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HomeMy WebLinkAbout018-1098-23-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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: City Village X Township Kem en, M ron Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: /~ boa (3~y1 I G5~' TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ ~ ~~r /'Z,,~ ? S~ Dosing Aeration Holding zc/ba.~ ~ . r oG+ TANK SEf BACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~V ~T r, , -~-ZS t ""ZL Dosing O"s ~J, ,~ oar ,.- ~~ , ^~.: r._ - Aeration Holding PUMP/SIPHON INFORMATION Manufacturer nn Demand Ve•wt 4~5 GPM Model Number EPOS 3Y.y~L TDH Lift Friction Loss System Head TD Ft ~ o• ~ b 3 •a~s y.5 ~ ~~ .Sq Forcemain Length ~ Dia. Dist. to Well 15 Z. o Nor : i•-- SOIL ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: 453380 0 State Plan ID No: Parcel Tax No: 018-1098-23-000 Section/Town/Range/Map No: 30.29.17.830 ELEVATION DATA -7,35' * $. 1 1 S,'•/S STATION BS HI FS ELEV. Benchmark ,,''''ii 9$•5 ~d6 Alt. BM tjp, 9.4-~ ~jo.'11 Bldg. Sewer 9. ~j~i p, St/Ht Inlet ~~. ~~ ~ Q a~ St/Ht Outlet ~ ~ ..~, Dt Inlet \ Dt Bottom ~ S y v ( ~ 0 Header/Man. 5 •Zq Dist. Pipe ~ t S S.ZS- G'~ t f , ~ a "t Bot. System w+ Ya o~ ~~ •O~ C' 2'" 7 Final Grade st Cover 7 ~5 ~3. D Go~.~-a,X ~~ s~ S.at~ ~3 . ~c~ at„~~t t cS-r o.2 Ivo.Z /ov.c~ ~~L BED/TRENCH Width ~j Lengthy No. Of Trenches ~ PIT DIMENSIO S No. Of Pits Inside Dia. i uid Depth DIMENSIONS ~ ~co~ 1 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM L IN Manufacturer. INFORMATION CHAMB T Of S ype ystem: /L'l ~ ~OJ ~ 5, , V N o-r K R IT umber. v ~... - . r DISTRIBUTION SYSTEM "eJe.~ Header/Manifold Distribution ~j x Hole Size raj x Hole Spacing ~ Vent to Air Intake ,. Length .3 Dia Z. Pipe(s) 0' Length `rt rl .2 Dia / • S Spacing 3 • D • t r'` , ~ 3. - SOIL COVER z Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center I ' Bed/Trench Edges I ~ Topsoil ~l Yes L] No Yes _~ No C~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / ZZ/.~ ~ Inspection #2: 4 / Z3 /~ rI0k1 ~~ (r:r~- ~btr 1 Location: 755 154th St Roberts, WI 54023 (SE 1/4 NW 1/4 30 T29N R17W) Emerald Acres Lot 23 Parcel No: 30.29.17.8~3/0 1.) Alt BM Description = S.,c (K~ W Q-1` ~,a cr,.J-~ o~ Nom` ~ ~ "S' ~ ~c ,~~ h/ ~~ 2.) Bldg sewer length = ,~7 ; ` ~ OcJ~- set-~,~ ~ ~, t~ -amount of cover = ~ ~ ~ecSJ t -, ~---- - - -- ~ -- - _ -, ,--- ; --T~~ -, No I Q ~ L~ ///~ I~ Use otherlside foruadditional in Yes ~ ~J - _ ~ - _- formation. _~ ~~ O i i' ' 1.~(~' Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) ,~ ~] ~ ~ ~ (~ r _ Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 C' !q ~S, ~ ~S~O Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) i r I Department of Commerce (608) 266-3151 Sanitary Permit Application scare Plan I.D. Number persomai infotmadon you provide Wis. Adm. Code In accord with Comm 83.21 Q / ~ T /D =~ , , may be used for secondary purposes Privacy Law, s15.O4(1)(m) _ ,,,_,,, . .._.• M ~ Project Address (if different than mailing address) ~ .~ . ~,~.a „..w_ I. Application Information -Please Print All Formation ~ `' L/ f~ = Z7S 8 ~ , i_ , S S Property Owner's Na me ~ A--~~ ,', i; ! z~. Parcel 11 ~,~ p\ Lot ~ Block H Property er's M ailing Addres j Property Location ~~C 'k,~'k,Section ~ City, State Zip Code Phone Number _ / (circle one) (check all that a l ) ~ e of Buil n T II pp y ~ g yp . eo S Subdivision Name CSM Number L7 1 or 2 Family Dwelling -Number of rooms t . ^ Public/Commercial -Describe Use ~ ~ • ~ ! ~~~ ~'~ ~ ~ ^ State Owned -Describe Use (TO ^City_^Village I~'1`ownship of - •O O. ~ III. Type of Permit: (Check only one box on line A. mplete line A' I~'New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS S stem: (C eck all that a 1 ^ Non -Pressurized In-Ground Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis rsal/Treatment Area Information: Resign Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Retluued (sf) Dispersal Area Proposed (sf) System Ele tion 9 ~ o , ~ . ~ C/ ~ 5~-+~ mo Gvo VI. Tank Info Capacity in Totat Number Manufacturer Prefab Site Steel Fiber antic Gallons Gallons of Units S . j. ~rLr'~~ Concrete Constructed Glass New Tanks Existing Tanks ~L '~ ~~ / Septic o~i~tdC /Z v ~ ~ Aerobic Treatmem Unit Dosing Chamber ~ s., ~ - VII. Responsibility Statement- I, the'ttndersigned, assume responsi ' 'ty for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plu bet's Si gnature -~/MPRS Number Business Phone Number Fogerty Pfumhing ~• ~~ ~ ?jam - ,3„s- _ 9`0 0 Plumbe~r~e~ t~•~it~~tate, Ztp Code) 7/S-lo3.S = .S 1 ~G ~~X Spooner, WI 54$0. 6Si- ot- nd - VIII. Co se Onl - Y70 - L Approved ^ Sanitary Permit Fee (includes Groundwater - S h F Date Issued ing ent Signature ( Stamps) ee) ~ ~~_ .~ urc arge ~ rr ~ O en Reason nial l IX. Conditions of ApprovaUReasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach complete plans (to We County only) for We system on paper not tens tttan aril x i>, mcnes m sue ~ O wv Q r ~ O ~~ o ba ~ °~ ° ~ ~ A ~ M x~ ~ o ~ ~' °- ~_ ° - ran ~ ~ ~~ ~ a~ ~ ~ ~ ~ ~ ~ ~~ ~ o N d n z xt~~' ~ ~ . Q ~ ~ ~ A ~ tP .~' F+ O ~ ''*~ O ~ Q. o o y ~ , o ~ ;b 1~/t ~ ~ ° ~e~ w ~ tie ~ p ~ c~' 3~D ~~'t o ~ f ~ ° ~ ee ~~~ t3 ~ w ~ ~ ~ r o ~ v ~~~~c~ ~° ~'.. (/1 ~ ~ 3 A~ r O`F'+pM\ ~ W ,r~ ~" ~o ~ ±•p ~ ~~ F..3 { ' ~~ ~' ~ ~ ( A~p ~_ O J , ~ i0 ~, ~ r +~' ~ k ~~ o 0 w ~' 1 1 ~ s+ ego ~~ ~ ~ ~, a f~ ;' a o ~. j r( ~ t 3b W ~ c0 Q= b 4 rr 1 \ t~ ~ ! M f .~..~ o0 ti` comrnerce.wi.gov ^ ^ tscons~n .Department of Commerce Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264-8777 www. commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary June O1, 2004 CUST ID No.224059 KEITH E STONER 23220 WOOD CREEK RD SIREN WI 54872 ATTN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/01/2006 SITE: Identification Numbers Transaction ID No.1003861 Site ID No. 684061 Myron Kempen Please refer to both identification numbers, 775 154TH St above, in all correspondence with the agency. Town of Hammond St Croix County SE1/4, NW1/4, S30, T29N, R17W FOR: 4 Bedroom mound system Object Type: POWTS Component Manual Regulated Object ID No.: 959992 Maintenance required; 600 GPD Flow rate; 37 in Soil minimum depth to Iimiting factor from original grade; System(s): Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/O1) 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. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • This system is to be constructed and located in accordance with the approved plans and with the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD-10706-P (N.O1/01). • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD-10691-P(N.O1/O1). • The pressure network is to be constructed in accordance with publications SBD-10706-P(NO1/O1) "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems -Version 2.0" and/or the sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)". 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. KEITH E STONER Page 2 6/1/04 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 may be 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, Carl J Lipp rt Wastewater Specialist ,Integrated Services (715)634-3484, clippert@commerce.state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 ~ViSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Myron Kempen Mound Owner's Name: Myron Kempen Owner's Address: 902 Michealson St. N. Hudson WI 54016 Cell# 612-889-7971 Legal Description: Township: County: Subdivision Name: SE1/4-NW1/4-Sec. 30 T29N-R17W Hammond St. Croix Emerald Acres Lot Number: 23 Block Number: NA Parcel I.D. Number: Plan Transaction No.: Page 1 Index and title Page 2 Data entry Page 3 Mound drawings WT.$. P O Page 4 Lateral and dose tank . • ditionally C Page 5 System maintenance specifications on Page 6 Management and contingency plan Page 7 Pump curve and specifications ~ Page 8 Plot Plan c r DEPARTfiflEie+ o, „oMMERC QN OF SAFETY AND BUILDINGS pIV ar~""'"ra--m~ a g 5 SEE COR SPONDENCE ~~~ ~~ ,,~ ~~~ * ~ KERH Designer: Keith E. Stoner r •• STONE Iceslse (#umber: Designer# 1575-007 Date: 05/18/04 - p.157~horie Ni~nber: (715) 653-2324 Slren, Signature: ~$•.• :'~ ,e Mound Component Manual for POWTS Version 2.0 SDB-10691-P (N. 01/01), and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) Version 3.11 (R. 06/01) Page 1 of 8 Mound and Pressure Distribution Component Design Design Worksheet Site Inform ation (r or c) R Residential or Commercial Design 400.00 Estimated Wastewater Flow (gpd) 1.50 Peaking Factor (e.g. 1.5 = 150%) 600.00 Design Flow (gpd) 3.50 Site Slope (%) 93.50 Contour Line Elevation (ft) 37.00 Depth to Limiting Factor (in) 0.40 In-situ Soil Application Rate (gpd/ft2) Distribution Cell Information 100.00 Dispersal Cell Length Along Contour (ft) _ 1.00 Dispersal Cell Design Loading Rate (gpd/ftz) 1 Influent Wastewater Quality (1 or 2) Pressure Disribution Information (c or e) c Center or End Manifold 3.00 Lateral Spacing (ft) 4 Number of Laterals 0.156 Orifice Diameter (in) (e.g. 0.25) 3.00 Estimated Orifice Spacing (ft) _ 2.00 Forcemain Diameter (in) 115.00 Forcemain Length (ft) 82.00 Pump Tank Elevation (ft) 4.55 System Head (ft) x 1.3 11.50 Vertical Lift (ft) 2.88 Friction Loss (ft) 18.93 Total Dynamic Head (ft) Lateral Diameter Selection in. dia. o tions choice 0.75 1.00 1.25 x 1.50 x x 2.00 x 3.00 x Treatment Tank Information 1250.00 Septic Tank Capacity (gal) Wieser Concrete Manufacturer Note: Sand fill (D) calculations assume a Table 83-44-3 in-situ soil treatment for fecal coliform of <= 36 inches. 6.00 Cell Width (ft) Are the laterals the highest point in the distribution Y network? Enter Y or N If N above, enter the elevation (ft) of the highest point. 9.38 ftz/orifice Does the forcemain drain back? Y Enter Y or N 18.76 Forcemain Drainback (gal) 90.45 5x Void Volume (gal) 109.21 Minimum Dose Volume (gal) 34.46 System Demand (gpm) Manifold Diameter Selection in. dia. options choice 1.25 x 1.50 x x 2.00 3.00 Gallons/Inch Calculator (optional) Total Tank Capacity (gal) Total Working Liquid Depth (in) gal/in (enter result in cell 649) Dose Tank Information Effluent Filter Information 757.64 Dose Tank Capacity (gal) Zabel Filter Manufacturer 16.12 Dose Tank Volume (gal/in) A100 Filter Model Number Wieser Concrete Manufacturer Project: Myron Kempen Mound Page 2 of 8 Mound Plan View 1_ ..................................... ' 1/1~0~B~.'.'.'.'.'.'.'.'.".'-'•'-~-~Observation~Pipe .~.~ ~.Q .-. K. . ....'1 . ... .~. .~...~.~... .B ..•.•. .~. . ^. ..j..•.~. .'. ._. L't. ..'.'~' '. ~'~ .'.'. ~'. .'. _t J - T A I I I L Mound Component Dimensions Down slo a toe extension made. A 6.OOft E 8.52 in H 1.OOft K 7.19ft B 100.00 ft F 9.50 in z 9.00 ft L 114.38 ft D 6.00 in G 0.50 ft J 4.86 ft W 19.86 ft 600.00 (ftz) Dispersal Cell Area 1500.00 (ft2) Basal Area Available 6.00 (gpd/ft) Linear Loading Rate 10.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 95.79 (ft) ~I H ~ ~. . • ..................... 94 teral F Dispersal Cell .50 (ft) La 94.00 (ft) - Invert ispersal Cell ~~~:~:~:~::::: :::::':~:~~~~'~~~'~~:~: ~ Elevation ~' E ~' '~' D '~~~'~'~~:~~~:~:~~~~~~~' -: ~~ ~-: ~ : -: ~ ~-e..-_ .w ._, .__ .:._ . _.._. 93.50 (ft) ontour evafion 3.5 % Site Slope Geotextile Fabric Cover Shading Key ~ a ~ Dispersal Cell See lateral details on 10 ®Topsoil Cap c = 1.5 ft u .•~ Page 4 for number, size, © ""' Subsoil Cap ~ c ~ ~ ~ ~ ~ and spacing of laterals. uall Laterals are e ©~ ASTM C33 Sand ~ 2 / F y q ~-~~ ~ ~"~~' Tilled Layer t ^ 0 A ~ ~ c 0.5 ft Typical Lateral 't~ Lu ~ spaced from the distribution cell's ggrega e 5 v - , li i th t A '* ne n e cen er distribution cell (Ax6). Project: Myron Kempen Mound Page 3 of 8 Center Connection Lateral Layout Daigram Force main connection via tee or cross to manifold at any point. i ~ •=Turn-upm'ball valve or I{X--~IFK+Z I x1231 cleanoutplug Holes drilled on the bottom of the lateral. Number of Laterals 4 Orifice Diameter 0.156 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.18 ft Lateral Length (P) 49.29 ft Orifices per Lateral 16 Lateral Spacing (S) 3.00 ft Orifice Density 9.38 ftz/orifice Lateral Flow Rate 8.62 gpm Manifold Length 3.00 ft System Flow Rate 34.46 gpm Manifold Diameter 1.50 in Total Dynamic Head 18.93 ft Forcemain Velocity 3.52 fUsec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and -~ Comm 16.28 WAC ~4 in. min. Disc~ect Laterals are identic al s Laterals & Force main of PVC Sch 40 per COMM Table 84.30-5 Tank component is properly vented Wieser Concrete Capaci 757.64 Volume 16.12 Manufacturer Gallons gal/inch A B C D Dimension Inches Gallons A 26.23 422.75 B 2.00 32.24 C 6.77 109.21 D 12.00 193.44 Total 47.00 757.64 3" Bedd tank. Alarm Manuafacturer S. J. Electro Alarm Model Number 101-01H Pump Manufacturer Goulds Pump Model Number #3871 EPO5 Pump Must Deliver 34.46 gpm at 18.93 ft TDH F-- Alternate outlet location Forcemain diameter ~ 2 in. Weep hole or anti- siphon device P~off elevation (ft) 83.00 Doe tank elevation (ft) 82.00 Project: Myron Kempen Mound Page 4 of 8 Mound System Maintenance and Operation Specifications Service Provider's Name Tri-Coun Sanitation Phone (715) 386-0114 POWTS Regulator's Name St. Croix Coun Zonin Office Phone (715) 386-4680 System Flow and Load Parameters Design Flow -Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow -Average 400 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1250 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600 ftz Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Effluent Filter Pump and Controls Alarm Pressure System Mound Other Ins ect and/or service once eve 3 ears Should ins t and clean at least once eve 3 ears Test once eve 3 ears Should test month) Laterals should be flushed and ressure tested eve 1.5 ears Ins ect for ondin and see a e once eve 3 ears Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished .~~~~~........ ............... Grade 6-8" Diameter Lawn ~ ~ ~ ~ Threaded Cleanout Sprinkler Valve Box ~ .: ~ Plug or Ball Valve Distribution Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Myron Kempen Mound Page 5 of 8 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01/01) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access 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 a tank or component. Septic Tank he septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at I st once every 3 years by inspection. The utlet filte shall be cleaned as necessa to ensure ro er operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough o 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 continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 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. Mound and Pressure Distribution Svstem No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BODS, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L GODS, 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral lie flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as 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. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal pertormance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: Myron Kempen Mound Page 6 of 8 Page 7 of 8 ~GOULDS PUMPS I Submersible Effluent Pump 3871 EP05 V APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: 'la" maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'Iz" NPT. • Mechanical seal: carbon- ro[ary/ceram ic-stationary, BUNA-N elastomers. • Temperature: 104°F (40~C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: 10 foot standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 foot length, 16/3 SJTW with three prong grounding plug (standard on EP05). • Fulty submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic Semi-open design with pump out vanes for mechanical seal protection. METERS FEET to 9 30 a 25 0 a W s v_ z 0 a 0 7 6 s a 3 z i 0 00 10 20 30 ^ Bearings: Upper and lower heavy duty ball bearing consWCtion. AGENCY LISTING ~' Canadian Standards As9oaaUOn (CSA listed model numbers end in "C" or "F".) Goiids Pumps is ISO 9001 Regsoered. 5 GPM 2.5 FT 0 2 4 6 8 CAPACITY ^ EP05 Impeller: Thermoplas- tic enclosed design for improved performance. ^ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover. Thermoplastic cover with integral handle and Float switch attachment points. ^ Power Cable: Severe duty rated oil and water resistant. s 40 50 GPM ~ o ~ 2 m~lh Goulds Pumps ®2001 Goulds Pumps ~,. ITT Industries Effective May, 2001 ~ 83871 x ..Q o o ~ ~ &~ ~~ ~ ~ ~ o M A ~ ~~ ~ ~ ~• O ~ - ~ ~ ~ ~ ~ ti p ~ ~ N ~ ~ «~.. fn ~. ~ ~ ~ 'b d U trJ ~ e ~, `° ~ u w z x o ~~ ~a, ~ r ~ ~ ~w ~3" ~ ~ ~ u N a~~ b 0 0~ N ~ o ~ ~~~C t~D Q` ~ o "'~ "ye ~ ~ ~ p rror ~ A'~ ° w ~ e~°e ~p~~pD w ~ p ~ co ''-] ~ ~ R --~ ~ ~ II ,~ ~ Cl• ~ a ~_ n~a ~~ 4 0~~ A~ ~~ ~~ ~ti M ~° ` ~~ ~ O '1. >a y ~,, cp "~~~" ~ 0= ?t ~ O ~ Cyr O n ~ ro b A Q tp .,.~ ep ' D ti t,~ W ~ 40 'b 7 \ [~ !rl M 4D N ti Wisconsin Department of Commerce Division of Safety and Buildings (o SOIL EVALUATION REPORT %~~~~ Page / of u~ acwroa~~cc w+u+ wnnn oa, YY75. /1UU1. IiVUC County ~ C y Plan must Attach complete site plan on paper not less than 81/2 x 11 inches in size _ ro K . 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}). ' Property Owner Property Location ~iCJ t~~' -~ Govt. Lot S~ 1/4~w 1/4 S TZ N R ~ ~ E (or)~ Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1~ 3 ~ee T-. ~nme-~tc~ es City State Zip Code Ph~Ioc~n~je Nu~mb~eQr J -7 ^ City ^ Village [y,] Town Nearest Road ,, (~ New Construction Use: ® Residential / Number of bedrooms 3 - y Code derived design flow rate Y 5'L ~G o d GPD ^ Replacement ^ Public or commeraal -Describe: Parent material ~~ ~ ~ Flood Plain elevation if applicabl e ft. General comments 5Y SF~-^^ 2(-C V . , ~d~,Qv7 - ~" , ` _ + ,°:`°7 and recommendations: ~ f-e J ~ ~~n~~ r 9-~~ f:: c :; ~ ~ '~ ,, `. , 'C+~~~~~ti ~ ~' / Boring # ^ Boring °"' ? ~~~' ~~' `~ ~ ~~ t '''-~ / ®Pit Ground surface elev.~y~ /~ 7.`~~4__ ft. Depth to limiting factor ~ ~ ~. in. ~ ~~~ ~~ ,: G oil Ap ion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence u 'ots „'~ , !ftz '~ % ~ ' * in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. , ; E ` Eff#2 I o- ~l l0 r3/2 `-- ~l Z cab ~r ~ ~ '~-~' --- .-~ 5 .8, 2 /l-3~ / 4/y i~l 2m bl r cs - - y _ 3 _y9 ~ / - s ~ bk ~s -- . 5 . u -~~ C~~ ~s ~l~ ~s - _ - ~ ? ~ Z Boring # ^ Boring ^ pit Ground surface elev. ~3~ /~ ft. Depth to limiting factor 3~~ 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 ~ ~ -1 Z I 3 2 ___-, 5J) ~~ mfr ~ s ~' _ • ~' Z i Z -ZS ~ J ; c1 ms ~r ~-5 - ~ 3 - I 4 5 ~. ZrYt r ~~ - ~- Ci P `1. LS I m ~ - - . `7 / 2 _-_--~. * Effluent #1 = BODE > 30 < 220 mglL and TSS >30 _< 150 mg/L * Effluent #2 =GODS < 30 mg/L and T55 < 30 mg/L CST Name (Please Print) ignature CST Number ~ chum~ke,~ Z s33o9 Address ' Date Evaluation Conducted Telephone Number ~1~3 ~p~'' ~_ ~merse~~ ~l ~ ~oz 5 / Z-~~-o ~ ~~~s~2y~-yoo~' f .~ .... ., .. Jul 07 04 08:14p FOGERTY PLUMBING 17156355286 p.l ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSI~IP CERTIFICATION FORM owncr~er ~,~~ ~ig~Q~^•t~ - Mailing Address 9~~ ,~~1,~x}~p ~" ~/ y~, ~{~Qs ~~ ~'~o~~ Property Address , ~ ~ rJ 1 ~ ~ ~t ~ ~ ~ _ ~ / (Verification required from Planning Departmart for new construction) ~"`~"`~ City/State „~®/~~5Z'J'3' ul~ T~~.3 Parcel Identification Number O~~ -/oQ~ ~3~e~9 LEGAL DESCRIPTION property Location ,~~ %,, ~ %., Sec. ~~ . T. Z 9 N-RAW, Town of /fi~i~r.~r/•s~l~ Subdivision ~'~irra7~t) ~Lt'/~S .Lot # ~..T Certified Survey Map # ~~ Volume "'~` ,Page # • Warranty Deed # ,~,,..SG ~ . Voltune ~ ~~ .Page # .sue( Spec house O yes fiYno Lot lines identifiable G]-yes ^ no SYSTEM MAINTENANCE Improper nse and maiatenanceof your septic system could result is its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three yeah or sooner, if needed by a licensed pumper. What you put into the system can affect dre function of the septic tank as a treamaerrt stage is the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form. signed by the owner and by a mastcrplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on site wastewaterdisposal system is is proper operating condition and/on(2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of shuige. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, het+ein, as set by the Departoent of Commerce and the Department of Natural Resources, State of Wisconsin, Certification stating that year septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the t]rree year expiration data. _ ~----_ S~ ,8d 7`/~' ~ ~ DATE / ~ ' RB APPLICANT OWNER CERTIFICATION I (we) certify that all statements on this form are true the property 'bed above, by virtue of a wazranty APPLICANT 'best of my (our) knowledge. l (we) am (arc) the owner(s) of in Register of Deeds Office. ~, ~ y DA'IB sss««* ••••*• Any intortnatioa that is mis-represented may result is fhe sanitary pemsit being revoked by tha Zoning Depacfineat •• Include with this application: a stamped waaaaty deed from the Register of Deeds office a copy of the outificd survey map if reference is made in the waaaaty deed ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSI-iII' CERTIFICATION FORM' Owner/Suyer ~ Zo,t/ ,~^•tJ Mailing Address 9!S ~Lt~cG /~,rJ ~/ ~c~OtQS1 ~~•~ ~' ~/0/ G ~ s ~ ~' Pro~rty Address (Verification required from Planning Department for new construction) City/State .,~%~~r~ cc[~ 5~l-Z3 Parcel Identification Number O~ , /oP~' ~1 S - e~ LEGAL DESCRIPTION property Location ~~' %., ~ '/4, Sec. ~~ , T~_N-RAW, Town of /f/~io~x/•yD Subdivision /='ry::~ "~ ~ ,~" v'~ ~' __ .Lot # ~ •~ Certified Survey Map # ~- , Volwne "~- .,Page # Warranty Deed # ,,,7~7 S'~,6 , Volume ~ c c~ 7 _, Page # ~ Spec house ~ yes fi~no Lot lines identifiable Dyes D no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,.. if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastCrplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on site wastewaterdisposal system is in proper operating condition and/or~(2) a8er inspection and pumping (if necessary), the septic tank is Less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~ ~ DATE SIGNATURE OF APPLICANT OWNER CERTIFICATION I (we) certify that all statements on this form are true to t of my (our) knowledge. the property descn'bed above, by virtue of a warranty dee rded in Register of Deeds Office. SIGNATURE OF APPLICANT I (we) am (are) the owner(s) of / / DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** *• Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Jul 06 04 ll:lla Myron [Mike) Kempen 9526862992 u 2so~~ sss STATE BAR OF WiSCONSti~' 1~ORM 2 - 1998 WARRANTY DEED Document Number , . ~ .~.~_ .- _ -._~-_--... ~..-.=r. __ - .. -.._ _. ._ _ .._ This Deed, made between _. _. RI HARn O CTO f Arid 7AN _T D CTAfjx~ husban~_~d wi~,_ __.,__ _ .~__---..- J~ _ Grantor, ~~ and ~ nnto~.--o- ~r~~}E)ia fir. ~~1"3~£ - -l~sbaa3d-,~-.r - -- ~ ~' _ __- _ ,_ -` -- Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee [he following described real estate In - St Cs011r _. County. Slate of Wisconsin' Lot 23 Plat of Emerald Acres, Town of d, St. Croix County, Wisconsin. ~s~~~6 p.2 KATHLEEN H. MALSR REGISTER OF DEEDS ST. CRUIX C4. , MI RECEIVED FOR RECORD 07/01/2004 01:15P1! WARRAItTY DEED EXEIBT i REC FEE: 11.00 7RAlIS FEE: 227.70 GOPY FEE: CC FEE: PAGES: 1 ~` Name and Fe[urn Add.ess _ yep S'vlc>#'h 2 -~(s z #res t-ft.f.cl So n 1 wr r S~U~6 ~~~~ ~ 3~.RSq 018-1098-23-000 Aarcel bentttlcalpn Number iPIN) This i S CIOt homestead properly. (Is) (is not) Exceptions to warranttes: eaSeRlentS , restrictions, rights-of-way and covenants of record. Da(te~d .thls{~, ,, ~,s,t- day~of ~~~ ay,,~~, 2 ~ O 4 _,__ ,~J ~`-~~°1~-a-.is ~ [ (-~~:"."" (SEAL) r- ~ ~'~~`~ _ (SEAL) Richard n _ ~qLt _ .T~angr P _ Ste r __ ~ __ iSEAL} _._ (SEAL) AUTHENTICATION ACKNOWLEDGMENT ~: Sigr[ature(s) State of Wisconsin. 55. St. CroiX .County /`I authenticated this day of Personally came before me this ~_ t._,~-,~ day of ~~ S+*~ Y , ~nng" the above named t-t? .---- ~. --oi~.^~"t- ~^.~.---- ---- -- - v TITLE: MEMBER STATE BAR OF W15CONSIN ~ i __ to (IT noL me known to be [he person S wtw c:cetul ed lYir. fc[rCgUing authorized by §706.06, Wls. Scats.) Instr C a///nod ackno/w~ledget-the sgmn. THIS INSTRUMENT Wq$ DRAFTED BY 4'h+[d ~ ` f ""~ ~~/ln1 __ Janet P. stout Pamela A. Willman ^ 7 3 5 3 .71, W.~t t1lceP m Y°t vt,.G ~ w A _ 4J'.1 ~ ti.w .y__ "'~~ pbllC - I31xdSOn, WI 5401 6 ~~ Notary Public. State of Wiscomin StatA 01' WISCO11SIf1 My comrNssion is permanent. (1C not, state expiration date; (Signatures may be authenticated or acknowledged. Both are not ? ~i T - A~ _. „) necessary.) ~- ~ ~~ NamK o/parsons signing in any capsclty mux tm typed or pruwea below gx'ir algna[u nf. ~ `~ -~ _ - - - - .- - _. - STATE RAR OF WISCONSIN W~SCOna~n t.agoi aww. Co.. inc. WARRANTY DEED CORM No. 2 - tftae Muwadrpa. Ws. ,~ -- _ _. T ~ ~ ~ ~ , . _ ~ ;_ ~ 1 - ~ ~. ~ 'L ~~ ~- ;4 _ ~ i'` _ ~ f • 1 i • ~ V •` ~ ~ - ```U ~ w T ~ l~, ~ ~ ~ ~ i ~ ~ ~ m '~s i ~~ ~ . _ ~~~ , i 1'% ~, i - I •~ ,i .; v :~• _ • ~ ~ ~ -' '~ j - ~- I x y J ~ ! ~. •• . ~ f .. - f ~./. ` ~ ~ .~ ~ tJG ~ ~ ~ II (•!' I _ - 1~ `J - ~ .f~ ~ ` - _ ~ I.i - r (~ r. r ~. _ ~ .1 C . 1 ~ • ~~ ~~ =_ _ ~ti ~ _ - ~ _--.J~-= _i I~ ' -~- ~ ,~,:~- ;- - - -- __. z'd z66Z989ZS6 uadwa~ (a~liWl uo~RW dZS~40 40 ET ~eW