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012-1060-00-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information ydu provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Stoddard, Arlene Erin Prairie, Town of ;ST BM Elev: Insp. BM Elev: BM Descdpti n: ~ ~ tN~, t, C,5 `C` TANK INFORMATION TYPE MANUFACTURER ~~ j , CAPACITY Septic y,,~, , ~.Ji'eS.e-~~ ~ a~ j Z 5 U Dosing tt i t7w.bb 7•~ 7$O ~ 1 ~ ~ ~ c~.VV~.X.~ Holding TANK SETBACK INFORMATION TANK TO P/L ~~ WELL BLDG. Vent to Air Intake ROAD Septic .7, sd i ~ I / 3~/ 1 - Dosing 75vJ ~/ ~ 3$' _.--- Aeration Holding rumlwsllrrtuly lrvrvrcm~-l wn Manufacturer Demand ~~ GPM Model Number n TDH L~, ~~ Frictio~~l~s~ System ead TD~• ~JJ Ft Forcemain Len Dia.2i j Dist. to well ~ ``i~ 1 SOIL. ABSORPTION SYSTEM County: St. CroiX Sanitary Permit No: 506280 0 State Plan ID No: Parcel Tax No: 012-1060-00-000 Section/Town/Range/Map No: 27.30.17.415 ELEVATION DATA STATION BS HI FS ELEV. Benchmark , ,' ~ jt~ ~7 / Alt. BM y n.~e,~r ~.o~ cam. Z , 7Z. ~ $ , ~ t Bldg. Sewer ~'.a~{ 91. c~9 SUHt Inlet /D.a1 9a . ~z St/Ht Outlet ~ ~ Dt Inlet ~ \ ~. Dt Bottom I~•~ ,S6 ~ ,~q f - He~~ier/Ma~L ~ ..~t"_ I~ ~p Z ~ ~f~' S Z Dist. i e p ~ Z4 ~.y~ . 5'S Bot. System G`~. ,' y R• a ~/ Z. J Final Grade yl.Z 9~• 53 St Cover, ~ .,1 f Ct' z,7L ~~ ~ ~ f ~W ~•'f9 ~y•z`/ s~ D, ; 6,,~' 4 • yg 9~• z ~f G~,~,_ ~s ~-' ~, iy ~, 5 5 BED/TRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ ' ~+~~' _ ~ (~ -~ `~- ~-.._. \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: f3 I N CHAMBER OR /`'' INFORMAT O Typeppf System: , C ~- / j ~ ~w / 7 / ~ 35 UNIT Model Number: .,o,r~Je ~o DISTRIBUTION SYSTEM .~s,. .L\_ icl.>c,PliJr~i..Jan. Header/Manifold ~ ~/ Length Z T Dia i / s e T Distribution Pipe(s) Length ~ Dia \ Spacing ~ x Hole Size ` ~1 x Hole Spacing Vent to Air Intake ~ ~ ~ ~ Sell Cf7VFR v Drncc~~rn Sv~4om~ rlnly vv Mn~~nrl nr ~t_Grade Systems Clnly ~ rla~~ ~~CX Depth Over Depth Over xx Depth of xx Seeded/Sodded xx i ulched Bed/Trench Center .a. t1 ~(„~ ^r 1 Bed/Trench Edges \ Topsoil Yes ~~;, No ~ Yes ~= No .31 91•S COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1862 130th Avenue aldwi WI 54002 (SW 1/4s~ 1/ 27 T30N R17~~yr~~) NA~~Qt~~ Parcel No: 27.30.17.415 ~,~- ~a~c.r- 6~d ~~'6'kw„ jtioC~l-dl G.I~.+o,~ S ~- ~oc~ O~r~. 1.) Alt BM Description = ~ ~ r^,~ - ~, / 2.) Bldg sewer length = ~~ 54~.b+v~ ~<~-~ ~ p ;'~("~ bJ~--`b ~.. 'J O ~ 7 n's~CCL{Ie~ - amount of cover = / Z -Z-- ~•a--- o~ Plan revision Required? ~ a] Yes o !~ ~ ~ Use other side for additional information. --' - - _ _____ Date Insepctor' Signatu Cen Nc SBD-6710 (R.3/97) , ~ewo~- CORl1it~CCB«w1.gOY Safety and Buildings Division County 5~ L QU~ X 201 W. Washington Ave., P.O. Box 7162 ~~/"~ n~ /~'~ Madison, WI 707-7162 Sanitary Permit Number (to be filled in by Co.) QepartmenVt o^t C^amme^ras ~J ~ Lp Z g Q Sanitary Permit Applieatic~, state Transaction N~ber [n accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the a mental unit is required prior to obtaining a sanitary permit. Note: ed P re d f r econda b itt d t th D rt t f C P l i f i l ' QS Projec[ Address (if different than mailing address) ry su m e o e epa men o ommerce. ersona n orm on yo e o u oses in accordance with the Privac Law, s. 15.04(1)(m), Stat ~j ,J~ ~" ' D ~Q Z ~ 3 ~ " "~ ~v~ L A lication Informatio lease Print All Informati n . Pro erty Owner's N a me Parcel # n w i Property Owner's Mailing Address ~ Property Location / ~/ 5 / ~' RUE l 8 ~ ~ ~ . l O Govt. Lot City, State Zip Code Number Phone ~ '7 5(oj y~ y,, Section ~ / ^^ /TL f~ wl/(f Wl ~~/DG ~. © -f `, ~ 1 ~'~ ~ ('7 7 R (circle one T 0 N ~Z E or V~ ~ 11. Type of Building (check all that apply) Lot # , _ n ~l or 2 Family Dwelling - Number of Bedrooms [ ` Subdivision Name Block # ^ Public/Commercial -Describe Use ^ City of ^ State Owned -Describe Use CSM Number ^ Village of /~ , / ,p a /~ . 1T~ ~ ~ i9t~ I( ~ ~ ~~ i ~Townof /W ! "IT lS III. Type of Permit: (Check only one box on line A. Complete Tine B if applicable) '4 ^ New S stem y Re lacement S stem ~ p y ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. T e of POWTS S stem/Com onent/Device: Check all that a 1 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 Device (explain) V. Dis ersal/I'reatmentRrea Information: X 60 tl Tn.}.+e~~Lt. Design Flow (gpd) Design Soil Application to gp s ' ~ tspersa rea eq re Dispersa rea Prop ed (sf) ' System Elevation (ooo / r 7 8S7 9 0o q~tti8 VI. Tank Info Capacity in Total # of Manufacturer :; c a Gallons Gallons Units ~ :: Ne T nk E i ti T k I y o ~ ~ ~ w a s x s ng an s ~ , ^ ~ 1 W - l \ l / l t a U ~ ~ ~n v~ ~ ii C7 a ~ J / I Q,( l ~C „ t J y . Sep[ic or Holding Tank / ^ ~'V ~ ~ ~ p ,. • L~.4¢~ W ~ Dosing Chamber e7 (a J ~ /v VII. Responsibility Statem ent- 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 ~ RLt E ~ ~£c ~F v - ~~" (,~ a.1?~~-~` .~,.vt-~ ~ a ~ ~ ! a -~~5, ~~R - 33~~. Plumber's Address (Street, City, State, Zip Code) q6~ N _~~ ,~~ ~, S yv ~3 Vlll. Count /De artment Use Onl Approved ^ D Permit Fee Date Is ued Issuing ent Signature ^ ~ ~5v ' ~ 7 3 ~ d7 iven Re r Denial IX. Condit' easons for Disapproval ~t~f 8G9 (~ (( ~~ ,~ "' ' 3~ O ~~ ~ ~ '^' c~_,n.JCZS ~ 1. Septic tank,-effluent iNter aid - dPapersal cen mast all ~ teerv#ies 7 mair~aifled ~ as per management plan provided by plumt>.r. C.Ja ~ GO 2..Aq setback requirements must be maintained ' ' AKach to complete plans for the system and submit [o the County only on paper not less than 8 t/2 x 11 inches in size SBD-6398 (R. 01/07) Valid thru Ol/09 ,~ `'~- i I ~,~ ~.~ x ~ & r~ ~~ .~ t ~ ~ -~ ~a ~,, .~ { ~ ~ Y "~ `~~e. ~~ y_r."Jw + ...-., . .w.__..r..._.,. ~ ' ice„ 3 ~`. .,ti _ _. .~p ~ EJ t ~ to T ~ i S ~r~ • ~ R ~ ! x $ ~ , j ~{ry E~ ~. ~ a ~ ~ R az~, pp tr ~i ~ ~ ~ f ~ o ~ 4S ~ ~ 1 ~ ~ ~) d ~ _- L 1~~ ~ ~ ~ ~ ..l.r ~ r } t, ~ a ~y -~-t jai ~ ~ ;,,~~ ~~.~ r ~~ i '~ ~ bo ( ~~_ •~ o y~, ~'`~ e A -----~> --• 83 I ~. ~< ~ ~~__55~.- T- g ~' --- --_-____-- - --'~ -- - -- ~,-.~a ~~, ..--~ ~~~ ~ u~.A.a ~ ~~/~ So 0 0 ~ ~ ~ ° '0"`"-""` t----- r ~~ ~~~ ~~~ ~. 7- ~.~ -® 7 ~~~~ s` x c.~.~ ~t~. ~~~ f ~~ ~ ~,-c_e. Vrl a=L,.~ Y ~ ~a$ -~ ..._ ~ r ~. '~ ~,~ T r '~ °6 ~ '` r ~.~ T i Ta ~ ~ ; ~o o G ~'' ~~ ~ i' a~ x ~ ~ ~ d v ~ ~~ m i ~-i: c` d >~ ~. 6 ~ ,~~ vo ~. ~l~~ bhp a A ~~- fi-- •----~s--• 83 0 55 ~. ~I ^~ g~ ~ .:.y a ~.Q..~. ~ ~ ----~= ~a ~sr ~ ~_~~~~ .~~:~ x ~ ~' ~~ 7 - ~ ~ - c 7 Eros-~-. c,J ~-~.~-~-° ~.~~~Ia wrsoonsfn oepartrnenc ~ SOIL EVALUATION REPORT Page ' of `~ Division otSafety and Bw'ldings m st i Pl ~ 1 i i h u ze. an nc n s es Attad~ oarrplete site plan on per n ass tian 812 x irx~de. but not to: vertical and horizorNal r P~ (914I). direction and Q • V' O O Parcel l.D. - •• 0 es aeroer~slope. sc~e ardar~ansions.nor>fi arrow, arsd loption and ~stanee to nearest road. O/o1 • OG - O©• 0 Please print all informa~io~ trot (~) (m?) t Rm 6 Re ~ ~' Oate 7 Z! - acr aw.: msr ba arose rorrseca+dery p:voses i Perearw daoa+.stia-rou p~wra ~A1/~(S ~~~ ~Y~ ~ ~ ~ 7~ N R ! 7 E 4 ~ 1f4 S ~ T l p r. pout, l:ot 1/ y Ova's o ~ Lot # Block # Subd_ Name ar CSN~! ~~Cv 2 /3 v- Cigr State " Z~ Code Phone Number 13Ai~w~a u~/. cis, ~~~•S3~z 0 ~Y ^ Ydtage Town Neatest ~niN 1~~4i,e,'~- / o vie - ^ Naw.Curtian t1se: ~. aesiaer~ ~ Nurrrber of bedrooms. ~- crde derived Aow roes 5' S~ - pPD o Pr>s~oroorrunerd~-Desc~e: Pa~rrt s S 0 d Flood Plain eler~n if ~-- ~- pat>etal r~amrerr~ RE and 2007 Ar~A ~ 3pot Tested suitable for JUL 2 7 ~ conv~ntlonai inground system (P.O.W.T.S.) ST. . ~ ~~ Q 801i~~ a ~ O ~ ~' R ~'~ 7MT ~ Shc Ram i on H tlr Oe Oorrtirtartt iiedooc Oesctiption TetcWre Structure cor~sterroe Baxrdary Root rx a p ir. ~Ate~ Qu Sz: Cont. Color (fir. Sz. Sh. '~~ ` / p- /p 3 SL 2.15 S w 3 / C~ 2 •2b o L Ccv Z f . • p /b - S L ZfS ~Nn ~ ~ S t ~ • ~o . a• ~.s s ----- y ~tu~p ~ .2 ~ ~• s~ c~ ti 3 Bore ~~' ~ ~ , ~~ Z ft m Bound strrfaoe slat,. - ~ _ .. ~, ,tafe Fbrlaorr oort~nard Redox Desaiptkxr TexWne structue C«rslstatroe Borardary + pPWIE 6r. tam c~tr. Sz. Cont. color Gr. sz. sh. '~ / o• /z /DY1Q, 3 ~L 2.w1 S S w 3 'F . ~ ~`d z ~ • 17 ~. / S d-S cw Z ~ • 7 3 /7•a ~' S!L zfshK n~~R cs ~ ~ 7.5 ---- GS ~ a-S - / ~o 75 S ~ • EUluent #1= BOD > 3 0 < 2~D nglL and >30 ~ 1 50 mpA. aY2 = 80 D <_ 30 rtgA.. and T5S _< 30 mgll. ' CSTWtsrtber csr ~ t ~ 2ILI3 ~ t CtiT~ sip z 4 3~1 S _ S~ ~ 0 7 7!5.77' ' Private Sewage Consultants 2812 i 0th Ave. Spring i/aliey, WI 54767 ~ .. w~aorrsirr Depararrerh ~ Ca _ 1, g ~ SDI! EVALUATION REPORT ~e ' or `~ ~ivisionofis~fetyandBuik ..t~-°°`-..~ ~+ ST. G(2ot ~. . mach oonr ie~e site plan an Plan must 3'r ss 81l2 x 41 inches In Sze p p . bo G7 - .. indude, but not rerrited lo: ver6c~ and horiaontal r~erance point (BMj, d and peroentalope, sc~e ordimensior>s. norm arrow. a<+d location and to nearest road. Paroel lD. G/e'~ • O OO • o o tS Pease prjnt aN infnrmailon. by Oats Paoraw intom+~eon you Peovide eay b. used torssoondtrry PuP~ i~~Y tar.. a 15.x4 pi (m». •~ 7 z/ PnopertyOwrter t ~ ( E~~ ~ ~Jv(S ~~~~v~I~ ~ v Properlylccation R l7 E 7~ ~ '~ !' W ~ , p Z ( T.. PI 1/4 S (,tout. Let J 1/4 PiopertyOwnar's - Lat# Blodclf Subd. Name ar CSMf~ Phone Number 13~4i~wta u~/. c?/S} 79G-S3/~ ~ ~ ^ Vl~age Town Nean~st ~!?~.v 1J~4i,2i ~- o` v~¢ . ^ Naw Construesion tJse+Q.Q. Rol / Number of bedrooms Code derived design flow rale S ~ c~D ~ Pubr~ or oomrrrerdal - Parent materi~ S 0 0 Flood Pl~rr eis+raUon if app6cabie '~-~ - _ _ - R c3eneratoarn,netMs RE .ana 2007 prra~ Spot Tested suitable for J U L 2 7 ~ cnnventlonal inground system (P.O.w.T.S.) © a 8orir~ ST.~f _ ~~ * ~ Grotet . _~, Depth to ~rrrNirt$ fareor ~ " ~ in. ~ Soi Rafe tloriaon Depth Donirant Redox Dasaipflort Texiue Shucttre Cor>sisterrce Bartndery Goofs in. tifiur<se~ ~ltt. Sz Coat. Dolor Or. Sz Sh. 'E~1 'EiEp2 / D~ 0 3 SL 2,wt 5 S w 3 / C~ 2 •2d o ------ C cv Z f a• ~•s s ----- y ~~at a ~• SY Co ti . ~ ~~ > -l3atr~g ~ ~ c~or,ndsur~ceele+-. q5• ~ Deptl~rlolirfi6rrgfador 9.~ ;,-... ~, ,~ Haimn OepQr Oorrrtrrerd Redax Description Tmrbure Strtrcture Corralroe eotartfar)- Roots t irG Mursep Qu. S¢. Cont. Cobr t;r. Sz. Sh. 'E1~1 '~ / Q • !Z /D yR 3 ------ vac. 2.w1 S S w 3 f- . Co ~`d Z G2 • ~7 - G. / S d.5 ccv Z. ~ . 7 !7 • a ~' - Sly Z shK n~,~FR es ~ f 7•~S ---- GS ~, a-S - / ~v ~ 5 -- S C~ ,~ • Eflluerrt e'1= BOD > 3a < 22o mad and >30 < 1 5o mdl. • i~lhrart eft = 80D _< 9o moll. and TSS <_ 3o mgil. csr Nerve l PrinQ 2l U3 ~ ( C ~T s ~ S Dale Evaluation Teleptrorre Number rrtvate Sewage Consultants 2512 10th Ave. Spring Valley, WI 54767 .~~.~_~ •• Property owner Paroel to ~ ~ 2~ Hadmn Deptl~ Dominant Redoor Oesaip6ori Texarna Siuciuie tarrststerroe Boundary ' Rods ' ta'F OAt' ' i~. MunseO (lu. Sz Cann. Color Cx. Sz $h. 'Etf~1 'Etta o- ~oyR 3 s ~ z~sh~ d s ~ 3~ ; -o D ~ w 3 s' ~ iL 2~S ~-fi2 ~S ~ ~ G ~.s 2 --, G 0 -- i l~ ~~ a l ~~ ^ Pit t~armd surface elev. R Oepth to ~8 tacior h Sd R~tB Hortaon Depth Dari~arrt RedoorDescription Texture Sin~c~rre Gorrsistenoe Bourxtary Roots ~ in. Mtnse/ 11u. Sz Copt Cabr err. Sz Sh - 'f~1 b ^ ~~ # ~ ~ ~ Grourd surface elev. R Depltr b ~ factor irr. Sot Rats Hodson Oapt#r Dorra~arR Redmc Descdptian. Textun3 Strudrxe Bouardaty Rook h Mine! Qu. Sz Copt Color taY. Sz Sh 'E1~1 'Eta ~ ~su~eiev it Depdrlo~fador i<,. a Sol ftatie Hodson ~ Redooc Tercaae Sirucha~e a ter„ Rook in. Nurser ~. Sz Color Gr. Sz Sh. • r #1 ~OOs > 30 _<?ZO ngll and TSS >30 <_ ,5G mglL • EAk~ent ~2 = 80Ds <_ 90 mgA. and TSS _< 3o mg1L The Department of Commerce is as equal oppardtnity service provider and employer. if yon need assistance to access services or need matexial in an alternatie format, please cmttact the deparhtremt at 608-Zti6-31 S 1 ~ TTY 60&264-8777. s~~ y k s ' ~ -~ SC,g/..~ ; / ~~ _ ~ a o = r q~,0 A ~a a ` ~ ~ ~, ~ O b c17, 3' ! ~ ~~ ~ ti~ ~ ~ c _ 25 ,, yb .~ e ~3 i LC = ~ q~-D 4Z ~~, J3.~Cl~~ (1~% 1's d,,~ 7`a v/~' S -F,Gu (Q~ /~/ ~~ \ ~N ~' Z -ro p o~ p koN.~ 5~ ~~ = /pD~l~ l ~ ~ aaL ~. S ` , ~ s ` Ti4,v/G O ~9~~ ~~ ' ~ aG0 5~rr ~ T ~~~ ~~y ~°~ o~ ~' ~ ~p~ ~~ (- - Assvti.ti~-D ~xrT y~~o,~~ ~ o~_ 13~ ~~ ~. 25 Sp ~ . 1 ~~ 1 ~~ ~u4~ ~l1,Pti /~ ~~~ y~~~.e. y7,d ~ ~,~ D , 90. a - Ulbricht & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 J 25'i0P 299 STATE BAR OF WISCONSIN FORM 3 - 1998 QUIT CLAIM DEED This Deed, made between Arlene M. Stoddard, a single person, Grantor, and Dennis A. Stoddard, Darrell G. Stoddard, Diane S. Johnston, and Donald L. Stoddard, as tenants-in-common, Grantee. Grantor, quit claims to Grantee the following described real estate in St. Croix County, State of Wisconsin: The Northwest Quarter of the Southeast Quarter (NW 1/4 of SE 1/4) of Section Twenty-seven (27), Township Thirty (30) North, Range Seventeen (17) West; The Southwest Quarter of the Southeast Quarter (SW 1/4 of SE1/4) of Section Twenty-seven (27), Township Thirty (30) North, Range Seventeen (17) West; ~SL~506 ~i KATHLEEN H. MALSH REGISTER OF DEEDS sT. cROIx co. , wI RECEIVED FOR RECORD 04/02/2004 11:05AM oUIT CLAIM DEED EXEMPT iT REC FEE: 11.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 1 g Area Name and Return Address Judith A. Remington REMINGTON LAW OFFICES P.O. Box 177 New Richmond, WI 54017 012-1059-90-000;012-1060-00-000; 012-1071-20-000;012-1071-40-000 Parcel IdentiFcation Number (PiN) This is homestead property. (is) (is not) The Northwest Quarter of the Northeast Quarter (NW 1/4 of NE1/4) EXCEPT the North 416 feet of the East 562 feet of Section Thirty-four (34), Township Thirty (30) North, Range Seventeen (17) West; The Southwest Quarter of the Northeast Quarter (SW 1/4 of NE1/4) of Section Thirty-four (34), Township (30) North, Range Seventeen (17) West. Reserving and excepting, however, to Grantor the full use, control, income, benefits and possession of the described property for and during Grantor's natural life. Together with all appurtenant rights, title and interests. Dated this 30th day of March AUTHENTICATION Signature(s) authenticated this day of , 2004 E M. s ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. ST. CROIX _ _ County. ) Personally came before me this 30th day of March , 2004 tli~,nyls_Iw~i,~ Arlene M. Stoddard, a TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.1X, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Judith A. Remington, Remington Law Offices, P.O. Box 177, New Richmond, WI 54017 (Signatures may be authenticated or acknowledged. Both are not necessary.) to me known to be the person(s) instrument and acknowled¢e tht • Yudith A. Remington ~ Notary Public, State of Wisconsin - My Commission is pelirtanent. not, state explratlon +ate: •) 'Names of persons signing in any capacity should be typed or printed below their signatures QUIT CLAIM DEED STATE HAR OF WISCONSIN FORM No. 3 - 199E INFORMATION PROFESSIONALS COMPANY FOND DU I.AC, W1800-655-2021 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer /~ Y ~ ~. ~ °~ ~ ~d ~ c~ o~ Mailing Address Property Address ",~ ~~. ~a Id w~~,_ ~'~ (Verification required from Planning & Zoning Department for new construction.) 1 ~ Vc/ 1' a Parcel Identification Number City/State Q d y~ % th_ ®~ o~ ^' ~ ~ ~o ~ ~' ~ Q " C? 0 CU L.- 1/4 ,Sec. oT `~ , T ~ ~ N R , ~ W, Town of ` ~( v~ ~Yq ~ Y I ~ Spec house yes no Lot # Volume ,Page # Volume ~ ~ ~~' ,Page # Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION ~4Q 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 aze 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. Uwe, 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 yeaz expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe amaze the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. LEGAL DESCRIPTION Property Location ~ 1/4 , Subdivision Certified Survey Map # Warranty Deed # `7 ~ ~' ~y b ~~ N ber of bedrooms ~_ 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) ~ ,. ~, `~ t k' +~ 4" C.I. VENT PIPE • s ' ' ",, i' .2S FROM ODOR 12 MIN. ~ ~~ i WINDOW OR FRESH GRA[li i • ~ GRADE AtR INyTA~(E I ~ I { ' .eta^:..: , ,. JUNCTION BOX y ~. ~~ ,r~ la° MIN. ~ i ~, ~ ~ ELEVATION •°' °•, + ~ ~; ~{ k„=~ C~ r ~ PROVIDE ° ~ °s~>~ • ~ :' AIRTIGHT SEAL ~, ~- R :: Ff i i; APPROVED JOINT WITH C.I. PIPE ;i 6 y ~ • EXTENDING 3~ ~: ` ~, ~ ONTO SOLID SOIL :: C PUMP ~ t ~~: - ELEV. 87'~FT. a,. , a r '~`~ ~ •' C">'iRETE BLOCK .± APPROVED LOCKING MANHOLE COVER ANO WARNING LABEL ; ; • J' i , ~~• .~ 18° MIN. ~" I I III I I I ---- .: I ~ I I •~: APPROVED JOINTS I I ) •:• WITH C.I. PIPE I I MARIA I ~' EXTENDING 3~ ~ [ I i ,: ONTO SOL10 SOIL i I ON ~: ~ I ;! I ~ OFF :: :: M N ,o •J " r TANK BEDDING --_~• :,~ _ ,..._. ..~• - ~. - =; - ,• • •- '~ .•. t ,~ ELEV. 8~~ ~ ~' •.... .,. .. _ ... _.... _. •~~ '~ `~~` 1 ~ RISER EXIT PERMITTED ONLY IG 'YANK MANUFACTURER HAS SUCH APPROVAL n:: ; DOSE TANK I ~ 1~ANUFACTURER ~ ~~ NUN~BER CF DOSES PEF. DAY ~ t " .TANK SIDE (GAL; 7 ~ DOSE VOLUTE ' ? ' ALARM. Ii1CLUDING BACKFLOjd /ZO iiaL ~ ~,~ ~'~ • i NI,kNUFACTURER ~~~ CAP_~CITIES ~,, , ' ' I~~ODEL .NUMBER 7` _ /,.3 - - ~ A 8 ~ IT'JCHES OR SISq~~ GAL ;'~, ~ Nd ~ SI>~ITC:i TYFE ~ ~~~ ~ n B rt ~~, n `~~ ,;~ PUMP C ?.S°' " ~ [lvbq ~~ MANUFACTURER ~ o-.. I~ Q °' °' ! ~l3' $ "~ ~,~ . ~~ DEL NUMBER N ~ NOTE~% Pump e4nd ~.l . arm are to be ' SWITCH TYPE installed on separate-circuits. =~F ~ ~'~ ~ P ' MINIMUM DISCTi~.RG ~'TE /ti':R~ - GPT~ f1)i r r ~ .r ~ + ~' ; ;* ~ VERTICAL D ~FET~ENCE BET'::EETv~ PUT~:P OF,F k1ND JISTRIBJTION PIPE r0 FEET ; ~' ~ ,{ '. ' • -+- MINIMI7N: T~~ET',~tOT~K SUPPLY PRES SLF,E - FEET ': ~ ;~.Sf ~ ~ F'."+::~T OF FORCE MAIN X ~I,,rt $ ~'TJ 100 FT ~; ~ FRICTICiN F:,'~CTOF, _ %' ~~ FEET ~~~ `~ -~~ '~ ~ ~=. TOTAL D~YNAi~1IGHEAD ~ _ tr FEET ~~ '~~ " ~ ~ TANK SPECa. ~ . I EACH 1 Ii1i.H Gig DI:+.PT:~ w,G~,U.':LS /b ~ I' (~,~I,, .; ~ ` INTERNAL DiT='lETJSIONS 0~^ '^a.TvTK. ~ LETdGTH _ N>~ _ F ~ ~ _ ~~. ',~f IDTTT ~~ _.__.... k ~ LI~,UID JEPTT: ~~ `= ~.~~, ~= ~• s 1, r. rro,c! z C nrT~77 r p .T'1 ~ :y r *,~ - PUMP Vl1 -`~J:~.:i 4i.~VUa.: ~.JLV 110~1.~ ~i'u/ .J ~~~Ci. ~ V1.,T.1 vA~~+J ix ~._ ._. ~. 4' ~~" ~ .' z ,'~'~i.. ~' i ~. .. .. - .. r C-~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of ~~ ~. FILE INFORMATION Owner . R S Permit # DESIGN PARAMETERS Number of Bedrooms ~ ^ NA Number of Public Facility Units p ^ NA Estimated flow (average) ' f pia gal/day Design flow (peakl, (Estimated x 1.5) (p o D gal/day Soil Application Rate ~ ~ gal/day/ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD5) <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygeri Demand (BODS) 530 mg/L Total Suspended Solids (TSS) <_30 mg/L ~l,NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size %8 in dia. ^ NA Other: ~' NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity ~ ~p gal ^ NA Septic Tank Manufacturer (~ ~~~,,.,, ^ NA Effluent Filter Manufacturer h ~~ ^ NA Effluent Filter Model ~ . / p o ^ NA Pump Tank Capacity S`~j al ^ NA Pump Tank Manufacturer (,,~ V,,Q,~~, ^ NA Pump. Manufacturer ~~QQ,Q,^, ^ NA Pump Model ~ ~ ~ ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: ~NA Dispersal Cellls) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tankls) At least once every: ^ month(s) (Maximum 3 years) ~ yearls) ^ NA Pump out contents of tank(s) When combined sludg e and scum equals one-third (%3) of tank volume ^ NA Inspect dispersal Cellls) At least once every: ^monthls) (Maximum 3 years) ~ yearls- ^ NA Clean effluent filter At least once every: ^ monthls) ~ yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ®monthls) r ^ year(s) ^ NA Flush laterals and ressure test p At least once ever y' ^ month(s1 ^ year(s) NA Other: At least once every: ^ month(s) ^ yearls) ®. NA Other: ANA 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 <_12 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. Page of 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 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 fora nevii 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 biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name Phone 'j/5- ~yQ- jZJ~~-- SEPTAGE SERVICING OPERATOR (PUMPER) Name ~,y~~ ~,,~ 5,~~ Phone 7 tS- "7~l Q -of S ?j POWTS MAINTAINER ~ ~ ~~~ Name t~ pie Yti~"o Phone 'jt$-~7N4--33 a-~- LOCAL REGULATORY AUTHORITY Name $ 7. ~`„~ , ' Phone "jet- ~$~- ~6>?i This document was drafted in compliance with chapter Comm 83.221211b)1111d)&If1 and 83.54(11, 12) &-131, Wisconsin Administrative Code. Page of 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 celllsl. 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 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 nevii 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 biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ` Phone `j 15 - ~ e14 - ~?j ~ ~-. SEPTAGE SERVICING OPERATOR (PUMPER) Name ~~ ~,.~~ ~p Phone "~ t S' '~ ~t Q - ~ ! S ~j POWTS MAINTAINER ~ ~ ~ ~_ Name ~ ~~e~v-~~~ Phone ~i~_'7yQ--3~ a-~.- LOCAL REGULATORY AUTHORITY Name S Phone "jC.S ~- ~~~." ~6 ~ This document was drafted in compliance with chapter Comm 83.2212-(b)1111d-&(f) and 83.54(11, 12) & 13), Wisconsin Administrative Code. ~ . ~ PUMP PERFORMANCE CURVE MODELS 53155157159 0 6 20 Q w ~ 15 z 4 0 Q 10 I- 0 ~ 2 5 009891 0 10 20 30 40 50 GALLONS LITERS 0 80 160 FLOW PER MINUTE CONSULT FACTORY FOR SPECIAL APPLICATIONS Variable level float switches available. Variable level long cycle systems available. Available with special cord lengths of 15', 25', 35' and 50'. Alarm systems available. Duplex systems available. Sin le Seal Co ntrol Selection Listi n s Model Volts Phase Mode Amps Sim lex Duplex CSA UL M53155 & M57159 115 1 Auto 9.7 1 ----- ~ Y Y N53155 & N57159 115 1 Non 9.7 2 3 or 4 8 5 Y Y ' BN53 115 1 Auto 9.7 Y Y ' BN57 115 1 Auto 9.7 N Y ' BE53157 230 1 Auto 4.8 Y Y D53155 ~ D57/59 230 1 Auto 4.8 1 - Y Y ~ E53/55 & E57159 230 1 Non 4.8 2 3 or 4& 5 Y Y TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENT AND DEWATERING MODEL 53/55/57/59 Feet Meters Gal. Liters 5 1.5 43 163 10 3.0 34 129 15 4.6 19 72 Shut-off Head: 19.25 ft.(5.9m) i I I to vts ~ i i i i I SELECTION GUIDE -~ 3 3132 ~_ SK858 1. Integral float operated mechanical switch, no external control required. 2. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 3. Mechanical alternator "M-Pak" 10-0072 or 10-0075. 4. See FM0712 for correct model of Electrical Alternator. 5. Variable level control switch 10-0225 used as a control activator, with Electrical Alternator (3) or (4) float system. ' Single piggyback switch inquoeo. O CAUTION ForinformationonadditionalZoellerproductsrefertocatalogonPiggybackVariableLevelFloatSwitches, FM0477; All installation of controls, protection devices and wiring should be done by a qualified Electrical Alternator, FM0486; Mechanical Alternator, FM0495;Sump/Sewage Basins, FM0487; and Single Phase licensed electrician. All electrical and safety codes should be followed including the Simplex Pump ControllAlarm Systems, FM0732. most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. _~, MAIL T0: P.O. BOX 16347 ~ Louisville, KY 40256-0347 Manufacturers of.. 7 '• tl /~~,~! ~/ SHIP T0: 3649 Cane Run Road ~Q ~ ,/ ii : ~® Louisville, KY 40211-1961 Q~/TY PUAIPB SNCE ~,9s~s9 ~~ ® ~~/Y/~ ~O (502) 7 FAX (502) 774-36248-PUMP www.zoeller.com © Copyright 2006 Zoeller Co. All rights reserved.