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042-1013-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 561021 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: Collins, John P. & Jackie M. Warren, Town of 042-1013-20-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /Qid ~jl(Y1 1 GS ( 05.29.18.80A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 13. / AT 3 Septic y ~ / CC Benchmark L /!rZ 111-2- (/~J 140 ~C Dosing Alt 6, Z• 16 7 / 2 9~aEiee Bldg. Sewer Q 67' dJ Pt a 5z 7 Holding St/Ht Inlet 5• Z ~ .8 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent 16 Air Intake ROAD Dt Inlet Septic Dt Bottom > 50' AM 1 /G•5 q5Z 7-0•5 Dosing 7 50' /)Ar l3 1 _ Header/Man. Aeration J Dist. Pipe .a ID~• / Holding Bot. System PUMP/SIPHON INFORMATION Final Grade 3.6 /65. Manufacturer DeP ^and St Cofer D 2 16 7• V /t ~la,nn Model Number Zo• 3 TDH Lift' `Z Friction Los System H~ad~ 70~2+ Forcemain LengtGO / Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length INo.OfIrencheA PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth -7 DIMENSIONS /W &441 1 % _ SETBACK SYSTEM TO W P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type stem: A CHAMBER OR 'ots UNIT Model Number: Ov DISTRIBUTION SYSTEM Header/ManifoldI Distribution /A, x Hole Si e x Hole Spacing Ve 41nt e S Pipe(s) 5,160) 1 3V L1'5 Length Dia 5 Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only .~.n. Depth Over Depth over xx Depth of xx Seeded/Sodded xx Mulc kYes Bed rrrench Center 7# Bed/Trench Edges Topsoil I ~ es 0 No No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: '6-/ 7,Z- 13 Inspection #2: / / Location: 1070 110th Ave Roberts, WI 54023 (SE 1/4 SE 1/4 5 T29N R1 8W) NA Lot 1 Gj( R6 LJ Parcel No: 05.29.18.80A / (,s A 16 e.J O 1.) Alt BM Description = rN" Gaau_ 2.) Bldg sewer length = G~,a„,ti~ L ~~.5 Q - amount of cover 3 Plan revision Required? Yes I S 2 /3 Use other side for additional information. SBD-6710 (R.3/97) Date Insepctoes nature Cert. No. i r uf S ' a~ y ( I--- r on q- 0c, f / I r t 0 & JACKIE COLLINS 107 100TH STREET eA, 40 R l / L T 1 14 t SE 1/4 SE 1/4 SEC. 5 29 N R 18 W (r T. OF WARREN S E. =40' / r s BENCHMA #I:TOP OF TEEL POST ASSUMED E EVATION 10 ' r~ BENCHMARK #2: TOP OF TEEL FENCE POST ELEV ION 96.10' Not,- rno"4' f; lot SYSTEM ELEVATION: 101.25 ge Rc~ fiP~, PoA 3° C ~SS~~dr f t1 X commerce.wi.gov° Safety and Buildings Division County r W. Washington Ave., P.O. Box 7162 ST. CROIX i sco n s i nvEb Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce ''~ermit Application State Transaction Number Sanitafy In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 74 ~y unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary OT 1/~~T purposes in accordance with the Privacy Law, s. 15.04 t (m), Slats. C 1. Application Information -Please Print All Information Property Owner's Name / Parcel # JOHN & JACKIE COLLINS 042-1013-20-000p2'fj Property Owner's Mailing Address Property Location / 1077 100TH STREET Govt. Lot City, State Zip Code Phone Number _ y4 - y., Section 9 ROBERTS, WI 54023 (circle one) II. Type of Building (check all that apply) Lot # T 99 N; R 1,$__ E or W Subdivision Name 1 or 2 Family Dwelling - Number of Bedrooms 4 1 Bloc ❑ Public/Commercial - Describe Use Q ❑ City of 1_ lQ~ ❑ State Owned - Describe Use wCSM Number .(2QQ ❑ Village of ~ ~ , Town of WARREN 674 III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. 9 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner / IV. Type of POWTS S stem/Com onent/Device: Check all that applyl 7, ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 3h Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) t V. Dis ersal/Trea cut Area Information: Design Flow (gpd Design Soil Application R (gpdsf) Dispersal Area Required 096 Dispersall Area r6oposed (s System Elevation /D/ 600 .5 2,126 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U / New Tanks Existing Tanks o -8 a e~ a V rn H v, iL t7 a Septic or Holding Tank 1250 N/A 1250 1 WEISER X Dosing Chamber 750 N/A 750 1 WEISER FX VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ' atur MP/MPRS Number Business Phone Number PAUL KOEHLER - 225,410 15-24trr2660 Plumber's Address (Street, City, State, Zip Code) 321 WISCONSIN DRIVE, NEW RICHMOND, WI 54017 VII oun /De artment Use Only ❑ suing t Signature pproved Permit Fee~j Date I su d is ❑ Ow rven Reason enial $ Z2//3 IX. Conditi~vaUReasons for Disapproval J ~i 1. Septic tank, etTl ent filter and tom' 2.rrw. dispersal cell must all beservices`/ maintained r~ 1 f as per management plan provided by plumber; 2. All setback requirements Must. be maintainKt ac - p the system and submit to the County only on paper not less than 8 112 x tl inches in siz FEB ` 6 2013 SBD-6398 (R. 02/09) Valid thru 02/11 INDUSTRY SERVICES o~enRxa~~ Safety and Buildings 141 NW BARSTOW ST FL 4TH 0 WAUKESHA WI 53188-3789 3 Contact Through Relay ~ S www.dsps.wi.gov/sb/ ~yL {~Gw www.wisconsin.gov ° sSIONScott Walker, Governor Dave Ross, Secretary February 07, 2013 CUST ID No. 225410 ATTN.- POWTS Inspector PAUL R KOEHLER ZONING OFFICE COUNTRYSIDE PLUMBING & HEATING INC ST CROIX COUNTY SPIA 321 WISCONSIN DR 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 02/07/2015 Identification Numbers Transaction ID No. 2205746 SITE: Site ID No. 787870 John & Jackie Collins Please refer to both identification numbers, Lot 1 above, in all correspondence with the Town of Warren agency. St Croix County SEl/4, SE1/4, S5, T29N, R18W Lot: 1, FOR: Description: Mound, bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1412186 Maintenance required; 600 GPD Flow rate; 38 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD-10691-P (N.01/01), Pressure Distribution Component Manual - Version 2.0, SBD-10706-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. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD-10691-P (N.01101) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems WSON 2.0" SBD-10706-P (N.01/01). p The designer states that the downslopa toe of the mound will be at least 5 feet fr and1tli~ and cell will still be on contour without being on a concave slope. o~ 07 C s The building sewer and distribution network piping shall be of material listed in Table 384 And 384.30-5, Wis. Adm. Code. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must comply with the operation, maintenance and monitoring duties as described in section VIII of the mound component manual. A copy of this information must be given to the owner upon completion of the project. PAUL R KOEHLER Page 2 2/7/2013 All holding/treatment tanks are to comply with SPS 384.25(7)(a). Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. Owner Responsibilities: • SPS 383.52 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. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4) shall be considered a human health hazard. • SPS 383.55 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. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice, Julia Lewis-Osborne Please Include a Copy With Your POWTS Reviewer 2, Integrated Services Pavment Submittal. (262) 397-6005, Fax: (608) 283-7481 WiSMART coder 7633 julia.lewis@wisconsin. gov Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Safety & Buildings will be modified. Code references with prefixes starting with "Comm" will be replaced with "SPS" to recognize the relocation of the Division of Safety & Buildings from the former Dept. of Commerce to the Dept. of Safety & Professional Services. Additionally, all S&B codes will be renumbered and addressed in a "300" series. For future f6crenix. the Wiscoumn t um -fiertial Building (Eu u will be add -cAAed ~y SPS Chapiera 1600166. Department of Application for Review Private Onsite - ~lgs 'K Safety and -Complete all pages- Wastewater Treatment ,ZO P S o Professional NOTE: Personal information you provide may be used for Services Systems secondary purposes Law s. 15.04 1 (m), Stats.) ry (Privacy Safety and Buildings Division - ~~~SSfONL~'~ For plan status, check our website at hqp://www.dsT)s.wi-gov/SB/SB-DivReviewStatusSearch.htmi Several counties have been delegated certain authority to review plans in lieu of DSPS. For a current list of those counties and their delegation check our website at http://www.dsps.wi.gov/SB/SB-PowtsProgram.html. 1. Project Information - Fill in all known information. Confirmation of assignment to a reviewer. Project/Site Nam JOHN & JACKIE COLLINS Transaction ID: Location, Number & Street of project (if unknown, indicated nearest road) Previous Related Trans. ID: N/A Estimated Completion Date: Legal Description: qF 1 /4 OF 114, SEC 5 T 29 N R 18 W Assigned Reviewer: County ST. CROIX City Village Town of WARREN Assigned Office: Send to office of choice (addresses below): Hayward, LaCrosse, Waukesha 2. After plans are reviewed, please: (check all that apply) NOTE: S&B reserves the right to re-distribute plans _ Call customer 1, 2 (circle number)` among offices to balance plan review work loads. - Requesting party will pick up _ Mail plans to customer 1, 2 (circle number)" See http://dsps.wi.gov/SB/SB-DivDailyDoc.html#Next for office availability and next review date "Refers to customer number from below 3. Complete the following designer/owner/requesting information. Utilize the check boxes when designer, owner or requesting party is the same to avoid repeating information. Designer Information (Customer 1) DSPS Other Please Specify Below (Customer 2) DSPS First Name Last Name Customer Number First Name Last Name Customer Number PAUL KOEHLER 225410 CO YNbE PLUMBING & HEATING, INC Company Name Address Address 321 WISCONSIN DRIVE City State Zip+4 (9digits) city State Zip+4 (9digits) NFW RTCHMON11 WT 54017 Phone Number (area code) Fax or Internet cell hone Phone Number (area code) Fax or Internet cell phone 715-246-2660 715-246-2676 N?A Check if applicable Check if applicable or specify relationship ( ) Owner ( ) Owner ( ) Other-specify relationship 4. Information and Plan Submittal Checklists. Scheduling POWTS plan reviews are assigned to reviewers after receipt of plans. If you select a specific office, your completion date may be considerably greater than what would be possible in another office. Submittals received without a specific office indicated on the form may be assigned to offices other than the receiving office depending on reviewer availability. Submittal checklists can be found in each applicable component manual. You may email technical code questions to DspsSbPowtsTech@_%Wisconson.gov. Waukesha S8.B Hayward S&B La Crosse Area S&B 141 NW Barstow St 10541N Ranch Rd 3824 N Creekside 4t° Floor Hayward WI 54843 Holmen WI 54636 Waukesha WI 53188-3789 715-634-4870 608-785-9334 262-548-8600 Fax: 715-634-5150 Fax: 608-785-9330 Fax 262-548-8614 Make Checks Payable to Safety and Buildings Division Total Amount Due $ -7 Mail check and payment voucher to - DSPS Fiscal Plans, PO Box • Review Code 7633 8602, Madison WI 53708-8602 RECEIVED Check box to invoice designer and sign below Designer Signature FEB - 6 203 SBD-10577 (R 04112) For most current application, check the S&B WebSite: www.dsps.wi.gov/SB/SB-DivForms/POVJTS MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE RECEIVED Project Name: DERRICK / COLLINS FEB ` 6 2013 Owner's Name: JOHN AND JACKIE COLLINS INDUSTRY SMICES Owner's Address: 1077 100 th street Roberts WI 54023 Legal Description: SE 1/4 SE1/4 S 5 T 29 NR 18 W Township: WARREN County: ST CROIX Subdivision Name: Lot Number: 1 Block Number: N/A Parcel I.D. Number: 042-1013-20-000 Plan Transaction No.: Page 1 Index and title Page 2 Data entry Page 3 Mound drawings Page 4 Lateral and dose tank Page 5 System maintenance specifications Page 6 Management and contingency plan Page 7 Pump curve and specifications Designer: PAUL KOEHLER License Number: MP 225410 Date: 02/04/13 Phone Number: 7152462660 Signature: Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/01), and both 4 f' ) 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 7 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 1.50 Peaking Factor (e.g. 1.5 = 150%) fecal coliform of 36 inches. 600.00 Design Flow (gpd) 15.50 Site Slope 101.25 Contour Line Elevation (ft) 36.00 Depth to Limiting Factor (in) 0.50 In-situ Soil Application Rate (gpd/ft2) Distribution Cell Information 100.00 Dispersal Cell Length Along Contour (ft) = 6.00 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/ft) 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) C Center or End Manifold 3.00 Lateral Spacing (ft) If N above, enter the elevation ft 4 Number of Laterals of the highest point. 0.125 Orifice Diameter (in) 3.00 Estimated Orifice Spacing (ft) = 9.38 ft2/orifice 2.00 Forcemain Diameter (in) 95.00 Forcemain Length (ft) Does the forcemain drain back? ~Y 95.25 Pump Tank Elevation (ft) Enter Y or N 6.50 System Head (ft) x 1.3 15.50 Forcemain Drainback (gal) 6.00 Vertical Lift (ft) 90.45 5x Void Volume (gal) 1.45 Friction Loss (ft) 105.95 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 26.36 System Demand (gpm) 13.95 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 x 1.50 x x 1.25 x 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/Inch Calculator (optional) Treatment Tank Information 1.00 Total Tank Capacity (gal) 1250.00 Septic Tank Capacity (gal) 43.00 Total Working Liquid Depth (in) WIESER Manufacturer 0.02 gal/in (enter result in cell 649) I Dose Tank Information Effluent Filter Information 750.00 Dose Tank Capacity (gal) POLYLOCK _ Filter Manufacturer 15.00 Dose Tank Volume (gal/in) 525 Filter Model Number WEISER Manufacturer Project: DONALD KUBIK Page 2 of 7 n Views _ Mound Plan and Cross Section T 1/10 B J Observation Pipe : K rr.rxr.r.r• r r rxr -•r•r•r.r.r.r.rxr•r•r•r.r.rxr.r•r r r r.rxr r.r•rx ;1-- - - S 4 4 - •°6•°..1.S.1.S+S.S.ti.4.SxS.'°xR..S ti' "4• °L.4 '..S •r•rxr•r•r• r r r r rx .r• r.r.r.r.rxrxr.r.r.r.r.r.rxr r:rxr.r txrM. A °u•R•°e •'L ti °.x5. 'L.°.x!°. b.4•°4.'4•i.Sr.S.bx4•R..°L 4.1. 9cx4.°x°°. .r.r.r.r.rzr.rxrxrx, P:•r~e°xrxr r•r.r.r.r.r.r.rxrxr.r ~ r. r.rxr.r•r. S.4.L•'Lx 5.4.'4+4.1. t.4:1.. i.1.b.°4.4.S.S.'Lxt.°..4.°L.'Yx' M1."'°•4• a x`kxb.ti.'L . xY`. r.r.r.rxrxrxr•r.rxr..~ ~".•,rxp.rx r•r•ra r.r.r.r.rxr•r.r.r.r.r.r* txrxr•rx r•r•d.r. •d''xe°+`,f~,ttiJ'x°d'tirxr•'r•°rSr~r<`r~rx, :,e+~:rx°r~r1."~."xr~xr~d'~rx°r~xr~F•"r~`rx°r~r•r•rxrxr~°r•rx~rx'x ~rLr~r~r~ W ..I ' ' :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:I:::. . B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • - . 1 • L.. L Mound Component Dimensions A 6.00 ft E 17.16 in H 1.00 ft K 8.27 ft B 100.00 ft F 9.50 in z 15.26 ft L 116.54 ft D 6.00 in G 0.50 ft J 3.67 ft W 24.93 ft 600.00 (ft2) Dispersal Cell Area 2126.17 (ft) Basal Area Available 6.00 (gpd/ft) Linear Loading Rate 10.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 103.54 (ft) r,.,,..... G 1 H 1........ ::::F Dispersal Cell 102.25 (ft) Lateral 101.75 (ft)--0- - Invert Dispersal Cell Elevation D ; ; ; _ 4 4 ` _ _ _ _ 101.25 (ft) Contour Elevation 15.5 % Site Slope Geotextile Fabric Cover Shading Key EL Dispersal Cell See lateral details on 10 Topsoil Cap c c 1.5 ft Page 4 for number, size, rxrxr•rxr.r r.r.r•r•r.r.2 55 5.55 L S 5'.15.5 02 Subsoil Cap y c 1 ~tir r~r r s srsrtifiti and spacing of laterals. :"r r rr r r r. r r r. Laterals are equally Q 0 ASTM C33 Sand r5r5r5r rr5 r5r5ttiP r r5r5r5~ F -a Z SSSSS.-~. SS5•.5..55555=5 spaced from the r.r.° T ical Lateral r.rxr• ®®Tilled Layer 0.5 ft rti.5 _ v 5.5.5,4 distribution cell's r.r.r r:r.r.r.r.r.r:r.rxr SxSx°. . 0 r.rxrrrr.rxrxr•r.r.r•rxr•„ x 5x5.5„'. ~ .S.L.°..'L.4.S.L.4. }.r.rxr. Aggregate o r.s.r.r.r.r.r.~.r.r.r.r.;• centerline in the A distribution cell (AxB). Project: DONALD KUBIK Page 3 of 7 i Center Connection Lateral Layout Diagram F rrsa>i+ via too of "on to ffmooM at as pant, L*O ata *I# ° ai P 4- Turn -up v4t7a11 valve for X--41<- x#ZLwq-tat; 8 forco main of FAX Sch 4€I 0106noutpl ug Pa COMM Tabu $4..~II-~ Hb$ft ddkd cry ttp bKAxom of lawA Number of Laterals 4 Orifice Diameter 0.125 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.18 ft Lateral Length (P) 49.29 ft Orifices per Lateral 16 Lateral Spacing (S) 3.00 ft Orifice Density 9.38 ft2/orifice Lateral Flow Rate 6.59 gpm Manifold Length 3.00 ft System Flow Rate 26.36 gpm Manifold Diameter 1.50 in Total Dynamic Head 13.95 ft Forcemain Velocity 2.69 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and Comm 16.28 WAC 4 in. min. Disconnect Tank component is properly vented E Alternate outlet location Forcemain diameter WEISER Manufacturer 2 in. Ca acit 750.00 Gallons Volume 15.00 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 28.94 434.05 B 2.00 30.00 C Pump off elevation (ft) C 7.06 105.95 96.25 D 12.00 180.00 D Total 50.00 750.00 Dom se tank elevation (ft) 3" Bedding under tank. 95.25 Alarm Manuafacturer ALDERON POWER POST Alarm Model Number Pump Manufacturer HYDROMATIC Pump Model Number IHEF 40 Pump Must Deliver 26.36 gpm at 13.95 ft TDH Project: DONALD KUBIK Page 4 of 7 Mound System Maintenance and Operation Specifications Service Provider's Name COUNTRYSIDE PLG Phone 715246-2660 POWTS Regulator's Name COUNTRYSIDE PLG Phone 715-246-2660 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 ft2 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 ever 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Ins ect for ondin and seepage once eve 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (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: DONALD KUBIK Page 5 of 7 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 clogged 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 7 c Pir on -new CAP- 624 - - - - - r aj x R " 400 JOHN & JACKIE COLLINS ik At gd 1077 100TH STREET '9 S'-1" 40 Svc` ROBERTS, WI 54023 / LOT 1 SE 1/4 SE 1/4 SEC. 5 T 29 N R 18W TOWN OF WARREN a SCALE: 1"=40' BENCHMARK #I :TOP OF STEEL POST a ASSUMED ELEVATION 100' BENCHMARK #2: TOP OF STEEL FENCE POSE ELEVATION 96.10' F , aA !O SYSTEM ELEVATION: 101.25 a 6en c 112~s ors 5 ✓ lo3 0 C ~s ~rnf /0'v /vo • nfow a~ ~T . ~IS.IS I o° , S 2 P~IZ~-i f' 06C 7 31.256ff Iu, 2~ bt, cQ I ~ 4 O I~uSG GSM lr 3, F*69 4 sfi2~ N vc: I?S f 1 ~ Ic~~' EVE i l 50 1 S I 60LL1 f 2301 Wisconsin Department of Commer SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings iRgacc~rdance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations "I County Attach complete site plan on pape than 812 x 11~ches in size. Plan must St. Croix include, but not limited to: vertical and honz ference point (BM), direction and percent slope, scale or dimemsions, north arrow, ani-d`location and distance to nearest road. Parcel I.D. 2-1013-20-000 p~ • do J4 Please print ll information. view Date Personal information you provide may be a dary purposes (Privacy Law, s.15.04 (1) (m)). t-n4 ?ice Property Owner Property Location w Donald Kubik P, Govt. Lot SE 1/4 SE 1/4 S 5 T 29 N R 18 W Property Owner's Mailing AddYtSrY ,G - Lot # Block # Subd. Name or CSM# 1543 Transit Ave. 1 CSM QA- City State Zip "one Number I City Village a Town Neare Road 7 Saint Paul MN 55113 Warren 3, Pg. 694 1101 New Construction Use: y_f Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement J Public or commercial - Describe: Parent material Glacial drift over sandstone bedrock. Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for mound system ~with ~6" of ASTM-C33 sand placed on 101.25' contour. Infiltrative surface elevation to be 101.75'. 1! Boring # I Boring 0 Pit Ground Surface elev. 101.12 ft. Depth to limiting factor 40" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKt2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 1 0-9 1Oyr3/3 none Ifs Osg dl cs 3vf,2f 0.5 1.0 2 9-40 10yr4/6 none Ifs Osg dl gw 1 vf,fm 0.5 1.0 40-46 1Oyr4/6 f1d 7.5yr5/8 Ifs Osg dl gw lvf,f 0.5 1.0 4 46-73 7.5yr4/4 m2d 7.5yr5/8 fsl 1msbk mfr - 1vf 0.2 0.6 Boring # - I Boring V1 Pit Ground Surface elev. 95.37 ft. Depth to limiting factor 38" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/B2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 -Eff#2 1 0-10 1Oyr3/3 none Ifs Osg dl cs 2vf,fm 0.5 1.0 2 10-29 7.5yr4/6 none sl 2msbk dsh cw 2vf,f 0.6 1.0 3 29-38 1 Oyr4/6 none Ifs Osg dl gw 1 of 0.5 1.0 4 38-56 1Oyr8/2 c2d 7.5yr5/8 vfs Osg ml - - 0.4 0.6 zon rading to sand stone bedrock near bottom of horizon. Effluent #1 = BOD? 30 < 220 mg/L nd TSS >30 < 50 mg/L ' Effluent #2 = BOD5 <30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signat e: CST Number James K. Thompson / 5-- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 9/19/2012 715-248-7767 Property Owner Donald Kubik Parcel ID # 042-1013-20-000 Page 2 of 3 3 ] Boring # J Boring V1 Pit Ground Surface elev. 101.37 ft. Depth to limiting factor 40" in. Sal Application Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/3 none Ifs Osg dl CS 3fm 0.5 1.0 2 10-28 10yr4/6 none Ifs Osg dl gw 2vf,fm 0.5 1.0 3 28-40 0yr4/6 none fs Osg dl gw 2vf,fm 0.5 1.0 4 40-61 10yr8/2 m2d 7.5yr5/8 vfs Osg ml - 1vf 0.4 0.6 Horizon #4 grading to sand stone bedrock near bottom of horizon. ❑ Boring # -I Boring J 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/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # - Boring _j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P 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 (11,07/00) A.C.E. Soil & Site Evaluations ~ . o;/ 2t/R,/ua 017 Al* t~Xi S fi~+4 v/a clt Z1Q ,Pc~''~23of ~ona/off J~u.6i~~/p)0• iSY.3 7"~a.Zs• E ! 6. 43. 7m~ 5~ee1 F¢.~ce 56. P 5,5143 Posh. EJe~1. = 9~.ro' ~ Q ~o~-/ CsrrJ //off 34 lo~ 95.0' ! r r 83 ~ , ~ , ■ be, ~9 /B. S.z Q creo i f / lf ~9bs/qae J t /Z /w ~oe.o• ' Q¢ of e: Togo{S{,cc l ~'~ncc~oos-E• A65amcd e.Jtu; -im.co' n M M M 1 AM Parcel 042-1013-20-000 10/01/2012 08:21 PAGE 1 OF 1 F 1 042 - TOWN OF WARREN Alt. Parcel 05.29.18.80A Current OX ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner 0 - KUBIK, DONALD (LE) DONALD (LE) KUBIK C - KUBIK, RICHARD A RICHARD A KUBIK 1543 TRANSIT AVE ROSEVILLE MN 55113 Districts: SC = School SP = Special P erty (es): Primary Type Dist # Description 1070 110TH AV SC 2422 SCH D ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 18.520 Plat: 0694-CSM 03-0694 042-78 SEC 5 T29N R18W LOT 1 OF CSM VOL 3/694 Block/Condo Bldg: LOT 01 ORD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 05-29N-18W SE SE Notes: Parcel History: Date Doc # Vol/Page Type 11/18/2005 812404 2930/543 WD 2012 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/07/2012 Description Class Acres Land Improve Total State Reason PRODUCTIVE FORST LANDS G6 18.520 70,400 0 70,400 NO 10 Totals for 2012: General Property 18.520 70,400 0 70,400 Woodland 0.000 0 0 Totals for 2011: General Property 18.520 129,600 0 129,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount I Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 D 66" AS 86" N D REOD m 53" ~ z Z r 0 m v \ UP 52" / N 1\ 4"CAS m 1 3" 57" 6" -n 0 ;o co D m I -n I rn 48" -I I m m m D O r D I N I , V I I ~ I .Z7 mm UP 50" 12 m 4" CAS m p~ z -a N c .A ° m Do 51" rF D m cn I D I N m D r 2 D O D Z O Z Z v c m D 6 --1 -4 z ~fN*1 ~x 0m(n >gz D OF O D °ND> XZ COO~~Z1*1-IDZ 00 X- ~mz 2 v v c) =1 o -4 CD °m ~n AO xv~~ zo~oFu1 IV N (n (-n N m0 m o m = N D mz, No a Fn -Do c) c: Fn -Z oD NZ I ~C orn~m•• °z (5) m =1 Z A' F> z X~ ZZ n m m = DDm oo~~ N sN 'N M\ n ~N N C O D 0 OD N DNS N Cf~.. O s0~ s a~ <Z 0) o a t n V A M O N K f*1m N m NOD Dr WO'`''v~Ob ~ 0 N C7 < o o c p N zo z m~ z m m cn ao (n -u v o v t" W AO c N rr nDD DO N ° m D I m H D ~z V ZA E! zZ D=I ha Wo D r(zo,) ~ O Z Dv D ~ I 0;0 p g r _0 m ~ m X N W :3 -u 0 0C Z D 09 CA D .i1 v A -I _O v m r R1 JE) 0 r c n H Z r Z m z mm z \ cn M250/750-MR m DRAWN BY. SME SCALE: 1 4"=1'-0" PRE-POUR: EBER coullETE REV. MI ° - SEPTIC MANUAL DATE' JANUARY 2010 DATE:. POST-POUR: Z W3716 US HWY 10 MAIDEN ROCK. WI 54750 ° REVISED JAN. 2010 800-325-8456 FlLE: 110017" SHEF40 Submersible High Head Effluent Pump Applications • Septic Tank Effluent • High Head Sump • Dewatering y CM r ~~ft j r s is 3. a I i Pentair Water- TIM a J EM FEATURES The Hydromatic SHEF40 submersible pump is specifically designed to meet the demands of residential high head septic tank effluent or sump applications. The 1-1/2 inch NPT discharge pump features an energy efficient 4/10 horsepower motor, 115 or 230 volts, and is available in both automatic and manual configurations. The SHEF40 can handle capacities up to 70 gallons per minute and heads to 36 feet. The SHEF40 features a heavy-duty cast iron construction that provides durability for a long service life, as well as dissipates heat from the motor for cooler operation. All fasteners are stainless steel for corrosion resistance. The pump's semi-open, non-clog design impeller passes 3/4" (spherical) solids and is made from a super tough engineered plastic that provides the highest level of corrosion resistance and the toughness to withstand the impact of solid materials. The impeller, molded to a bronze insert, also features pump-out vanes to preclude material from building up around the shaft and seal. The pump's unique (patent pending) non-clog design baseplate has an electrostatically applied polyester coating for corrosion resistance and provides a strainer-free inlet capable of passing .00 two (2), 3/4" (spherical) solids simultaneously. The inlet area is raised off the bottom of the septic tank or sump basin by the pump's 2" high legs constructed of engineered thermoplastic material for maximum corrosion resistance. The SHEF40's oil filled motor provides superior cooling characteristics, allowing the motor to run cool and quiet. The oil- filled design also provides permanent lubrication of the shaft bearings, minimizing maintenance and extending the service life of the pump. The oil- filled motor design allows for even heat dissipation. The windings feature a r built-in thermal overload that resets automatically. Automatic models feature an easily adjustable wide-angle float switch, incorporating a unique piggyback plug arrangement. This plug allows for simple conversion to manual operation by removing the switch plug and inserting the pump's motor FIr- ® HYDROMATIC' Pentair Water Page 2 ' ! BENEFITS plug into the electrical outlet. This feature A. Oil-filled motor provides superior cooling and provides an easy way to periodically cycle the permanent lubrication of bearings, minimizing pump to ensure it is operating properly. maintenance and extending service life. The SHEF40 is a completely submersible B. Water resistant power cord with molded plug is pump for use in residential septic tank effluent available in 20' & 30' lengths and is easily field pumping applications and is available in automatic serviceable. Unique four point cable entry and manual configurations. Automatic models provides superior protection against leakage. feature a wide-angle float switch with piggyback C. Lower ball and upper bronze-sleeve bearings plug-in arrangement. Switch is adjustable, easy support motor shaft, minimizing the effects of to service and allows for simple conversion to impeller loads. This design results in minimum manual operation. friction and perfect alignment of rotor, for longer service. D. Heavy-duty, cast iron construction provides long life and assists in heat dissipation for cooler motor operation. E. Energy-efficient 4/10 HP motor runs cool and quiet for long life. Motor windings contain automatic reset, thermal overload protection. j € 'rr Mom- F. Mechanical shaft seal is carbon- and ceramic-faced - for long leakproof life. " G. 1-1/2" Discharge NPT H. Corrosion resistant non-clog base with strainer-free inlet capable of passing two (2), 3/4" diameter spherical solids simultaneously. r I. High corrosion resistant, semi-open non-clog 10 t impeller passes two (2), 3/4" spherical solids. rv i . .i t ' J. 2" High corrosion resistant legs raise pump's inlet L:.. from bottom of septic tank pump chamber. Z^' i ck swit Q 9 i I ° HYDROMATIG'§ Pentair Water Page 3 • s • DETAILS Pump Characteristics Performance Data Pump/Motor Unit Submersible 40 Manual Models SHENOM1 SHEF40M2 Automatic Models SHEF40A1 SHEF40A2 Horsepower 4/10 30 Fall Load Amps 12 6.5 5HEF40 Motor Type Shaded Pole (4 Pole) FT20 R.P.M. 1550 Phase 10 10 Voltage 115 230 Hertz 60 0 11-1 A Temperature 120°F Max. Fluid Temp. 10 20 30 40 50 60 70 NEMA Design A GPM Insulation Glass B Discharge Size 1 1/2" NPT Solids Handrmg 3/4° Dimensional Data Weight 28 lbs. 3-7/8" 6-5/8" (168.27) Power Cord 18/3, SJTW, 20' std. (98.42) ~5" (127) (30' optional) 3-7/8" (98.42) Materials of Construction 3-7/8" DISCHARGE (98.42) 1-1/2" NPT 1 (38.1) Handle Stabdess Steel Lubricoting Oil Dielectric 09 FLOAT Motor Housing Cast Iron SWITCH Pump Casing Cast Iron Shaft Steel Mechanical Seal Faces: Carbon/Ceromic Shaft Seal Seal Body: Anodized Steel Spring: Stainless Steel t 1'~8" 1o in s" (288.92) if (25 6) Bellows: Bmm-N Impeller Engineered Thermoplastic Upper Bearing Bronze Sleeve Bearing * (92.0 .o7) Lower Beard Single Row Bell Bearing 2 (+0 81 Bottom Plate Polyester Coated Steel Fasteners Stainless Steel All dimensions in inches. Component dimensions may vary t 1/8 inch. Dimensional data not for construction purpose unless certified. Dimensions and weights are approximate. On/Off level Legs Engineered Thermoplastic adjustable. We reserve the right to make revisions to our product and their specifications without notice. - Your Authorized Local Distributor - HYDROMATIC Pentair Water USA CANADA 740 East 9th Street Ashland, Ohio 44805 269 Trillium Drive Kitchener, Ontario, Canada N2G 4W5 Tel: 419-289-3042 Fax: 419-281-4087 www.hydromatic.com Tel: 519-896-2163 Fax: 519-896-6337 © 2005 Hydromatie Ashland, Ohio. All Rights Reserved. Item W-02-6680 1.5M 3/05 i` INSTALLATION INSTRUCTIONS •~inc. §r; PM6. ! Aim .a ktfic. PL-525/PL-625 FILTER PL-525/PL-625 FEATURES & BENEFITS Features & Benefits: s Rated for 10,000 GPD n: • PL-525 = 525 Linear Feet of 1/18" Filtration PL-625 = 625 Linear Feet of 1/32" Filtration t PL-525 PL-625 • Accepts 4" and 6" SCHD. 40 pipe The PL-525/625 Effluent Filter should operate efficiently • Built in Gas Deflector for several years under normal conditions before *Automatic Shut-Off Ball when Filter is Removed requiring cleaning. It is recommended that the filter be cleaned every, time the tank is pumped or at least every *Alarm Accessibility three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the *Accepts PVC Extension Handle filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. RECOMMENDED PRODUCTS Polylok PVC Fitter Extension Handle low 5 ~.t Y 7 y1q Z. f r ~ r Risers & Riser Corers Extend & LokTM Riser Safety Screens Filter Alarm Panel and SmartFilterTM Control Polylok risers bring your Polylok.Extend & Lok'"I Polylok safety screens Switch septic tank cover to grade. is a simple, easy to use prevent tragic accidents This allows locating and solution that can extend from happening by children Polylok filter alarm panels. servicing your filter easier the inlet or outlet pipe and and pets falling into open and switehs provid a visual and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of nating digging to find tank installation a snap. impending filter and tank entrance. Fits 3" and 4" pipe. servicing. For a full list of Polylok products please visit our web site at: www.polyfok-cam w Y W U n- o v ZQaf 0- LV i N W U m Z O M : o~' Z° ZU~Z W v) 9 f- F- ° ~cc w ~U O CL 0.< O< lcn O Q ~C-) o~ rn r CO C7 W O M ~ u u W O U M U M U GO N C7 Op OO N LO M C c- cd u J ~ U Lr- O ~ r co N -T14 O U Lq ~ 'ct N u H ~o W~ U LLI Q N 1111~~~~~ N~ z~ e ~ N O E1_ J CO W U W U U U `t _j co LL F- J O v w m z w ZD ~ U a> 0 C/3 = 4 LO 0 ``ann J J LLLI N V ® U¢ F- d- J z W E: z z-j m 0 0= Q ZZti CO a- (n = Q>M LO . J Q WOf ~ COQ Of COL tI)Z~~Wd NI-W ~Jm ~QQO:=) L? aaM20co 07/02/2009 11:46 12032842064 _ EI+ PAGE 01 Report uato 2-Juk09 EML Project ID..... 080822-F'WO Your Yo ID- Polylak_525 Effluent Oftr POLYLOK TEST FACILITY Date Sampled........ _ 22-Jun49 3 Fairfield Blvd Date Submitted.. 22--Jun-09 Wallingford, CT 06492 Aftrt: Mr.° Peter Gavin Values in. mgt unkws at rwtae noftd, NO C Not DekWed AIR -r- At Ro d Amended' Report #5 #525 " Par~m 89ft+re After eiochemicaal Oxygen Oa wad 944,5 355.2 5 TQ#Ail Suspended Solids 840:, 53.Q _ ras~r..rc chnicai Rev(pwe .:w ~.F. Transcript Revi AMC' awl ~uan~v.~T CT G~TnGaON ~rMO,M~ MOKiT 4A00~►T~1HyS i ty . t?l.1 & l41, PAl9S' 1 . coNWOMM 002 1'k 11'. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEiV1ENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ' Mailing Address Property Address ~ ca (Verifica(ion required from Planning & Zoning Department for new construction.} citylstate { Parcel Identification Nwnber t - LEGAL DESCRIPTX N Property Locatio-i 1/4, %4 , See: T = N R ` Val, Town of Subdivision , Lot # Certified Survey Map # , Volume , Page # Waxrawly Deed # Volume Page Spec house yes no Lot lines identifiabl yes )"o SYSTEM MAINTENANCE AND QWNER CERTIN ATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper mairiteniinc a consists of pumping out the septic tank every tree 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(l) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner' agrees to submit to St. Croix County Plarming & Zoning D artment a certification form, signed by the owner and by a master plumber, journeyman, plumber, restricted plumber or a licensed pumper versifying that(]) 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 113 full of sludge. Ilwe, 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 campleted 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 farm are true to the best of mylour knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Numb edi ms SIGNATURE OF APPLICANT(S) DATE 'Any information that is misrepresented muy result in the sanitary permit being revoked by the Planning & Zoning Department.. Include with this application a recorder/ wan-anty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08105) I I • uv..a.- )o z POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1 of FILE INFORMATION SYSTEM SPECIFICATIONS _ Owner Septic Tank Capacity 1250 gal ❑ NA Permit # Septic Tank Manufacturer WEISER O NA DESIGN PARAMETERS Effluent Filter Manufacturer POLYLOCK DNA Number of Bedrooms 4 q NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units ® NA Pump Tank Capacity 750 gal N4 Estimated flow (average) 450 gal/day Pump Tank Manufacturer WEISER D NA Design flow (peak), (Estimated x 41.5)600 I gaVda Pump Manufacturer WEISER D NA Soil Application Rate • 5 al/day/ftt Pump Model HYDROMATIC SHEF 40 ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit O NA Fats, Oil & Grease (FOG) 530 mg/L E3 Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA D Mechanical Aeration 0 Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA Biochemical Oxygen Demand ISOD5) 530 mg/L ❑ In-Ground (gravityl ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L 0 NA ❑ At-Grade X:KFAound Fecal Coliform (geometrio mean) 5104 ofu/100mi la Drip-Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: O NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tankls) At least once every: 3 0 month(s) (Maximum 3 years) Nit year s) Pump out contents of cask(s) When combined sludge and scum equals one-third (Y.) of tank volume 11 Nit Inspect dispersal cell(s) At least once every: 3 00 month(s) (Maximum 3 years) 11 NA Clean effluent filter At least once every: 1 Q month(s) ❑ NA • l :0 year(s) Inspect pump, pump controls & alarm At least once every: 3 D month(s) ❑ N/, ear(s) Flush laterals and pressure test At least once every: 0 month(s) ❑ W. 3 13 ear(s)AS NEEDED Other: At least once every: 0 month(s) © NA O year(s) Other: O N.C. 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 surfacs. The dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes and to check for any pond'ing 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 11:1, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmerit units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintalner. A service report shall be provided to the looal regulatory authority within 10 days of completion of any service event. • IL - Ill~iillll►11111i1llllllilllhl 8 0 xs4078 7 9 6945 3 STATE BAR OF WISCONSIN FORM I - 2000 965969 WARRANTY DEED BETH PA BST Document Number REGISTER OF DEEDS THIS DEED, made between Richard A Kubik and Donald A Kubik ST. CROIX CO., WI aka Donald Kubik, Grantor, and John P Collins and Jackie M Collins, 10/23/2012 4:15 PM husband and wife, Grantee. EXEMPT#: N/A REC FEE: 30.00 TRANS FEE: 225.00 Grantor, for a valuable consideration, conveys to Grantee the following PAGES: 1 described real estate in St. Croix County, State of Wisconsin (the "Property"): Part of the Southeast Quarter of the Southeast Quarter Section 5, Township 29 North, Range 18 West: Lot One (1) of Certified Survey Maps recorded in Volume 3 Records, page 694, as Document No. 352006, St. Croix County, Wisconsin. Recording Area Name and Return Address: Pi It # 1$578 Title One Premier Group 706 19th Street Hudson, WI 54016 . Together with all appurtenant rights, title and interests. 042-1013-20-000 Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways Easements and Restrictions of Record Dated this 5u' day.of October, 2012. Richard A Kubik * Donald A Kubik aka Donald Kubik AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. authenticated this Personally came before me this 5th day of October, 2012 the above named Richard A Kubik and Donald A Kubik aka Dona Kubik to me known to be the person(s) who executed TITLE: MEMBER STATE BAR OF WISCONSIN the f e oin nstrnment and knged the same. (lf not, authorized by § 706.06, Wis.•Stats.) *Jac a O'Neill THIS INSTRUMENT WAS DRAFTED BY Wry Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 8/14/2016 ) Michael H. Forecki, Attorney (Signatures maybe authenticated or acknowledged. Both arc not necessary) JACKIE O'NEIIr.L _ *Names of persons signing in any capacity must be typed or printed below their signature NOTARY PUBLIC STATE OF WISCONSIN 1 Of 1 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. I-2000 1 _ r 352006 CERTIFIED SURVEY MAP GERALD WEISS Part of the Southeast 1/4 of the Southeast 1/4 of Section 5, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. N 9'OG' 35E Fa18. 15~ !n • 4 . W~ o ' Iwo p FU) W f- G. s_ Wkin 0 IY O< U IA. 52 AC RCS W aW 0 3 - ?{400 .0 ~t>_a0 10 mOz N W~ o Z (I 00 y 4-IF z Z SCALE , moo' f P I'3' `jET 33.0 s S€ CO R. SEC.5 OFF5fC.LINLr T wN RO O St99 1~3UW ~3gt, RI$W_ .4-ao ± OFT- q, ROAO S , 89a 1-7':5d 'VV To )3 8Z"- F0 I" r. P, sF--r o Indicates 1" x 24" iron pipe stake weighing. 1.13 lbs./ft. set. • Indicates 1" iron pipe found.* Description: That certain parcel of land located in the Southeast 1/4 of the Southeast 1/4 of Section 5, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, more fully described as follows; Commencing at the Southeast corner of said Section 5, thence along the South line of said Section 5 go S 89017'30'"d 681.58' to the POINT OF BEGINTIING of the parcel to be herein described; thence continue S 89017'30"W 613.821; thence go N 00011'20"W 1308.861; thence go N 89006'35"E 618.151; thence go S 0000010011E 1310.87' to the POINT OF BEGINNING, containing 18.52 acres, more or less, being subject to an easement for Town Road purposes. (For purposes of this description all bearings are referenced to the East line of the Southeast 1/4 of Section 5, Township 29 North, Range 18 West, assumed N 0000010011E) 1 2 D ,1P ~gNaal,ulrnrra/4/1 SEp 271978 cSG o,/ys, Vol....1.__Page. 69h~ ~'clpNNJU Cy( . '5~/. r Certified Survey Maps &9W" o..e, JAMES L 84 awk St. Croix County, Wiscons c'"'b, Cl,, MURPHY •.1 6' = - _S__1-0-42 (Continued on reverse) gp$ RIVER FALLS, ffi0 fG_ mix W15c. . _.k,