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018-1094-12-000
;in Department of Commerc,~ PRIVATE SEWAGE SYSTEM and Building Division + INSPECTION REPORT :NERAL INFORMATION (ATTACH TO PERMIT) ;rsonal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Midwest E uities Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: /G~ • Y1/~ 1 ~ ~ ~ ELEVATION DATA TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~7 ~ ~"7~ i2.~ /7~~ .~, Dosing / ~ ~ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand G Model er TDH Friction Loss System TD Ft Forcemain Len ia. Dist. to well TANK IN FORMATION TYPE MANUFACTURER/ CAPACITY Septic ~~ ` Dosing Aeration ~~r ~ ~ r 1~ / Holding SOIL ABSORPTION SYSTEM County: St. CfOIX Sanitary Permit No: 430638 0 State Plan ID No: Parcel Tax No: 018-1094-12-000 SectionlTown/RangelMap No: 17.29.17.752 STATION BS HI FS ELEV. Benchmark 3: ~.~ /e 3. j~~ Alt. BM ,~, S `, ~~,. ~ ,(~ /Od ~ ~ Bldg. Se er x,71 `/~,Zj! SUHt Inlet S~3i 4g SUHt Outlet ~ ~ ~g Dt Inlet S.y 98.d5 Dt Bottom /~ 35 (o 9 .) Header/Man. (0•~7 c~ ~ ~ 5~ Dist. Pipe lo. 77 9' 7- /g Bot. System ~r'~ 9~ `~ Final Grade St Cover I ~ ~, ~~ Width ~ Leng th .Z No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth D MENSIONS __ ~ `` \ / l.V . ~ J 1 ~ ~(~ad~ cY.~ SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer:.-~ -1. ~ ~zi'-1 a Typ~O f System: ~ (~ ~ f ~ ~ 1 ~~ / UNIT Model Numberr ~ (~l)t~ CC~o ~ , DISTRIBUTION SYSTEM ~ - ~ ~/ / ~ S(, ~ ~~-6.SL_~ Header/Manifold, ~~ Distributi n ~ Pipe(s) x Ho a Size x Hole Spacing Vent to Air Intake Length i ~ . ~J Dia_~~ Length Dial Spacing ~ , ~/ ~ ~ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv 1'~ ~~ ~.. a6~-" 1 l2 r..cl.~ De th Over Bed/Trench Center De th Over Bed/Trench Ed es g xx De t f To soil~ p xx See d/Sodded i ' xx M hed ~ r = Yes j No s No COMMENTS: (Include code discrepencies, persons present, etc.) Location: 982 117th Street Hammon/d,,WI 54015 (NW 1/4 NE 1/4 17 T29N R1 1.) Alt BM Description = 5~~ ` ~" u~~ ,~ ~ ~v'~~` 2.) Bldg sewer length = 1 L - amount of cover = ~ ~~ Plan revision Required? l ~~ Yes o ~ ~ ~ ~ O Use other side for additional informat~ ~~ ~' L_-----i----- -___ --- Date SBD-6710 (R.3/97) Inspection #1:~/~/~ 7W Prairie Run Lot 12 Inspection #2: / /_ Parcel No: 17.29.17.752 Cert. No. ~i~+~ v~ ~~ Safety nd Buildings Division County ~ ~ 1-20 Was " n on Ave., P.O. Box 7162 ~o~~ r ' .tit ' ~~~ca-n~ ~ J ~ ]l~tadis n, WI 53707 - 7162 SaNtary Permit Number (to be filled in by Cot Department of Comm ^.e `` ~~ v ~y 8) 266-3151 p ~ 8 Sari~ta tion State Plan I.D. Number __.--~-- In acwrd with Comm 83.21, Wla. Adm. Code, personal Information you provide tray be used for secondary purposes Privacy Law, s15.04(1)(m) Protect Address. (if different than mailing address) 1, Application Information -Please Print All Information ~,yl~~ Property Owner's Na me Parcel # Lot # Bh~ck-A`- _ ~ ~ /~ v _ _ roperty Owner's M I Address Property Location ~ ~ ~ ~ Section ~ [~ ~,i ~~S6 Pity, State ,Ip Cale Phone Nutnhcr , _ , , • , S_ (circle n ~E or~ T~ N; R~ , 11. Type of Building (check all that apply) ~ ~ Name Q3ivt-f•lnmber bdi i i S I or 2 Family Dwelling -Number of Bedrooms v u s on ^ Public/Commercial -Describe Use I~ State Owned -Describe Use ~ ~o S ~ ^Ciry ^ 11ageTownship of III. Type of Permit: (Check only one box online A. Complete line B if applicable) ) ;~. ^ New System ^ Replacement System ^ TreatmendHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal - Permit Revision _ Change of ..... .. ^ Permit Transfer to New . L' - s- ermit.~rnber-atkhfla -Iss .~"_-:_ ~~~~ ~ . l2. ~~ Before Expiration lumber Owner _ ,, /Dw = ~ ~ _ [V, T of POWTS S stem: (Check all that 1 ) Non -Pressurized ln-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter I) Constructed Wetland ^ Pressurized Tn-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ~ .] Recirculating Synthetic Media Filter ^ Leaching Cham r ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) _ v. Dispersal/Tr'entment Area Information: -//JD I~~•sic~~ (tow (gpcf) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed{sq yttem Elevation VI. 'I':rnk Info Capacity in Total Number ~ Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Hording Tank D °' .. .Cy , Aemhic Treatment Unit Dosing Chamber VTT. Respo sibility Statement- i, the"Undersigrred, ume responsibility for installation of the POWTS shown on the attached plans. Plum is a me (PrinO~ Plumber s Si r MP/MPRS Number Business Phone Number ' _S - ~ P umber' Addre ss trcet, Cit ,State, Zip Code ~ t _ ~ VITI. Count /Dc artment Use Onl ~AppmvM ^ Disapproved Sani!ary Permit Fee (inciudys Groundwater Date IssuecJ 1ss 'ng gent Signatur ( Stamps) (~ surcharge Fcc) ~ ~~, Q9 .___...-.-- Owner Olven Reason for Denlel , tx, t:mullUons of Approvnl/ sons far Disapprovnl Op _~ ~~ _ ., ~-. _ _ ~, l.s L.fL.v t~ t.0~~ tw ` 1~ (~'t ~, t ~- 0. ~ ~ ltJl1ZA -~ A-I~ complete r D i,,6u111~ -~ on paper not Tess than 81/2 X 11 ~ ~-~ .~~ . 0 t~~ SAD-6398 (R. Ol /03) .~.L~,,~~,/i - ---- -~ ~ ' _ ~ ,_ ~ K ~~ ~ __~ _.~ ~~ __-I .; ~~ ~~1 ,'~I ~~ w ~ ~~ '~ ~t a0~ ~~ ;- ~. ~1 ~_ O ~- --~_ ., ~ T- f - r ~ I ' _ ~ ~~ _. i I ~ __ ~~ ~:c~ ~~:5~ ~'Ibf _ ------ - - f ~! _ ~ ~ Q ~ ~~ -- _ . -. - i, _ ,~ ` ~_ \ ty 1 ~ ~ --~ . ry~\ \l ~_ ~~ i i e '\ I ~ ~ ~ - ~ ~~_ ~- (~ ~ ~~ ~. !~ \ f -- ~ ~ ~ ~ ~ a ~. _! ~.. __ I __. - • -- T -~ 1. ~ ~ , I ,^ - -~_ __ -- _ --,, ~ ___.. _- _ ` I -~ ~~~{~5, ~ibt 3/ i `~ ~ ~ - - - _,_ . ... - .._ -- -- ~ O ___. ._ 3 ~ ~~ ~Q ~~ ~ ~ ~ ~ ~~ ~ ~ ~ ~~ ~ `~ ~ ~ ~ :~ ~~ _ ~ ~ ~~ ~"''~. ~~ ~, _ ~_ _, ~ .~``. _ ~ ! ~~ ~ ~ __ ~~ Y~~ ~ - ~_._ e _ _ ~ ~j p9 _~_ _ . , __ \ ~I ~ ~ -~ ~ ~, \ ~ ~~ ~ ~~~ ~ '_ ~ 1 ~~ ~ , ~ ~ ( _ Z I a `~ d !~ .__ . -- ._ ~ ~ ~ ~ _ ~~ ~' ;_ VVisoonsm Department of Commerce Division of Safety and Buildings ~~~~. ~' SOIL EVALUATION REPORT ~~ Page ~ of m accoraance wnn wrnm a~, vvis. ram. ~.oae County Attach axnpiete site plan on paper not less than 81/2 x 11 inches in size Plan must . include, but not Limited to: vertical and horizontal reference point {BM), direction and Parcel I.D. percent sbpe, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information. e ' by Date Personal irdormation you provide may be used for secondary purposes (Privacy l.aw, s. 15.04 (1) (m)). ~,b 9 P Owner Property Location r ~ Govt. Lot ~Zi 114 ~ 1/4 S~ N R (o ' ' Property Owner's iii ddress Lot # BI # Subd. or,CSMIf C' _ ~ ' City Stab Zip Code Phone Ntunber ^ village ,Town Nearest Road ^ City , ~ ~~ ( ) . -_ New Construction - _ --- User Residential / Number of bedrooms _ `r Code derived design flow rate y.S~/~ GPD ^ Repiaoement ^ Public or commeraai - Descxibe: ~_ __- ,__ Parent material T / ~~ Flood Plain elevation if applicable ~/v~ ft. # O ring pi( Ground surface elev. ~~~ tt. Depth to limiting factor }/ ~ in. Sal ication Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Mansell Qu. Sz. . Cdor Gr. Sz. Sh. •Etf#1 •Efr#2 ,~ ~ , - ~/ -~` ~s ..- ' ~,3~ Boring # ^ Boring ~i- 2/ ~OR Z ,~ Pit Ground surface elev. ~L~~ R. Depth to limiting factor 5/f~,~ in. SoU ication Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP DlfP in. Mansell Qu. Sz. . Cdor Gr. Sz. Sh. •Etf#1 •Eff#2 l ~ ~- .~- 0 • Effl #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mglL E ueM #2 = D < 30 mg/L and TSS < 30 mgll CST Name ) t - - Signature CST Number Address } ~ v uatwn Concluded Telephone Number ~d _ s. I ~ Jr, 1~ Property Owner ~ ~-~/~ ~ Parcel ID # Page ~ of ~~ ^ Boring `~ ~ pit Ground surtace elev. ~?'~~ ff. Depth to limiting factor ~~ in. Soil ication Rate Horizon Depth Dominant Ca Redox Descxiption Texture Structure Consistence Boundary Roots GP D/fF in. Munseli Qu. Sz. nt. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 b - _~ .c ~• 2 (off, Z ~9 # ^ ~~ ^ Pit Ground surface elev. ff. Depth to limiting factor in. Sal ication Rate Horizon Depth Dominant Redox Descxiption Texture Stnx;ture Consistence Boundary Roots GP D/(F in. Munseli Qu. Sz. Cor-t. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ^ ^ Pit Ground surface elev. ff. Depth to limiting factor in. # ° ~'~ Sal ication Rate Horizon Depth Dominant Redox Description. Texture Stnxxure Consistence Boundary Roots GP D1fP in. Munsefl Qu. Sz. Cont. Cdor Gr. Sz. Sh. 'Eft#1 'Eff#2 'Effluent #1 =BODE > 30 _< 220 mgll and TSS >30 < 150 mglL ' Effluent #2 =BODE < 30 mglL and TSS < 30 mglL 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. sso-sew trt.doot .~s~~~/ ~ £ ~ ~' \. ~~ I --. ~ -_ __ _____ ~.7/ff f=S, ~,1~ _- _ ~ ~ ~~. M ~ ~C ~\ O 00 ~ ~~ ,~ ~ ~ ~ ~ ~~ ~ ~~- ~ \ ~ ~ ~~._ ~ ~~Y ~ ~_ 1C~r ? ii \ ~\ \ ~, \ a ~~ ~-~.o f - - ~~ Q .e I ~t ~~ ~ ~ ~1 ~ \~ ~ ~ ~~ h~ ~I~ ~ y ~ ~ r,~\ _~ ~ a~ ~ - ~ ~ ~ ~ ~,~ ~ ~~ ~ \ ~ _~ ~ ~ ~ ~ ~~~~~ ,y ~~~~~~ a .~ ., m°. 0 M ~~ ~4 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Na~~ L ~F FILE INFORMATION - ~ Owner ~ r /!,~ Permit # ~3 ~ 6 ~~, DESIGN PARAMETERS Number of Bedrooms O NA Number of Public Facility Units ~SNA Estimated flow (average) al/da Design flow (peak(, (Estimated x 1.5) - al/da Soil Application Rate ~ ~ dal/daY/ft? Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease lFOG1 s30 my/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/l. Total Suspended Solids (TSS) 530 my/L O NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ys in die. O NA Other: ^ NA 'Values typical for domestic wastewater and septic tank ©ffluent. SYSTEM SPECIFICATIONS Septic Tank Capacity. , - --- - aI ~r:~. Septic Tank.Manufacturer ~r ~ ^ . S' O w Effluent Filter Manufacturer 0 r~i~ Effluent Filter Model U t~~; Pump Tank Capacity al ,~ trA Pump Tank Manufacturer -~ NA Pump Manufacturer ~ ,~ NA Pump Model ,I~ NA Pretreatment Unit O Sand/Gravel Filter O Mechanical Aeration ^ Disinfection O Peat Filter ^ Wetland ^ Other: .~`N~` Dispersal Ce(lls) Jai ln-Ground (gravity) ^ At-Grade ^ Drip-Line O NA ^ In-Ground (pressurized; O Mound ^ Other; _ Other, U NA Other; O NA Other: O NA MAINTENANCE SCHEDULE Service Event Service Frequency Ins ect condition of tank(s) P At least once eve ~'~ ~ month(s) (Maximum 3 years( ear a •. O NA _ Pump out contents of tank(s) When combined sludge .and scum equals one-third (Y~1 of tank volume O NA Inspect dispersal cell(s) At least once every: ^ month(s) (Maximum 3 years) .-~ ~Yearlsl U PJr' Clean effluent filter At least once every: ~ ^ month(s) ~'yearls) O NA Inspect um ,pump controls & alarm P P At least once eve ry~ ^ month(s) O earls) ~ NA Flush laterals and pressure test At least once every: O month(s) : ^ ear(s) ^ NA Other: At (cast once every: ^ month(s) ^ earls) ,~r.iA ..~ Other: ^ tiA 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 pending 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 pondinc; of effluent on the ground surface. The pending of effluent on the ground surface may Indicate a failing condition and requires tfiu immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-third lY~l or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servloing Operator and dlspoaed of In accordance with chapter NR 113, Wisconsin Administrative Code. ~ • Alt other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatme~ 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. (3MW 141011 Page ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanklsl fay the presence of painting products or other ohemicals that may impede the treatment process and/or damage the dispersal cellls-. ~f high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shalt not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above Hormel hlghwater levels, When power Is restored the sxoete wfaeteweter will be discharged to the dispersal cellls) In one large dose, overloading the oslllel and may result In the beokup or surieoe dlsoharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servioing Operator prior to restoring power to the effluent pump or contact a Plumbor 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 anothor inert solid malarial. 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 boon evaluated and may bo utilized for the location of a replacement loll absorption system. The repiacement area should bo protected from disturbance and compaction and should not be Infringed Upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ 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. .ODITIONAL COMMENTS --- _ ~; ?OWTS INSTAL ~ POWTS MAINTAINER Name Name Phone / = Phone EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ,' Phone ~ / - ~ ~' _ `!,is document was drafted in compliance with chapter Comm 83.2212)Ib-(tlld-&Ifl and 83,54(11, 12) & 131, Wisconsin Administrative Code. r i L, Wisconsin Department 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)l. Permit Holder's Name: Midwest E uities City Village X Township Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding County: St. CirOIX Sanitary Permit No: 430601 0 State Plan ID No: Parcel Tax No: 018-1094-12-000 SectionlTown/Range/Map No: 17.29.17.752 ELEVATION DATA TION I BS I HI I FS I ELEV. Inlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Bottom Header/Man. 'Bot. System Final Grade Manufacturer Demand GPM Model Number TDH lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDfTRENCH DIMENSIONS Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Onlv xz Mound Or At-Grade Systems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedlrrench Center Bed/Trench Edges Topsoil 0 Yes ~ No ~ . ~ i -'J Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ Location: 982 117th Street Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 12 Parcel No: 17.29.17.752 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? [] Yes 0 No I Use other side for additional information. ~ ~ _ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) r RECEIVED I .~ Sw, DEC 0 9 ~Q~ fety and Buildings Division 7082 O l 'W hi P O B A County n ' v I ` ~ ,SCO ~ ox as ngton ve., . . adison, WI 53707 - 7082 l~ Sanitary Permit Number (to be filled in by Co.) 01X CO NTY (C08) 261-6546 ~.~, ~~ ( p De artment of omm tNG OF ICE 0 Sanitary Permit Application Stag Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal infomtation you provide may be used for secondary purposes Privacy Law, s15.04(I)(m) r Project Address (ifdifferrnt than ~ g address) I. Application Information -Please Print All Information ~ 98 .~ eS ~ 7 Property Owner's Name Q ~S ~~~, l a Parcel # [.ot Black # 9y o! ,g,~ ~',w tJi~ ~` a .e2r) U ccSe. ~ ~ ~~ ~ Property Owner's Mailing Address Property Location O ~ ~ Section ~~ '/ ~~ '/ Ci S tY. Zip Code Phone Number ', ., CrOS.s~ C.t~I. 5'~{l0 r cucleone) T R~~r W II. Type of ding (check all that apply) r, ~ 1d'I or 2 Family g - Number of Bedrooms S Su Sion Name C~slt4-Harttber ^ Public/Commcrcial - rite Use Q ~ /'/ a td.17 ^ State Owned - Describe U City ^Village ~'f o ship of • III. T ype of Permit: (Check o one box on line A. Complete li B if ap ) A' ^ New S tem ys ~ Repla t System ^ Tr rnt/Holding T cem ^ Other Modification to Existing System B ^ Permit Renewal Permit Revision Change of to New List Previous Permit Number and Date Issued Before Expiration Plumber r 3~3 IV. T e of PO stem: Check sll that a S¢ ~~, 3' X - i .Ler L Non -Pres zed rou ^ Mound >_ 24 in. itab it ^ ound . of suitable soil ^ A -Grade Single Pass Sand Filter ^ Co true ed an ressurized In-Ground Idin ea ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Rec culating etic Med 'Iter ^ Leaching r e eve ess Pipe ^ Other (explain) V. reatment r Information: uJ e-I IGb C ~. 3.T Design Flow ) Desi it Application Rate(gpd D' er r equire f) lspetsa ea roposed (Sf) System Elevation 75 d .~ ~s ,3 i ~/9.~a ~T.s.A: ,D I VI. Tank I fo p in Total Number Ma cturer Prefab Site Stcel Fiber Plastic to Gallons of Units Concrete Constructed Glass Ne Exis anks Ta Septic or Holding Ta ~ S8 S , , l nn / Gl~ Q r l0»C . ' / v Aerobic Treatment it Ibsing Clamber ~ 9sa •e sc r c. ~ VII. Responsibility Stat ent- I, the undersigned, me r nsibility for installation of the PO own on the attached plans. Plumber's Name (Print) Plum is Si re MPp.4pR,S.IJumber Business Phone Number c ~~a,-, - 223~17~ ~ls GS~y- s/6~ Plumber's Address (St City, State, Zip e) I~O. ~ 2103 i!/~ c~/. sS~oaP" VIII. Coun /De artment se Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is uin ent Signature ( tamps) ^Owner Given Reas or Denial Surcharge Fee) ~ • ~ z - IX. Conditions of ApprovaURea s for Disapproval n - 3~ ~ I~t 6~ a ~ . SYSTEM OWNER: 1 Septic tank, a nt filter and "~ i SY ~ ~ ~ ~ ned dispersal cell ust all be serviced /mainta t l r ided b lumber ` ` t ~ ~ be~+~em a 5 = p an p ov y p . as per managemen ... 2. Alt setback requirements must be maintained t(. ~~3 ~~ as per applicable code/ordinances. 1 ~ ~ Attach compkte pleas (to the County only) for the system on paper aol less taco aaa : r 1 lneaes to stz~ ~9ti~ SBD-6398 (R. 08/02) . ,cocafed prao. s+~a~ --- ~~d~ of des~~a~ d~a;,,ic~ ctrt4. roc Wla~. : T o{' l~z., . v,c. p,-pe. ssu.~~~ ~r i i / / / / ~~ i / ,~ i a 4 i 8 ~'~'~ i ~ ------- i - ~ P~epascd i s~~~ I I I t lt. Tp of E~~` =99.70. Y % ~ / ~ / ~" / / ~ / ~ ~` / % c~~ / ~ ~` / / o,'' / :~°~ / 1 % -~ ~~~ % / ~ / ~. / / dr P~opose.d u~`U j % proposed wccur' % ~ C.onC~e~C w l~s i / ~ ~~ ~- ~ ei~ i / / / z" r~~. S!„sc/i. y0A/.C.6a,ldin ~ /~ erxa~n F.eds Stu~cr ~v Lu;nsu:/a~ / / / "~{.S.T,wI. - Q S (JLi L'o.nut. 8,2, 30(ll)(q),Z(; / % , p j e/' ~~ ~ % ~ ~ o h , ~ _ ~ a / v~ M ~~ C~p~ of ~~o '~O\ na/~c5~ e~ 32"r 7S'' Cka,,, ,6.c.-~ per t~~ c.+t . ~ ~ ~vF d v c Vu c ~' . v / Q , / v! ~a~' a' .~-- /67~ 3~~tt i ~oR . ~d' ~ L~\ 1 vL~'1L Wla. ~ T o{' I %L„ ./,C. pi/~Q. SSurnC- etew = iAo,w: i i i i i i I u ~ ~ ~ ~ 8a ~ ---- 1 j Pia ~ SL 1 I ~c t I I I / I ~„sue, voR/,c.bk,~d,-,~ J Q S /.ILr Q...,...u o e ?N..\/. \ sad / /s. Top of Elm . q9 ~o; LLt 7c., v. ~......,.~ ~----r ...~ . - - l.~sihq ~z s~o.,dare,Ci~o~;~ustr ~foC,k C'.~tQ~n~,y.e~-~~oer'tltn~. • .Cacafed ~Ora~O. Spa --- &~~d~ o~Fdes~~a dra; .,a~ a rtq. So,(eda /ua~6 ~~~oi 6 cn/c.: / = f~O Stye e~ Dose Tank Information Electrical as per NEC 300 and -- Comm 16.28 WAC Disconnect ~- Tank component is properly vented Wieser Concrete Manufadurer _~ Ca it 950.00 Gallons Volum 25.00 gal/inch A Dimension In s Gallons A 19. 478.04 B 2.00 50.00 C 4.88 1.96 D 12.00 30 0 Total 38.00 950.0 ~ 3" Be Alarm Manuafadurer LevelArm Alarm Model Number DLV Pump Manufadurer Goulds Pump Model Number EPO4 Pump Must Deliver ®.c~O Project: David & Kathleen LaBeause 5~ B C D at ~3.~5 ~' Dose Conventional Locking cover with warning label and locking device and seated watertight 4 in. min. F- Aftemate outlet location ~ Forcemain in. eep hole or anti- siphon device P• ump off elevation (ft) 85.00 . Dose tank elevation (ft} 84.00 4 of 9 x ~ ~ i:~ 'F ~~ e ~k "E ti Y t ~ . ~ ~ ` ~ ..f + S \ ..\ 3 } ~, 3 ~a ~ b ~ i f4 ~~j `a .a a '.~ Pump Specifications '/3 H P ~^~ Up to 40 GPM ` ~ Discharge size 1Yd' NPT Solids: 3/e" maximum Motor Single phase: 115V Materials of Construction Brass/thermoplastic Features and Benefits •Top auction eliminates i!npelle~~,logging. aCorrosion resistant construction. +F!oat actuated sv~!itch. METERS BEET .5 _ -- -- ------ ----- , - ' ~ MODEL DUPO3 z~ ,~ .I - - -~ a = ~ ~ ' `f - 1 ~' f ~ _ o~ ~~ _ - _~~__--,s z", - _ _ _ _ - 0 25 3J 3~~ 4l S GPM _ ~ __L _ __ 0 2 4 8 t tO nl'mr __ _ _ CAPAi;ITY _`_ METER, FECT r _ _ ,._- ~~I ---- ,- --,---------- - _ ' - Y ! . MODEL. 3871 _ ____ ' ! b _ 1 t-- - --- - - _ z~-~--- -~-- --- --- - -~- l -- r i - - -_ - ~- I ~ o u - - - -- a ~ -t -- --r- - , - ~ - --- I 4 I - 1- -- ~ _ _ cAPACIrv 37. Sb g.o...~. P p Spe ' ~vations Features and Benefits o anti "~ HP • EF'0~ impeller- semi-ope~~ design p to 6C GPP:~ vl~it~~ rump out vanes to aiotect Nlaximur hear ~0 32 me~~!~ani~~al seal. Discharge size 1'/~' NP - • EP05 impeller -encloser design Solids: 3.-0' ~r~.x~r-u~rn ~~ ilrproved perfonnarn,e. Motor • Ru- ~d class-filled thernuTpiastic A ; n~o crs to ~t Ira bai a~;r~ ~ ~ base des~~gn i~r w~:J~ bt,ar n: ;Iris n cn~sn ~ t ennc r ~: yth and ccn gs~cr S~'1~]!e J la:~P ~ ~'~~~ 'd~53nCd. ~ IVlaterias o1 i;cr structlon ' Est iron rnutor h ~ ng for . st irul C<~ ?t1i~~rnt heat transfer. rgth. , 1-her~nloi~lasti~ a~i~:: l arability. Stainle~~~~ steel • ~~o~rosior resistant threaded sr~i~ less s~eel shaft. • Availab~~~e f;~r autol~a~.ic a~~ii rl~~n~lal oaeratidn. • ~~~t± !steel models a~~ailab~e. A;l P/lodels are designea nor conrinuou5 operation a~'c! fea%u~T~ sta;nless steel hr,rdware. LaBeause 5 bedroom Dose Conventional Pump Chamber Calculations 1. Force Main Diameter 2" Length 75' Flow rate 48.00 gal./min. Friction loss 3.75' (75')(4.99ft./100ft.) = 3.7425 ft. 2. Total $I~namic head: Min. pply pressure 0.00' Vertic 'ft 10.00' friction l0 3.75' Total d ead = 13.75' 3. Pump selection: Manufacturer: Goulds Model number: 3871 EP04 Pump will discharge approx. 3 . 4. Dose chamber: Manufacturer & capacity: liquid depth: Sizing: A) One day holding cap B) Alarm setting: C) Dose volume + flow (SOOgaI.)(20% D D) Reserve storage: 13.75' TDH 20.00" = 500.00 al. 2.00" = 50.00 gal. Eck: 4.00" = 100.00 gal. flow) +(.164)(75') = 112.30 gal. 12.00" = 300.00 gal. TOTAL 38.0" = 950.00 gal. Dose Conventional POWTS Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10567-P (8.6/99). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank ® The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. Th outlet filte shall be cleaned as neces t .The filter cartridge should not be removed unless provisions are ma a to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Aa~ss openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Depamnent of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface within the system and will promote frost penetration during cold weather months. Cold weather installations (October- February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BODS, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing biologically clogged adsorption and dispersal media and replacing said components as deemed. necessary or by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the master plumber in charge of the system installation or your county zoning inspector. artment of Commerce ` PRIVATE SEWAGE SYSTEM Safi gilding 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: Midwest E uities City Village X Township Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION County. St. CrDIX Sanitary Permit No: 430384 0 State Plan ID No: Parcel Tax No: 018-1094-12-000 Section/Town/Range/Map No: 17.29.17.752 ELEVATION DATA STATION Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM 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: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Svstems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No ~ f Yes ' No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: ! / Location: 982 117th Street Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 12 Parcel No: 17.29.17.752 1.) Alt BM Description = _ 2.) Bldg sewer length = - amount of cover = Plan revision Required? U Yes ~ No Use other side for additional information. _~ ~ _ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. ' Safety and Buildings Division County ,~ .,, 201 W. Washington Ave., P,O. Box 7162 7( ~~ SCOOSIO Madison, WI 33707 - 7162 Saaitpry 8ormit Nutttbar (W be tU-ed (a by Co.) De artment of Commerce (~$) 266-3151 ?,~'' Sanitary Permit Applica ' S~"° F'"'~'~' N"'~' ' In accord with Comm 83.21, Wis, Adm. Code, personal infer tion y~ ~yvLtt~`~ ~ ~ , ~ ~ tna be used f r cond r r P i L l U4 1 ~ rli ' If dlff h dd y pu poses y o se a r vacy aw, s ( )(m) an ma ng a ress] ect ( orant t 1. Application Ltformation -Please Print All Information S E t' ~ ~ 203 , Property Owner's Na me S 7. Gll(}IX L ~ OUrJ i , ~ ZONIN P l X Loth Block N ) - G OFFrCE ^ Property Owner's M ail'ng ress Property LoadOn Q cti u lf u S Cit St t Zi , , o o ~- y, a e p Code Phone Number j- (circle ) u ~ _B , N; R„ T II. ype of Building (check all that apply) 1 or 2 Family Dwelling -Number of Bedrooms ,~ j Subdivbion None CSAt'NolrJ~r ^ PubliclComm vial -Describe Use ^ State Owned - ribe Use Z t ~~ TZ - '^City_^ViU Owaahip of III. Type oP Permlt: eck only one box on line A. omplete line B if a livable) v ( - 0 9 - il: A' ~ New System eplacement System ^''Preaunrnt/Nolding T RcplacotnetU Only ^ Otb~hlodlfkatbn W yatem B. ^ Permit Renewal ^ Perm evasion ^ Change of Permit T Hafer L' Prevlow P t Nttmbe D ued Before Bxpiration Plumber Owner IV. T e of POWTS S stem: (Check n at a l) Non -Pressurized !n-Ground ^ Mound > , of suiwble soil Mound < 24 in. suitable P and PUter ^ Constructed Wetland ^ Pressurized In•Ground Holding T ^ Peat Filter ^ Aoroblo T Nt Sead FUter ^ Recirculatin S nthetic Media Palter ^ Leachln C be Dri Lino ^ Gravel-less Pi ^ V. Dis ersai/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) rsal Area Requi~ (sf) Dispersal Aroa P~posod (sf) ya Bleva VI. 'l'ank Info Capacity in Total Nut r ~ . Manufacturer Prefab Site ~ 'ber plastic Gallons Gallons of nits Concrete lea New Existing Tanks Tanks Septlc or Holding Tank • Aerobic Treatment Unit Dosing Chambrr VII. Res nsibility Statement- 1, the undersl ~ d ;usuutc respousibiUty fvr btstaUatior{ o POWTS t:bgwn pA the attavbed Plum r' a e (P ' ) Plum MP/MPRS Numbe BWhtata Phoao Number ' ~ ~ ,~ i S Plu tier's Addre ss (Street, Ci y, State, Zip C { .q t ~ ' ;'~ . VIII. Count /De artment Use Onl ~,Approvpd ^ Disapproved Sanitary Prrmit Pee (Includes Oroundwator $UlChargC FCC) - Dato issued Agent Sl (No Stamps) - ^ Owner Given Reason Dental ~ ~~ ~ , IX. Conditions of Approval/Reaso or Disapproval . , ~ , ,,, ~' ~, ~ .~ ~ SYSTEM QWId~R: 3~ =ee ~ ' ~ ~N_ "; ~ t .. ~ ~~ 1 Septic tank,. eifiluent fit rand ~"/j'~ n ~"':'J ~ ~"'--'-' dispersal Belk must. all servic ~ G aX~tr<+e~ .~ ~~ ~ • as per management tt prpurded by plumber. Cs~ 2. All setback requirements Fllllg~ ~@ ~lfl~~~~ as per applicable code%rdlnsfl0®6. ...__~ _ ...wp..,. y..w {w wo wuntr vnir/ wr IW qf{w VO p11p•r YV{ NN {aa0 iiR; is IOCON M We SBD-6398 (R. 01/03) ~ ''' i ~ ~ 1 _ ~~ - _ _ __ 3ar,~g~ ~t~~_ , ._ _ ~ p ~ ~~ ! ~-y-~ / s.i~,~~ _ -- - __ ~~_ ~ ~ _'~ ____ ~~s ~a ;N : ~s ~ ._ _ _ _ ~ __ _. '. O~~ ~k..J __ ~o Ei{/6i / .0 ~~ ~,COPBFf~' 4~ ` ~ . ~ _ ~_. . ~u ~' 3 ~I~ ~ _ ~~ /. _ _ _ f ~~ ,~ 1; .. 1 s _ _ __ .. o' - ~_ - ___ _ ~~ ~ f ~- _ ~ . __ ~ _ .. . -, • Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT ~ ~ ~u P Page / of ......,..,,.....,,.,,, ..,,,, ,,,,,,,,,, ,,,,, ,,,~. r..., .,.,,.~ County ~-~ C r01 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must , 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 information. Re ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ 2 ~" Property Owner Property Location Govt. Lot ,Uw 1 /4 Aj~ 1 /4 S / ~- T Z % N R / ~ E (or~ Property Owner's Mailing Address Lot # Block # S bd. Name or CSM# q~G /~~ s~ 12 ~il I~ n City State Zip Code Phone Number ^ City ^ Village ®Town Nearest Road // /~lN+VY~a~ W( $-yo/S (7/S) 79G~ Z~9 ~~Hranc/ /GG~a ~GY . [~ New Construction Use: [~' Residential /Number of bedrooms 3 _y Code derived design flow rate °/SG/GO G GPD ^ Replacement ^ Public or commercial -Describe: Parent material Ti ~ ~~ Flood Plain elevation if app-icable /~/ .`,= ft. General comments ('`/5~~ .P~,~V~ rOr/(j,s.fU L.o~,,~.e,~ ~/S• Zo '~°_" and recommendations: T .~ ~ ~; ' ~ . N.,. ~,''~ \ a C' a,~;rKr i3r'~'CE .~,.~ 1 Boring # ^ Boring // ~. Pit Ground surface elev. 9~ r7 ft. Depth to limiting factor <Q~ in. `•• ._____ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I 1~ Z ~-- S i l rr~r ~ 5 I ~' • 5 • g ~ 4~-y.g r y --- s~ k ~5 - 5 9 3 l ~ l(n - ms ~ I - - -1 ~ ~ Z •~v~qS. ~ 2 Boring Boring # ® Pit Ground surface elev. T ~~ ~ ft. Depth to limiting factor /D~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~ -cc~ r s~ I ~s ( • ~' z - s~. cs -~ 5 9 3 I 4l r~ S ~ I - -- /. 2 .~ * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 _< 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Ple se Print) Signature CST Number ~~1-~m ~ehurrnker- ~ - Z ~ 339 Address '' Date Evaluation Conducted Telephone Number ?113 b'U~-`' ~~. ~pmer~, lt`11 ~~l6ZS ~~-ZB-a/ ~1i5)Z~/7- ~ac~~ 3 SBD-8330 (R07/00) Property Owner ~G(~ Ins Parcel ID # Page ~ of 3 Boring # ^ Boring ~ Pit Ground surface elev. 9~ia ft. Depth to limiting factor ~~~ U in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 2 - =~ s k ~ ~5 - .5 9 3 --I~ I I ! m5 O 1 _ . Z ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 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 Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 'Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) PAGE~OF 3 ~TA_I~IE ~-~uc.J k-,' ~t S LOT# ~Z LEGAL DESCRIPTION Nw ~ A/ la ,S ! ~ T La N R. l ~ E(or~ SCALE: 1"= y~ , BM 1 ELEVATION ldG • O BM 1 DESCRIPTION -(~ p o•~ ; " /c. P~P-e BM 2 ELEVATION 9q• ~--c~ BM 2 DESCRIPTION ~c, p 6-~ ~y ~~PUC, P ~'~ SYSTEM ELEVATION ~ p 9S fJo CU4. « ~S, Z o ALTERNATE ELEVATION.~oP 9~/. so ~~ 9S ~ 6 CONTOUR ELEVATION 99• U ~ ~- In ~ • o N _ ®•-~- CPC • / ~ ~ ~~~ ~a SIGNATURE ..~ .1: ~ DATE / z-/ Z - o/ I . POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~ FILE INFORMATION Owner. - _ _ _- ~s c Permit O DESIGN PARAMETERS Number of Bedrooms ~ O NA Number of Public Facility Units NA Estimated flow (average) al/da Design flow (peak-, (Estimated x 1.5) ~ d al/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent duality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ys in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al O NA Septic Tank Manufacturer - ~ S ^ NA Effluent Filter Manufacturer O NA Effluent Filter Model ^ NA Pump Tank Capacity. al ~NA Pump Tank Manufacturer 1?NA Pump Manufacturer ,~. NA Pump Model ~ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Fiker ^ Wetland ^ Other. ^ NA Dispersal Cell(s) ~In-Ground (gravity) O At-Grade _ ^ Drip-Line ^ NA ^ In-Ground (pressurized( ^ Mound ^ Other; Other: s ~ O NA Other. O NA Other: ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ monthlal (Maximum 3 years) earls( ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal ce(lls) At least once every: ^ month(s) I;Maxlmum 3 years) earls( ^ NA Clean effluent filter At least once every: O month(s); ~ ear(s) O NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ANA Flush laterals and pressure test At least once every: ^ month(s) ^ year(s) ~A Other: At least once every: ^ month(s) ^ earls( ,(ANA Other. ,y , O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septaga 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 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 snd 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. CiMW (4/01) `' Pago ,~, of ~ , START UP AND OPERATION For new construction, prior to use of the POWTS check treatment rankle) 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 deteoted have the contents of the tanklsl 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 CONTINQENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must.. be taken, _t4. provide a Dods compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ~ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances. in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. O 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. < <WARNIN(3> > 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 INSTALLED Name , ~ ~® Phone ~ ~ - _ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~ ~• Phone Phone This document was drafted in compliance with chapter Comm 83.221211blltlldl&Ifl and 83.64111, 121 & 131, Wisconsin Adminlatratlvs Code. owner/Buyer Mailing Addrt E'roporly Address ~~~~~ (Vcrifrcation required from Planning Department for new City/State LL2'~'~ 1"~ Parcel Identification Number,? "^ / B/PU~ LrGAI, DrscR>rr. TON Property Location ~.'/4, ~~.. `/,, Sec. J7 • T~N-R..,L~W, Town of ,~~~2~Z~n=~-- Subdivision / ~xi1, ~,'~ ~LA'i/ .Lot #s` ~. Certified Survey h'Iap # ~~~ , Volume ..__ .Page ## Warranty Deed # ,Z~,~~7 ~~ . Volume ~~-~ .Page ## c~ a-- Spec house D yes no Lot lines idetitifiable~yes D no SYS'T)EN1! MAINTENANCE Improper use and maintenance of your septic system could resul t in its prcttiature failure to Itandle wastes. Proper utainteaance consists of pumping out the septic tattle every tltrec years or sooner, if ,needed Uy a licensed pumper. What you put into the system can affect the function of the septic tank as a treattticnt stage in the waste disposal systettt. The property owner agues to sabrtut to St. Croix Zoni++g Department a ccrtifrc;atiou form, signed by the owner and by a ntast~rplumber, journeyman plumber, restrictcdplumber or a liccttsed pumperverifyivg that (1) the on-site wastcwaterdispvsal system is in proper operating condition aud/or (Z) a[icr inspection and pumping (if rtcccssary), ilte septic tank is less than 1/3 full of sludge. Uwc, the undersigned Itavc read the above requirerneuts and agree to maintain the private sewage disposal system with the standards set forih, herein, ns set by the Departntcttt of Conttncrcc and ilte Dcpartuterti of Natural Resources, State of'Wisconsin_ Certification stating that your septic system itas been maiutaiucd umst be contplcted and rcturrtcd to the St. Croix County Zoning Otficc witlrin 30 days of tIt three year expiration date. ~~~~ DATl; SIG ATURI3 r APPLICANT ~JWNI~R CrRTIIf+ICA'I'I:ON 1 (we) certify chat all statcrne+tts on this form are into to the best of any (our) knowledge. I (we) atn (arc) the owner(s) of the property described above, by virtue of a warranty tlecd recorded itt Register of Deeds Office. NATU Or APPLICANT ~/ DATE Any information that is mis-re~rese+~tcd tuay result in the sanitary permit Ucing revoked by the Zoning Departnacnt. *"`~`*"* •+a**• "`* Include with thls applicattott: a stamped wananty decd from it+e lt.cgistcr of Deeds office n copy of Qte cct~iificd survey male if reference is made in the warranty deed .. ST CYrOII~C Ct)gJiV'1 Y SL~PTIC TANK MAINTENANCE AGREE~NT .AND OWNI;RSIIIP CERTIFICATION FOTtM s s I ,J I J / I I SHEET I l ~ I I i 03" W 91 I. 86 200.32' --- ~ ~ ~ v \ 116.35'----+r 111.8~~ ----- ------- --..~`,bb,6,/eb,~~. \ h F~ • ~ S29° 56' 20' W ................... ........ .......~',~,..Q'~., ......8.38'_....... \ \ ® r r, ''• . F,rr rya ~ •~ ~ ~. cry ~ '' ~~diV ~`''g2s y' ~~• ~ ~. o \ .• w J ~ ~ ~ Q ° , ~~- 00 a. -.. - L N W O ` ~ ~ N Z... -229 47' z'M.b~ ~ 9Z'j' .~,.._---------- - st . -- ~ i°zzs' W ~- - ~ ~°`~ AREA M ;og °a' ° rn a' 03" E g 927. 12' ° ~ ~ Z 22 T. 89' 213. 58' 313. 48' __ ----' 129. 98' '` _ - ,~~~ N 35 T. 88' •. .~~ ~ '~. si r .ti, ~ '•. lei .~ ~ -C, .~.,.r . ~~ ~ 'f' ~` e~ ~ ~L r~•, ~ ,~ H: '•. r. ~ ~ o ~. tig V ~' ~~' ~. oNi o O ~ Q ~ g •,~ N ~ ` g '~, y 0 ~~~~, -gym '~ '~ ~ ~ o •, ., ~ ~' ~ a '~ `~ 1 ~ ~ ~ ,`~ ,, F ~ N ~ . , ~ ~ ~ 43 9 r,. , ~ ~~ A ~\ ~N a ~o a. Z Q dG 1'~ ~ ' W\ ~~ (~\ r- e- ~ ~ ~,, •~'~ ~c rW Z O ...,J ~` DOCUMENT NUMBER ~~ ~ 'J 2252P 3y0 WARRANTY D&ED William E. Hawkins, Grantor, conveys and warrants to Midwest E~++• ~ Q, LLC, Grantee, the following described real estate in St. Croix County, State of Wisconsin: Lots L, 3," 6, 10, 11, 12 13, 17, 18, 19, 22, 27, 30, 35, lA and 3A, Prairie Run, Town of Ha. NAME ND RET RN ADDRESS / 4 ~.~~ n ~~ Sao ~-- 18-1037-10-000; 18-1036-90-000 18-1036-80-000; 18-1036-70-050 Parcel Identification Number This is not homestead property. Exception to warranties: All easements, restrictions and rights-of-way of record, if any. Dated this S 3 day of May, 2003. (SEAL) William E. Hawkins (SEAL) AUTH&NTZCATZON Signature(s) authenticated this day of 2003 (Siannturel (Name Printed or 7YDed1 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by X706.06, Wis. Stats.) THIS INSTRUt~NT WAS DRAFTED BY: Leo A. Seskar Rodli, Beskar, Boles s Krueger, S.C. P.O. Box 138 River Falls, wI 59022 7 2 2 7 5 1 KATHLEEN H. 1iALSH REGISTER OF DEEDS ST. CROIX CO. , 1iI RECEIVED FOR RECORD 05!23/2003 02:20PM 1tARRAHTY DEED EXEMPT # REC FEE: 11.00 TRANS FEE: 594.00 COPY FEE: CC FEE: PAGES: 1 AClQdOWI,EDG7~NT (SEAL) (SEAL) STATE OF WISCONSIN ) ss. COUNTY ) `J ~ o' •+1 J , ^^~~~~ v . Personally came before me this~LJ `.:8~}rt3~•~M~p, x903 the above named William E. Hawkins' :' t Y to me known to be the persons(s) whO•er~duhe r foreq in instrum t and acknowledc~e;~ j4.,s~ne.p~ v'. V ~ M f ,}- Si nature * <' ~ 7 ~V '. Name {{,,r' `6d or T ed Notary Public "~~ . ~o~in~y, 'Wis. My commission is permanent. (If not, expiration date:) ~r ~~ a~a~ ~ I Cv ~ w _ .--~- O I O i ~..! / J I 6 s' I I / 1 I SHEET I _,_.. I I ~ -=------- ~'~ , ~<v _ _ _ _ -- - -- so --- ~ R p o ~ `'~ / 3 W 911.86 ~ ~ ~ ~ 116.35'----~ i1:4~; ---- 200.32-------•----~-` ,6,/ ,~. ~ - o - -- 227. 89"~a•., a 's~;'~.. s2s° 5s' 20" w ® ~ as .~ •szN ~, ~ .... .....'.~ ~,~ ...... a. 59, _ ........................ ~ ~ ~ ~ ~.~ os ~ ,: .~ ~ .. ~ ~ art O ~~ ~w ~\ ~w ,~• w U c~ 0 • w J t~}} ~ _ N ~ O O . ~ ~ g0T - au • o~ 2"- I -229.47 ~ '~.by1 '9Z~•~, _ et -- a o ~; N AREA ~ jog °D ~ ~ _ ,~ ~ -. g ~ Z 03"E 927.12' 215.58' ° 227. 89' ~-.. _ ---- 129.89' '•` ~ 3 f 3. 48' ` O " -- •~~ 7.88' '•, a J ,, .tip ~ ~ d~ti ~1. ~ •.~.r~ °~~~,~'•., `fib 0~ I~ ~ ~~e ti~~ eN ~ / U ONi ~O L Q M i~~` ~~~ ~ (7 '` h ~ p' ~ ph ~~~, Nd~ ~ ~ J N _' ~ `A - ~ ~ ®~ \~• ~ ~- .~ e-~ ~ ~ Vim' LV o v J y ```•• - / Monica Lucht ~ ~- ~~~ ' ~ ~` ~~~ Subject: #430384 Kim O./Midwest Equities LLC -- L~ ~~ ~~~ ~{ ~-i ~` Location: T of Hammond, Lot 12, Prairie Run Start: Mon 8/9/2004 2:30 PM End: Mon 8/9/2004 4:00 PM Recurrence: (none) a O h ~ o~ a 0 N N d kr '~ •~ O N V •~ O V `iii W Z ~' ~ Z ~ z c (7 O Z '~ ~ ~ m Z v vi f- .- c a~ .c m a a g (q ~ U d GC w C ~I .~ c~ r~ .:. d L O y C O ~ N ~ ~ ~ n c rn ~ o o E ~ N E f6 O ~ _ a a ~ L C v a ~ A I 3 0 3 0 3 0 I O~ O~ I O~ I I ~ I ~ I ~ I ~ I I cco I ; I I E I o. 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