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HomeMy WebLinkAbout018-1090-52-000r I I ~ a n N c O ~ ~ d ~ ~ N ~o ,~ ~ D . N oo ~ m O ~ rn ~ ~ 0 ~ to Z D ' m cn D ~' .~ ~ c o c ~ _ . .' O I I M O ~ -0 =^ I ~ 7 C rv 3 o' o m ~ n n I N I a I Z I 3 O o ' vv ~ °~ ~ I o ~. 3 ~ C W 7 ~ ~ C ~ n m ~ // 1{ I Z O c n ~ N ~ 1 ~ OS .~ !/1 ~I ~ O ~ 7 __-.. p . ~ (O N 7 ~ d (tl ~' S I ~ K ~ ~ I ~ ~. ~ I ~ C~ cn -1 2 D ~ ~~p~ a N ~~ v m =n a ( i ~ m ° 00 c. 7 v i a • m f7 O C11 ,. N ~. fD O S N N ~ ~ ~ M N 'O p ~ tC W Q (D D, -p O N ~ ~ 3 ~ I ~ $ I w m a ~ o ~ I ~ ,: o ~ ~ ~ ~ o ~`~ Z~ I -o3~a~ I >>,~~c ~°• v s ~~ ' N d ( n N, ~ m gt m m c a o? ~ o ~ ~ a ' i m I o O °o ~ ncnO' 3d c d ~~~ °~; ~n ~. _. ~. ~ o W M 3 N ~ ~ V ~ ~ ~ ° ~ ~ a,o n I o ~ b o ~ to ~ ~ o ~ rn ', m s s -o O ~ ~ a ~ 4 e ~. C ~ ~~ , _ N N ~ 3 I N N W W p_ N 0 C Q 3 N • < < d .~ 0 0 ~ ~ ~ ~ f~A ~ N ~ ~ ~ v o 3 °-' ~ ~ 3 ~ M y. C (~ Z °- ~ ~ ~ .'7 o' ~ ~ ~ a N .-. N ~ C N - ~ , - , d N O ~ v A Z n 0 c -~ .~ ~*, 7 a I p ~ 7 .. ~ ~ W ~ ~ C < tNp o, i ~z ~ ~ A ~ 3 i m ~ (R Z ( r A A l T C 7 a I I I fi ,~•` ttiu O ~ I a '~ ~ ' ~ ~ ~ ~ ~:. ~ ~ ' ~ Safety and Buildings Division Washington Ave., P.O. Box 7162 201 W C~tY ~~~ . ` onsin Madison, W l 53707 - 7162 i rani Permit Number (to be filled in by Co.) (608) 263151 se 3D 3 ~-(p Department of Commerce State Plan1.D.Number Sanitary Permit Application: ~ ,~- rovide i i r ,r ln accord with ~y ~ uun ~ vacy on you p ormat n w, s15.tYi(lxm) ect Address cif di ~ t than mai,ing address> ' 9~~ ~ ~6 ter 1. Application lnformatlo -Please Print All~lnformatlon eltt L.ot ri Block t+ rc Pa Propert wner's Nam ~ ~D , _ ~ ~" ~~ .~.r- ' Y' ST I COUNTY i> ~* Property Owner's Mailing .. r: Property I,ocauOn f Lc ~LI' ~ /~ /~i(/ y., ~~h, Section /L City, State D f Ili Zip Code Phone Number ~ Q~J ' ~y ~r~ ~ v` t~(~J I~Q ~y(circle o e) TAN; RI/ Eor~ ', Il. Type of Building (check all that apply) S ` Subdivision Name CSM Number ' I or ?Family Dwelling - Number of Bodrootns l lr ^ Public/Commercial -Describe Use 3 ^Ciry_^Village,~Township of /~ ^ State Owned -Describe Use ' 111. Type of Permit: (Check only one boz on line A. Complete line B [f applicable) ~ ^^ ~ ~ • ~ ' A' New System ^ Replacement System ^ TYeatment/Holding Tank Replacement Only ^ Other Modification to Existing System ~ t Previous Permit Number and Date Issued li B. ^ Permit Renewal ^ Pemtit Revisits - e of ^ Chang ^ Permit Transfer to New s Before Expiration Piurnber Owne 1V. T e of POWTS S stem: Check all that a 1 Non -Pressurized Lr-Ground ^ Mound ? 24 in. of suitable soil ^ Mound < 24 or. of suitable soil ^ At-Crrade ^ Single Pass Sand Filter ^ ~'rrConstructed Wetland ^ Pressutizod In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recimulatin S thetic Media Filter ^ Grave P ^ Othc lattr) V. Dis ersal/I'reatment Area lnformatloa: J S stem Elevation Deli Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) 's Ar Proposed (sf) Y 9s-a ~ /S --- ~6~0 .S 200 r VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic 1 Concrete Constntcted Glass Gallons Gallons of Units Ncw Existing ,~/~ ~ ~ j ' / Tanks Tacky ~ a.~d*ng'rnur i s ~ TI` ~~~ ~ Aerobic Tmx[mca Unit Du+ing Chamber /~ ~ Vll. Responslblli Statement- 1, the under d, ass s nslbtll for tnstallatlon of the POWTS shown on the attached fans. ' MP RS Number Business Phone Number Plu 's Name (Print Pl S Plumber's Address (Street, City, State, Zip C ~`~ S"GD od' ~l-o~1~~~ Vlll. Count /De artment Use Onl Sanitary Permit Fee (includes C}roundwater Date ]sued issuing Agent Signature (No tamps) Approved ^ Disapproved Surcharge Fee) ~~ Z ^ Owner Giver Reason for Denial ~ya~ q,~~ 1X. Conditions of ApprovaUReasons for Disapproval 3 1 ~~ ~ ~ ,.o,~.m~Cl~ ~~"""__ ~-TT __ :~ SYSTEM OWNER: .%~. ~ ~, s atk, A:~~ J 1 Septic tank, effluent filter and ~~ ~ ~ - dispersal cell must all be serviced /maintained -"~ ~ t 1 as per management plan provided by plumber. ' ~ 1 . ~ ^~~ ~ N~ 2. All setback requirements must be maintained 0 ^ 'pp'" (~~n'~ ,, nn ~~ //~~ _~ -- ~^ ~, . . 11 as per applicable code/ordinances. ~ ~~ ~es+,e,JIOL Z1tlD~ h~ tti1~y~¢O(._ Attach mpkt ~) s s BBD- .O1 3 `'~t °` CS) .~ r the County only) for the ass moo per oot~t~tha~i;~ i 1l, l laebca ~ s~9t ~t~, ; r _ _(~ ~~ ~~ ~ ~ 1 °~- q ~. s`~. . Sot ~s+~^~,~ ~f Q u T.L. Sinz Plumbing Inc. E5609 708th Ave. Menomonie, WI 54751 e~ , ~. -,~/~~~- „~ ~ ~ ~ ~~ S Phone: (715) 235-2644 / ( dNcJ Fax: (715) 235-2592 ~ r 5Z ~~~~~~ T ~j~r www•tlsinzplumbing.com ~r ~~• , try ~~~~ ~ ~ rt: ~Z ' ~~~ ~ ,~3 ~~' .~ 7~ T.L. Sinz Plumbing Inc. E5609 708th Ave. ~.~~~- ~ ~ ~ ~£ S Phone: (715) 235-2644 Menomonie, WI 54'751 dNcJ Fax: (715) 235-2592 ,Lp T 52 ~E/~-S~Vr/T- ~j~l www.tlsinzplumbing.com ~r ~~. ~ ~E /~ 0 /~ 0/` ~ ~~~~~ ~ ~~ _~~o ~~Z-~~, ~ g / -7uJ ~~~~~ L>' o~ o~~ ~y ~jr~Ov. ~~WT /2S~/~S~o~o~c~~ W / ~ pip v~-+~f2 z- ~~-c'~ ~~°-~ ~~1 ~ W ~ Z,h-k3Lk~ ~t bD ~ ~~. ~~ / `~ So ' Uv ~~ I ~ ~>KZ ~i~ qP ~ ~~ ~L t sT ~~,~,/ ~ys% q ~~~ 3 r~~'4~~ fNsi:ons~ Department of Commerce SOIL EVALUATION REPORT Page ~ of~ Divjsion of Safety and Buildings ' m accvraance w~Tn ~.vmm a°, VVIS. l1Urn. WU6 County Plan must lan on er not less than 81/2 x 11 inches in size Attach com lete site a • p . p p p , include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all infor-patigrr: ---. '` iewed by Date 4'1 ' Personal information you provide may be used for se dayl.ptrrpds~s.~iv c s. 15.04 (1) (m)). - 9 Property Owner .;\~~~ ~ ~, perty Location ~`~C~ .Lot 1/4 ~ 1/4 S ~ T 1, N_ R A E (or~N Property Owner's Mailing Address r,.~ ,~~QO Block # Subd. Name or CSM# City fate Zip Code on rr~r _ ity ^ ~Ilage ®.Town • :Nearest Road> ~ (~ New Construction Use: ~ Residential / Nu Code derived design flow rate ~~~ GPD ^ Replacement Public or commercia - i Parent material ~ • ~l Flood Plain elevation if applicable ft. General comments .s,(s~t /yl 'G~i.(J• Q'y 9Q and recommendations: ~ LT• ~'~ J~ ~ ~ • $,v r Boring # ~ Boring Pit Ground surface elev. q ~, ft. Depth to limiting factor ~_ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~ -~ Z --- s; I c v~ . 5 •~ 2 - - LS 1 r c -- .-1 1.2 ,~k- 4s. ~ 3~-8 ~ •8" 2 Boring # ~ Boring ~p Pit Ground surface elev. `f O. ~ ft. Depth to limiting factor _~~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 2 IZ- 1 ~ - Lg 1 - .Z ,~. ~ '_' S ^' 5.4 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mglL and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Adam Scti yn-1~ r .~ - Z53 9 ArTdress Date Evaluation Conducted Telephone Number Zll~ ~)~ ~~ ~rner5e~ LUG S~C)z,~ /~~-IU-Oy ()~~ )Zy7-~/D0~' • .f Property Owner ~ ~ ~ Parcel ID # Page ~ of 3 Boring # ~ Boring ®Pit Ground surface elev. 9~ • ~ ft. Depth to limiting factor ~~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 0-12 - S' c. I r.C Z _ ~ • ~ .:. ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftt in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor ~in. ^ Pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft'- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2 4 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) PAGE ~ OF NAME I JO r1 ~ ~ LOT# J Z LEGAL DESCRIPTION S w '/.uE'/4 S I (oT ZR N R 1 ~-E (or) ZOC~> SCALE: I"= ~UQ , BM I ELEVATION `(~~ BM 1 DESCRIPTION •Faop o ~ ? 11~ Conde ~ f _ -}•- - BM 2 ELEVATION "/ ~. ~ / X ~ I (~ ~ ~. BM 2 DESCRIPTION ~P 0-~ ? Nand ~~t• }- SYSTEM ELEVATION ~~ ALTERNATE ELEVATION ~ ~ • ~ d CONTOUR ELEVATION /tJ~~• ~~ c of ~a ~~ 1 5 S~ /O /Q FR1JM CERTIFIED SOIL TESTINI; FAX N0. 715 233 x398 • ~ Cx,~- C'~~.~..,~ I.,OG;Kr~G COY&R Lc/A~NWG ~/rQF~ ~4tCIL Of~tA~uiGT-~ b ~ .~"f 1.'ini ~~ ~4 ~~ ~ ~~ r ~`° p f ty G 3 ~ NptSTUA~p .SOiL. i 2a" 7...~. MA>1LL4Lr` .._ rc.,~r- a~a.o~r..o A CET 3tJ~.lT'.~ .y ~FFr...E A~aR,rS pJC I 1 -~r~- ofs ~ ~ l "i' ~E.v : r O w'C~ a. Le ~ . J `~' ~ . Ij ~~ ~•~ ~~ r .Jun. 14 2002 05:52A!~1 P „ ~ a~~x ... M ~, ~ r WE~Ykf:APRCkJF Ju+~cT:c>• !~ ~.w~p I N (L.C I ~ ~~ ,,`` n t `-F^ 5 Pub' Go~treEr~ bcac+C 'y. Y ~7% i % %T.;.7 .~ ~~ ~ ~~ .~ 40 Y Y'~rY- !f,' ~~ _ ~L. a~ 3'trr-o f ~.-~ (j i.~:~;J u C f --_ __._ - _._ _ 1 ~~ ~ ~ ~ j N - . S£PT1C E __~PEGI~1~tArT~~~S ~-l,y~ ...~. ~ DoSF K~~Gy.~ Tn-.!••5 M.tit.l(JFACTUSICR: t.1LlMBE.R OF pOyCS; ~,~. NLh C~.~ TA1JK SJZZ; (25~0'~ ~ t3iFLLORIS ~.005C VOl1JF'+E / ~~ _ pL,-,SLY~ l~kUUiACTUiZGR` S 1 ~~~LS.~v~r IfUCL(50>>aG 6?+CXfL.GW: r (,~~.~~s r(OpIVL 1JI..lYr~Cft: . \ a ( 1-~ ~ CJtPAGfTIES; A = ~D {1JCNC5 4h J~/Z ;_,1+.'~.:,.:: .v.,`. bwl~° 4 SWITCH T~PC: `"' Bn ~-' J.VCxES~R 3~.1$ C.t:c..~! '' // ~ilMP 1"5AIJUPACTl1ilCl~- !'~'1~/d v><R'~iG 1:,a~iut.rtf5 OK ~~'D' :.~~..=%'ti'~ - MODEL f,JUMDC~: Sf~~ 3D D• ~ tu~HES GR lO~'~~"G~~.~_G~.:~ SwtT~x TAP[: ~"''~',""`~ +` ._....,,.r uQ,rs: pUHp AUD ~,LAa/~( .ARC To be t~i>`tIxUM OISGHJ1fRGE RA1'f:~.-.....,_Gf N ~1J51"ALLEO 0-J SEP~AnTL CIKC::•'"~ VfRTICAt Dt>'FC1<Ef~~li 0~1`WCf-fJ PUMP bif Ar,,lo pISTR(QUT10U PlP£.. ~ ff=£"f i- h~ulr,,ux A,1~T(.lastli SUPP~.y PRFtsu~ £ . _.~,..~. Fi_CT ,/ ~ / + I/b t'CET pF lpRGC r~.fu X /~•9~ f/pp~~FKICTIPIJ FAGTGI4. a.i~ SECT Y+ ...-. G -- TaT~,~ o~uAx~c µc~a ~ ~~ FEET it •,, ~ ~ n ~. ~ lUT£RUA;. DIMlLA151oh~1r Of TAUK: LE.-JC.TN ^ _ ;W~prH ~ _; LIGy,yID OCPT ~ .~.--- Wholesale Products Page: 6350-1 Section: Performance Data Dated: January 2001 12 r 40 9 ~~ 30 _,~ ~ ~;' ~`~ W V'1 LL W Z ~ 6 -~~ 20 SHEF30 ~ z Q ~-- X 3 10 0 ~- 0 Capacity-U.S. G.P.M. 10 20 30 40 50 liters/Second 0 1 ~'~ 2 3 The curves reflect maximum performance characteristics without exceeding full load (Nameplate) horsepower. All pumps have a service factor of 1.2.Operation is recommended in the bounded area with operational point within the curve limit. Performance curves are based on actual tests with clear water at 70° F. and 1280 feet site elevation. Conditions of Service: GPM: TDH: ~~ HYDROMATIC A POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATt N Owner ,~ ~„ Permit ;a O 3 DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units A Estimated flow (average) D al/day Design flow (peak), (Estimated x 1.5) al/da Soil Application Rate s7 al/da /ft2 Standard Influent/Effluent Quality Monthly average " Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand IBOD51 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Oemand IBOD51 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean- <_10° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity Q al ^ NA Septic Tank Manufacturer ~~~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model -7'Q p ^ NA Pump Tank Capacity Sp al ^ NA Pump Tank Manufacturer ~ 'T' ^ NA Pump Manufacturer v ~L ^ NA Pump Model ~' ~D ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: A Dispersal Ce(lls) ~n-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: A Other: NA Other: NA MAIN 1 tIVA1VGt a~.ntuu~t Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) ? earls) ^ NA Pump out contents of tank(s) When combined sludg and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month(s) (Maximum 3 years) ~ ~ 3 earls) ^ NA ^ month(s) ~~ ^ NA Clean effluent filter At least once every: /~/ year(s) Inspect pump, pump controls & alarm At least once every: ^ month(s) Z.~ ~ earls) A ' ^ monthlsl p A Flush laterals and pressure test At least once every: ^ yearlsl Other: At least once every: ^ month(s) ^ year(s) ^ A Other: ^ A MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal ce(lls) 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 IY,1 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. " ~• Page of • START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellls). If high concentrations are detected have the contents of the tankls) 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 cellls) in one large dose, overloading the cellls) .and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and replacement system: ~~ cannot be repaired the following measures have been, or.must be taken, to provide a code compliant A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. e si as n been alua d to ide i a sui a repla ent ar a Upo a ure of a WTS sit d site alu io t e p o m to Iota a itab rep ace nt rea If n r cem ea is a aila a ho ing ma be installed a last resort to place th ailed PO S. 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 PAWTfi INST~I LER Name L ~i~li' ~i~6~ ~/v C. Phone .~ ~.- POWTS MAINTAINER Name ~-•,.~jtJ`L~ ~' ~~'~.- Phone S'~ ~~'~' SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY ~AU~TH~ORITY 1~ ~,' Name Name ~%~•Ir/rd a~ (~~" Phone Phone ~~-° ~s ~ This document was drafted in compliance with chapter Comm 83.221211b)11)(dl&(f) and 83.54111, 12) & (3), Wisconsin Administrative Code. ST CRO1X COUNTY ~E~N,I, G CB A SEPTIC TANK AND OWNERSHIP CBRTIFICATION FORM OvwerBuyer Mailing Address property Address n (Verification required from Planning Department ror new City/State ,~l" ~`~~ ~~ Pal Identification Number r ~yQ1 h ~~ T EGAL DESCRIPTION q ~~~ GG,,'' ~ t. Sec. IO T ~1 N- Town of ~IM h~ . property Location 6+~ /4, _._.~ / , ~--~ R~© -~~- ~ sa subdivision ,~ _ .Lot # ~-~~ • Volume _______- -• .Page # -- Certified Survey Map # _ t~v~$y~ ~ Volume ~~~ Page # ~~ warranty Deed # Spec house ^ yes '~ no Lot lines identifiable ~ yes ^ no eYSTEM MAINTENANCE remature failure to handle wastes. Proper maintenance Improper use and matntenanceof Your septic system could result in its b a licxnsed PumPC1• What you put into the system consists of pumping out the septic tank every three years or sooner if needed Y can affect the function of the septic tank as a treatment stage in the waste disP°~ gym. eat a cetti5cation form, signed by the owner and by a The property owner agrees to submit to St. Croix Zoning Deparbn that (I) duo on-site arastewaterdisposal system mastcrPlumber+lourneYtnanPlu~r, ~tn~~plumberor a liceasedpumPerv°rifYiag ~ tic tank is less than 1/3 full of sludge. wndition and/or (2) after inspection and pttmping (if ztioccssary), ~P is in pmper operating `' ` the vate sewage disposal system with the standards I/~, ~ mod have head the above r+oquir+canents and agree to, matnt~ pn as set b the t of Commerce and the impartment ~>Nataral Resources, State of Wisconsin. Certification set forth, h in. Y ~ lcted the returned to the St. Croix County Zoning Office within-30 ~~ t 'c system has been maintained must be comp days o the y expiration data ~,. ~~ ~~~ ~ !1'>'~ I ~. ~' ,'` rte'' `-~ DATE NER t;L<' K "ll<„~~-t~ .~ sv i. our kn,~wled c w) certify that all stattements on this form arc true to the best of my ( ) ~~• the pr d ~~ above, bye, v e f a ~ ty deed recorded in Register of Dom" a; T _ _ I (we) am'(are) the owner(s) of 9 iz~_~u3 DATE •.sa • pny information that is mis-represented may result in the sanitary pemnit being revoked by the Zoning Department. ~ deed from the Register of Doeds office a« Include with this application: a stamped. vvarraaty ~. reference is made in the warranty deed a Dopy of the crrtifiod survey map U 1960P 504 • I STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number WARRANTY DEED This Deed, made between _Ronald C. Bonte and Glenn Knudtson Grantor, and Matt Ries and Sonja Ries _ _ Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Pheasant Hills First Addition, St. Croix County, Wisconsin. ~^ Recording Area 688451 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO., NI RECEIVED FOR RECORD 08-28-2002 9:30 AM iINRRIYVTY DEED EXEMPT # R£C FEE: 11.00 TRANS FEE: 105.00 COPY F£E: CERT COPY FEE: PAGES: 1 IJamr nnA R~h,m AAAn-ca Estreen 8r Ogland 304 Locust Street Hudson, WI 54016 PtUl8-1034-30-OSO Parcel Identification Number (PIN) This is not homestead property. ()¢) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this 19th day of August 2002 ~~~~~ i « R nal,/~C. Bonte _ X.(G -. _ • Glenn Knudtson AUTHENTICATION ACKNOWLEDGMENT Signature(s) _ -_______ _ ^ STATE OF WISCONSIN ) ss. - St. Croix County ) authenticated this day of ~ Personally came before me this 19th day of August 2002 the above named - "'--~" Ronald C. Bonte and Glenn Knudtson _ - _ .- TITLE: MEMBER STATE BAR OF WISCONSIN to me known to I (If not, - .- instru e d a~ authorized by § 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine O land ___ _ Notary Public, Hudson, Wf540~^ __ My Commission (Signatures may be authenticated or acknowledged. Both are not necessary.) __ __,-_.. "Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF W ISCONSIN WARRANTY DEED FORMNo.2-1999 Syyyho executed the foregoing 'i, 5 e• i pi . {5pt, state expiration date: 4.'__, 2003 •) • inf6rmation rrotawn.u eoma.fn, Fond a Lac. MA eaoass-2ozi ~~ R i t~ ~"~"'°°~~'~ PHEASANT HILLS FIRST ADDlTlON t +° ~ L GCATED f N' THE Vk' f /4 Of T?~ff- Vf 7 /4 AND ! V TN,E' SW ; i4 OF 7:~E NF.~ ! /4, A~tiD ;A~ THC SE' ?i4 r)p THE NF Ii4, At.L iN 5ECTt0N +6, T.1JN., R.;IpJ., a UNPLARFD LAND9 TOVJrV OF HA7v td0NL', $i~, C?7piX C.^,Ut•; 7y, Wi SCChS?rd ' ~ ~ uw ,Ar I N8Y'!3'45`C 850, M' m ua w w.,uw ~ . ,. M _" .z,',.a`nrt,. i ~ \ ! Iw .._. . ~, S . .. Y \\C .C)~ LOT ~0 `l/ j . w.. j are[ rar. Aar as T ~ ~.r, J ,aHD^ t r N'YLA' . sr, to r ~ `~ FD.' .. ..... \ :tl9°PA'OY ~. .. \ .. / ,c ~ ~ ra+w 89P. 09' (iC NE CY%. I OT 371_ .... ._ ... _ _ ~~ ~/~ 4 a n G.- 6 .SSr R~ i ~~ry, L 7... ®' ~~-.. / , ~" Y / .craw ea W ! t+r5 f!YI': f / / / ~/~~ ~. i t _ .... i. S ~ } ~ € SEE ... .,..«.,,~ ,.. 2 ~,',~; ~ ~4- as, s zo. rrl LOT 54 ~ ~ t.CT S,S °~ .,.y__€!43"_S_Tf. ._ ~ w a t. r. ,cxra P ~ ~ ~ rm r. rr ~~ S .. i F`ar CLOT u7 ~~`,\ ~~ a,.a.w ~e. s3. -. & nYrta ar. ~In LO>S_ .o P ,; .. :~D ~ :' ~ t alp as .rr ra.., .. .rs € = c~; A® ', lar 52a ~~ ~ ...,a >K „~ ~ a,.w -~.w. Y t ~ N r. ta• a °- ..a, ~ ~~ ' R ~ ro .set so: u 4 r '9s.ti x~Y y~~.. _~ _. I ' ~ a: ~ i .- w - I s SHFFT ss[oa ~. -- - ~.. . , PUf3L ! C ... ~ - 1 ~A ,,.... .,. ., - .w ' _.. w as ... ... tar . a. an -- .....__. Yr--o ..a~_ Na. ~ N ra a ~ ANA r S ~ _ ~ +.aa .r• r>.rw •m. ,r w. .,..~ . s .. ~ . ~. ) I S wa~uw wxa LOT 84 ~ S ,..... i i. k ~ -§ M ,"°"'"' ...... ....... t •I zLaa°riu'.. ~ ~~ ~ 4' iao<. Yt c, . , 5 aYw .r.. .s, % ~ - LOT 68 `I t07 87 LOT 66 + /. LOT 63 =~ ' ~~ r aa, as .. t r Rzs 7 ~ ~ r, is aase LOT 62 ._ . y waerztaY = J!'i r, 4t> J0. r ~ r'IetrJO. tr r. ~ ~ 1 t to. r i, iiz AS r ~ T G: r~ `~ ~' T( ~ cv, n T. .. r Y ~~~zr~~~LLr ' x 4 \ N tl yY76.-eegwra~~'~'~art 1 Y i ' 1 ' .. ~,. 4 i I f' r.,,..r .w. ' Y w., ri Ra,.,. ~ ,, .ar,a ,. a ,, .,, ~ . a.w >,.e: ~ ~. _ _. ,a .~ aw,..aa, ~ UNPLAT7ED LANDS rw r~wrr a,a ] wu~+w w•aw'M'o wwwa.~v w w<r~ar .~ w'ar:xe { MAeaPI' r7•W YY!7. 01' (T0 9F.' :OR. PLAr) ~ r. , UNPIA!TED ~~ 53t4', W' ; TO t48r WARTER CDRNCA) ra0 r~rw+a anrti ~~'O a 2oD +~ LAaro3 ~'_' ~ "N",~-~,~, -- _i F.i3~~A ~rM.~.,~r..~..wK. 4AAr. -........ '~ ~ L~~ , ~~ N.,..rn....a i'"'"a -........ sNrer . a t ~'~.v.' ~ ~e .ra Wisconsin Departm@nt of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ~ • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Ries, Matt Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: ~~~~.~Lr ~,•~, ~ I TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~:~-,T"~ ~'~ ~~ ~C>i~h~ ~ ~ ~ L~ Dosing ~\ ~~~ Aeration /~ ;C i,~~~ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~~ ~ ~ ~ ~ ~ ~ i .~ ~~ _. Dosing Aeration Holding --- -._. PUMP/SIPHON INFORMATION ~d ~~ _~~,w~,~ Manufacturer I~2,1 ,~ ~~ ~~ ~ ~~~ Cs Demand GPM Model Number ~~.-{ TDH Lif(„ ~. Friction Loss /~ y System Head TDH t Forcemain Length Dia. ~-- Dist. to Wel~ c~ ~ 1 ~ ELEVATION DATA county: St. Croix Sanitary Permit No: 430376 0 State Plan ID No: Parcel Tax No: 018-1090-52-000 Section/Town/Range/Map No: 16.29.17.717 STATION BS HI FS ELEV. Benchmark ~~_~ icc'~.3 ~~,`~ Fw Alt. BM SUHt Inlet - / / ~~ O SUHt Outlet b~ Dt Inlet ~~ Dt Bottom ~ ~~ ~~ `15 7%.~ eader/ an. os3 r.~ "~`~ Dist. Pipe Bot. System n S`r...al, c 10~~3 "' ~ . c - 9'f• ~ Final Grade St Cover ~ z >' `j :~. 't ~ 5 7 )~.U ~/ 3 ~ +~ a bs/3 ;~ -~. ~ ~ SOIL ABSORPTION SYSTEM ~.~ r~ I ~ G~tu~..,,~.Or1.aJ ~i'o OO ~ ~°I ~~D BED/TRENCH Width Length k No. Of Trenches PIT DI ENSIGNS No. Of Pits Inside Dia. Liquid Depth__, DIMENSIONS ~ „_ ~~ .;~ •--- _. SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~ : ~ ~' i Type Of System: c ~ ~ ~~~•[ . r ~ •,~ {~ ~ t I I `~ ti ~ r , ~ _ UNIT _3 - [~ r~,~ • n Model Number ~fcl DISTRIBUTION SYSTEM ~ ~ ~ ~~~.~ ~ -3- Header/Manifold ~ •~ Length ~ ~~' Dia 1 ~ Distribution --- / Pipe(s) Length Dia Spacing x Hole Size ___ ~ _ x Hole Spac g __ ~ ,~?, ~"'" SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center - Bed/Trench Edges ,~ Topsoil J Yes Ls;a No ~ Yes i i, No COMMENTS: (Include code discrepe cies, persons present, etc.) Inspection #1: fl / fL / 6 ~ Inspection #2: / / ~~ ti~ <<:..-~ t ,, ~ ~ U .~ ~ ~ ,..~.,~ ,Y. Location: 957 176th Street Hammond, WI 54015 (SW 1/4 NE 1/4 16 T29N R17W) Pheasant Hills 1st addn. Lot 52 Parcel No: 16.29.17.717 ~~ CS T" ~? ~ e v «, [ • t, n S Wl r ~ e.~.-lr/ .t~ (~ /rz.~ it ~ 1n s . ~ r y 1.) Alt BM Description = ~ /~~.~ ~, ~ ~ _ I r it: ~• „ ~. , ~- ~~ rt~• ~ ~, n ~k~ 2J Bldg sewer length = ~ 5 ' ~~. (cn ~ <_ L,~ ~-~-r trZ,,.~ ~, ~ -amount of cover = ~--.. ~ ` N~ i~l a ,,,•--~ ~- ~' ~ ~-' ~ t"'s" •-~ [ (.Ytti.w~^ _ ~r k~-~ Plan revision Required? (~ Yes [.] No I~ i Use other side for additional information. _L__~- ~_____. ______-.____._.__ ._____- __ -~ I __ t_____L_ I __ +/ a e Insepctor's Signature F Cert. No. '3D-6710 (R.3/97) ~V 1 ~ ~ ~ s s /LL , n _ _ ~~~y -~/ ,R~ , /1 010 _ in Vent to Air Intake •