMy WebLinkAbout022-1098-90-000 PRIVATE SEWAGE SYSTEM County: St. Croix Wisconsin Department of Commerce Safety and Building Division INSPECTION REPORT Sanitary Permit No: 556356 0 (ATTACH TO PERMIT) State Plan ID No: ' GENERAL INFORMATION 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: Peskar, Adeline J. Trust 7 Kinnickinnic, Town of 022-1098-90-000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown/Range/Map No: /1-7 -7 6ej-r 34.28.18.533 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BBSF / HI FS ELEV. Septic Benchmark W /3-7 13. `7 /acs Dosing Al BM yQ1 Aeration s Bldg. Sewer Holdin St/Ht Inlet ,07 St/Ht Outlet TANK SETBACK INFORMATION TANK TO P /t WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom 15-7 r7. Dosing j 2.7 ! Header/Man. Aeration Dist. Pipe -7.$'iS 'ADS. W 3 Holding Bot. System • d %Q • 7 ~jo Z J~~.S PIMP/SIPHON INFORMATION Final Grade Manufacturer DeP Aand St Cover r At v ~q g.rJ K• Model Number TDH Li Friction L ss System Heado TDHr,' ` F2 Forcemain Length Dia.Z Dist. to Well 1 SOIL ABSORPTION SYSTEM BED/TRENCH Width f Length j No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer :i► I Yom. INFORMATION CHAMBER OR Type Of System: <I 149' -50 UNIT Model Number: DISTRIBUTION SYSTEM 26i-Z3 = ~ fe► Header/Manifold ~I Distribution x Hole Size__. Ix Hole Spacing Vent to Air In ke i Pipe(s) g `Z, Length s~ O Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx ched Bed/Trench Center 94 Bed/Trench Edges ~...r Topsoil~r es ❑ No Yea No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I / Inspection #2: Location: 1248 RIFLE N,GEE.RRDD River Falls, WI 54022 (NE 1/4 NW 1/4 34 T28N R1 8W) 40 acres Lot Parcel No: 34.28.18.533 1.) Alt BM Description = ll`e ~ t, ° 'i4,L.. ~j 2.) Bldg sewer length = 12 4 - amount of cover = Plan revision Required? ❑ Yes No Use other side for additional information. Date Insepct s Signat Cert No. SBD-6710 (R.3197) County Safety and Buildings Division C~ a <`p Sx . 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 T~ p S t ~2o ' 14 5~~ 3 Ali State Transaction lulu her i ary Permit Application In accordance wii® 03083'21(2), Wis. Adm. Code, submission of this form to the appropriate gove unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. J Z(,L ~lC (X~~ 1. Application Information - Please Print All Information Property Owner's Name Parcel # 40 Dtlw& -:x- t~sf~ u sf 0 ~ 98-90- ~L) Property Owner's Mailing Address Property Location (,5-33) Q / Govt. Lot City, State 0 Zip Code Phone Number J1J IG ~4, Section ~L lj GU( S z 6 Z i' 7 6 ~s oa ucle one Z T~N; R Eo~ H. Type of Building (check all that apply) Lot # n,,,s L Subdivision Nam~e~ / S1 or 2 Family Dwelling -Number of Bedrooms wN TI ~ 6~~ Block # ❑ Public/Commercial - Describe Use ❑ City of CSM Number 1) Village of El State Owned -Describe Use Town of k1 NAfIC CCJ,Al iJ (C III. Type of Permit: (Check only nne box on line A. Complete line B if applicable) A. ❑ New System Replacement Syste ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit =esued B. El Permit Renewal Q Permit Revision El Change of Plumber El Permit Transfer to New f/ a f U Before Expiration Ownerp IV. Type of POWTS S stem/Com onentfDevice: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑,Mound 24 in. of suitable soil Q M~and < 24 in. of suitable s ❑ Holding Tank ❑ Other Dispersal Component (explai Pretrea ent Device ex 1 V. Dispersal/Treatment Area Information: n = Desi Flow (gpd) Design Soil Application Rate dsf) Dispersal Area Required (sf) Dispersal Area Proposed l E ion ~d 8 0-0 ~ 12 /o o 0 /0 0 0 20,1/ ~o VI. Tank Info Capacity Total # of Manufacturer o Gallons Gallons Units U w y New Tanks Existing Tanks o w a a U 07 i.=. C7 a Septic or Holding Tank Zd D r' fiCJ~~s Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number D G~Z LSD Plumber's ddress (Street, City, State, Zip Code) 7i Z b T~ 7 ~LG ~v d'7Z Sr`~~~ VIII. oun /De artment Use Onl Permit Fee_ Date Issued ing Agent gn :e/ proved ❑ Disapproved S ~rD ❑ Owner Given Reason for Denial IX ~ I tf\# ,yaUReasons for Disapproval LJ) o (~y~azZ4'Y1 t cr r, 1 Septic tank, effluent filter and D G 0 dispersal cell must all be serviced / maintained as per management plan provided by plumber. r 2. All setback requirements must be maintained Gl J Attach to complete pleas for the system and mithe Coty only on paper not less l an 8 t/Z z 11 inches insize / " - ;(//►,~y-, SBD-6398 (R. 11/11) Wisconsin Department of Gr"il SOIL EVALUATION Z3RT page 1 of 3 Division of Safety and B "s m accordance with Comm 85, Wis. Adm. Code County ST. CROIX Attach complete site pla per r)ot Van 81/2 x 11 inches in size. Plan must rock de, but not limited to. o r 4 reference point (BM), direction and Parcel I.D. 022 - 1098 - 90 - 000 percent slope, scale ordirni N north arrow, and location and distance to nearest road. 146=9 prfnt all imbrmakin. Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location • ADELINE J. PESKAR TRUST Govt. Lot NE 1/4 NW 1/4 S 34 T 28 N R 18 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P.O. Box 507 .4~ city State Zip Code Phone Number OC4 Yllage ■ own Nearest Road River Falls, WI 54022 ( ) Rifle Range Road ® New Constriction Used Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public /or,~commercialj De be: Parent material 4et "'_M fllliYVl 1 c f'~.C~. / Flood Plain elevation'rfapplicatilc ft. NA- General comments ~7 e b 2 - nventi al In-gr trenche - 0.60 loading ra and recormruerxfations: v ` ~°~zj o _ 5 y~, S ty l~odA - la Boring # 0 Boring Pit Ground surface elev. 107.44 ft. Depth to limiting factor 80 in. Soft Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPI in. Munsell Qu. Sz. Court. Color Gr. Sz. Sh. *EfF#1 'Eft#2 1 0-8 7.5YR3/1 - sl 3fgr ds cs 3vf-m 0.6 1.0 2 8-18 7.5YR3/1 - sl 2fabk ds cw 2vf-m 0.6 1.0 3 18-43 .5YR3/2 gO-KJ G1 sl 2fabk dsh cw 1 vf-m 0.6 1.0 4 43-64 7/%~- sil 2fabk dh as 0.6 0.8 5 64-80 10YR5/6 s Osg dl 0.7 1.6 f 21 Boring # ® Boring 111.04 90 • pit Ground surface elev. ft. Depth to limiting factor in. Sod pication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efl#2 1 0-9 7.5YR2.5/2 - sl 3fabk ds aw 3vf-co 0.6 1.0 2 7.5YR2.5/2 01' QS ' sl 3f-ma&sbk ds cw 2vf-co 0.6 1.0 3 24-40 7.5YR3/3 lCS et y sil 2fabk dsh as 6 0.8 2vf-m 4 0-90 oyl;t s Osg dl 0.7 1.6 s-l~v►~ ~,fi ~a' 107- 36 -7 z% * Effluent #1 = BOD > 30:5 220 rng/L and TSS >30 < 150 mg/L ' Effluent #2 = B0135:5 30 mg& and TSS 30 mg/L CST Name (Please Print) CST Number Mary Jo Huppert ollister's Soil Testing & De IM, , 224832 Address Date Eva n Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 10 - 09 - 12 (715) 426 - 1775 Property Owner PESKAR Trust Parcel ID # 022 - 1098 - 90 - 000 Page 2 of 3 3 Boring #E_Boring 0 pit Ground surface elev. 107.84 ft Depth to limiting factor 85 ❑ in. Sol Appfication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/FF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2 1 0-5 7.5YR2.5/2 sl 3fgr ds ab 3vf-co 0.6 1.0 2 5-14 7.5YR2.5/2 sl 3f-mabk ds cw 2vf-co 0.6 1.0 3 14-32 7.5YR2.5/3 I 2fabk dsh cw 2vf-co 0.6 0.8 4 32-54 7.5YR3/3 I 2fabk dsh cw 1 vf-m 0.6 0.8 5 54-85 10YR5/6 s Osg dl 0.7 1.6 0 / `C ❑ Boris # H Boring Pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring F-1 Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soli Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#t2 * Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD8 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material m an alternate format, please contact the department at 608-266-3151 or TTY 608-2648777. M-8330rest (807M) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property Owner oEc.la~ .:,e Trc I"=40fz Legal Description iv E A er- Ti4f- N W►/4. s ZIA, (except where noted) s ?-%10 , TZ, t 8yj-DWA or- kImN ICK1NNIC, ,Sr. CROIA p = Backhoe Pit UI.N SCaq 5tin~ . ~D ~c./C~5 5~-V4 e 2- s e Q d° North J' Of' R w v 4 /oxSd LOT ago crtictcsd Coop LN7E~~N~ ~NK~ 6P~ _ 0>r nBl ELL- t}pt 5t- 1 Dt.y 7' #1 ly ~p p~ I84 p Dw~wn~G ~M A vl ' N Site Location: See-- 3y CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: to 1101, + Owner's Address: t-- &A-Av:3 (a7 led q D ,~l UGC .e A-c.G,~r U-"( ~'~'a zZ Legal Description: fU )kJ k/ $ Z g ,/Z W Township: J,J~JCc County: C 6+. V Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 3W System Sizing & Cross-Section Page 4 '(A Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 Q -9-e~`Plat~F,U C/20SS rec. l°u-~t/~ Ctc/21~ Attachments: Soil Test & House Plans Designer/Plumber: NtN License Number: zb y~q Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 C (}(G1~~A Z'' ~I ~ Co©P l 24~ k ~uw l►x /01~`r~ M6 w2~LZaut~ rl, ~eu~V R-®~ n 121 f= Q5- k A-99 6- Soil Absorption System Cross Section ft 4" Schedule 40 Fina Grade PVC Vent Pipe With Vent Cap z2I__. ft Leaching --jo► Chamber ft System Elevation ..L_ft ft Soil Absorption System Plan View ft 3 ft { ft Vent Or Observation Pipe Leaching Trench 1 Chambers R 4" Dia. Trench 2 Header Leaching Chamber Specifications FEISARating urer And Model Ll plus s sq ft per chamber Soil Appli cation Rate gpd/sq ft w T -t-k- Soil. Application Rate TIaEISA = Chambers 2 rows of chambers each. Page of Quick4 Plus Standard Chamber Side and End Views 2 48" v (EFFECTIVE LENGTH) 12" s- ~.a A ~ - LN 50 34 Quick4 Plus All-in-One 12 Encap Front, Side and End Views 11.2" 13" TW ll 8" INV+ ERT 2 8" IN VERT 5.3" INVERT --18.2" - 33" Quick4 Plus All-in-One Periscope OUICK4 PLUS ALL-INANE PERISCOP (360-SWIVEL ) 12.7" INVERT aulcl<aPlus ALL-IN-ONE 12 ENDCAP Quick4 Plus Standard Chamber Specifications Size (W x L x H) 34" x 53" x 12" (86 cm x 135 cm x 31 cm) Invert Height 0.6", 5.3", 8.0", 12,7" (1.5 cm, 8.4 cm, 18;5 cm, 22.6 cm) Effective Length 48" (122 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured,by Infiltrator ( "Units"), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered - by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty INFILTRATOR does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, inc. including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. systems Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the minimum ground covers set forth in the installation Instructions; the placement of improper materials into the system containing 6 Business Park Road • P,O. Box 768 the Units; failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook, CT 06475 terms set forth in this Limited Warranty, Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's installation instructions. 800.221.4436 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.inflitratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. I I .e 6 0 ! 0 U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer, Quick4 and Quick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. 0 2009 Infiltrator Systems Inc. Printed in U.S.A. PLUS0510101SI-2 P. 25. 20 12 8:19AM No. 4831 P. 3 A ~ mm cli G, o w a r, m rn y to' X oo Y z oN r 3 Cy ~m rn v m rn T W ~ ~ n o iD A tV co C-3 u ~ L O CAD T "O w =T1 ~ rn A O , CD z;D ZAO Do0, ~N oW to ~'lm 7o~z v m n O>~Omc'o O _A0 _ ;0 D O ® Ilf I~i63 0 No O m n ~ r m n ~ fzrl ~ Sep. 25, 2012 8.19AM No. 4837 P. 2 ~nN g~ o o a ME O Wpm o,mano~oooc~o~ooo~ mm Q wQOmmcnornr-. rn oCn4~U., V., 30 r D ~7 6l +v "1 n N 00 0) ~ ~ CO --~°"+goY~N m r r r :KKMXKMM MM91 mmm Ell %W E o~ c 8 0 ~J O IMM ~i, a~sa n ° ~ Wo3N'Z5~°o -nN > n m r c s' o z oEn y ~ o i W=M O a ° a n E t ~ m m w c ~ ~ i ~m .M O ~ r7r ~ m ~ m r ~ O Z m I~ I ` POWTS OWNER'S MANUAL MANAGEMENT PLAN ~Pa FILE INFORMATION SYSTEM SPECIFICATIONS Owner /&t Septic Tank Capacity 2 4:7D al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model jj ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity 197e_*y al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer 0 NA Design flow (peak), (Estimated x 1.5) OV gal/day Pump Manufacturer FJLC d ❑ NA Soil Application Rate 00 & al/da /ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average' Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODa) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD6) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: El NA "Values typical for domestic wastewater and septic tank effluent. Other ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 p ear(s) (s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: .3 ® ear( ith(s) (Maximum 3 years) ❑ NA Y / Clean effluent filter At least once every: [3 month(s) ❑ NA ( ® year(s) Inspect pump, pump controls & alarm At least once every: 3 8 earth(s) ❑ NA Flush laterals and pressure test At least once eve ❑ month(s) 13 NA rye 3 1M year(s) Other: At least once every: 13 ear( j(s) ❑ NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of, combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.. The ponding of effluent on the ground surface may indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, Including but not limited to the servicing•of effluent filters, mechanical or pressurized components,. pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result In the backup or surface discharge of effluent: To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve .the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with 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 repl m ,pKt system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption ('I~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 systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be Installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area Is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ . Mound and at-grade soil absorption systems may be reconstructed In place following removal of the b)omat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name © & 2 L SCA Name Phone 5 - Z 7 3 _ 7(!r Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 74 c4Z944 2p ~✓lti Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/B€tfer 79b6-L11L/(t- ~1- P637~<i42 . ~12 1~5 94 P7 Mailing Address J~(~ L L S Lc' Property Address (Verification required from Planning & Zoning Department for new construction.) City/State cif VM f*L - ' Parcel Identification Number ® Z Z &:2 f1 O LEGAL DESCRIPTION Property Location 1/a 1/a Sec. ✓ TN R W, Town of (-ClNA1/C /,c Subdivision , Lot Certified Survey Map Volume Page # ,,C;- Warranty Deed # ,Volume , Page # / V ~T?41 Spec house yes Lot lines identifiabl 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 §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. I 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. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms /~lllllZ SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) lllllllll , llil4ll Illl6 llll5 llll9 llll6 lll9Illlllll1 Document Number QUIT CLAIM DEED 865969 KATHLEEN H. WALSH REGISTER OF DEEDS Adeline Peskar a/k/a Adeline J. Peskar, a single person, quit-claims to ST. CROIX CO., WI the Adeline J. Peskar Revocable Trust, dated 12-13-2007, Adeline J. RECEIVED FOR RECORD Peskar, Trustee, Bernice A. Larson, First Alternate Trustee, Ronald J. 12/20/2007 11:00AM Peskar, Second Alternate Trustee, each, respectively, with full power of QUIT CLAIM DEED sale or encumbrancing, the following described real estate in St. Croix EXEMPT 1 16 County, State of Wisconsin: REC FEE: 11.00 All that part of the SY2 of Section 27, Township 28 North, Range 18 West, PAGES: 1 lying Westerly of Highway EXCEPT the North 100 acres thereof, and EXCEPT part to C.S.M. recorded in Volume 10, Page 2916, and EXCEPT part to C.S.M. recorded in Volume 11, Page 3004, and EXCEPT parcel described in P431 B, and Recording Area EXCEPT parcel described in Volume 1316, Page 163. Name and Return Address Ali that art of the N1/ of the N1/2 of Section 34, Township 28 North, C. L. Gaylord p Attorney at Law Range 18 West, lying Westerly of Highway EXCEPT 1.156 acres to P. O. Box 46 C.S.M. recorded in Volume 4, Page 1185, and River Falls, WI 54022 EXCEPT parcel as described in Volume 1350, Page 38, and EXCEPT part lying West of fence near Westerly line, and EXCEPT part to C.S.M. recorded in Volume 10, Page 2916, and )22-1076-30-000,022-1076-60-000, EXCEPT part to C.S.M. recorded in Volume 11, Page 3004, and )22-1076-70-000,022-10764W-000, EXCEPT C.S.M. recorded in Volume 13, Page 3558. 22-1077-50-000.022-1077-90-000, 22-1098-20-000, 022-1098-95-000, 022-1098-90-000 (Parcel identification Numbers) his is and is not homestead property. Dated this 18th day of December 200 7 (SEAL) (SEAL) "A eline Peskar a Adeline J. Peskar (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature of Adeline Peskar a/k/a Adeline J. Peskar STATE OF WISCONSIN authenticated this 18th day of December PIERCE COUNTY 200 7 e' Personally came before me this day of "C. L. Gaylord , 200 the above named TITLE: MEMBER STATE AR OF WISCONSIN to me known to be the person who (If not, executed the foregoing instrument and acknowledge the authorized by § 706.06, Wis. State.) same. Notary Public, State of WI My commission expires THIS INSTRUMENT WAS DRAFTED BY C. L. Gaylord Attorney at Law P. O. Box 46 River Falls, WI 54022 `Names of persons signing In any capacity should be typed or printed below their signatures. 1 of 1 INFORMATION PROFESSIONALS COMPANY FOND OU LAC. WI 800455.2021 Combination SepG-Ic;•Tank atd PL1•MP CHAMBER CROSS SECTIOW AND SPECIFICATIOWS WCATHCR PROOF NEAT CAP uuCTN 60X . • 10 C.I. VCWT PIPC APPROVED LOCKING MANHOLE COYER Pjv IQ ` wARIJI~.IG L.l+.6EL. ' FROM DOOR, '.IINDOW OR FRC5H co~Cx~tr ~r~sP oaJ ~tp~ A R wTAKE Z • ~ ~>~-tczT16 qtr' ~ - ~ I • bpi MS'JC . / I MI1J. Ij (y'MW. l~O T I I r \ i., PROVIDE I IIJLCT AIRTIGHT SEAL. I II~ APPROYEO JOIiJT; APPROVED JoluT zMe Ft~ I III I W/C.1. FIPE0 . gp'. W/C.I- PIPEoR Tank construction I II ALARM shall comply with 11 ILHR ('33.15 and $3.20 6 I I ow I PUMP -1 OFF 0 CONCETE 2-LO, 3" APPR\- RISER EXIT PERMITTED OULy IF TAIJK MAIJUFACTURZK HAS SUCH APPROVAL SEpOING 5CPTIC r SPECIFICATIONS DOSE In)~ ~ JCS TAUK MAQUFACTURE:R.: WMdER OF DOSES: PER DAy . TAWK ,IZE: GALLOAIS 0051: VOLUME 11~ ALARM MAUUFACTUP F_R: INCLUDING 6ACKFI.0W:-GALLONS MODEL WUM6ER: I C) L Nw CAPACITIES: A- IIJCHES OR GALLONS SWITCH TyPt: B Z IUCHWOF zr,G LLOUS L_._IULHES OR / < V1/ t ALLOUS PUMP h~AMUFACTURER: S s.l C- 7 MODEL MUM6ER.'. D12 2-WCHE5 OR(Z3'hGALLOMS . SWITCH TYPE: IJOTE•: PUMP AMD ALARM ARE TO OL MIWIMUM'DISCKARGE RATE . GPM INSTALLED OW 5EPARATE CIRCUITS VERTICAL DIFFERENCE DETWCEIJ PUMP OFf AU0..015TRIBUTION PIPE.. I-EET -t- MIUIMUM NETWORK SUPPLY PRESSURE . ; , . . , , . e2 FEET + FEET OF FORCE l1AlN X Z"W/IpofLFKICTIOU FACTOR.. FEET . TOTAL. O y ' A D = F EE T As per-manufacturer 7. al/in. a RPR-12-2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 [IGOULDS PUMPS Submersible Effluent Pump PE ' 44W rump. SPECIFICATIONS MOTOR FEATURES Pump - General; General: ■ Corrosion resistant • Discharge: 1 ih" NPT • Single phase construction. • Temperature: 104°F (4000 • 60 Hertz ■ Cast iron body, maximum, continuous when • 115 and 230 volts X Thermoplastic impeller and fully submerged. • Built-in thermal overload pro- cover, • Solids handling- Ih" tecdon with automatic reset. ■ Upper sleeve and lower maximum sphere, • (lass B insulation. heavy duty ball bearing • Automatic models include a • oil-filled design. construction. APPLICATIONS float switch. • High strength carbon steel ■ Motor is permanently Spedally designed for the • Manual models available, shaft. lubricated for extended following uses: • Pumping range: see PE31 Motor service life. • Mound Systems performance chart or curve, • .33 HP, 3000 RPM ■ Powered for continuous • Effluent/Dosing Systems PE31 Pump: • 115 volts operation. • low Pressure Pipe Systems • Maximum capacity: 53 GPM • Shaded pole design ■ A l ratings are within the ( • Basement Draining • Maximum head: 25' TDH PE41 Motor working limits of the motor. • Heavy Duty Sump/ PE41 Pump: • .40 HP, 3400 RPM ■ Quick disconnect power Dewatering • Maximum capacity: 61 GPM a 115 and 230 volts cord, 20' standard length, with • Maximum head: 29' TDH • PSC design 1heavy duty 15 or Z 0 volt grounding PE51 Pump: PE51 Motor: lu Maximum capadty. 70 GPM .50 HP, 3400 RPM ■ Complete unit is heavy duty, Maximum head. 37 TDH 115 and 230 volts portable and compact. METERS FEET • PSC design ■ Mechanical seal is carbon, 40 - ceramic, BUNA and stainless MGDars: PE31, PEat, PEST steel, • ~~~1r I I V I I I i ~ I 33 t' I i I I I ' HN .33-40, so ■ Stainless steel fasteners, 0 F41` 1.1 _10- 2 GPM i I I II -~i AGENCY LISTINGS 1 FT X Q~a'' ~ i l f ~,Iw i I I ~ I• i t ~ I I' I• i X ZS c I i ' Tested to UL 778 and CSA 22210$ Standards o~ 15 i I t , ey Canadian Standards Anodwon File #1R mg 10 ^---t Goulds Pumps is iso 9001 Registered. 5 !I O O ~I i j I. 1~1 I,' I' 0 10~ 2 30 40 50 60 70 GPM g0 0 s 10 15 m3/h Goulds Pumps ® 2004 ITT Water Technolo CAPACITY Effective June, 3004 Inc. ~E3,,14, ITT Industries