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HomeMy WebLinkAbout008-2001-30-050'.'.Fisconsin•`Jepartment of Commerce PRIVATE SEWAGE SYSTEM ~S2fety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village X Township Keehr, Ross & Elizabeth Eau Galle, Town of CST BM Elev: Insp~ M Elev: od BM Description: !_ ~ ~~ ~ ~1 5T' ~+e- TANK INFORMATION n TYPE MANUFACTURER ~,p,ej CAPACITY Septic ' r , 7,~ /~~ Dosing ~~~~ ' ~ ^^ ~. 1 f ~ ~...._ P <_r ~. .-x c~. „3 Holding TANK SETBACK INFORMATION TANK TO ~ ~ d WELL BLDG. Vent to Air Intake ROAD Septic ~ ~s ~~ ~ ~ 7 Dosing ~ ~ ~ Z7 / Z7 ~ Aeration Holding PUMP/SIPHON INFORMATION _ t Manufacturer ~- i ~, ~ `' ~ Demand i ' ; ~ `% ~.,._i ~-• t_:,~.; GPM Model Number n `~~ J' J~ .~- r-- _ TDH Lift Friction Loss System Head ~, TDH, , Ft ~fr~~.. ~~~ f~'1 Forcemain Length Dia. t t Dist. to well ~, . Z ~'-~ SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 514978 0 State Plan ID No: Parcel Tax No: 008-2001-30-050 Section/Town/Range/Map No: 36.28.16.542620 STATION BS HI FS ELEV. Benchmark ~ ~s /~• ~, !~ Alt. BM ,, ~ a ~ • ~ I ~ • ' ~ `-~ BI g S r D ~~ 'o f dw n~ (j : /D•7 7• 93• $~ SUHt Inlet ~~~ ZS qz • SUHt Outlet ~. r, '~••,,.. Dt Inlet ~__ ~.._` Dt Bottom /~ ~ $+ / `/ ~ 7 Header/Man. ! . ~Z ~$ • y3 Dist. Pipe Bot. System ~ • ~ ~• Final Grade St ~ver ,} c:~ BED/TRENCH Width I Length No. Of-Trent ~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS +;~ ~ ~; ~ ~, ~ ,.~ ~~ ,..~ ~ ; -.-~__..__.._ `- ` \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: __.` RMATION INF CHAMBER OR ` O T e Q( stem: YP jr s~ ~ , //!~ ~-- f n 'j ~ ' l UNIT Model Number: -.,,,,Y DISTRIBUTION SYSTEM i~.~; _ ; HeadedManifoldi; / it // . yt ! ~ ~'.~ Length tG Dia Distribution ,~ i/ ~i Pipe(s) s `7~ !i :~,> , ~',~1, Length Dia Spacing x Hole Size i t t r : t: ~' ' x Hole Spacing i7 ~ ..~ Ver/gto Air In ke rl"J i ~. S SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~~a~-~. Depth Over ! Depth Over xx Depth of xx Seeded/Sodded ~ - ~ xx Mulched ~,. Bed/Trench Center ';!r ~+ ~ Bed/Trench Edges `''•• Topsoil Z ~,~~.--+ Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~/~ +/~~ ~/~0 D Inspection #2: / /_ Location: 81 Cty. Rd. B Spring Valley, WI 5476 (NW 1/4 W 1/4 36 T28N R16W) NA Lot 1 C.InO~'i;K. I Parcel No: 36.28.16.542620 1.) Alt BM Description =~)~`' ;`'~'t ~-- •~ '~-~~+~~...~~ ~ S4S~Cvv~ /'0 ~.J v`!~//~~ 2.) Bldg sewer length = Z'7 c„b~ey~~. P~d c~-.J CJ ~, -amount of cover = / 'S~taSL. (k0?~+-. ~G~^''~`~ 7 ~ 81~. axe'-• Plan revision Required? Yes `'~ No i %'~) Use other side for additional information. ~ ~ _ Date SBD-6710 (R.3/97) ~, ,.~ i Cert. No. commerce.wi.goV Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 i sco n s ~ n Madison, WI 53707-7 162 Department of Commerce Sanitary Permit Applicatio In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to 0 governmental unit is required prior to obtaining a sanitary permit. Note: Applic ms for state-o~ POWTS are submitted to the Department of Commerce. Personal information you r r y~bo„~ secondary purposes in accordance with the Privacy Law, s. 15.0 I. A lication Infor -Plea se Print All In orma ST. CROIX Sanitary Permit Number (to be filled in by Co.) S1~57~5 State Transaction Number 1579415 roject Address (if different than mailing address) 1 COUNTY ROAD B Property Owner's Name Parcel # 008-2001-30-050 ROSS KEEHR Property Owner's MaIling Address Property Location ~'/~ (~ S237 GOLFVIEW DRIVE T [~ T. CROIX COUNTY Govt. Lot City, State Zip de ZO er NW ~'/a,NW '/a$ection 36 SPRING VALLEY, WI 547 715-778-5093 (circle one) II. Type of Building (check all that apply) ~- Lot # T 28 N; R 16 W ®1 or 2 Family Dwelling - Number of Bedroorp~ 3 ~ ~ Subdivision Name ~J 1 N/A ck # ^ Public/Commercial - Describe Use ~ ~~C N/A ^ city of ^ State Owned - Describe Use / / CSM Number ^ Village of S X s ~ ZS V 20, PAGE 5106 ®Town of EAU GALLS III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ^ New System ®Replacement ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) System~1 B. ^ Permit ^ Permit Revision ^ Change of ^ Permit Transfer to List Previous Permit Number and Date Issued` / Renewal Before Plumber New Owner Ex iration IV. T e of POWTS S stem/Com onent/Device: (Check all that a 1) vtr~ OJI / lL/ r ~ ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ®Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment evtce n t V. Dis ersa Treatment Area Information: d~~ ~"t +r~ V Design Flow pd) Design Soil Appli on Rate(gpdst) Dispersal Are equired (sf) Dispersal Are Proposed (s System Elevat' n 450 1.00 0 . ~P 450 ~~j d 450 $(~, ~0 97.40 ,~ VI. Tank Info Capacity in Total # of Manufacturer H z Q Gallons Gallons Units ~ `~ U ~ a a ~ r New Tanks Existing Tanks / ~ ~ l~ ~/ ~ ~ o ~ N H ~ a ~, a ~ ~ Septic or Holding Tank 1000 1000 1 WIESER ONCRETE ® ^ ^ ^ ^ Dosing Chamber 600 600 1 WIESER CONCRETE ® ^ ^ ^ ^ VII. Responsibility Statement- I, the undersigned, assume responsibility for ins allation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' ignature MP/MPRS Number Business Phone Number BENNIE HELGESON 292 715-772-3278 Plumber's Address (Street, City, State, Zip Code) W 1229 770TH AVENUE, SPRING VALLEY, WI 54767 VIIy. 'County/Department Use Only X Approved Permit Fee Date sued Issuin gent Signature !-' Owner Gi eason enial $ / ~^ I ~ ~a~` ~tiC! IX. Condi~t~~~,~~1/Reasons for Disapproval $ Cbv~ i7d„t o~~ ~ ~1. S~'~ ~~ ~~ 1. Septic tank, effluent filter and G~C~k' ~ / ~ / dispersal cell must all be servtces /maintained ~~ ° ~ as per management plan provided by'plumber. al Q n _ ' / ~ 2. Atl setback requMBments must b® maintained y> Q~ ~ Sy5}~C~„~ ~ bL Ip ~(G'r~,</ as pier appucawe code / otd~+ces. J At 1 1 f h b h C t I t l th 8 lie 11 'n h s' e 1 lath to comp ete p ans or t e system and su and tote oun y on y on paper no ess an x ~ c es m >z SBD-6398 (R. 01/07) Valid thru 01/09 ~~ ~ ~~ . ~ ~ ~o~ r- ~.~y Aer-~s ~`J' ICx.uv ~.~p r } ~ n ~ ~ `e f 1 ~214e S o ~-, .~ ~ ~f'~ C~ oac~ U c ~ (-e UJ ~ S"Y D~ QB.~" 1. l 01. ~ u~lCsrv. a~ F-Ia~Se- rn`7 cT~~ - f ~ ~~~ ~ ~ ~~ i s r~~ ~~ ~~s~~g 3 f~@ ~~` ~ DF~ ~~~ ~ ~ ~$ qtr ~~E~c~sk~~~ 5.T. ~~II V A/c fpoo/ boo Ga I, ~ 1~~c Sep / pag T.~ ~e~ ~ `''~Pol y l ok. F~ If~~- ~ ~ i ~~ ~ `~J/ / ~o q5~' ~ A/ q~ ~. ~4 , I ~~, C`c~ `f'ob e~ ~hon~e. I~~ -- ~h~c.. Q~a~ " OU~Q "~'l.bw ~- ~tJw~ o~Ncd y Sic, 3~T~$ R 16 ~ ~, CR~,k Coc.~~. /v ~~: Y ~ ~~ a /~ 1 ~~ ~ ~ f C,J vv~ e ~'l COPY Pi -~ ~- ~~ ~ ~, l-o~- f - ~.r4 /~rres cA~ ~er' lP~ss .k~~ 1, ~- f~~-,- ~~ c~oa~, u, ll.e uJ I ,~yo~~ G_ ~ ~~ ~ ,vw~ o ~ JJ(x3 ~ Sic. 3 ~ T~$ R l6 ~ ~, CRu rx Coc.~~~ l ~s ,._ y ~ ~~ a / ~ 1 lV©T''C ~, L- X/51-~r1 ~` ~. T,~ ~O ~ ~ ~c~w~lJ e c~ `f"o~ e~ ~'hon~e 1 ~~Q commerce.wi.gov ^ ~sconsin Department of Commerce Safety and Buildings 3824 N CREEKSIDE LA HOLMEN WI 54636 TDD #: (608) 264-8777 www. commerce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary August 19, 2008 CUST ID No. 220292 BENNIE W HELGESON HELGESON EXCAVATING W1229 770TH AVE SPRING VALLEY WI 54767 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/19/2010 ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1579415 SITE: Site ID No. 741430 Ross Keehr Please refer to both identification numbers; 81 County Road B above, in all corres ondence with the a enc . Town of Eau Galle, 54028 St Croix County NWl/4, NWl/4, 536, T28N, R16W FOR: Description: Mound /Three Bedroom /Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1196699 Maintenance required; Replacement system; 450 GPD Flow rate; 32 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (R.6/99); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior tooccupancy or use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component arm. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. Cottd~ ~~ 1 01~ ~L~/~.r, SEE CORRI • Inspection of the POWTS installation is required. Arrangements for inspection shall bemade with the designated county official in accordance with the provisions ofSec. 145.20(2)(d), Wis. Stat BENNIE W HELGESON Page 2 8/19/2008 • Comm 83.22(7) A copy of the approved plans, specifications and this letter shall be orrsite during_construction and open to inspection by authorizedrepresentatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes.. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may bemade tome at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~~~~ ~ ~~~ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday charles.bratz@wisconsin.gov Fee Required $ 175.00 Fee Received $ 175.00 Balance.Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. INDEX SHEET PROPERTY OWNER: ROSS KEEHR 5237 GOLFVIEW DRIVE SPRING VALLEY, WI 54767 PROJECT NAME: ROSS KEEHR ~F~F~~Eo A UG Y 5 2008 SAFE & B~~LD INGS PROJECT LOCATION: NW 1/4, NW 1/4, S 36 T 28 N, R 16 W MUNICIPALITY: TOWNSHIP OF EAU GALLE COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Perforated Pipe Detail Page 4: Septic Tank & Pump Chamber Cross Section and Specifications Page 5: WLP 1000/600- MR ZABLE Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 l Sign Date: August 13, 2008 ~~o~~rdty ®~ED T~ ~~ fNGS SPONDENCE Synthetic Covering ~~sT~~t C 3:3 Medium Sand ~_ Topsoil • ~ y % Slope ~ I \a- Aggregate Cross Section Of A Mound Signed: License Number : ___. Date : ____ L P~,e ,~ Or $ Distribution Pipe Fl ev ~q. a _ G rs F ~,,~ D ~ ~ ~' Or1~t' V . Force Main Plowed From Pump Layer A ~ Ft. e mot. K 7~ ~/ F t . L 7/. c~S'~t . ~ ~ Ft. T .7~ 3 Ft . W~D.~ Ft. D ~ ~Ft. E , S~ Ft. F o $d Ft . G ,,$bFt. M l.8 Ft. Observation Pipe J ~ ~ - - - - - _ -~--- K I~___,. ___,._~ --_._.~._-_------------ o --- ~ eve w ~ B _ - -~-------- ---------- ~ ~„ ,„ Distribution E~t.l. Of 2 ~ 2'2 Pipe Aggregate I Observation Pipe C3as~.l ~4~-~~.. - g~o•~3 ~' Plan View Of Mound Cleanout Access Threaded Cleanout FnA NiT~nifnlll Holes Located on Bottom Are Equally Spaced ve Main From Pump t Hole Next to Manifold Signed: License Number: Date: Perforated Fipe Detail ~ ~~ End Vl~:w Perlorala0 PvC Piva p .~'~ R S .3~`r x ~7 `~ Y ~ ~ ~~ Hole Diameter ~/~. Inch Lateral " / C'~`.J Inch (es) Manifold " ~ Inches Force Main " ~ Inches Invert Elevation Holes Per Lateral ~~ Number of Laterals Total Holes SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" {~UG,•.VENT PIPE 12" MIN. ABOVE GRADE E NEATNERPRUOF 25' FROM DOOR, WINDOW OR JUNCTION BOX FRESH AIR INTAKE r--WITH CONDUIT APAROVED MANHQLE COVER w / PAD-LOCK E WARNING LABEL _._. 4 " MIN . Zy" t 18" IN. ~ s. D. ~ MIN. `~ . 18~~ , INLET ~ ~, .. , WATER TIGHT SEALS GAS- ; '~ TIGHT ~ ~APPROVED FINER -~-~- A SEAL ; ~ JOINTS »ITH APP~tOVEO ~ ~O~ -~- ~ ALM APPROVED PIP; PLPE 3' ~~5._-~ _'F_ ~ ; ON 3' ONTO ONTO. SOLID ~ ~ ~ SOLID SOI SOIL PUMP OFF ELEV . (~~~FT. -~- , OFF D j 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE -- TANK MANUFACTURER : ~ i~Ser- fC~ ~ ,~~ X `~ = S/ . S (~c3I , TANK SIZES: SEPTIC 1 GAL. DOSE VbLUME INCLUDING DOSE ~~p GAL. y. gq~~l, --~FLOWBACK: e~~, 7Y GAL. ALARM MANUFACTURER : 5:3. v-cy CAPACITIES : A = ~_ INCHES = ~-~~ t. b ~ GAL . MODEL NUMBER: p ~~ SWITCH TYPE: ~ B = /Z INCHES 3~ . S.2 GAL. PUMP MANUFACTURER, ~ ~_cQ C = (c, LNCHES = 1~}O,S-~ GAL. MODEL .NUMBER : ~g~r ~ pQy t! ~' SWITCH TYPE: _ /V- ~ • ,~ D _ ~ INCHES = j~~7 ~ :SAL. .. :, REQUIRED DISCHARGE RATE O, 7 GBM PUMP E ALARM WIRING AS PER ILHR 16..23 WAC -~~ VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ~ FEET + MINIMUM NETtJORK SUPPLY PRESSURE ~~ FEET + ~_ FEET FORCEMAIN X.~.~7 FT/100 FT. FRICTTON FACTOR ~ FEET TOTAL DYNAMIC HEAD = _~'~: FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID D~P'I`F~' ~'"~(r.s!_, SIGNED: LICENSE NUMBER: DATE: ilea i~.. t~~ L ~ . ~~ F ~ V OV O W O Q ,~ 0 U Z W J Q LL. O' J O F Va O d~ ~ Y W ~ ~ Q~ ~m ~Q ZZ ~ ~ ~ Q N Q U J J ~ ~ ~ ~~ JWw C.7 C7 ~ Q 0 A i m ~~0~~~~ ~ I N~ ~ 0~ mWw ~~ ~ ~ A rn N~pO :-:_i~ F-~Q FNQ ^ N~ ~ A ~ ~~ w ~ j ~ ~ ~ WZ- r''f ~J -~ ~OF=~ 3 = vi 0 wH OOY N OOw a U w [ p .. OQ ~ ¢wz00 0 omfn ~cOnO ~ O O ~ ZA Q Z v ~ J J ~ Q D Z Z O J ~J J „Z~b z i ~! .a ~ _W ~ ~ O J U F k a ~~ ~ (~ a ~ \ N w U § CO _ N ~ Co`r ~v'Z ~ ~ ~o~ O~(n 'a N ~o~ ~ w U a~ o ~ O~w 33rr ~ _ ~d~. l ~ N O n n n I ~ ~ I N L ~ _J ~ J w ~ ~ O ~ ~ W } W ~_ J U F- w ~ „6~ „95 b~, QM 1, Submersible Effluent Pump METERS FEET 8 7 O = 6 U ~ 5 d Z >- 4 J h 0 3 F- 2 1 0 25 20 15 10 5 ~,~ :fib ~ ~ ~ .~ .~ . MODEL: 3871 SJZE. 3/4 SOLIDS. RPM:1550 H P: 0.4 E!(ealve October, i X88 - - . - - . _ _ ...~...,. ,.. ~...n'.r DRINTFn W USA.. FILE INFORMATION Owner RUSS KEEHR Permit # DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ~ NA Estimated flow (average) 300 al/day Design flow (peak), (Estimated x 1.5) 450 gal/day Soil Application Rate al/day/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) S30 mg/L Biochemical Oxygen Demand IBODSI <_220 mg/L ~ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (RODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ~ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHFnIII F POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 Septic Tank Capacity 1000 al D;NA Septic Tank Manufacturer WIESER CONCRETE O NA Effluent Filter Manufacturer pOLYLOK ^ NA Effluent Filter Model pL-525 4 NA Pump Tank Capacity 600 al ^ NA Pump Tank Manufacturer WIESER CONCRETE ^ NA Pump Manufacturer GOULDS PUI`1PS INC ^ NA Pump Model 3871 EP O NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: ~ NA Dispersal Cefl(sT ^ NA ^ In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ~ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA SYSTEM SPECIFICATIC)NS Service Event Service Frequency Inspect condition of tankls) At least once every: 2 ^ month(s) (Maximum 3 ears) ® ear(s) y ^ NA Pump out contents of tank(s) When combined sludg e and scum equals one-third 1%31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: 2 ^ month(s) (Maximum 3 years) ®year(s) ^ NA Clean effluent filter At least once every: 13 ®month(s) ^ year(s- ^ NA Inspect pump, pump controls & alarm At least once every: 13 ~ month(s) ^ year(s) ^ NA Flush laterals and pressure test At least once every: 3 ^ month(s) ~ year(s) ^ NA Other: At least once every: ^ month(s) ^ yearlsl ^ 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 tankls) to identify any missing or broken hardware, identify any cracks or leaks,. measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (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. OWNER: ROSS KEEHR Page ~ of $ ~TARI' 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 cellls-. 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 ceII1s) in one large dose, overloading the cellls) 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 replacement system: ^ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement. area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement 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. (XI Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNIN^v i > 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 Name HELGESON EXCAVATION INC Phone 715-772-3278 SEPTAGE SERVICING OPERATOR (PUMPER) Name OH - Phone 715_273-5811 POWTS MAINTAINER Name JOHNSON SANITATION Phone 715-273-5811 LOCAL REGULATORY AUTHORITY Name ST CROIX COUNTY ZONING Phone 7 This document was drafted in compliance with chapter Comm 83.22i211b)11)(d)&If- and 83.54(1), (2) & (3), Wisconsin Administrative Code. S Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~_ of Division of Safety and Buildings rn accoraance w¢n Comm ao, vvrs. Ham. ~.oae Plan m t ize it th 81/2 11 i h i Att h l t l t l ~u~y ST. ~~'D/ ~ . ess an x nc es n s ac comp e e s e p an on paper no include, but not limited to: vertical and horizontal reference point (B ire dis l d loc t l di i th l~a tai" rcel I.D. ®~ ~ ` ~~ ~ '"`3 ~ ' ~S arrow, an G percen s ope, sca e or mens ons, nor Please pri ~f°)! ed ed by Date L i d f d P i f b 04 (1) (m)) 15 ~ vacy a e e or on ary purposes ( r Personal in ormat on you provide may . . s. Property Owner ~ 1 on PropertyLocati `` J~~- SY '' \\ ovt. Lot ~ W 1/4~~1/4 ~ ~ T a $ N R ~ ~ E (o W Property Owner's Mailing Address S C'rtQ\G F1C~ ~ °~ t # Block # ~ Subd. Name or CSM# ZOrw S ~ 3 ~d I .,.~ / ~ a o - P~ .~ SSG ~ State Zip Code umber City ^ City ^ Village own Nearest Road ~ rr~ aI~ GUl S~/7 (71~) - 093 ~~-~- s / ~~ '~ ^ NewConstruction Use: Residential / Number of bedrooms ~_ Code derived design flow rate U~~ GPD eplacement ^ Public orcommercial -Describe: , / Parertt material ~ o ~ cS O U e s- 7.' / ( Flood Plain elevation if applicable N /-~- ft. General comments (1SE ,• ~ ~~ man ~ ~~ ~e~ c.c~~v ~~5~ o d~ Ce/ and recomm ndations; ~~,~'~ w~ s ~ I C' fy ~~ /-~ ovt c oar ,Lour 96.9 / Boring # ^ Boring C [G~ p t Ground surface elev. ! ~~ ft. Depth to limiting factor ~_ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 o y' 3 .- ~ t t .~ ~ - ! o ~ . s L f ~- tti.~'r - , ~ I 1 I Boring # ^ Boring ~ N I °~ I LI~Pit Ground surface elev. 7 /~ ~ ff. Depth to limiting factor ~ ~ ~n• Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~3 )S 33 ~~ -- S L ~,,,, sl~i r ~ t.~ ~ ~ ~- ~ ~ ~ ~ ~ `l 3" ~'~D '~ sY2 scL ~ s l~ - ~ `i * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg1L * Effluent #2 =Bobs < 3v mgn_ ana I ss < ~ mgn_ CST Name (Please Print) J ! c S~a~ tore ~~~/~~. ~a CST Ntunber ?' Pvt n r -P .lL 11C l/C, 2S ~ -~ jL! ~ Cb~ ~ .? Address ~ e Evaluation Conducted Telephone Number ry~ZB ss~~~ ~ Property Owner ~©~ kc`e ~ ~ ParcellD # Page ~ of 3 Boring # I^-~~Boring ~S ~~ 3~ ,/ I~ Pit Ground surface elev. ~ ft. ~^Qepth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 - lr'~ll~ •-' S ~L ~ dk rr ~ i~~ b "f~ -~ SLR r b~ c c../ - c Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fiz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) Property Owner 1 \Q~ ~~'~ ~`~ PprcelJD# Page ~ of D Boring # ^ Boring Q 'Pit Ground surtace elev. /s.t~ ft N ~i~epthto limiting factor .3~ in. = Soil Application Rate Horizon ,Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 l D- I b iZ ~ L ~ ,~ ~-F'~- ~ 5 r ~ v~ ., (o . ~ _ e ~ ._. ;L w.sb l ~ ~< . ~ ~ S - ~n~« ~ s c~ ~ sbh ,~ ~ ~~~ S fo 3' cap -.sy~~' ~ L_ ~- -~' Ya? .~ Boring # ^ Boring ^ pit Ground surtace elev. ft. Depth to limiting factor in. Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring Boring # ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fi= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 "Effluent #1 =BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07l00) ' ~ Cam, iY ~~~~~ ~-~`~ ~~ Ccx~l1~ h ~ 1~ C'~ S_S ~~2 ~F' /U(.(~ a ~ ~ ~/ ~ ~~. 3~ T~8/~ R~ ~i ~.CJ C. 5. T .' ~ ~ 2~ es~~ ~~~ ja ~"o~u~ po ~F, ..Ear Ga I(~ S~. 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CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~`~SS ~£ EN IL .Mailing Address _ ~Q $p~ LF~ Property Address ~' ~ 1 ~ Q-D g I,J ooD~ 1 ~ ~`t • ~~{ Oa.$ (Verification required from Planning & Zoning Department for new construction.) City/State v~1 t S Co NS ~ ~ Parcel Identification Number Gd 8 - ~~ 1 -~- ~ -a ~~ LEGAL DESCRIPTION Property Location. % , ~~ I/, ,Sec. 3~ , T ~N R ~~ W, Town of E~.,ti ~~,-~ ~ Subdivision u ~m Lot # ~ Certified Survey Map # Warranty Deed # Volume Page # grj 3 Volume / ~ ~ v ,Page # ~ ~ (~ J~J~ 5~1 1 Lot lines identifiable ^ yes ^ no Spec house ^ 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. 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 I?ep..rtment of C6mmerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St: Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms C `~/31/0~ SIGNATU 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) ~a~ ~.~~~~~~~f~4fi DOCUMENT NO. 58t1S81 STATE BAR OF WISCONSIN FORM 1 WARRANTY DEED This deed made between George Solberg, Herbert Solberg and Shirley Busch, each an undivided one-third interest as Grantors, and Ross A. Keehr and Elizabeth L. Keehr, husband and wife as survivorship marital property as Grantees, Witnesseth, That said Grantors, for a valuable consideration * ~~~~ /~ ~~ (SEAL) George Solberg, conveys to Grantees the following described real estate in St. Croix RETURN TO: County, State of Wisconsin: DIANE L. GAVIC P.O. BOX 344 SPRING VALLEY, WI. 54767 P.I.N.: COli-2001-30; 008-2000-95 LEGAL DESCRIPTION: - 1. The South Half (S'/z) of the North Half (N'/z) of the Northwest (NW'/<) of Section 36, Township 28, Range 16, except that part lying Ely of the Town Road. 2. The South Half (S'/z) of the Northwest Quarter (NW'/a) of Section 36, Township 28, Range 16, except the following described parcel of land: Commencing at the southeast corner of SE'/4 of NW'/4 of Section 36-28-16; thence West a distance of about 50 feet; thence North to public highway a distance of about 225 feet; thence in a Southeasterly direction along the south side of said highway a distance of about 98 feet to the east line of the above described forty and about 160 feet north to place of beginning; and excepting that part thereof as described in Volume "519", page 373, document number 325296. This is not homestead property. (SEAL) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee, simple and free and clear of encumbrances, except easements, restrictions and roadways of record, and will warrant and defend the same. Dated this I th d of May, 1998. ~ (SEAL) Herbert Solberg Shirle Busc AUTHENTICATION George Solberg Signature(s) of Herbert Solberg and Shirley Busch authenticated this 18th day of May , 1998 ~~ ~ Diane L. Gavic, A orney TITLE: MEMBER OF STATE BAR OF WISCONSIN (If not, authorized by 706.06, Wis. Statutes) THIS INSTRUMENT DRAFTED BY: Diane L. Gavic p.0. Box 399 Spring Valley, WI 59767 ACKNOWI+EDGN~NT STATE OF WISCONSIN)ss. Pierce County 1 Personally came before me this day of ~U~~ ~~ R E~TSTER''S""t7~FiC E sr, CROlX CU„ WI Rac'rJ /ur f'.icord JUN ~~ 1998 TRANSFER ~ 3'75 -- FEE 1997, the above named to me known to be the person(s) who executed the foregoing instrument and acknowledge the same Notary Public, Pierce county, Wisconsin My commission is permanent. (If not, state expiration date: )