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018-1098-17-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide m~ be Used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: Itoh, Steve 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 Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 429939 0 State Plan ID No: Parcel Tax No: 018-1098-17-000 Section/Town/Range/Map No: 30.29.17.824 STATION ~S I HI I FS I ELEV. Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH 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 Svstems Onlv zx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No C Yes ~; No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1520 76th Avenue Hammond, WI 54015 (SW 1/4 NW 1/4 30 T29N R17W) Emerald Acres Lot 17 Parcel No: 30.29.17.824 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = r - --- I Plan revision Required? ~ Yes ^ No ~ ; i; Use other side for additional information. I~___ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No --- Safety and Buildings Division ~~ County J /1 ~ ~ 201 W. Washington Ave., P.O. Box 7162. T• l +~-a L - ~~~O~~,~ Madison, WI 53707 - 7162 Sanitary PetTrtit Number (to be failed m by Co") w (608) 266-3151 ~ Z9 -/ 3 Deparftment of Commerce State PIanLA. Number Sanitary Permit Application 8~3~~`f = ¢~,,r:s~,n s Tom. i In accord with Cotnm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law,s,hSA4(11(m) ~`~-`--, Project Address (if different than mailing address) ~~~ 1 I. Application Information -Please Print All Information ' ' SZ.c7 '~ -' ~~ . _. ~- , -- ,1 ^ ' Parcel # Lot # Block # Property Owner's Na me i Property Owner's M ailing Address __ ,.... - "-• --- Property Location ~ 1 g+ 1 O~ g ~ 11 ) City, Stat Zip Code / Phone Number ! ~ C, ~j C".~f T ~ / N; R~cE o~} ~ O ~ 1 II. Type Qf.~uil ng (check all that apply) ~ Subdivision Name CSM Number 1 or 2 Family Dwelling -Number of Bedrooms ^ Public/Commercial -Describe Use _ - _nn p ~ C~ - ~D X ~ ~ `~ ^Ciry_^Village ownship of I ^ State Owned -Describe Use I III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A" ew System ^ Replacement System ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System List Previous Permit Number and Date Issued B. ^ Permit Renew Permit Revision ^ Chanee of ^ Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) ^ Single Pass Sand Filter of suitable soil At-Grade und < 24 in ^ M . o ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil Tank ^ Peat Filter ^ Aerobic ldin ^ H Treatment Unit ^ Recirculating Sand Filter g o ^ Constructed Wetland ~~ Pressurized In-Ground ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Information: S stem levation Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf? y ~c r . Tank Info Capacity in Total Number Manufacturer 5•:eel Fiber Plastic Prefab Site Concrete Constructed Glass Gallons Gallons of Uniu New Existing ~ ~ "tanks Tanks Septic or Holding Tank V I ~ I l~ ,4erobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersi d, assume responsibility for installation of the POWTS shown on thBusinesh PhonenNumber ~ Plumber's Na me (Print} Plumber' i gnature MPiMPRS Number ~ ~~ ~ ~Q 7 ~~~- Z 6P~~ l~ ~~ Plumber's Addre ss (Street, City, State, Z e) / I,rJJ ~ ~ s~17~ ~' - ,u ~ ~ , VII .Count /De artment Use Only Satutary Permit Fe (includes Groundwater Date Issued Issui Ag6nt Signature (N Stamps) ~ppioved ^ Disapproved Surcharge Fee) J ~ ~ .~ ~ 0 2. ^ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval ~ i a1Q 4 Q~ ~ ~~ .. . Attach complete plans (to the County Drily) for the system on paper not less than 8>ra x >.i """° "' "" ~ ~ is~ons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-7831 TDD #: (608) 2648777 www.commerce.state.vri. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary July o8, 2003 CUST ID No. 226900 SHAUN R BIRD BIRD PLUMBING, INC 1008 192 ND AVE NEW RICHMOND WI 54017 ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/08/2005 SITE: Steve Itoh Town of Hammond, St Croix County SW 1/4, NW 1/4, 530, T29N, R17W Idescation Nuritbers ~° Transaction ID No. 883744 Site ID No. 658198 Please refer to both. identification numbers,' '' above, in, all correspondence with the a ''en FOR: Description: Three Bedroom At-grade System Object Type: POWT System Regulated Object ID No.: 900421 Revision to Transaction Number 862439 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the septic tank outlet filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. • Note corrections on plans by reviewer A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~~ oy G. sky, W tewater p cialist (715) 726-2544 Voice (715) 726-2549 Fax ljansky@cammerce. state.wi.us Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 WiS1v1ART code: 7b33 .~ Cover Page x;:,$$3"744 Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 P.O.Vg/.T.S. Cofat~~tiOI~CCI'dy v DEPAR7f~(E?~T OF COtv1MERCE DI IOtJ OF SAFETY AND BUILDINGS ~~c ~~ ~~~F s,~ "z~ , a FFj y ~~~~ ~ B~0 ~soi~ CORRECTION NEEDED Date: 6/18/03 SEE CORRESPONDENCE SEE RRESP DENCE Owner: Steve Itoh Location: SW1/4 NW 1/4 S30 T29 N,R17 W Lot 17 Emerald Acres Hammond System type: At-Gradl: Manuals Used: At-Grade Component Manual version 1.0 SBD 10570-P (R.6/99) SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST- SAS (01.81) Page# 1. Cover Page 2. At-Grade Plot Plan 3. At-Grade Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7-9. Maintance and Contigency plan 10-12 Soil test Shaun Bin Signature License n~ PLOT PLAN PROJECT Steve Itoh ADDRESS 9112 91st. Cottage Grove Mn 55016 SW 1 / 4 NI1N ~ /4 S `30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE6/18/03 BEDROOM 3 CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of chambers none ,BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.3' 76th Ave Scale = 1 /4" = 10' Well is to meet all setbacks found in Comm. 83 Pro 3 Bedroom House Property Line B.M. 'Alt. B.M. 98'~ 96.3' 96' Tank is to be properly bedded and provided with lockdown covers with approved warning labels Huffcutt Combo Grading is to be done to divert run-off away from system Property Line >300' ` B- B-2 g 4 , /B - 1 1 polo Area 15' below Slope system is to remain undisturbed ~~~ u` ~~ ~a ~~ .._~ ~ s !~ > ~t ~` .~.._ ? 5` /~~ ~~- A L__-~ B = ~ ~~. L =~ ~ ~~ ~~ ~ ~ ~_ ~t . 1 # - w ____ ~ J .~ ATf,.RAL "'~ STA84t_tg,£D O$~°~ `~RTtari ~EL~ y ___ .~- O ~` ~~- r` _ ~ _ - - ' i/68 ~ ~f~ 118 f ~_.___- ~i*` Z IZi ACzGR~..C~~FE GE~-~ o~ ~t P Q iLbit E D S'Y t~Ti~E~t~. ~"Ct ~? C +~ 5-~~B~~i~~a Qaserva~ic~n------,.._ thle ~ ! ,,~ .. >_ 5` _ ~ - ~ /'~ ~~, SLbg~ ~istrsbu~+os~ Lateral ~~,~~ Cover ~" ~ .. ~\ ~ f ~~ > ' 2 i --- ~ Wisconsin Ar~~rade Urtic wiCh a .^.ross Section of Plan View and SIo it Site Sin~,1e Absorptzvn Area on a ~ g .~'"" ,. r ,. ~'-T UtRt~ - ,~ Pte'` --- --- - __~ C._,, ti ~ r•I A T u ft E.. 1OTFl_ DYNArssi HEAD/CAFAi;I(Y G`;~ Iv1i'vU?~ EFFLUENT ~' ~D uENdAI EKING D s 0 ~-- nfOULL I i I_I i 1:~3 ._--~_ __ Mctzrs ~ C3L~ i ! i~ f- ~ rLiier -__- gal -r i I ~ i i`.: rs . , ~e - ~ --, ---- ; 5 ~ 1.~ i 6~ I -r- ._ ! 20l ! - ,- ~I ...-- ----~ , ., i I Lei -h--~1 +~ I -~ -{------T-~ _.__ iv .j E.l ~ -r ~ - ~ iu~ :~~ loJi ~ ~ ---t--- - - - -- - ~- r i--- ---r--...-_ -l- _ ._ 1._ -.` -- -.- ._-~---~,. ~ ~. I ~.,.~ - ~ - i2 i 3.; _. -___~___ a., ~ t2% I -- 'T ~ -- ~ t1 I 4 I ~~_ _ Lail. Jaive i ~,:~ ( __- -I a - -- -_-- -- _ I (1'_6rn)Ih" D ft._~_3.4m).. 0 CONSULT FACTORY FOR SPECIAL APPLICATIONS • Timed dosing panels available. `" - Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable !eve! long and short cycle controls. • Sealed Owik-Box available for outdoor installations. See FM1420. • Over 130°F. (54°C.) special quotation required. 151J153 Series 152!153 MODELS ~ - Control Selectio~~l ~_ Model ~ Volts-Ph Mode I Amps --- Sim~Iex _ - _ Duplex- ~I IJ152 T115 1 ~ Non 8 5 ~ t ~ 2 or 3~ BN1521 115 1 i Auto 8.5 Included I 2 or 3 T 1 Non 1 4 3 1 2or3 E752 2 30 . BE152 230 1 Auto 4.3 Included 2or3 _ N153 tt5 1 Non I 1(i.5 t0 5 t Included 2or3 2 or 3 BNt53 115 t Auto I E153 230 1 Non 5.3 1 I 2or 3~ BEt 53 1230 1 Awo j ~_5 3 Included i 2 or 3 D CAUTION All installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes should 6e followed including the most recent Nationa(EleCtric Code (NEC) and the Occupational Safety and Health Act (OSHA). r. -~ I -- -, /~~ ~ ~, ~ ~; ~~ `'. ~,~ ~~ ~., „ r ~;-i 12 1/ i Iii i i _1-- SELECTION GUIDE t/c I _ _ ~_ snzosa 1. Single piggyback variable level flo2_ switch or double piggybackvariable!eve! float switch. Refer to FM0477. 2. See FM0712 for correct model of =tectrical Alternator E-Pak. 3. Variable level control switch 10-0«~ used as a control activator, specify duplex (3) or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. _,.rTr-,~.T MAIL TO: P.O. BOX 16347 i -~ ~:~ `~'~ Louisville. KY 40256-0347 Manuracturersof. . ~ SH1P T0: 3649 Cane ftun Road ,:~ ~ 11~~~ Loursviue KY 4o21t-tsst Q/ra/7rr~~Mas S,vcE /9,99" D ~~ ~l \ ~ (502) 778-2731.1 (800) 928-PUMP http://www.zoeller.com ~ %PUMP !O. FAX (502J 774-3624 © Copyright 2000 Zoeller Co. All rights reserved. Maintenance and Contingency Plan for a At-grade System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Dose Chamber is to be pumped at the same time as the septic tank. 3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 4. Once every 3 years the mound is to be inspected via the inspections pipes in the at- grade. The laterals are to be inspected via the cleanouts. 5.Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 6. Pump and electrical components are to be checked at the time of the pumping. 7. Owner agrees to leave the area 15' below at-grade undisturbed. 8. The owner agrees to save this plan. 9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is not be driven over. 10. Effluent Quality is not to excede the requirements found in Comm. 83 Contingency Plan 1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if needed, then bypass pump float and try pump with out float. If this works, float is bad, replace float. If pump still does not work, check power at the pump with a electrical device such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is power, then pump is bad and needs to be replaced by a plumber. 2. If at-grade fails, determine cause of failure, test another area or remove pipe and sewer rock, retill soil, install new mound system. 3. Replace any other failing components as needed. Important Phone Numbers Plumber: Shaun Bird 715-246-4516 Pumper: Tom Mondor 715-246-5148 St. Croix County Zoning 715-386-4680 MAINTENANCE INSTRUCTIONS n one ~~ u"' •~..~--- ns of tanks and dispersal cells shall be made by an individual carrys 9 clot POINTS Maintainer, Septage lnspecUo t+llaster Plumber Restricted Sewer: POWTS Inspe to identify any missing or broken cerbrf~tions. Master Plumber: Servicng Operator- Tank inspections must include a visual inspection of the tank(s) ~ to check the effluent levels cracks or leaks, measure the volume of combined sludge and scan' and to check for any back up hardware, identify any The dispersal cell(s) shat( be visually inspect a ponding of effluent on the or ponding of effluent on the ground surface. of effluent on the ground surface- authority- nding ulatory in the observation pipes and to check for any Po wires the immediate notification of the local reg ground surface may indscate a failing condition and rec{ uals one-thud (Y) or more of the tank volume, the e and scum in any tank eQ erator and disposed of in accordance vrnth ch- NR When t#re combined accumulation of sludg a Se ~ e Servicing Op entire contents of the tank shall be removed by " p g , vents, and any 113, Wisconsin Administrative Code. onents, pretteaagment compo r;ormed by a certif-ed POWTS Maintainer. Tile serviGng of effluent filters, machae ~~ °op12 ~o th$ o~~ S ~i be ~ -on of any sennce event. other maintenance or monitoring ufatory authority witfisn 10 days of compfeti A servsce report shall be provsded to the local reg ~ for the p: esence of painting products or other STARTUP ANO OPERATION if hi h cencentrations are For new construction, prior to use of the POWTS deck treatment tanks, chemicals that may impede the treatment process bndlos P~9e see ~~g operato l(pn?or to ugse. detected have the contents of me tank(s) ANT PEJaN Page of . ~ _~..,,r-rc nwi*lER'S MANt~~+•L $ N[At~1~GENt ~{r.-a~t-st~,t~[S - - _ ~ ~ n at the infifitrattVe surface. Page of . S~'stem startup shad not +oct'ur when soil cond~t,ons are froze wer is restored ~e excess es ump tanks may fill a`b°'re normal htghwater levels. When the Cep s and may result in the t3uring power outag P csa[ cell(s) in one large dose, overloading um) tank removed by a wastewater wits be d'tscharg~ to the dispe e of effluent To avotd thts sttuation have the ~ n~n~r~o ~ Piumbec or POW7'S Maintainer to backup or s>,rface O motor prior to restoring Power to the effluent pump Septage Servicing Pew tfte pump contrnls to re$fore normal levels within the Pump tarot assist in manually operating C1o not drive or parse vehides over tanks and dine rsa~ ~ild2 spool aot~~~o r ~a_over, or otherwise disturb or compa , the area within i 5 feet dawn slope of any moon -9 rfomtiance and pratong the fife Reciuc~ian or eiuninat5an of the following from the wastewater stream may improve the Pe dental floss; diapers; of the POWTS: antibiotics; baby wipes: d9arette butts; condoms; cotton swabs; deg asotss~e; grease; herbiddes; meat disinfectants; fat; foundation drain (sump Fume) water, fruit and vegetable pee ~s9 and wafer softener brine. scraps: medicaiYOns' 0l4 painting products; Pesfic"tdes; sanitary napkins, tempo ABAI~IDOI~MENT rmanentl .taken out of service the toi[owrtng steps shalt sae taken to insure that the When the POWt'S fails andlor is pe Y system is properly and safety abandoned in compliance with ch_ Comm 133.33, Wisconsin Administratnre e: Its shall be disconnected and the abandoned pipe openings sealed. . All piping to tanks and p~ disposed of by a Septage Servicing Operator. The contents of alt tanks and pits shall be removed and property • After pumping, all tanks and pits shall be excavated and removed or their cavern removed and the veld space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a e comp lent replacement system. A suitable replacement area has be ~ areatsho~uld be prof led from d~stu~rbancefia~nd compatction and should not abso lion system. The reptacem tot lir:es and welis_ f=allure to rp ~ infringed upon by required setbacks from existing and proposed strv re, protect the replacement area will resultmstmus comply wi~Wthe,rules inteffect at thatttime~biish a suitable replacement area_ Replacement syste i] A suitable replacement area is not av~i ~ as a fast etsbort o epoace ,the ~ ed p~ 'VTS~g advances in PO c technology a holding tank. may be Ins n failure of the POVYTS a soil and ~~r The site has ~ been eva~a~~ to eocate as uitabble cep(acemeen tae2a. ~~o ~Piacement area is available a - site evaluation must k>e pe holding tank may be installed as a laststems maepbe re~oonstn-ctedO P ce foifawirg removal of the biomat at Mound and at-grade sot! absorPhon sy y +ems must~comply with the Ntes in effect at that time- the infiltrative surface- Reconstnt~ons of such syn. «t{'11At4NING» SEPTIC, PUMP AND OTHER TRFATMEI'fT ER TREATMENT TTANK UNDER ANY ~ RC MS1"ANCESF DEATH MAY DO NOT ENTER A ~EPTiC, PUMP OR OTH RESUt_,T. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAYBE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS iP1STAL~ER j Name ~ c~,~c~•/ ~ r~~ Phone `'/ J -~`j~' ~.3 SEPTAGE SERVICING OPERATOR PUMPER ~ Name ~y~ a iG~ ~~ _ r Phone %'l J =- ~7 ~~ :~3 ~~ P'OVYTS MAINTAINER ~-L Name J/` r~-ur~ j~''i Phone ~d = ~ ~~ ~'~' ~~ LOCAL REGULATORY 1+UTHOR(TY Agency ~jl rrr~%( ~fdi,r /~ '~~- Phonz /Jr~-~~~°e. ~~~ uetfe and Waushara County Zoning and Sanitation agertcles. Tills document meets rnis aocx,menC .ran Grafted by ffie statti`s of the Green ~ ~. Ma1q E3 1 mart does not the minimum requirements ofi di. Comm 83.22(2)(b)r 1{) (t3 54{ }, (2} & (3j. Wis~nsin Admirttstlai>~ Code- t3se of this doCU ('M1N (210 i ) guarantee the performancx of the POW fS- S + Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page m ac:coroance wnn t,urnm oa, vns. horn. ~,cwe ft` er not less than 8 1/2 x 11 inch sin si 14~ Attach com lete site lan on a ~ my J ~. p p p p ~~ ~~ ° indude, but not limited to: vertical and horizontal reference point BM), i ofl an Pa I.D. percent slope, scale or dimensions, north arrow, and location an dista nce to roearest road. Please print ell information, i~,~ ;~ ~ 7~~~ R ed by Date Personal iMormation you provide may be used for secondary purposes ( ivacy Law, s. 15.04 (1) (m)). , ~ Z Property Owner J ~ ~~ ~ ~ prbpd , tpn ~, __ - r _ _ ~l T ~ N ~ /4 S~ - R ? E /~./ vf'To ~ 1 /4 (/ r) Property Owner's Mailling Address / ` 1- Lot # Blod< # Subd. Nam~je~or ~CSM# ~ ~ State Zip Cod Phone Number e ^ ci(y ^ Village Town Nearest ad ~ 1` New Construction Use. Residential /Number of bedrooms ~_ Code derived design flow rate ~Sfl GPD ^ Replacement -1 ^ Publijor com erdal -Describe: ,_.~____ __-_ ___________ __ Parent material ©/~-~Guu i~~i/L~~~~ 5~~~ Flood Plain elevation if applicable N ~ ~' ft. General oommeMs /~~~ /f _ °1 ~ J ~, and recommendations: ~~l K~x-/ ~~./ JJp Boring # Bonng pit Ground surface elev. ~~' ~ ft. Depth to limiting factor _ ~ in. ~i lication Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. •Eff#1 •Eff#2 c~°- 3~Z. -~ c L'~ ~-- S' 2 - 3 0 ,-S - - r~~~e 1 ~~ /J j/~1 Boring # Boring !,~ Pit Ground surface elev. / ' ft. Depth to limiting factor 1p, 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 o- ~3/zs ~--- ~ r ~ ~ S' '~ -~32 ~,~ G- ~ 2 1 1 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 1 'Effluent #2 = BOD < 30 mg/L and T55 < 30 mg/L CST Name (Please Print) tun: CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Ev nation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 5401 ~'.~ ~ ~ -- ~~ 715-246-4516 3 of L ~ Z ~ a Property Owner 1 ~ 1 Boring # ~ Boring Parce! ID # Page of ~~ /t~hlt vruunusunausc~CV. ~ ~ a. vcNu~ w unuwiy ~auv~ ~+ ~ Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dlff° in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. `Eff#1 `Eff#2 3 - s _ N ~-- S ~~ ~ l f~ ~~ r' ~'~-_.~.. ^ Boring # ^ Boring ^ pit Ground surface elev. ff. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil ication 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 `Ef(#2 `Effluent #1 = BODE > 30 < 720 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. seaa3ao ~e.~ao> r ~ Soil Test Plot Plan / Project Name .Steve Itoh Shaun Bi Address 9112 91st. "~ CottageGrove Mn 55016 CS #226900 Lot 1 ~ Subdivision Emerald Acres S W 1 /4 N W 1 /4S 30 T 29 N/R 17 W Boring 0 Well PL Property Line BM or VRP Assume Elevation y00 ft. System Elevation 96.3' *HRpSame as Benchmark 76th Ave Date 6/18/03 Township Hammond County ST. CROIX Top of Steel Fence Post Alt. BM Top of Survey Iron @ 96.5' Scale = 1 /4" = 10' Property Line Pro 3 Bedroom House B-3 9 8' 0 ss' ~ B-2 B.M. * Alt. B.M. Property Line >300' 9 4' ~ B - 1 10% Slope Wisconsin ~D,~el;artment of Commerce PRIVATE SEWAGE SYSTEM Safety and i~a]Id~, 7ifvisi~~n INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. -ELEVATION DATA Permit Holder's Name: City Village X Township Itoh, Steve Hammond Townshi CST BM Elev: 1 Insp. BM Elev: ~ BM Description: n .. ~ ~W~ S ' ~ Cam. c7 PO. a t~ S ~e = ~,J~ •fr ~-K. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic 1= ~. ~ -t- ~o b3 0 Dosing ~ ~ ~ t ~ Aeration Holding TANK SETBACK INFORMATION County: $t. CrOIX Sanitary Permit No: 429939 0 tale Plan ID No: 3 3 ~f = ~,.ss, i4 Parcel Tax No: 018-1098-17-000 5ectionlfowNRange/Map No: 30.29.17.824 STATION BS HI FS ELEV. Benchmark 4a~""" Alt. BM al..~. ~ ~v~ of {..w.~..d' rte' k ~, 0 3 •~0 Bldg. Sewer ~o~(, n / ~'. loo ~g sc~ St/Ht Inlet C yp , ~y- 93.95 ~ Dt Inlet Dt Bottom _ 3 ~ 40.30 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~~~ Dosing ~+ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer ~~- Demand GPM Model Number ~ ~ r TDH Lift Friction Loss System Head TDH Ft Forcemain Length i ~r Dist. to Well 4e Z ~) SOIL ABSORPTION SYSTEM BED/TRENCH Width t Lengt DIMENSIONS Q SETBACK SYSTEM TO INFORMATION _. I rt't' ' ~u DISTRIBUTION SYSTEM h ~ No. Of Trenches o (-) P/L BLDG WELL zS + > ~ s'~~ C~~ Dist. Pipe C~ \ Z- ~ 9'S ~., ~ Bot. System ~1J ~. ~ t .v Final Grade PIT Cover I~-~o `• 1 p `)$~ 0 / CHAMBER OR UNIT Head r/lylan~ld t~ Len /- Dia ~ DistributioQn f /~ Length y~'~ Dia ~ Spacing x HoleCSize tt J /32 x Hole SpaciCng~ ~ 2 / Vent to Air Intake ~- SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedffrench Center Bedlfrench Edges Topsoil r~ Y,es n No [] Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspect`# ~ ~ Inspg;'o~~2:~_ Location: 1520 76th A enue Hammond, WI 54015 (SW 114 NW 1i4(3~0~T~29/JN R~1,7W) Emerald /cres Lot 1 Parcel No: 30 1.)Alt BM Description ~S•T N"o~-~~. t~/ ~+^~'~t~°F T~"^^~"v~•• oL{ IUW h-~.Ctiu~) ~ ~.•i ~/ 'r~ ,I~ 2.) Bldg sewer length = ~~ 1 .•~r`D , L~'- r ~"" - amount of cover = ~~ S ;~ ~~-r.NS. ,,r , ~,,,a Plan revision Required? ~ Yes [~_ No ~ ~ ~ ~ ~~ --- -1-- - -- --- 1 ---, Use other side for additional information. ~ T I ~ Date Insepctor's Signature Cdr No. SBD-6710 (R.3/97) .~- yT N~"' -~ , is~o~isio nenartment of Commerce Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 (608) 266-3151 Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(lxm) T. Application Information -Please Print All Information Property Ownerc's N/a me ~ L r cwt P ~ r4~ ~~o /~ Property Owner's M ailing Address 912 r /~~ City, State ~ ~ Zip Code II. Type of ding (check all that apply) ~/ bo `X/ 3w6 ~or 2 Family D 'ng -Number of rooms ~ uM Ce•~~- 9 ^ Public/Commercial - cribe Use ;,< County ~~ ~ Sanitary Permit (m be fdied in by Co J Plan I.D. Number \ $(0 2`f 3~ = Trews . /o. ~) ect Address (if different than mailing address) ;el T! Lot ~/ Block /! I '..) psi-. t ~ ~ ''v~ 4,~ L 6l J Nppfber, ~ i ^ State Owned -Describe III. Type of Permit: (Check o one box on line A. Complete Line B if app ' A' New System ^ Repla m System ^ Treatment/Holding T place B. ^ Permit Renewal ^ Permit Revisi ^ Change of ermit Trar Before Expiration Plumber w-ter IV. T of POWTS S em: (C k all that cep ^ Non Pressurized ln-Ground Mound > 24 in. of su e ^ Constructed Wetlartd ^ essurized In-Ground ^ Holds ^ Recirculating Synthetic Media Filter ^ Leaching Chamber V. Dis rsaUTreatment Area Information: Design Floyw-(gpd) Design/Soil Applicafion Rate(gpdsf) ~/ I /' YI. Tank Info Capacity in Total umber Gallons Gallons of Units New Existing Tanks Tanks Septic or Holding Tank ~ aired (sf) Dispersal Area ro (sf) ystem Elevation S~v ~' (~ acturer Prefab Site Steel Fiber Plas[ie Concrete Constructed Glass Ding Chamber YII. Responsibility Statement- I, ttitdersi assume r nslbi~h' Orly f installation of the PO shown on the attached plans. Plumber's Na me (Print) Plumber' t tore MP/MPRS Number Busit~ss Phone Number Phunber's Addre ss (Street, City fate Code) ~ ~~/ /J,~7 VIII. Coup /De artm Use Orel Sanitary Permit Fee (includes Groundwater Date Issued Agent Sigm (No Stamps) Approved ^ D' oved Surcharge Fee) ^ ner Given Reason for Denial ~~~ `~~ 0~ IX. Conditions of Approval/Reasons for Disapproval ~ 6 C~ ~ "`-' 1 " "' `-~ f f )~4?~ ~ ~ ~ ~ - ~- Attach ~mplete places (to the Connty only) for the system on paper not less than 81/2 x 11 incites in size !4,~~!f,section~~_ /cl ne) N; $t/ E W Subdivision Name _ ~ CSM Number =~~r. ^City_^Villa wnshipof_r~ d rg- lo9g~- ~ _~ Only ^ Other Modification m Existing System . ~ soil Mound < 24 in. o~le it r~ ^ Singie Fill ^ Peat Filter ^ Aerobi rt ^ Res' Filter 'p Lim ^ Gravel-less Pipe Other (explain) r SBD-6398 (R. 01/03) • ~ ' ~ PLOT PLAN Steve Itoh ADDRESS 9112 91st. Cottage Grove Mn 55016 i/4 IVVV i/4S 30 /T 29 N/R 17 w TOWN Hammond COUNTY ST.CROIX -- __ MFRS Shaun Bird 226900 4/20/03 3 DATE BEDROOM CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK XXX 1000 gallon LIFT TANK SIZE 1 MOUND SEPTIC TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 450 # of chambers none BENCHMARK V.R.P. TO Ipe ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 100.0' B.M. #2 B.M. #1 = 1" 4 Property Line 98.5' 99' 99.5' Area 15' Below Syste B 1 is to remain ~ undisturbed Grading is to be done to 2~~° ,/~ divert run-off away from Slope //' system -3 ~ Tank is to be properly bedded and provided with lockdown covers with approved warning ~ labels - 2 To 150th St. Property Line -~ Huffcutt Combo Tank Pro 3 Bedroom Well is to meet all House setbacks found in 1 Comm. 83 `~ a ~ ~scons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary Apri124, 2003 CUST ID No.226900 SHAUN R BIRD BIRD PLUMBING, INC 1008 192 ND AVE NEW RICHMOND WI 54017 CONDITIONAL APP~OVAL PLAN APPROVAL EXP1~S: 04/24/2005 SITE: Steve Itoh 150TH St Town of Hammond St Croix County SW1/4, NW1/4, S30, T29N, R17W FOR: Description: Three Bedroom Mound System Object Type: POWT System Regulated Object ID The submittal described above has been reviewed for conl and Wisconsin Statutes. The submittal has been CONDIT chapter 101.01(10), Wisconsin Statutes, is responsible for ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Transaction III. o. 862439 Site ID No. 6 98 Please ref ` to both identification numbers, above, i, correspondence with the agency. 900421 th applicable Wisa APPROVED. The `vith all code reau: administrative Co es as defined iit .. L r`- The following conditions shall be met during construction installation d prior to occupan r~ General Approval Requirements: • This system is to be constructed and located in ac rdance with the enclosed roved plans and with the "Mound Component Manual for Private Onsite astewater Systems VERSIO SBD-10691-P (N.O1 0 and the "Pressure Distribution Component Ma al for Private Onsite Wastewater atment Systems VERSION 2.0" SBD-10706-P (N.O1/O1). ,. • Per manual cited above, limited activities a allowed in the area 15 feet down slope of the ponent area. ~. Soil compaction, excavation, vehicular tr fic and other similar activities that impact the trea t and dispersal are prohibited. • The off setting (D) is proposed to be; six inches from the bottom of the tank. The pump pad, along with the legs of the pump, may leave the im llers out of the liquid effluent before the pump off setting is reached. This should be checked at time of cons " ction to insure this condition is not encountered. This setting maybe adjusted, with the inches coming om the reserve capacity area. Conn • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c ~PR DEFARTMFI • A Sanitary Permit must be obtained from the county where this project is located in accordance with the ~ N OF,S~ requirements of Sec. 145.135 and 145.19, Wis. Stats. SEE CORE • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat JkiAUN K BIRD Page 2 4/24/03 - . • ' PLOT PLAN PROJECT Steve Itoh ADDRESS 9112 91st. Cottage Grove Mn 55016 SW 1!a NlV11 1la.s 30' !T 29 N!R 17 w TowN Hammond couNTY ST. CROIX MPRS Shaun Bird 226900 DATE4f20l03 BEDROOM 3 CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 450 # of chambers none BENCHMARK V.R.P. Top of 1" Pipe ASSUME ELEVATION 100' Filter Zabel A-1Q0 ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 100.0' B.M. #2 B.M. #1 1 ~~ = 4 ~ P erty Line 98.5' 99' 99.5' B-1 Area 15' Belo stem ~ is to remain undisturbed ading is to be done to 2°° divert run-off away from Slope ~ system -3 ~ Tank is to be properly bedded and provided with lockdown covers with approved warning O labels B - 2 To 150th St. Property ~ Line cutt Combo Tank Pro 3 Bedroom Well is to meet all House setbacks found in Comm. 83 LeSlg11@r Date 7. Slops 4" Observation Pipe Perforated Below Filter Fabric C-33 Sand " Topsoil -1~ F Non-Woven Filter Fabric Distribution Pipe ~~ - 4 ~ . Force M.oin F r orn Pump s~do~~j~ x%2 Ornin Rock Cross Section Ot A MoundSystem Using A Bsd For Ths Absorption Area A c'3 Ft . SSA Ft. I ,~ Ft J ~ F . .. K, r t. L Ft. .S Ft: No << Sr: jkrn~t`1~ i-`- L °' A s 3 0 D 4 Obs e t° .~ ^ ~..._....r. Distribution , Pipe ~„ 4 Observation ae t ion C c~ ,~P1owt La l I >:r .tea ' --~- k ~ J~ __ '_ ~--------------------~f .~ ._..r.._.. _.._._.... Bed Oi ~Z~- 2 %Z Drain RocK I Ptrmoneni Marker Pi pa or Rods K Ct Main Fr Pump Plop Vicw Of Mound U~tnQ A Bed For The Absorption Arefl PAGE OF aka Perforotnd P+pe Detoit SEPTIC TANK ~ CRt?S5 ~rcATrorrs •• MIN . A80V E GRADES KEpTHERPR00F ~" CI VENT PIPE 12 JUNCTION 80X APPROVED ~ 25 ~ pRp,H DppR ~ WINDOW 4R WITH CONDUIT ltAI1HOLE COVER FRESH AiR INTAKE ---~-"-"'- W! pppLOCK 6 --wARNIN6 LABEL FINISi'!ED -GRADE 18" C.Z. a~IFE ~. s'. D. ~a Ms N' !!!R ~ . INLET t GAS- ~ WATER TIGHT SEAL' TIGHTS TER ---~- A SEAT, f ~ ~O=~S NItH ~..._ 11PPAONEO PIPE 0 ~ ~~ s~ c ~ y, ;•~ : ~ {' ~ Sa1.ID SOIL 0lri'O SQIIQ ~ r~ r ti FF St1I~ PUMP OFF EL ~ FT- '~ D 3" APPROVED SEDDI UNDER TANK C~CRETE PAD SPECIFIC ONS ~~J/ S` G~ t SEPTIC / POSE NUHB OSES PER DAY: ~,.,_ ' TANK MANUFACTURER: GAL. D V O I NLp BACK~G' 1~ , .,S ~ L , TANK SIZES = D~ IC~=~~~~ ~L. ~ n ~~ ES = ~~ •~ GAL• S ACITIES: A ~ ~ ALARM! MA~FAC1~lKER: GG' ~ ~ 2 INCHES = F~~6AL. MODEL I+Rj'!lBER : ~.-. .. 9 SWITCH TYPE: s~ ~ KCEtES =~ • .~ GAL- PtIMP MAtR3FACIVRF.R = GAL . ~""" MODEL NUidBER: ' 1 5~,,,,_,_._ ~j~r. 1~! a I ES S~12?CFI TYPE: .~.... '? A~,ARI~! WIRING AS P LHA 16.13 WAC PUMP REQUIRED DYSCHARGE RATE FEET VERTICAL DIFFERENCE g~rtEE MP OFF AND DISTRIBUT-ION PIPE - . EET + MINIMtUM Ng'~riOR1C Si1PPLY ESQ ~~RFT/ 1Q0 ~ FT. • FRICTIOld FACTOR • . • /- + ~ FEET FORCEt'1AIN Z..G-- ~,'pTAL DYNAMIC HEA`D = /s • F `" C~ DIAMETER ._..,..r.- iNTERNAL DIMENSIONS OF pUHP TANK: ~ Q D ~~H•-'~~~..- ~. SSE CORRESPONDS,, LICENSE ~MSER= DATE: SIGNED: _ _ 1188 HEAD .CAPACITY CURVE MODEL 152/153 12 "'" 152 x v_ ~ 8 >- 0 F 20 0 f- 1 O 20 40 fio s0 loo - TOTAL DYNAMIC HEADJCAPACITY PER MiNt1TE EFFLUENT AND flEWATERiNG MODEL 152 153 Feet Meters Gai. liters Got. Liters 5 1.5 69 261 77 291 10 3.1 61 231 70 265 15 4.6 53 201 61 20 6.1 44 167 52 97 25 7.6 34 129 159 30 9.1 23 87 33 125 35 10.7 -- 22 85 40 i 2.2 -- - 11 42 Lock Vorve: 38.0 (1 t.6m) 44.0 Ft. (13.4m) LITERS ~ 80 160 240 320 _ \\ 27 Fl PER MINUTE \ CONSULT FACTORY OR SPECIAL APPLICATI • Taped p~lels avalTat~e. • rae alternations, for duplex systems. are ava~able and suppFied wiul ~~. • v~iabie level contrd switches ae available for cpntronirrg single; phase • bads variable level floes switches are ava8abie for variable level long and shat cycle controls. • Sealed tic-Box ava~able for outdoor instaNataxis. See FM1420. • Over 130°F. (54°C.) spedai quotation requlred• 15tl'15;i Series 1 teod~ voles-Pn >roae Con - uu N152 115 1 Dion @.5 t 2a3 tNN52 115 a AuW 8.5 Mw3uded 2or3 Ei52 230 i Non 4.3 1 2or3 BE152 N153 23Q 1 115 1 ADD Non 4.3 10.5 k~cMdad 1 2w3 2or3 BNi53 115 1 Atao i0.5 ineladed 2or3 Ei53 230 1 Non 5.3 1 tar BE153 230 1 Aub 5.3 riisaidea 2 or A cAUnoN Aa ~ cenvols, devices ana wkbig be ~ by • Nelionaipectrrc ~a~socrun'n°"~satMrtt~grnccKlsNA}. r2 ~/a sz 3~ ~t s rl/8 _____!__ e~cme+ SELECTION GUIDE t. Sugle pggybadc variable le~retMoats+xOch a dotdlle piggyback variable level float swhdi. Refer to FM04n. 2 See fM07i2 for oarec- model of Elecbic~ Altfsrriator E~Pak. 3. Vadabie levelca-tsat swdch 10-0225 used as a cantrolaciva0or, spes#y dugecc(3) a (4) float system. RESERVE POWERED DESIGN Maintenance and Contingency Plan for a Mound System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Dose Chamber is to be pumped at the same time as the septic tank. 3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 4. Once every 3 years the mound is to be inspected via the inspections pipes in the at- grade. The laterals are to be inspected via the cleanouts. 5.Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 6. Pump and electrical components are to be checked at the time of the pumping. 7.Owner agrees to leave the area 15' below mound undisturbed. 8. The owner agrees to save this plan. 9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is not be driven over. 10. Effluent Quality is not to excede the requirements found in Comm. 83 Contingency Plan 1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if needed, then bypass pump float and try pump with out float. If this works, float is bad, replace float. If pump still does not work, check power at the pump with a electrical device such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is power, then pump is bad and needs to be replaced by a plumber. 2. If mound fails, determine cause of failure, test another area or remove pipe and sewer rock, retill soil, install new mound system. 3. Replace any other failing components as needed. Important Phone Numbers Plumber: Shaun Bird 715-246-4516 Pumper: Tom Mondor 715-246-5148 St. Croix County Zoning 715-386-4680 pt3WTS OWNER'S MANUAL & MANAGEMENT PLAN P~e_____ot SYSTEM 5P~4~C~~.f+~ ~v~~a Septic Tank C D tdA SepLk Tan[c til[anufai~er G tVA C-~Nuent Fit6ar Mrur~rfacttrr+er .~ ^ NA E der Model -- dZ7 ~ NA pump-Tank C ` C~ .~O al ^ NA pump Tank Marw ~ NA .pump Marwf~idr~er' ^ NA Pump Model ,~.2.... ^ NA pn~rtetrt Unit O SandPGrr~vet ~ D Peat Fltter D Medtardc~t Aeration D Wetland O D~ Manufacturer ^ Other_ s D in-grotmd (9cavilY) ~ ^ tn~round (pressurized) Q At~rade ~ou~ 0 values typical for domestic tin wasLawdcer ens .. pretreated wastewater. u+,,,,, ~...+........._..~ --- Service Frequency Service Event At least once every ~ D months r(s} (Maximum 3 yrs.) Inspect oolldition of tank(s) of tank volume When c~nbined skrdge and scum equals one-thad (Y) Pump Dirt conterrLs of tank(s) st once every At l ~ ~ mortths~Y~Ks) (M~udmum 3 yrs.) Inspect dispersal cis) ea ^ matths s) K f,'~an t3ftfuent filter At least once every t once every . ~ O a~ortths s) D [dA Inspect pump. t~P controls & alarm A t orioe ever f l ~ D months r(s) D hlA f=lush laeersis and Pressure test y eas A D months D year(s) D PlA over: At least once eatery .,..,~.. At least once every D months O year(s) t1 NA ~~ ~ t ~~l ~ ~aa be made by an ind'ntidual c~ry~9 ~ of the fog or powTS Mainta~ec: se~tage o~ Ma`s phtmber; Master Plumber Restrk~ed Sewer; POVif TS to ider~il5~ ~Y S a b~cen S pP~tor Tank inspe must inducts a visual ktspedion ~ scem and to daedc tar any !~k up t~afdYVat'e. kler~ify an7f or leaks. measure the volume of combined sludge m comic the effluent levels ~ ~tdtng of effluent on the ground surface- The dispersal oel~s} shaft be vet ~ effltrertt on the in the obs P~ and b° ~c for any P~~g of effluent on the ground surfs ~ ~ ~~y authori-y- totmd surface may in~cate a fang ~~ and requkes fhe hnmediate rtotifr~flOa 9 and scum in arty tank equalsone-third (Kl ~ rrrore of the Lank volume, the When ttre oombin~i accumulation of sludge and disposed of in accordance with ch. NR entire contents of the tantc Shari be removed by a SeP~9e Selvicirtg Operatoor 113. tly'~cortsia gdininistrartive Code. - t ~~, and say The ~ ~ effluent ft~t+ers. nk~! ~ pressurized POVVI'S components. P~ by a POWTS Maintainer other ntadatenactoe «' rnoafloria9 at intervals of t2 rrtotttfis or less st>aH be pertvcmed of any service event. A secwige repot sMaq be provided to the kx:al regulatory auttwtny vwthtn 10 days of oomptetioa STARTUP AND OPERgT{ON s for the presence ~ paiafln9 products or cther For new oortstrtx~on. P~ ~ use of the POWTS check treatment tank() s . ff h oonoentrations are the treatment process and/or damage ~ d~Pe~ ~) N9 ,chemigis that may impede detected have the oontrmts of the tanks) removed by a septage servicfi9 operator pact to use. System start up shatl,not ooourwhensoil-conditions ars frozen at the inttThative surface. Page ~ pub p~ ~~' pump tam may ~ above ttotma~ higttvvater levels. VVhert power ~ resdored the excess wastewaterw~ be dlsc~auged to the etas) in one large dose. otnerbadirtg the eestis) and may nr fi the backup ,~ stsfaoe of . To avoid this soon halts the corteertts of the pump tank removtgd by a Operador prior. resdoring power b the pump or contact a Plumber a POUYT'S Makttairter to i assist in may ills punk eot~ots m resdore nomnal levels wrth&r the purrs tank. Do nd drive a' park ve!>ides rw~ taudcs and dispersal eBNss. Do not drive or pack over, or otiterwise disturb oc oorrtpad, the arty within 15 feet dotwt sbpe ~ any mound or at-grade soA at>s8rption area. Redudiort o[ wort of the totiowing front ttte ~ stream may &ttltrove the perfennance and prolong the 6f+e - ~ tits POWTS: arttibiotk~ baby w"ce6t~ 6uRfs: condoms: cotton swabs: degrea9e~ dents Roses fiap~s; disktfectattts; t>~ foiuid~6tort dta~t (swop t~P) ureter; fnrit and vegetable peel~lgs; S 9 ~: meat sxxaps; rrtedicaNats; oi'i: padtMkt9 P ~: Y : brrrtportsy and wader' sotierter brine. ABANDONMENT . 1Mtten fhe POWTS fail and/or ~ PaY-taken out of service the fo~avu&tg steps st>ap t10 hdloert to &lsurie !f>ed the system is property and safely aiandoned In eornpGartce with ch. Comm 83.33. lA/rsoont;3rt Adm~is6atit-e Corte: • Aq piping to tanks and pits shah be diseonrteded and the abandoned pipe openings seated.. The of ati tanks and pis st>rt• be removr3ci and property d'~posed of bff a Sept~e Servidng Operador: Alter t~ssmP~B. ag tanks and pits s be excavaded acrd retrtoved a they Douses rerrtaved artd the voW space t~ with sob. gravel or anotl>~ inert so&! material. CONTINGENCY PLAN lfi the POWTS fads and be repaired the Bowing rrteastmes t-ave been, or must be taken. to provide a code compliant aeptax~ement system: O A suitab~ rep{aoemertYarea trews been evaluated and may be utilized for the lorttiort of a nit sod absorption system. The teplace<rtent area should be protected from disturbance and eompadion and should not be irttrir>gwi upon by- required setbacks firom existing arld proposed strudtrre, ld lines and weds. Fa~ure to prated ttte replacement array wAt r~euet in the need for a rtew sal and alts evatuatiat to estabiistt a suitable replacement area. Rett sY must comply with the rules in effect at that Tine. O A sortable replacement arty is trot ava~abte due do setback and/or soil kmitations. Barring advances in POWTS technology a holding tat>it may be as a last resort to replace the faded POWTS. The stTe has rte been evaluated m identity a suitable replacement area. Upon failure of the POWTS a sosl and stie evaluaflort must be to tocade a suitable repiacemertt area. if no replacement area is available a ~ttoki'irtg tank may be as a last resort to replace the farted POWTS. ~6-,MOUrtu and at-grade sod systems maY be reconstnrded &t place foNo~wing rerrtavat of the biomat at the kttitaative surface. Reaonstrucdions ofsuch systems must comply with the rules kt effed at that tittle. «IfVARNING» SEPTIC, PUtYtP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AN~OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNOt~ ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE tNTER10R OF A TANK MAYBE DIFFICULT OR lMPOSSIB[.E. ADDITIONAL COMMENTS cz~.urr~ ~-~cTwr t RQ Name ~, rti.~ POYYTS MAINTA{Nt]t Name ` Phone j/ J •' ~..-~srnn_c ~co~nr~t'rt= nPRResnR /PUYPt~tl LOCAL REGULATORY AUTHORITY .,.... Name - - ~ - Phone ,~ _a .~ ~' Phone rr-ts aoamrer+t was drafted by a>s:~ a q~e evean tee. ktargrrerte ana Wa County zoo and sanitauorr ayeneias. ~ aoaa<nent meets ~~m ~ ~ a.. Comm a3.z~rox+xatacrl and s3-s+cfl. m s ~l. w~n~n ~a roae. t>m of tn>: aowmere goes sot guarantee the performance of the POVVT'S. GMVV t?J~i) } .. Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT ~~ Zog~e Page / of ni a~.w~uanuc mug Wnun uv, vr~p, nuns. vuuc County -~ C y Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must . ro include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel 1.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print aU information. Re 'ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ Q ~ 2~ ~, Property Owner R Property Location ~ -~' Govt. Lot Sw 1/4/(/t.~J1l4 S`jo TZc( N R j ~ E (or)~- Property Owner's Mailing Address Lot # ~ ~ Block # Subd. Name or CSM ~ 53 ~ee ~- ~i~)c es City State Zip Code Phone Number ~15 ~~ ~ Old -{ (]City ^ Village ~f Town ~ Nearest Road l ~ ~5~ ( ) 1 b m~ri~ . ~ New Construction Use: [~ Residential / Number of bedrooms 3 _ ~ Code derived design flow rate ~ U GPD ^ Replacement - ^ Public or commeraal -Describe: ' ' " ~--' - Parent material 7 / i~ ~ ~ Flood Plain elevation if applica ~ a ft. '~ ± General comments ¢ ~ s.~yy~ ,e~ .tv 9 ~~ O~ Y ~ .~ '~ r• ~ l~ `~ ~~•'~' L and recommendations: ~ ~ O ~ e. v ~ Con-Fa ~ ~- e l `j ~,~M1- (~ 1 1 ? QO ... 1 -. ~ ~ // ]j y~~,~ `A~~Ir l d / Boring # ^ Borin9 5~{t -,,W,,a';ac~v "_~ Lt7 Pit Ground surtace elev. ~U~ $~ ft. Depth to limiting factor ^,~,_jclrl. t`" pplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boun _ GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 0-~2 10 r lZ - S/~ abk -~r ~ .~ . ~' Z JZ -ZO /Q ~ ~ y/3 sicJ 2m s~k -,~~r ~ s - 3 Zd 3y ~e r 3/~ -" s ~ 2 m b~ m~'f c - . 5 . 9 y y-~5 jb r.3/~ F! F 75 r ~l y s ~. 3 ms~k rYr~'~' ~" -' • 5 . ~ _.~--- Z Boring # ^ Boring ®pit Ground surface elev. 9f1,1o~ ft. Depth to limiting factor 3y in. ~- Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 l d l r 3 Z -' Si ! 2r~ c ~j •~S z ~~ z~ c -~ ~ ;cl ~ - - ~ 3 z~-~/ ~ .~ s~ m~ ~s - ~ 9 U 3`~-SU ~1F 7. S Y/~ ~ ~3~ k-- i - . 5 . 9 ._.~---- * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 _< 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mgll CST Name (Please Print) Signature CST Number ~ h mocker- Y ~,.-~ 2 s3~9 Address Date Evaluation Conducted Telephone Number 21r3 ~a ~ 5~ ~m~~ ~vl syozs i 2- ~ ~-~ ~ ~7i s1 Z ~~-~~ • Property Owner 5-~o v-~ Parcel ID # Page ~ of 3 a Boring # ^ Boring QQ~ .1 Pit Ground surface elev. ~- ft. Depth to Limiting factor Zg ~n• Soil Application Rate H i th D Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 zon or ep in. Munsell Qu. 5z. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 Z ~ - 8' l~ ~ 5 ~~ Z I ~- cs ~ • y . 3 1 ZS r-~ 5 ~ Zl,~~ bk m~r- ~ 5 - . 5 - `~ U Z~'-~D /0 r / K 7- 5 ~ ~ ~- . 5 . cI ____--- ^ 8orng # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate i H D th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz or zon ep in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 Boring # ^ Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 p in. Mansell Qu. Sz. Cont, Color Gr. Sz. Sh. "Eff#1 "Eff#2 Effluent #1 =GODS > 30 < 220 mg/Land TSS >30 < 150 mg/L ' Effluent #2 = BODE < 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. S6D-8330 (R.07/00) i N NAMF SAO U ~ I OT# I ~ LEGAT_ DESCRIPTIONSw %tVW14 , ~ T Z4 ,N,R. ! ~ E(orX~ SCALE: I"= ~/© BM 1 ELEVATION /~ . D BM 1 DESCRIPTION 7~ ~ .~ ' ,D v L BM 2 ELEVATION q~ ~d BM 2 DESCRIPTION ~ p a~ UC SYSTEM ELEVATION 9 I• ~ ~ SYSTEM TYPE MG u ~d ~v~'t•Cw~ CONTOUR ELEVATION q ~. 00 "? .c_,~_~~-~L~ ~r~ ' ~- PAGE~OF~ ~ -~ 1 c I ~~ / ' Li 1 ~~ _~/ 4! a Li ~q,~ ~ -~ ~~ ~" C /~ /~ 1:-~ ~3~' ~q 5 ~ n~'° ` ~~~ SIGNATURE ,~--/~ ~- ~z ~__. ~ DATE _~ _ _~,,~ -- C?~ ST CROIX COUNTY - - ~ . ' ~SI?P3'IC Ti~NK MA'il~'!'fi1~ANCB AORBLMEN'I'` - ._ - ;1~1~TD -.. - .. ~ . OWNE&SHIP CERTIFICATION FORM t OwnearlBuyer Mailing Addy Propearty Address (Verification requinsd from Planning Department for new City/State Parcel Identification Number o(~S - Ic~q_& - I ~- c~ (. aZ~) I LEGAL DESCRIP'T'ION ~ ) /n Lacation~4~ils~~t/'/., Sec~~'~,~N W, Towa of ~~ ._ P~oP~Y ~" Lot # ~~ - Subdivision ~.~~~~~/'/~~,~J _---- ~ ,Volume _ Page # , ~_ Certified Survey Map # _ , Warranty Deed # ~ ~" ~~ ~ ,Volume _?-~ 3 `~_ .Page # _ 36 Spec house ^ y~ Lot lines ~dentifiable~Yes D no SYSTE1VIs A~IAIl~t"I7GNAi~ICE m~ewasbes.properma nse and~~ se~io systemcouldres~l~ is its pzem~+e consists of ping aul the septic tank e~tety thru years or soot if nzaled by a lives ~flbat y'0n P~ ~a ~ can affect ~ f~Ctian.of the septic tank as a tread stage in ~ waste sy~- The agrees to sabamt to S't. Qrouc Za~aig Dcpartmeol a ~ficatias<faa~m, sig~osod by tba owner and by a °~ that(1)drec~ibevva plunnber, jou~eymanp resinctcdpi~m~ber or a liceusedprcanper'verifym-g ~ l~s than 1/3 fall of shrdge. is is proper operating ~~ and/or {2) oiler inspection and p~Pmg C~ '~ ~ ~- 1~ $~ ~ have read the above roq and agree to maintain the private sewage disposal wig 1~ set by the Dot of C~omnm~erce and ibe Department of Natcaal Reseraces, State of W ~ce within 30 set Earth. herWa, has beenrnaintamed must be oornpleted and returned to 8re St.~ Croix Canty Zoning stating days of r~'xatiaa datie. APPLICANT ~~ DATB OWNER TTFl ' 'hurt -- ; ( tall stag on this foam are tone to the best of my (our} knowledge. I {we) am (are) the owner(s) of ~ by virtaee of a warranty deed rcemded m >>er of Deeds Officx. • 'DATE ; F Al'PLIGANT t r~wokedby fire Zoning Dew- *'"*" **«~*t Any informationdrat is mis-representedmay nsuit in thae sanitatY P~ ~~` Indnde with this application: a stamped warranty deed from the Itcgister of Deeds office a copy of the certified survey map if reference is made in the wanant}- deed . ~l 2~3'iP 361 STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED Daumenl Number This Deed, made between RICHARD 0. STOUT and JANET P. STOUT, husband and wife, _ _____-.~ _ Grantor, and STF.VF.N K. ITOH and DEBORAH A.~._._j.T4~ _..__hu~,b,ind and wi fi?r .. _ _ __ _, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate In St _ CrO1X _ County, State of Wisconsin: Lot 17 Plat of Emerald Acres, Town of ond, St. Croix ounty, Wisconsin, 6 9 7 0 4 9 KATHLEEN H. MALSN REGISTER OF DEEDS ST. CROIX CO., VI RECEIVED FOR RECORD 11-04-2002 11:30 AM WARRWITY DEED EXEMIJyT # REC FEE: 11.00 TRANS FEE: 209.70 COPY FEES CERT COPY FEE: PAGES: 1 r : ,,.., __ ~~ Name and Return Address f Fti ~- ____ .. _ _ 018-1067-10 000; 1067-30-000 018-1067-40-000; 1067-50-Op0 Parcel Idenlitica,ion Number (PIN) This 1S nOt homestead property (is) (is noQ Exceptions to warranties: easements, restrictions, rights-of-way and coaenants of record. /~~~ /~~. /~ Dated this __._~ day of C:/~I~I~/RJ(, 2002 C~~~ ,~ (SEAL) ~ ~ ~ "'~' " - . _ (SEAL) Richard O. Stout Janet P. Stout (SEAL) AUTHENTICATION Signature(s) authenticated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (If not. authorized by §706.06. Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout _ 1353 Awatukee Tr. _ Hudson, WI 54016 (SEAL) ACKNOWLEDGMENT State of Wisconsin, 55. St. Croix ~Coun -~ PersoOrtil~~t~f~~te this ~ day of ~~J% (J /"` 2002 ,the above named Rir•hard n StnuY and .Tanet P. Strut - -- L~.-Tr Nfl~~y iD_~-twGT~ __......_..- W.~YE~C=i tvTJG~'~1.~3i7'~ to me knowyfF~by ~~v~i~.9xeygted the forcgo,ng My (Signatures may he authenticated or acknowledged. Both are not ___ _~ ~ necessary.) ' Names nI persons signing In any capacity must be typed or printed below [heir s4gnahu'e. STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 1998 Stare of Wisconsin ,~~ permanent. {Jf not, state expira ion~latc: 1 Wisconsin Legal ©lank Co., Inc Milwauwee. Wis /( j+ W r ~~ 8 w • na 0 r ,~ W a r: t +.v i f"'" :- a N I~ I I r p Z W ~ H O r W ~ ~ ~ O W 2 ~ J ~ _ +, ~ •I Z S01 °00'43"E 623.00' ~ N ~ N ~ ~' ~ o ~~ -- ~ a ~ ~ ~ !. ~~ ij U V ~ ~ i i i~ 1 '. \\ ~ ~. `!. ~' ti ~~ ti~1~ ~~ ~~ __~~ W O r~/ ~0~ h ~o ~~ r $ o ,,`o a ~ ~~` N GG~b,3~ c~ o0~,_v$v W ~ ~ ~' ~ V~ a W~ ag ~ ~o r ~ a ~ g - °`~ ~ ~ 8 aN ~ r $°D a~ N - - - - I i i i +~ NOO°13'19"E 959.99' r