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010-1032-40-000
Wisconsi~~,,Department of Commerce Safety an116uilding Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) ersonal information you provide may be used for secondary purposes trnvacy caw, s., ~.uv t,/tine ermit Holder's Name: City Village X Township Boche, Timoth Emerald, Town of ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION n TYPE MANUFACTURER ~/"~ i CAPACITY Septic '^' ee.~s r~ ~ l Z Dosing ~v,~,~ 5 5' 8 ,•, ID k 25 Holding ToNK SETBACK INFORMATION TANK TO P/L !d- I I WELL BLDG Vent to Air Intake ho ~. ROAD Septic ~ ~~~ 9~ //,] ~6d _,.. Dosing /OO ~ ~~' ~ ~ 7 / ~ I~J~ / _._. Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand pul Q~ GPM Model Number ~ (~ TDH Lift $ 3 Friction Loss '"System He~dS< TDH Ft Forcemain Length i Diai Dist.Lt~joFF,weIIJJ 2G~ ~~~ ~ SOIL ABSORPTION SYSTEM tt_tvA I lurv vfa I H county: St. Croix Sanitary Permit No: 515158 0 State Plan ID No: Parcel Tax No: 010-1032-40-000 Section/Town/Range/Map No: 13.30.16.199 STATION BS HI FS ELEV. Benchmark ~' GQ / O ,~.L J I`~ w Alt. BM ~ 3 15 ~ c' $ Z J Bldg. Sewer ~ 7 ~ $~ ~/Q$ ~~J St/Ht Inlet ~l r O q7, $ g SUHt Outlet ~~~ fit) Qj ~ , 37 Dt Inlet ,/r 32 J q ~ ~ ZS Dt Bottom /~ t~7 J ~ CJ~/~ d 7 Header/Man. ,1 ~ T ~d ~ g Dist. Pipe 5 . ~ (O ~ l ~ $ ~l Bot. System S. 75 ~~ Final Grade ~ . ~ / ~ ~7 St Cover ~~ _ C.Av~..~ ~ $ •~ ~~v i '~. f~o~- G.S~ -~3~3 a ~o~„7s BED/TRENCH Width Length / No. Of Tren~{s PIT DIMENSIONS No. Of Pits Inside Di\ Liqui Depth DIMENSIONS / [~~ Ci3 e 1 / ~. ~ /~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~ INFORMATION Typ~fSystem:n 1 1 y ,O~ ~ Z7/ ]~ N UNIT Model Number: Y OJ,n.-c 7'~ ~O e.re~~r~~ ~`rl/1~1 ~V~+TC1111 11 11 ~I. _ _U VIV ~~~~vv~.v.~v.v. HeaderlManifold i1 r... ~~.I .-ti.~ Distribution ~ // ~ x Hole Size ~~ x Hole Spacing ~ Ve to Air Intake C ~ / Z3 / i ~ ~ Pipe(s) ~/ ~ ~ acing th 7~~ ~ Dia ~~ ~ S L 3 / ~ ~' v Dia ~ Length p eng e.~n n~~i~o ..____._.__ ..___~_~_ r._~.. .,., nn... ~...~ ri. nr_r_~~nn AVCiPTC unw i Depth Over ~~ C t Depth Over Bed/Trench Edges ~ xx Depth of ~ Topsoil xx Seeded/Sodded ~ No V- Y ched ~es ~ No er ~, en lied/Trench ~ es ~~ _ °`.~ a~ ~r COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~U / 7i /_~~nspection #2: / / Location: 2686 Cty Rd G`/EJmera , WI 54013 (SE 1/4 SE 1/4 13 T30N R16W) 40 acres Lot G~n, SL3~ Parcel No: 13.30.16.199 1.) Alt BM Description = ~ EZ ~'O`1O~ ~/Of'"~ "~ ~ ~ ~J ~ 2.) Bldg sewer length = /5~ w~ 5c,teaS r~ ~a ~ ~~ ~r - amount of cover = ~ i '}' 2 ,~,.c~-~ `7 0~ GaJt~ b tJc.~. Q ~ S ~o Plan revision Required? Yes ~ No ~~~ ~ (~ Q ~ (p 3 Use other side for additional information. _~.~ Date Insepc is Signatur Cert. No. SBD-6710 (R.3/97) ~G nt11 ~/~~D ,fin 9 pit Safety and Buildings Division W Coun ~ G ` ~ ~ 201 . Washington Ave., P.O. Box 7162 rC ~seons~n Madison, WI 53707 - 7~ Sanitary Pcrrni~ umber (to be filled in by Co ) Department of Commerce (608) 266- Sanitary Permit Application te Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 70 may be used for secondary purposes Privacy Law, s15.04(I)(m) Project Address (ifdiffcrent than mailin s) _ g G ~ t. Application Information - Ple riot All Information ~ ~' Zr_ g~ `P VV Property Owner's Name 900f1 • ~ ~ J L ~7 Parcel q Lot N /9 Block tt /¢ ~ 0 0~ o z-yo-~o~ Property Owner's fling Address PLANNING 8 ZONING OFFICE Property Location / ~ ~~ ~'/ S~'/ i S City, State Zip ode C Pho ne Number Q ., ., ect on ~ / /1)~ / / .,Z~~... ~/ ~ T ~t7 N R~t~oe.C`l I I . Type of Building (check all that apply) : '4 'L/ Cr {f gJ~l or 2 Family Dwelling - Number of Bedrooms ~ 'q t/y~ Subdivision Name CSM Number ^ PublidCommercial -Describe Use / / ~~ ~LNt' urld- ^ State Owned -Describe Use ~( ^City_^Villagc~Township o(~m e~~l II1. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ^ New System ~Replacemcnt System ^ TrcatmenVHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Rrnewal B f i E i ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Datc Issued e xp rat ore on Plumber Owner IV. T e of POW7'S S stem: Check all that a I p V ^ Non -Pressurized In-Ground Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Linc ^ Gravel-less Pipc ^ Other (explain) // V. Dis enaVTreatment Area Information: ~(' Design Flow (gpdy Design Soil Application Rate pdsf) ~ Dispersal Arca Required Dispersal Arca Proposed (sf) System Elevation (~ / , ~ 1 X06/, ~ ~ dbd /~o~ty~ pOt q2 / Vl. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing ~ , / Tanks Tanks /~~ ~7/ ' Septic or Holding Tank ~~ ~ / q L r Aerobic Treatment Unit Dosing Chamber ^~ W VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Namc (Print) Plu is Signature MP/MPRS Number Business Phone Number Plum 's Address (Street, City, Stfa~te~, Zip Codc) ' , /~ ~ ~j •-~ `'~ s VIII. Coun /De artment Use Onl roved tsa vcd Sanitary Permit Fcc (includes Ground atcr Surcharge Fcc) C ~ Datc Issued a~G/d Issuing Age ignaturc (?Jo ps) i ~~ /b ~ O 7 ~ ven R or Denial ' IX. Conditions of ApprovaVReasons for t pproval 3, 6~ ~~~~ ~ ~ I /~ SYS?FEM 1?1NNER: J d.bq,,w,~ 1. Septic tanki eBluent finer and Go ~~ dispersal cell must alt be servk:es 1be J maintainer ' as per management plan provided by plumber. u \ ~~ 2. Ah'setback requirements must be maintained '7' J ~o,~,.Q,; ~';`~g ; ,., t~~ ~.G~{.tcsa, , as per applicable code !ordinances. ~ a tin ft w ~ r 1 ~. ~ nsucn comprese puns tro me t,ouory Doty) for the system on paper not Ids than 8!!1 x t I inches in siu ,~ SBD-6398 (R. 01/03) `~ __ ~~ \ • ~ o ~~ \ ,- _.. ,___ . T„~ e S,~ js~c sP~ >3 r 3o R l6 w ~rCC~ Z',~, DAD- lD3Z'~{0'~> .SCy:-~P. ~~~5!0~ ~~ h/o f~c y~ ~~~~/ ~ / / ~ i ~~Q~ ~ / ~ ' __ ~ !~ ~ ~~ , / ~~ i ~~ ~ ~ ~/ ~ ~ _ ~ . . ` 3~ _ _- - ~_ _ _ _ . __ _ _ . _ _ ~ ~ ~~ ~ ~ b~ ~~N S~-t ~ a"~ ~o~~~ ., ., ,ao .~~ _. ~, `~ ~~ _:_ ~,, , _ - ~,~ ~rv~ _. Q ~ 1 ~,a 5~" ~Q~.fa~ ~b~`e 0~~ a~S i _: 1 , I- I . __ _ __ \i \ I \ ~ ~~ o ~ .2~I Yn t b l~COPY _. T,-v~ ~e SkjSE SP~13 r'3o Rl6w ~.~~ i Z, p. 010.- ~a32-~fo -~ Scri- le ~ "~ yo. '~o f~c re ~~~~1 ~~ r i~ . ~~ J~~ ~ o uy i~ ~~ ~5 ~~~,~~ ~b~e ~~~~ "~ \` `~~., ~\ ~! 1 _ _ . . J l!~' t __ __ o D~,~.l ,~ ~ i ~ .; ~ ._ _ ~ tip. ~ ~'l \' ~! _~ ! Q ~.. i ~~ ~~~ Dw i c~ ~,_ 1 i ii ~ f` ~ 3;_. ;_ _~ _ ~, f. ;\ ~~ `J i ~\ `~ _ I ~ ,~ ~~ ~ ~ / ~~ ~~ commerce.wi.gov isconsin Department of Commerce Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 Contact Through Relay www. com merce.wi.gov/sb/ www.wisconsin.gov Jim Doyle, Governor Richard J. Leinenkugel, Secretary October O1, 2009 CUST ID No. 226524 ROGER L TIMM T]MM EXCAVATING 3128 20TH AVE WILSON WI 54027 A77t'V.• POWTS Inspector ZONING OFFICE ST CRO1X COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/01/2011 SITE: Tim Boche 2686 Cth G Town of Emerald St Croix County SE1/4, SE1/4, S13, T30N, R16W Identification Numbers Transaction ID No. 1706692 Site ID No. 751463 Please refer to both identification numbers, above, in all comes ondence with the a enc . P.~7. FOR: '_x Description: Mound, 4 br res ~ ~ ~ `' Object Type: POWTS Component Manual Regulated Object ID No.: 1240617 ~ ;'~` ,"~'`~~ Maintenance required; Replacement system; 600 GPD Flow rate; 25 in Soil minimum depth to limiting factor fro ~ original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distrib ion ~~ Com onent Manual -Version 2.0, SBD-10706-P O1/O1 ;Effluent Filter --~~ P ~• ) SEE C~~~,-l 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: Key Item(s) • 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 insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. • Deep and thorough chisel plowing shall be done to the absorption area to help break up the platy soil structure that was reported at the site. The county may, at their discretion, request verification that appropriate plowing is accomplished prior to sand or aggregate placement. • The revised soil test (regarding comment on chisel plowing) on which this approval is based shall be recorded with the original soil test. • The designer proposes to install a state approved effluent filter to achieve the requirement of wastewater particle size. Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the effluent filter is required. The access opening used to service the filter shall terminate at or above fmished grade with a watertight cover. 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. Beginning October 15`, 2008, small wastewater holding tanks with estimated flows less than 3,000 gpd that are based completely on approved POWTS component manuals must be submitted to the appropriate governmental unit and will no longer be accepted by the Safety and Buildings Division for review. Please refer to s. Comm 83.22, Wis. Adm. Code for further information. ROGER L TIMM Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • The existing POWTS must be properly abandoned per s. Comm 83.33 Wis. Adm. Code. • Insulate building sewer per COMM 82.30(11)(c).. 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 provid"e`a cod' of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely atricia L Sy~aridorf '~ ~WTS flan Reviewer , (715) 634-7810,/Fax: (71 d Services 150 , M-f 7:45 am - 4:30 pm Page 2 10/1/2009 Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Monday, 7:00 A.M. To 3:30 P.M. Notice: Starting July 1, 2009, no person or entity may engage or offer to engage in construction business in ' Wisconsin unless they hold a Building Contractor Registration, or equivalent, issued by the Safety and Buildings Division of the Wisconsin Department of Commerce. "Construction business" means a trade that installs, alters or repairs arty building element, component, material or device that is regulated under the commercial building code, chs. Comm 60 to 66, the uniform dwelling code, chs. Comm 20 to 25, the electrical code, ch. Comm 16, the plumbing code, chs. Comm 81 to 87, or the public swimming pools and water attractions code, ch. Comm 90. The term does not include the delivery of building supplies or materials, or the manufacture of a building product not on the building site. For further information, go to our website: www.commerce.wi.gov/SB/SB-BuildinaContractorProeram.html ROGER L TIMM Page 2 10/1/2009 Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • The existing POWTS must be properly abandoned per s. Comm 83.33 Wis. Adm. Code. • Insulate building sewer per COMM 82.30(11)(c).. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. 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. Beginning October 1~`, 2008, small wastewater holding tanks with estimated flows less than 3,000 gpd that are based completely on approved POWTS component manuals must be submitted to the appropriate governmental unit and will no longer be accepted by the Safety and Buildings Division for review. Please refer to s. Comm 83.22, Wis. Adm. Code for further information. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide as cow}' of this letter to the owner and any others who are responsible for the installation, operation or maintenance of thgPOWTS. Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 L Sh~aifdorf -' ~~Plan Reviewer , •ated Services 4-5150 , M-f 7:45 am - 4:30 pm WiSMART code: 7633 (715) 634-7810,;Fax:(71 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Monday, 7:00 A.M. To 3:30 P.M. Notice: Starting July 1, 2009, no person or entity may engage or offer to engage in construction business in ° Wisconsin unless they hold a Building Contractor Registration, or equivalent, issued by the Safety and Buildings Division of the Wisconsin Department of Commerce. "Construction business" means a trade that installs, alters or repairs arty building element, component, material or device that is regulated under the commercial building code, chs. Comm 60 to 66, the uniform dwelling code, chs. Comm 20 to 25, the electrical code, ch. Comm 16, the plumbing code, chs. Comm 81 to 87, or the public swimming pools and water attractions code, ch. Comm 90. The term does not include the delivery of building supplies or materials, or the manufacture of a building product not on the building site. For further information, go to our website: www.commerce.wi.gov/SB/SB-BuildinaContractorProQram.html Y MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name Owner's Name: Tim Boche Owner's Address: 2686 Cty Rd. G Emerald WI. 54013 Legal Description: SE /SE s 13 t 30 r 16 w Township: Emerald County: St. Croix Subdivision Name: 40 ACRE parcel ,,, ~ ~, rL~ Lot Number: NA Block Number. Parcel LD. Number. 010-1032-40-000 ~ ' ~~ ,F ~~. ~~~ J. 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 ~ /a ,C 1~/ct..~ Designer: Roger Timm License Number: 226524 Date: 09/02/09 Phone Number: 715-772-3214 Signature: ~„~,~, Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/01), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01) Version 5.1 (R. 06/06) Page 1 of 7 ~I Z Mound and Pressure Distribution Component Design Design Worksheet Site Inform ation R or C R ( ) Residential or Commercial Design __- _ -=_- 400.00 Estimated Wastewater Flow (gpd) r 1.501 Peaking Factor (e.g. 1.5 = 150%) 600.00 Design Flow (gpd) ~ 8.00 Site Slope (%) 100.00 Contour Line Elevation (ft) 25.00 Depth to Limiting Factor (in) 0.60 In-situ Soil Application Rate (gpd/ftz) D__i_stribution Cell Information ~ 93.00 Dispersal Cell Length Along Contour (ft) _ 1.00 Dispersal Cell Design Loading Rate (gpd/ftz) ~_ _ 1_ Influent Wastewater Quality (1 or 2) Pressure Disribution Information (C or E) ; C! Center or End Manifold 3.23 Lateral Spacing (ft) 4i Number of Laterals __ __ _ - -, ~~~~ 0_.156; Orifice Diameter (in) 3.50 Estimated Orifice Spacing (ft) _ 2 00 Forcemain Diameter (in) ___168.00 Forcemain Length (ft) _ 97.00 Pump Tank Elevation (ft) 1 2$ l {~ Project: 4.55 System Head (ft) x 1.3 3.58 Vertical Lift (ft) 2.87 Friction Loss (ft) 0.00 In-line Filter Loss (ft) 11.00 Total Dynamic Head (ft) Lateral Diameter Selection in. dia. o tions choice 0.75 _.. _ __ . 1.00 x 1.25 x _ 1.50 x _ x.__-- , 2.00 _ _.._ _ x L __ _ 3.00 x i Treatment Tank Information 1260.00 Septic Tank Capacity (gal) fWeeks Concrete Prod Manufacturer Note: Sand fill (D) calculations assume a Table 83-44-3 in-situ soil treatment for fecal coliform of <= 36 inches. 6.46 Cell Width (ft) Are the laterals the highes_ t_ point _ _ _. in the distribution Y_ __ network? Enter Y or N If N above, enter the elevation (ft) of the highest point. 11.55 ftz/orifice Does the forcemain drain back? __ Y _ Enter Y or N 27.40 Forcemain Drainback (gal) 83.95 5x Void Volume (gal) 111.36 Minimum Dose Volume (gal) 28.00 System Demand (gpm) Manifold Diameter Selection in. dia. o tions choice 1.25 x 1.50 x x 2.00 3.00 Gallons/Inch Calculator (optional) __ ___ Total Tank Capacity (gal) _'1, Total Working Liquid Depth (in) ~~ gal/in (enter result in cell 649) Dose Tank Information Effluent Filter Information 800.00 Dose Tank Capacity (gal) ! Pol~Lock ___ _ _ _ Filter Manufacturer ,--- ~- - ! 21.74 Dose Tank Volume (gal/in) ; PL 525 ~ Filter Model Number ;Weeks Concrete Prod Manufacturer Page 2 of 7 Mound Plan and Cross Section Views W I I L -~ _} _I -• Mound Component Dimensions A 6.46 ft E 17.20 in H 1.00 ft K 8.90 ft B 93.00 ft F 9.50 in z 10.76 ft L 110.80 ft D 11.00 in G 0.50 ft J 5.34 ft W 22.56 ft 600.78 (ft2) Dispersal Cell Area 1601.19 (ftZ) Basal Area Available 6.45 (gpd/ft) Linear Loading Rate 9.30 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade F 100.92 (ft) ~ - Dispersal Cell Elevation 102.71 (ft) H 101.42 (ft) Lateral Invert ,~ 100.00 (ft) Contour Elevation 8.0 % Site Slope Geotextile Fabric Cover Shading Key m c, ~- Dispersal Cell See lateral details on 10 ®Topsoil Cap c °- 1.5 ft •~:•••• • •••• • • • • • • • •• • Page 4 for number, size, 0 ~~~~~~~ Subsoil Cap ~ o ?:~`•~'`•''•''•'`•'`~'~'`•'`~'`••'•:`•~~:•' ~ and spacing of laterals. ~`• ~`• ••• ~''' ~'• Laterals are equally ASTM C33 Sand R ...... ® Tilled Layer = m 0.5 ft '•~ Tvaical Lateral ••• ~•:~: spaced from the a ~ ~~t~•:~•~.~•:~•~~•~~•~~•~•~~~•~~•~ ~~'•• distribution cell's :*.'•~' ~' ,~ centerline in the }.-- A * distribution cell (Ax6). Project: Page 3 of 7 Center Connection Lateral Layout Diagram ing under tank. Alarm Manuafacturer (Septronics Alarm Model Number j_ 2501 ' - -.._! Pump Manufacturer Gould -` _~_ ~i Pump Model Number EPO 4 Pump Must Deliver 28.00 gpm at 11.00 ft TDH Force rnai n connection via tee au cross to manifold at any poiru. I P •=Turn-upwi't>allvalvaor IFx-~IF>dp I x12.)I cltianoutplug Hobs dry tin the bottom of the lateral. Number of Laterals 4 Orifice Diameter Lateral Diameter 1.50 in Orifice Spacing (X) Lateral Length (P) 45.75 ft Orifices per Lateral Lateral Spacing (S) 3.23 ft Orifice Density Lateral Flow Rate 7.00 gpm Manifold Length System Flow Rate 28.00 gpm Manifold Diameter Total Dynamic Head 11.00 ft Forcemain Velocity Dose Tank Information Electrical as per NEC 300 and ~ Comm 16.28 WAC Disconnect laterals are idernic al S Laterals & force main of PVC Sch 40 per COMM Table 84.30-5 Tank component is properly vented Weeks Concrete Prod Ca aci 800.00 Volume 21.74 Manufacturer Gallons gal/inch ~- A B C D Dimension Inches Gallons A 19.68 427.76 B 2.00 43.48 C 5.12 111.36 D ' 10.00 217.40 Total 36.80 800.00 Project: 0.156 in 3.66 ft 13 11.55 ftz/orifice 3.23 ft 1.50 in 2.86 ft/sec Locking cover with warning label and locking device and sealed watertight 4 in. min. Alternate outlet location Forcemain diameter ~ 2 in. Weep hole or anti- siphon device P~ ump off elevation (ft) 97.83 Dose tank elevation (ft) 97.00 Page 4 of 7 Mound Svstem Maintenance and Operation Specifications Service Provider's Name Roger Timm _! Phone' 715 772 3214 POWTS Regulator's Name St. Croix ; Phone; 715 386-4680 J Svstem Flow and Load Parameters Design Flow -Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow -Average 400 gpd Maximum BODS 220 mg/L Septic Tank Capacity 1260 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600.78 ftz Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Effluent Filter Pump and Controls Alarm Pressure System Mound Other Ins ect and/or service once eve 3 ears Should ins ect and clean at least once eve 3 ears Test once eve 3 ears Should test month) Laterals should be flushed and ressure tested eve 1.5 ears Inspect for pondin~and seepage once every 3 nears ___ _ I 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 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: Page 5 of 7 . System Management 'vanagement of this system is critical. As a condition of approval of these plans this system management section must be -:. ~e~+ed ~~ ith the owner, and the owner must be provided with a complete set of plans including this management section. If problems ~e~ clop with the adsorption system or any other system components, the installing plumber, Timm Excavating, 715-772-3214, or the St. roix County Zoning Office, 715-386-4680, should be contacted for assistance. General Proper func[ioning of an on-site disposal system, "septic system," is significantly dependent on the volume of water which flows ,nto the system and the level of contaminants in that volume. The lower the volume of water and the lower the level of contaminants, the ocrter and longer the system will function. Typical system components include a septic tank or compartment to settle out solids and contain creases and oils, a filter on the outlet of the septic tank to retain small particles of the same density as water, a pump tank or ;ompartment to allow a dose to be accumulated, a pump and controls, and finally some type of soil adsorption cell to recycle the water n a manner to protect ground water quality and public health. I f the septic tank is installed prior to sheet-rock and/or painting, pump the septic tank before normal use begins to ensure adherence to contaminant load design criteria. Install water-saving appliances whenever and wherever possible. Repair even small water leaks as soon as possible. fever pour grease or oil down any drain or stool. Garbace disposals are not recommended; if you must have one, use it sparingly. o ~o paper products other than tissue should go into the system. - ~o chemicals should go into the system. s ; ~ o~d surge flows of water; try to spread laundry throughout the week. Maintenance The septic tank must be inspected every three years by a properly licensed person. I f necessary, the septic tank must be pumped to remove solids and scum; pumping is required if the combined scum and solids volume equals one [hird of the tank volume. _ ~l hen the septic [ank is pumped, any solids in the bottom of the pump tank must be pumped, and the filter must be back-washed into the septic tank to remove accumulated material. - Periodic observation pipe inspections should be made by the homeowner to examine the state of the in-situ soil adsorption cell. Quarterly inspections are recommended; a licensed plumber should be notified if effluent is consistently ponded in the adsorption cell If this system contains specific treatment components other than those mentioned here, maintenance requirements will accompany their specifications. The pumping components for this system include an alarm which must be installed and remain on a separate circuit from the pump 'fthe alarm is activated, minimize water use and notify a licensed plumber for service as soon as possible. The system allows resene :zpac~n to accumulate some necessary Flow until normal service can be restored; this volume is minimal, and no more than one or "•~u dais should pass before any necessary repairs can be made. - ~ ~ oil compacnon such as vehicle traffic within I S' down-slope of the adsorption system. ~~oid disturbing the system itself such that might encourage erosion or disturb the required seeding of the system. Panrcularly avoid winter traffic such as sliding or snowmobiling which might compact snow and lead to increased frost depth. ~;~ surface drainage must be diverted around the system; avoid landscape changes which might send surface run-off into the system area. Contingency Plan ~4'astewater monitoring of volume and quality is not a normal requirement for low effluent strength systems; such monitoring ^-a~ become necessary if problems develop. Any necessary monitoring shall be done in accord with the requirements of Comm 83.5:3 ~) Pumping and hauling of wastewater may be necessary while analysis and repairs are implemented. Additional testing, designing, and or installation of additional treatment components or conversion to a holding tank may be necessary. v Page 8 of 8 . ~GOULDS PUMPS APPLICATIONS Specrfically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: '/a" maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'/2" NPT. • Mechanical seal: carbon- rota ry/ceramic-stationary, BUNA-N elastomers. • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components, Motor: •EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EPOS Single phase: 0.5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset, • Power cord: 10 foot standard length, 16/3 SJTW with three prong grounding plug. Optional 20 foot length, 16/3 S1TW with three prong grounding plug (standard on EPOS), • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic semi-open design with pump out vanes for mechanical seal protection. METERS FEET 10 9 3i s z~ 0 7 Q x v 6 2t s ~ 1` Q 4 0 ~ 3 1C z~ 1 s o~ 00 Submersible Effluent Pump EP04 & EP05 Series ^ EP05 Impeller: Thermoplas- tic enclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING Canadian Standards Association s ~' Fle # LR38549 Goulds Pumps is I50 9001 Registered. i -- -, + -- --.... - i i -', ~~5 GPM u zs ET ~ i ~ !- - ~ ~ _.. .. - - - ~ -- - __ _.. - - ----- i - _ ' -----i- -..-..- = - --- ' -- _ -- -- -- -.._..i.- EP05 - i ' --------- --------- !-~ -_ - ~ -._-- ---- - -=- .-.....- ----- - -- - -- - EP - 04 ------ - - -- - -I - -----.----~--.--.--- ---- -- i I ~ _i __ 0 2 10 20 30 4 6 8 CAPACITY 40 50 GPM 10 12 m'/h Goulds Pumps 2003 Goulds Pumps Effectiveluly,2003 ITT Industries n-Wisconsin Impartment of Commerce SOIL EVALUATION REPORT i `v Division of Safety and Buildings In accordance with Comm 85, Wis.~{~m. Code Page 1 of 3 "~ County CrO1X St '-------...-. Attach complete site plan on paper not less than 8'/z x I 1 inches in size. us~ • Include but not limited to: vertical and horizontal reference point (BM), direction ~~ Pazcel LD. O10-1032-40-000 and BM referenced to nearest road. north arrow Percent slope scale or dimensions , , , Please print all information Reviewed by Date Personal information you provide may be ses (Privacy Law, s. 15.04 (1) (m)) PropeRy Owner Property Location Tim & Valerie Boche Dour. Lot SE v. SE v. s 13 T 30 N R 16 w Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2686 Cty Rd. G ~ ~ `'""zoHINC oFFlce City State Zip Code Phone ^ Clty ^ Village 0 Town Nearest Road Emerald WI 54013 715-265-4978 Emerald C . Rd. G ~ New Construction Use: 0Residential /Number of Bedrooms~_ Code derived design flow rate 450 GPD 0 Replacement ©Public or Commercial -Describe: Parent Material Lcess over Till Flood Plain elevation if applicable N/A General comments and recommendations: Chisel plow soil to 14" to break up platy structure observed in the second horizon of boring #3. J Boring # 0 pit Y a Ground Surface Elevation 100.0' ft. Depth to Limiting factor >48 in. 8 I' 'on R Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP /ft2 in. Munsetl Qu. Sz. Cont. Col r Gr. Sz. Sh. 'Ef'~1 •Et'i#2 1 0-8 10YR3/2 - SIL 2-m-gr mfr gs 3f 0.6 0.8 2 8-14 10YR4/4 - L 2-m-bk mfr gs 2f 0.6 0.8 3 14-36 10YR4/4 - SL 2-m-bk dh gs 1f 0.6 1.0 4 36-48+ 10YR4/4 - SL 0-m dh - 1f 0.2 0.6 Boring # ~ Baring LlPit Ground Surface Elevation 97.0' ft. Depth to Limiting factor 25 in. S it lication R to Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/tt~ in. Munsetl Qu. Sz. Cont. Color Gr. Sz. Sh. *Et~1 •Eff#2 1 0-9 10YR3/2 - SIL 2-m-gr mfr gs 3f 0.6 0.8 2 9-18 10YR3/4 - SL 2-m-bk mfr gs 2f 0.6 1.0 3 18-25 10YR4/4 - SL 2-m-bk dh gs 1f 0.6 1.0 4 25-45+ 7.5YR4/4 7.5YR4l6 & 513 f-1-d SL 2-m-bk dvh - 1f 0.6 1.Q r;ttluerit # t = tSUlls> :iU <_ dlU m~L e[1Q IJJ > SIl ~ 1~U mgiL ' nIIluem ~~ ~ nvus ~ JV ing/i. ~uiu i JJ ~ ~v u~g~i. CST Name (Please Print) Signature CST Number Mark Iverson ~--- 46672 Address Date Evaluation Conducted Telephone Number P.O. Box 155 Hammond, WI 54015 August 18, 2009 715-796-5664 ft. Property Owner Tim & Valerie Boche ParcelID# 010-1032-4Q-000 Page 2 of 3 3^ Boring # ~ Boring OPit Ground Surface Elevation 100.0 ft. Depth to Limiting factor 31 in. S it A I' lion 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 1 0-8 10YR3/2 - SIL 3-f-gr mfr cs 3f 0.6 0.8 2 8-13 10YR413 - SIL 2-m-pl mfr gs 2f 0.0 0.2 3 13-21 10YR4/4 - CL 3-m-bk mfi gs 1 f 0.4 0.6 4 21-31 7.5YR4/4 - LS 1-co-bk dh gs 1f 0.7 1.6 5 31-45+ 7.5YR4/4 7.5YR4/6 8~ 5/3 f-1-d GRSL 0-m dvh - 1f 0.2 0.6 ^ Boring 4 Bormg # OPit Ground Surface Elevation ft. Depth to Limiting factor in. Soil A li lion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft2 in. Munsell u. Sz. Cont. Color Gr. Sz. Sh. 'EfI#1 'Eff#2 Boring # ~ Boring tt------~~ ®Pit Ground Surface Elevation ft. Depth to Limiting factor in. Soil I' lion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ttz in. Mu sell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'EfF#1 'EtI#2 * Effluent # 1= $ODs > 30 <_ 220 mg/L and TSS > 30 5150 mg/L * Effluent #2 = BOD, < 30 mglL 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. 0 ft. 24 ft. 40 ft. 80 ft. N ~~ Page 3 of 3 ~~ B-2 B-3 DO Bnrt~ & Description -Bench Mark B 1 - Borin Location ~ Elevation HOUSe Elevatio~ n~ - 10b' - 9 BNI#3 -Bottom of Sidin 113.6' Owner: Tim 8~ Val Boche Site Information: Completed By: Mark Iverson, PSS #197 2686 Cty Rd. G SE1/4, SE1/4, S13, T30N, R16 680 Larcom Street Emerald, WI 54013 Town of Emerald Hammond, WI 54015 St. Croix County 715-796-5664 Phone: 715-265-4978 CST# 46672 Sep 28 09 08:42p Evergreen Irrigation Inc. 715-796-5246 P 2 4 Division of Safcty and Buildings in accordance with Comm 85, Wis. Adm- Code County S~ CCO1X Attach~ol9pt a sate on paper not less than 8 %x 1 t inches in size. Plan must parcel t.D. OlO-l 0320-000 lnclud~but nqt ~ ~ d to: vertical and horizonfil t~ference point (BM), direction and Percent slppe, scale or dimensions, rrotth arrow, and BM referenced to ncatcst road. Reviewed by Dale Please print all information Personal informaUoo you provide may be used for secondary purposes (pnvacy Law, s. 15.44 (1) (m)) property Location P,ropert}~ Owner Govt Lot SE v. SE '/, S 13 T 3O N R 16 w Tim & Valerie Bache Propen)' Owner's Mailing Address Lot q Block # Subd. Name or CSM# ~i 2686 Cty Rd. G Nearest Road Ciry State Zip Code Phone ^ City ^ Village ~ Tom G Rd_ G Emerald Wl 54013 715-265-4978 Emerald Code derived desist flow rate 450 GPD D New Constructran 13se: 8 R-esidentia] / Ntunber of Bedtrootns~-_ D Public or Commercial -Describe: ~I Q Replacement ~ R parent Material Loess over Till Flood Plain elevation if applicable NIA General comments and recommendations: Chisel plow soil to l4" to break up piary structure observed in the second horizon of ~; boring #3. ~ ~~-,', s.e..t p} c ~ , r, ~c, i ~I + w ~ I 1 6-ruz.lc -t-t.~ r ~ddi~-; ~~E~n,J ncrf-~2.-'' ~~f-~-G 1~ ~ _ lak 5'r2wC.- t- ~,-, -, ', cl-, M~~.-s c~ 1 ocxd '..--. f c~ O c.: O - ° ~ - ' !o G~-7 Z.. Bortng ~ - ~' _ U 1 Boring # [,~ pit Grotand Surface Elevation 100.0' ft- Depth to Limitutg factor_ 48 _'n- °l h Dominant Color i Redox Description ~ Texture Structure Consistence Boundary oo ~t~1 rung ~ER#2 Horizon Dept , Munsell u. z_ on .color ~ Gr. Sz Sh. 3f 0.6 0.8 in. SIL 2-m-gr rnfr gs 1 I 0-8 10YR3l2 - L 2-m-bk mfr gs 2f 0.6 0.8 2 8-ti4 10YR4l4 - SL 2-m-bk dh 9s 1f 0-6 1.0 3 14-36 10YR4l4 - dh - 1f 0.2 0-6_ 4 368+ 10YR4/4 - SL 0-rn - a Bo ring # ~ 1] Boring Oprt Ground Surface Elevation 97.0' _ft• 25 Depth to Limiting factor in. goit A - _ _ Iication RatE Redox Description Texture Structure Consistence Boundary Roots GPDfft~ •Eff#~ 'C-11a0t2 Horizon Depth Darninant Color Munsell Qu. 5z. Cont. Color Gr. z. Sh. 3# 0 g 0.8 in. SIL 2-m-gr mfr 5 9 1 0-9 10YR3t2 - -bk 2 mfr gs 2f 0.6 1.0 2 9-18 1DYR3/4 i - SL -m 2-m-bk dh gs 1f 0.6 1.0 3 18-25 10YR4l4 - SL 1f 0.6 1.0 5YR4/4 7 5YR416 & 5/3 f-1-d 7 SL 2-m-bk dvh 4 255 . + . • E61ucr CST Name (Please F Mark Iverson Address ~, n ~,.., ~ G G ~ 1 = HODs> 30 5220 mg![. and l'SS > 30 <_ `VZ 54015 Effluent ~2 = BODs ~ 30 me~1. and TSS <_30 mg/L 18, 2009 46672 Telephone ~l~rntser 715-796-5664 1.v. ~- . `A ~ '. ~~~ hi.Et`I-t-- NZ7 ' - --~ - TIfJ$ SPf.C~E F:SSERV ER. TDR REG+ZRDING ~'sAT~ = - . STATE BATt O7+'.: WISE-LVSIN .FCA1~4. i~ ivar~ P ~- ~W i'CJ.~or : ~ -' t~ i - ' ~y ~+~r t . t .a hI t t '. >•+ - f-.a ri ri: anti _ Paul r iertun~ anon vim ict_ r 1 , .ii .y, - ?~ `~n Q o ~~ -^~ c wi *- e ~ a ? _r~,e._- =~~ i= :s P~;~' -L [v S' 1 em ~z~ ~---arid :il~ctl~t ' N 5.3.0 ~ ~ '_ P,N; - ~ _ . _ - -~~~ - 1~m._ - .:E.- .~ _ ~~ _- _ .... .... '_ ~ ~~--- ~ = 7°r t Y t James O'Comte ft w i l i .,> nn _.d_s~ ~., ~... s c -... .- -- .. ... -- -- -------- -- - - _-~ ,~~ -- - soct}~l --husband--and- w ~E-- -- •--- --- •-- --•-- ~~. s e ;v ~ ~J LtJ _; epu y . .. ._...... ..............-.._..._._._...... ... __.._..__............._..... .... RETURN TO - . i• ~\' the follawing described sea) estate in ._.. St. L`r07.x ---- - -•- - -- ._-- -- -•--...-..._Courty. ~ ~ ~ ~~ Stake of 6V isccrsin : ~ ~'~- ' T az 3'arcei Noe --•-----•---••-----•--•--- •--• ' The South Half of t~d~ Southeast Quarter (S'Z of 5E3,) , Section } T'r}irteer, (13) , Tc,vTnsliig_ Thirty (30) North, RangA Sixteen (16) ~7est, SUBJECT to highway aad otl.er easernents of record. This died i.s executed solely for the purpose of fulfilling that ,~. ' certain land contract between the parties dated January 6, 1x75, records-d January lb, 1975, in Volume "5?9", page 338, as Document No. 325375. ~1:_~~ ~.~aE_.--.-.-- This .. .. 1-S ..,........._ homestead property. (is) (is not) Excep&iOn :o ~t•arranties: Dated this .. ..............14 tit ........ day of ... ~- ~~ , ~~~.!~.... .r.... f= 'L~y.......... (SEAT.) ?!% . . Paui Plerting March ._ ......... ..... I9.~.5 .. v-ctC!-'C-C/I:.. ~. rCL ,<~..-c.~a- . ~ . . ....... . ..... ! S b: n - Violet Fleming ~,J ------------------------WEAL) ..... ... ........ ........ -- --- - _......._. -....(SEAL ALTTHENTIOATI9N ACFiNQWLEI)GI12ic.NT Signature(s) STATE OF ~YISCONSIl`T f' ss. -----------------•----•---------•---------------------------------------------- ----St. Croix - -----------------------------County. authenticated this _....-..day of______________ ______, 7.9__..._ Personally came before me this 14th . ------ M_arch _ 19.5__ the above named -•-•- --------•--------------------•----•-------°--- ---------------------- Paul Flemin _ an Violet Fl.emin --------------------•----------g-------------- -------------•---------------`3- '-- ----------------------•------- ------ ------•----------------- ---•-- ---also---known as Paul_.W'---FZ!~ming_._?bid --- - - - - ------------ - TITLE: MEMBER STATE BAT. nF ',~ISCCNSLN Violet E. Flemin !If not. --------- --------------------- -•---- -.... `..-------------------------•-----•-------5-- ---- ----- •: ~,~~~'_. authorized by § 7GB.G6, Wis. Stets.) n me known io be the person ._____.._.. titiho,Ug~„mcttl~ the -• -:^s:~. instrument/end ac nowledge t3i~~tln.z '~C` t~ T: J!5 !!`:STP.UMEHT WAS DRAFTED HY -~ - ...-„~4 ~ 4 ~ ~Q ~ Reinstra, Van Dyk & Nec-~dham, S . C. -~-J~~U`- :~ '--'•:. ~ ~~J- -: ------~~---s---~ --~5,'ttcrn~ys---a-C--i,-i~------------------------------ -------- „ Tan L. G1a5c... =. ?'-.`•' _ ~, ,`•3 -_New_-Riclzmr~nd,---Wisconsin 54017_ --0127 Notary Public ____- St. Croix .`~,,,~t--~~,y~•c` (Si?natures may he authenticated or acknoviled^•ed. Toth M}• Commission is permanent. (If not, stave ¢.a~il•-_ ..... are not necessary.) date: 4-~_g ~ ............. 19........., •Namca of Derson9 signing in any aepecity aF.ould he typed or printed bylaw their sig rarnres. H.GLtitbrCm~.arr,try~i STATE BAR OF WISCONSI!v ~ „~ ,,,,,,,,, '~~ reFtvl No. z- aesz 5.oek No. 131D02 -, OwnerBuyer Mailing Address ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ~/~c. ~L Property Address ~j'~t-Ym~ (Verification required from Planning & Zoning Department for new construction.) City/State ~j/hC U~ ~~ Parcel Identification Number D !I> ` l ~ 3 Z ~ ~p -- ~ LEGAL DESCRIPTION Property Location ~'/4 , S~ t/4 ,Sec. ~J? , T 30 N R~W, Town of ~'l~x~.vu~d Subdivision ~~ ° 7(~ ~~/>!j ,Lot # /~ nr . Certified Survey Map # Volume ,Page # Warranty Deed # ~/b Zq ,Volume ~~, Page # y~Jr Spec house yes no Lot lines identifiable 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. 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 year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms I"~~t ~~ SIGNATURE OF APPLICANT(S) . ~13e/ a9 ' 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)