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HomeMy WebLinkAbout018-2011-53-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division 4~ INSPECTION REPORT GENERAL INF"JRMATION (ATTACH TO PERMIT) Personal information you provide may be used for sewndary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Bast, Kernon Hammo d, Town of ;ST BM Elev: Insp. BM Elev: BM Description: ~ ~"~ r„` /OL7 el.~~,,.J Jul z., -~- b rANK INF[1RMATInN ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic l~J~~ ~ C-~' i ~ ~ v Dosing ar~"RiaTl ~~~ q /~ T~ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD e tlc p ' ~~~ `7`~G ~jl~ ~t Dosing / ~' fit. ~ `_~(`; / .~ I ~ ~ I Aeration Holding PUMP/SIPHON INFORMATION ~~`~~ Manufacturer /~-~ / ~ and l~~ c~ ( GPM Model Number /= TDH Li ft ~,1 'f Friction ~oss ~~ System Heat( TDH ~ ra 1 Ft Forcemain Lengt2 L t / ' Dia. / / Dist. to wen 7 l 1 Z SnIL ABSORPTION SYSTEM County: St. C;ro{X Sanitary Permit No: 463282 0 State Plan ID No: Parcel Tax No: Section/Town/Range/Map No: 30.29.17. STATION BS HI FS ELEV. Benchmark ,o ic~a.~ /e'O Alt. BM G~~ z.a ~'q. ~ Bldg. Sewer ~''~ ~7 ~ SUHt Inlet ~ ~~ / z SUHt Outlet \ ~~ Dt Inlet ~~ Dt Bottom ' 3' IZ ~~ , .~ Header/Man. ~ + 7~ ~ ~ , 6 Z Dist. Pipe 4 , ~1~ y 4 -~"Z- :~. q~ ~~ •`fZ Bot. System ' Final Grade 3~Z ~~ Z St Cover z b ~ 9 ,,~, ~-Z 3 s~ q7-~ .o Y5-i BEDITRENCH Width ~ Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '~ ~ -iii ~~~ 1~ ~ ~ i~ i SETBACK SYSTEM TO P!L BLDG WELL LAKElSTREAM LEACHING CHAMBER OR Manufacturer: _.- L1 . ~ ,(..,,,, ~a ~ `~"""'`- INFORMATION Type Of System: _~ /\~) _ ~ V e ~I ~o1 G~.T~ / ~~ / ~~ c~ ~ '7J J ~ UNIT Model Number: ~.J `"~ fIICTRIRI lTl(1N SYSTEM 27L.~- 7.'7 ,- ~ `~ _- / t Header/Manifold ~~ Distribution x Hole Size cing x Hole Spa Vent to Air Intake /~ ~ ~ ~ ~ Pipe(s) ~ ~ ` ~ \ l . c'. Length ~ Z Dia g Length Dia Spacing --- Sall CnVER v Dro~cnrc Svc4cmc Only YY Mnnnd Or At-Grade Systems Only .Sf r~i r;.~_~_A ~ • v Depth Over / Bed/Trench Center ~ Depth Over Bed/Trench Edges xx Depth of Topsoil ` xx Seeded/S dded ~ Y N xx M ched es No ~ _ ? es o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 787 154th Street Hammond, WI 54015 (NE 1/4 NW 114 30 T29N R17W) Emerald Acres 1st Addition Lot 53 Parcel No: 30.29.17. 1.) Alt BM Description = ~~ G6/ ~~ ~~; ~~ ~ ~~ z--~S c ~'~. 2.) Bldg sewer length = 3 t L (~ I~CX ~ ~ ~ ~,/ l f ~ Jzc~ - amount of cover = ~ ! ~r Plan revision Required? ,Yes No , 1 .2Z ~ f ~ ~ s Use other side for additional informati n- -T 7 Date Insepctor's Signat e Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box T162 •S~ C s ~ - Pa~mit Namber (eo be filled in by ~.) ~~c®ns~n ~) 6~3 (V~ 3 2 b Z- Department of Commerce Sanitary Permit Applicati n S~ Plan I.D. Number ~ D E~ `~ ~ ~ ~ ,~ 4 Code 21 Wis Adm d with Comm 83 P ~ Jro-t Pro I , , . . . n accor may be used for secondary pntrposes Privacy Law, s15. lxm T. , 4 N ~ ~ Address (if different than mailing address) ~ T t U I. Apgliration Information -Please Prunt. AII Information r') , , _ ~ _ ~1 tt~ ~~ 7~ ~T }/ v / ~l 0 Property Owner's Na oie Parcel ~~ ~~ Lot p Block !r .rJ n/ T -~vG -,6r - ,S3 .~ Property Owner's M ailing Address Property Location • ~ 5f.~~i4,Section .~~ City, State Zip Cade Phone Number ~Ll Q /~ Gv,.,L ~ " ~ 6" ~ (circle _ T 19 N; R~~E a~ " (check all that a l ) f B il ~ II Ty p,, pp y pe o n g . S CSM N b ~1 or 2 Family Dwelling -Number of Bedrooms S . um er Subdivision Name It - ^ PublirJCommercial -Describe Use -- ^State Owned -Describe Use "- ~ " - - ^City ^Village ~owitsltip of III. Type of Permit (Check only ot~ boot on line A. Ct>tnplete line B if applicable) A' New System ^ Replacement System ^ TreaanendHolding Tank Replacement Only ^ Other Modification m Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ PetmiE Transfer to New Liu Previous Permit Nnmba and Date Issued Before Expiration Plumber Owner c IV. T of POWTS S (Check all that a ) Q~Non -Pressurized In-Ground ^ Mound > 24 ia. of suitable ^ Mound < 24 in. of suitable sotl ^ 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 Lirte ^ Gcavd-less Pipe ^ Other (ratplain) V. Dis tment Area Information: c s - ' ~/ ' - 3 ' ' rv s Design Flow (gpd) Design Sots Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area (sf) System ElevationG'- ~ ms's ~' Z S O ~ t • ,rm0 ~ / v ~ c- • ~ VI. Tana Info Capacity iu Total Number Manufacturer Prefab Site Steel Fiber Plastic Galkuu Galbffi of Urms Concrete ComlrucLed Glass New Tanks Existing Tames •T f~.EIC -~ /~%1~/ ^. Septic or It~RlRtg~ank 1 j7/ '~' 1 / Aerobic Treatmen Una Dosing Chamber / !t/ . / f' - shown on the attached plans. VII. Responsibility Statt~tt- I, the'imdasigped, assdnte for installation of the POyfPls Plumaer's Na me (Print) Phtmber's Si goatnre •it$'fMPRS Number Busiiress Phone Number Fogerty P[umbmg ~x / 7!-i - 3 - 9`0 p~ Plumb L~"LSD"l~ ~~e' ~P ~) 1 __ 7/S-~3.5 = s 1 ~G ~X Spooner, WI 5480 6Si- ol- 06 vlII. ~o - ~ - Approved ^ D' ~ Pamir Fee (incht~s Gro»ndwater Daee Lssttod - Agent Sigttawre (No Stamps) ^ O 'ven Reason for ~ ~ IIi:. Conditions Ap ~ S ~ ~J1~ ~ S~._-~. Jer-, t / ~~ SYSTEM OWNER: S S ~'~"- t ~ " Q'~ "~~ 1 Septic tank, effluent filter-and ~ ~ __ nn ~_ ~~-- /1~~~ / dispersal cell must all be serviced I maintained ry,~+~yf Z~ S~c~ C~nat.i~,..MS s.,~ ~ `"'`"' ~I °° ~ as per management plan provided by plumber. ~ /~ /~ _ r1 -~i ~ S 2. All setback requirements must be maintained ~~ ~~ ~ Sa,,~o+CS~~ Y'~Q as per applicable code/ordinances. ~~~ terns ~ ~~~ ~ Attach complete plans (to the County only) for system oa pope ant tens roan sus x 11 m es m stze J tid E~v~~~~ ~F r~n,5, ?l ovL~ ,~o/rrv~ .# .z FmvN~ - Sy~r.E~ .~ sysnESN E'4~'U. 1 K~covsr~acr~ F~o~ r~~ $cKt,~JC'. © 3) ,rJ k,~ ~ s osG Tys~'s .~ L~rc',~ rf Brts~ ,s~L . ~. ~ v~,~tt~~ xJ ~O,wv ~ w~~ ,per ~w ~ o w ~or~ civ~5 • F s yrrEs n ~acE.~R ~-- ~ i ~ ' ~vr~: ~~ N,~~ T, ~ ~,,sccr, • , Fogerty Plumbing X221180 28288 McKenzie Rd. Spooner, WI 54802 (715) 635-9609 ~~~ /1 - ~ -OS 78~ ~Sy~` si yot ~ ..'.'.... ': MV .. 1~1Ta' 1 ®~~ ~~.~ LaT # s3 Scd1rE' ! ~ = y0 ~ .~~/ g,,,,, ~ of / ~vL ~~ r vG' 9~~ X _ 11a~~ ~ = F~arvA tmRw~X Rai ~ ~ ?ja/7Sb LO/!!d4 w/t~L7~'%~ -w~X~?L w~LC~ 7 sn ~ /'~ ~y~~,c,- ~F s~5»rA' s ysrFis. = ps ~ Dc~` C - a ivy/ LtdLirs~ y S, D ~ D~~7YF ~ _ 3 /oy L~ivL»~1 qy.8 ~ d~r'`f C~pY -~ ~~ Y ~ '' ~_ _ N ~..,~ ~a ~ ~~T ~~' \. ~ ~ < <~ Fogerty Plumbing X221180 ~ 282£'8 McKenzie Rd. Spooner, WI 54802 (715) 635-9609 ~~~ ~(E~[~/O~v ~~T / ~ - ~.G - vs yo 1 ~l 9• Q ~o~ '~_ Go ~ i~~ t ~ y ~v~ jk-ttE I o ~ ~ .~r I ---, i' I y 0 ~c~xv~ ~cE o~ ~,ys . .7) oy<~ ,l~o/tsiv~ -~# -z FmvuD - S~fr.Em ~ sc/sn~ ~ E~€v. K~-cmivSt'~kc~T~1) Fi~o~ T~~ ~t©r~tnlL', ® 3) ~ cry 7~ s orL j~~ES ~ l~irc~ m~ ,lTrts~ ,sF~ . ~ if v~fiCC~9-~x~ /30~',n1~ c.~~Lc /I~= .cb~/,c o.eJ ,~?oJ'f/ ~'rvDS • F s yrr~`.-~ ~~ - G ?/7 ~ LdT # 53 Sc/l1~' C~=YOB ~¢ ~ vG/ 9~, x = ~.<.~~ ~ = ~a^/1~ CmRx/~ER /ZcD © = /~~;a~7SV cos~do w ft3'L7~1~ -t~~i~7Z ~) wFLC~ ~ ,Sro ~ /•~ ~,,,y ~,~~- sF sys»~'~' S r,STFNT e - f /oa'l~.v~7~/ ys ~ Dc~n~ C- Z ivy L6id~7~f 9s,o' 0~~~ G - ,3 /oy Ls~ivcCN! 9y~ ~ ~~ tior~: puff ~,s~os T, ~ ~x.~. v ~- N ' Wi~cc+ sfi Depr~itmenl of l,.vmmerce SOIL EVALUATION REPORT Payo _L_ ut 3 Division of Sefaty and Bufid'ntgs ' in arx:ordarn,~e wiUr Comm Q5, Wis. Adrn. Cudv - Altadt cvngrlete site p non ~~ 1/2 x 1 irrclros irr size. PMn rnuet ----- --- - vert ca aril Cvunly fidude, hid not flmlted ~ toiizontal referon point (D ,direction and Parr~l LU. percent~rupe, scale o Imonslvns, rtorlh arrow,Mand to ion and d lo~ rest road. - __ _ Pfea~e 4~r~~ti~af~~~rrna nn. /J Levi ©d Uy Uato u ~ ,/ Penonel Inlwmnllon provide mey be used fw secondary Wr oeoa tPrivncy Lnw, ~ A (1 n , ~ `F ProperlyOvnrer ~ NlN OFFICE ProperlyLoca oir R( Govt. Lot NC, 1!4 Nr,~114 S 3~ ~1' 2°i N 12 /~ E (or W r---- Prvperly Owner's Meiling Address Lo Gluck # Sulxl. Name ur CSM// (3 S~ /~u.~oau-keL -Tr. ~3 ~~~ _ l~~c~ l~_Add,-F~o-~ City State IJp CcxJe Plrvne Number [~ ,,,ry ^ Villaye town Fdearest Road ~-~ SG h t W I I ~-1OI (~ I c 7(5 ~S`{R-fez 31 ,r tnn o I-~l o~ C _ (~+ _ T T ew Constructiat Use:~"Resdenliall Number of bedrooms _~_ Crx1o dorived desiyn Iluw tale ___~{~U _~~.(10 __-_ GPU ^ Replacement ,/,,_ ^ Public or cvnunervial - Describe: _____ ___-______ _.___ _________ Pnrent melerial _-fir , ~ ~ __ _ _ _ __ _ ----------- Fkrod Plain elovalion iF aplrlicablrr _-__- - _~[~~_ General crnnrnertts S~Sf 2 v~ 2 ~ Q ~/ . QS Z 6 arrd reconrmendalkxrs: ` ~-~-0~ ~ a .~.~a v~ -...,-_v ~ -- ....-.. ~-~ - ....--- - Boring # ~^ ~Buriny QQ q5 $O t i i l (~~ -- - - - --- - ~ or __ n. _ R. Depllr to Ilnr t ny fac `~Pil Ground surface elev. ___ _ _ _ _ _ ___ Sol Appl'rcalion Rate Horizon Deptir Dominant Color Redox Description Texture Shudure __ Consistence E3oundary Rrxrls GP Ulft' in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. 5h. 'Elf#1 _ 'Eff#2 ( Z o-ip lO-2~ lo;rr312 SOT{-~4 --- s~ 51-. 2r~b~ ZmSbk ~ rrt~r_ --CS-- LS l ~ ~ ~ . (.p . C.o I. ~ 1. b - -- --- of 9`f-~r•~ IZ Boring # ~ Bonny ~g Ground surface elev. g~_ ft. Depth to limitiny factor _ ~ ~ _ in. Sol Application Rate_ Horizon Depth Urxninartt Color Redox Description Texture SLuctuie Consistence Boundary Roots T GP Dlitz in. Munsell Qu. 5z. Cont. Cobr tic Sz. Sh. 'Eff#1 'EFF#2 I 0-ZI ~ o r312 --- s f I ZInS~ m~r _ ~ ~ I ~l . 5 •8 3 Slo I 5/y 5 ~- 2m5.b~ ~r ~ 5 - ~ (- O -- - .a!- ~s ~~ - --- 2 0 - - -- -- Eflkrenl iM1 = BOD > 30 < 220 ng/L aril TSS >30 < 1 rU mylL ' EOluent #2 = BOD < 3U my/L and TSS < 3U mylL CST Narne (Please Print) _ Sic~.ta re CST Number Address Uate Evalualivn Conducted Telephony Number 2,l ~ ~ ~D~ ~. ~a(rnet~ ~ ~ ~,/I ~6Z5 ~~.; ._ ~,-=~-`~ ~---- -- C_~' ~~7(PD_OZ~~1 Properly Owner _~U~ _-__-- 53 Parcel IU i! ~~~_ ~~-"------------- Paye __~ of LJ Boring ; ~ ~ 3 Boring # tY7 1'It Grvu Horizon DepUl Uorninanl Color in. Mansell nd surface elov. _~~ It Redox Descriptron Qu. Sz. Coal Cobr . U Texture _ epUl to Grnitiii~ l Structure Gr. Sz. Sh. aclur Consistence - irl• Boundary _ Roots _ Sul n , lic •EIIlIGPD a6a[ Rate iIFEIt#2 ~ ~ I _ Z 3 b--2~ F~ 5~- t0 2 ~ ~t lu y l~ -- -- G P "1.5 r I Cv ~~ s~ --~5 2rnsb 21~ ~ rr'~c_ ~~~ m l ._~~_ _~-- ,- 1 J~ - _-- _- -~ ~ ~ . _ 1. a _ ~ -- Boring _ I~ Boring # f'1 _ n..,..,,,1 ciuracr, elev- f1. Ue lh Io limitin factor _______ in. -' p g I Roll Annliralinn Rate r i u ru xture T SUudure t'unsislence Boundary Runts GPDlIF Horizar' UepUr in. Dominant Color Munsell Redox Descriplpn Qu. Sz. Cont. Cobr e Gr. Sz. Sh. 'EII#1 'Etl#2 (J Boriny Boring # Ground surface elev. ________ tt. Depth to limiliny factor _ _ ___.___ in. ^ Pit Sort A IicaUon Rate Horfzcxt DepU[ Dome[ant Cvlor Redox Despiplion Texture SUudure Consistence Boundary Routs GPDlfF in. Munsell Qu. Sz. Cont. Cobr Gr. Sz Sh. __ 'Eft#1 'Elf#2 ' Effluent #1 = BOD, > 30 < 2Z0 mglL and T5S >3U < 1511 lnylL ' Etlluent #2 = BOUS < 3U my1L and T.SS <_ 30 nlylL 7 he UCpattntent of Conunerce is an equal opportunity service pavvider and employer. If you need assistance to access services or need material in an alternate fomtat, please contact the depa[Lnent al GO8-2GG-3151 or 'i"I'Y GOB-2G4-8777. sso-uwrrt.orroor ~~ )~ ~oc1 ~ ~ I I'(~r1Ll)I~SI.'IZ11''1~1~)t~!<~1~U~l~li~1,,`~30IZ`~•t`I,It,~~-1:(ut r -- - SCALE: 1"=--.~U----- - -- _ _- - $rn~ ELLVA'I~ION:_ ~QC)__~ __ _ .. Dht 1 UL• SCIZI I' 1'IOIJ:_ ~~_ ~__ ~_ ~~_~-.__~~ t~'~ -_ BM 2 GLEVA'il(JN:-_- R g~- ~---_--_--__ ___._-_.- ~. BM 2 DLSCRII'"I'IOhI: ~ a~_~_~PvG__~'~-~- . SYS'I'Givl LLLiVi\'I'(~)tJ:--- _ °~S • ? ~_ . SYS'I•GNt '1'1' I'1 ~.: ___._ (~Gdl ~_~y~'}~^~?~a ~. r (~ ~ ~ g, \ ~ f~'"" r -• ~ I° 1 -~ L S ~`~{.p ~ ~" ~ /~ ~~,.. - ~ / ~~ ~y 5~ `0 Kjr, ~ t7 ti ~`t ~ ~ ~ '`` ~ ~ ~2~Z • I ~l ~+,,,,~, Z i~ G~T~s3 ~`-~ Combination Tank Component Cross Section Approved Manhole Covers With Warning Labels and Locking Device / 4" Min. Above Final Grade " 4 Sch. 40 Vent > or = to 12" Above Final Grade Inlet Approved Effluent Filter ~ < or = to 1/8" Baffl Particle Size p~ Weather Proof Junction Box Electric per NEC 300 & CONflv1. 16.28 WAC .--, Alternate Outlet Location W/Approved 4" Sleeve _ Force Main Diam. _ ~ " Hole or Anti Siphon Device B ~ I Pump Off Elev. C Tank Mfr. avh I I D Dose Tank Elev. _ Vertical Difference Between Pump Off and Distribution Pipe = _~ Minimum Required Supply Pressure ...................................... _ - o - ~ FT. of Force Main x /. s y Friction Factor/100FT.... _ , qi ~~M) Total Dynamic Head .................... = 7. Z Number of Doses ... _ ~/ Per Day Gal. Per Day/ #of Doses = ~ Gal. Volume of Backtlow .................................................................... = q, gy Gal. Total Dose Volume ..................................................................... _ ~s4 gyGa1. Pump Tank Capacity so Gallons Dimensions Inches Gallons Pump Tank Volume /y is GaUInch A a 7~ 7 ~~/P6 B z 2s°'.3 Pump Mfr. ~maL D s C /i 3 Pump Model .E,a o 4/ D i 2 ~,~ Minimum Discharge Rate = ,3o GPM Alarm Mfr. s -r ~~___ c~crno Total= S 3 7~' y9 Alarm Model i©~ - o~y Bed Tank per COMM. 83.45(5) ~~ Anchor Tank as necessary to negate buoyant forces per COMM. 83.43(8)(g). ~,~ {, ~a v S~ ~~a '. ~~~PumpF~Specificattons ~ ~~~ ~ ~` `~~° Y~~ ; _ i ~~ Up to 40 GPM ~ `'~ ~'TM Discharge size l'/: NPT. ~ ~ ~? "~` Solids: ~~ maximum '~ :-~ Motor ~ - .~ Single phase:115V Materials of Co~lstruction Brass/thermopt~stic Features and Benefits •Top suction eliminates impeller clogging. • Corrosion resistant construction. • Float actuated switch. METERS FEET ' ~ MODEL DVP03 0 5 zo = 5 v 15 ~ 4 3 10 2 5 0 00 5 10 15 20 25 30 35 40 U.S.OPM 0 2 4 6 8 tOm~llO CAPACITY METERS FEET 10 a 8 7 0 ,ai, 6 ~? 5 4 Y 0 3 a 2 ~ °o 0 o z a s i io iz „a,1,r CAPACITY Pump Specifications Features and Benefits '/+~ and'/2 HP • EP04 impeller- semi-open design Up to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seal. Discharge size 1'/2' NPT • EP05 impeller -enclosed design Solids:'/~" maximum for improved performance. Motor • Rugged.glass-filled thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase:115V resistance. , Materials of Construction • Cast iron motor housing for efficient heat transfer, strength, Cast iron Thermoplastic and durability. Stainless steel • Corrosion resistant threaded stainless steel shaft. • Available for automatic and manual operation. - • CSA listed models available: MODEL: 3871 ~o - 25 20 - 15 EPOS 10 EPO4 5 2 0 a o 0 o s o US.IiM All Models are designed for continuous operation and feature stainless steel hardware. ~ . ~ ~ I ~ v. I 11 I • ~ I! LO ~~a1 M II ~ o m~ ~ ~ ~ ,-. ~ - .n ~ 'd I cv ~ cs~ ~' ~ .. ~t ~ - -- 4 y ~ ;.~:-: ~I ~ '~ ~R_ .. '~ ~ cv ~ ~ ~ ~` _ ~ ~ m~ .• ~ r~ III •~ _ :~~ . ~. ~~ _ _. ~ ,~ a :.:_ . ._ . _ _ \ ~., ~ ~ a ~ ~ ° c~ ~ IQ- .. . 1 ._.____ ~ .,y~ .- o .., . Z.~ ~ ~ `~ 0 ~ .E" '~.-.. ~~ I ~ 1*A - - -___ ~~ I~ ~ ~ ~:. ~r- 0 •• O Q~ ^i Q /t~ (~ I~ I~ _ o ~ ,O c `n ~ H POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~'' FILE INFORMATION Owner C~IUON ~~ (, Permit # 32~-Z DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~NA Estimated flow (average) ~ gal/day Design flow (peak!, (Estimated x 1.5) ~ al/da Soil Application Rate al/day/ftZ Standard Influent/Effluent Quality Monthly ave rage* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly ave rage Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity 2S~ al ^ NA Septic Tank Manufacturer ~c.~.~ NA Effluent Filter Manufacturer ~ NA Effluent Filter Model . W ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ~(C. ^ NA Pump Manufacturer l~ ^ NA Pump Model ~ p ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: l A Dispersal Cellls) '~In-Ground (gravity) (^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: A Other: Other: A AAAl111TC1UA111(`C C!`LJCr1111 C Service Event Service Frequency Inspect condition of tank(s) At least once every: 2j ^ ear(>tls) (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ month(s) (Maximum 3 years) ~ yearlsl ^ NA Clean effluent filter At least once every: ^ monthls) yearlsl ^ NA monthls) A Inspect pump, pump controls & alarm At least once every: ^yearlsl ' ^ month(s) A Flush laterals and pressure test At least once every: ^ yearls) Other: At least once every: ^ month(s) ^ year(s) A Other: A MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) 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 cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products•or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the celllsl 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 Isump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. ~ The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code 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. T a o in tank alua ' g ~~ e ai e ~fZp I'6 Tf~T~ ~i2 n/~ ~NS7RUc~1.p~J ~ ~ ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~ ~I~I~I(~j~ fJ Phone q ~, ~3~, I(~ ~ SEPTAGE SERVICING OPERATOR (PUMPERI Name `~ Phone This docume t was drafted in compliance with chapter Comm 83.22(2) POWTS MAINTAINER Name ` Phone ~ LOCAL REGULATORY AUTHORITY - Name S-~-, ~ ( bUtil ZD/l){l~Cl Phone .-]lS- 3~(p- (p (~ (b)1111d)&If1 and 83.5411), 121 & 131, Wisconsin Administrative Code. . ~ST CROIX COUNTY " SEPTIC TAI~IC MAINTENANCE AGREEMENT AND .OWNERSHIP CERTIFICATION FORM OwnerBuyer __r~"sr.~.t1~'it~ ~,~sj Mailing Address ~ ~p /~rr,r ~ /,l~~,r/ w,~ YO/~ Property Address 7 ~. (Verification required from Planning Department for new City/State _~!~/~,~, c~ Parcel Identification Number _ -~ ~ LEGAL DESCRIPTION Property Locations ~/,, ~ y,, $ec.30 , T 19 N-R /Z`VV, Town of _ d~,~riway~ Subdivision ,~,E,c,,yr,~h ,y~,~ ~ -s'` ,Lot # S3 . - Certified Survey Map # Volume ,Page # _ Warranty Deed # _7G6 ~ pi Volume 2s9 > ,Page # 3~ Spec house ^ yes l~'no Lot lines identifiable ['yes ^ no SYSTEM MAINTENANCE Improper u~ and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out tbe 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 master plumber, journeyman plumber, restricted plumber or a licensed pnmiper verifying that (I) the on-site wastewater disposal system ~ ~ PmP~ operating condition and%r 2 after ' () inspection and pumping (if necessary), the septic tank is less than I/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration data S AT[JRE O APPLICANT - ~ ~ DATE OWNER CERTIFICATION I (we) ccriify that al! statements on this form an true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the p rty descnbed above, by virtue of a Warranty deed recorded in Register of Deeds Office. SIG ATURE OF LICANT 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 .0 2~9~ P 30Q •• ` ' ~ STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number WARRANTY DEED This Deed, made between Gillis Farms Inc Grantor, and Ke_rnon J. Bast an-,51 Richard O. Stout, te~}ts in common a~ to y4 intefest egch Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): NW '/~IW '/,, Except Certified Survey Map Vol. 14, page 3829 and also except Certified Survey Map Voi. 14, page 3829 and also except Certifies Survey Map Vol. 14, page 3967; NW '/~ NE i/., NE'/. NW 1/•, All in Sec. 30-T29N-R17W. St. Croix County, Wisconsin RETURN TC1: METRO LEGAI SERYlCE5,1NC. CViINNEAPOtIS, MN 55401-3211258 ~44etro Legal Services EDIRfs'I' 4339?1 A 3717744 t~'D ''902=16 18-lOti6-60-000:18-1066-90-000:18-1067-00-OOo Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties; Easements, restrictions and rights-of--way of record, if any, Dated this I ~ day of June , 2004 * Gi Farms Inc. ~ l~Cfi+^,o rvs, By: * td ~ _ ~ Y~ ~ ~ _ ~ -. -- -- -, * AUTHENTICATION Signature(s) Gillis Farms, Inc. By: authenticated this f ~ day of June , 2004 '~ Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.Ob, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Krishna Ogland Hudson, WI 54016 f (Signatures may be authenticated or acknowledged. Both are not necessary.) STATE OF Recording Area ~~~~~~ KATHLEEN }!. kALSH REGISTER OF DEEDS ST. CROIX CO.. MI RECEIVED F'OR REGARD 06/16/2004 01:20Plf MARRAItjTY DEER I:XElIGT lk REC FEE: 11.00 TRANS FEE: 3300.00 COPY FEE: CC FEE: PAGES: i ~' ' ~~ Name and Return Arktress ( C` ,.~ ~~v ~tvf ACKNOWLEDGMENT ---- ) ss. County ) Personally came before me this _ day of the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. : ; Notary Public, State of _ __ _ _ _ _ __ __ _ ' My Commission is permanent. (If not, state expiration date: .) Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WLSCONSIN WARRANTY DEED FORM No. 2 -1499 Information Professiomis Co., Fond du I-a , W I 800-655-~OZ l ~ _ _ : 86,5yU ,W. t I. '", L.B.O. - 1045.80 ~ ' ' ~ 8 I LOT ~ ~ ~ LOT a6 .2.00 P Ne9°48'08'E 434.35' 08 ACRES 2 87 181 . , 90,534 SD. FT. L.B.C, = 1053.50 Na9~asar i i ~ ~ LOT a2 ~ ~ ' $ 33.aa 39.D0' "$ 2.00 ACRES FT 125 S0 87 ~ ~~ ~~ . : , . ° ' Z ~ N89°45'02'E 188.92' 45 N89 ~ ~' ~ ~ ~ ~ ~ t : ~ L46 - N 8°47 'E ' 434.35' v 4, , 217.21' 3 ~+, I __ _-• 1 ,~ ~ 49 ~" -- ~ w ~ J ~~15' Z ~ ~ 15~ ~ ~ ~ I LO ~ 100' j 1.97 ~ • _ ~ ~ LOT as ~ , ~ ~ 85,91 ~ LOT a3 LOT a4 ~ 8 2,00 ACRES ~ ' ES 2.00 ACRES ~ ~ 87,125 SD. FT. r T 87,125 S0, FT. ~ ~ 87,124 SD. FT. g ~ ~; ~ ~ ~ Z Y ' ~~ ~~ ~. ~, ~. i ~ ; y~~ ~ \~ ~ c ` 1 ~ i ... ....... ... ............... \ ~ ~ .... ... .................... .. ......... ~ 9\ j~\ 4 S~~ ~ n~ $~ .X Z \ \ ~3 ~ ~3' 3~ p ~~ 2 ~ ~ ~ ~ . L- -- -- -- -- -- -- -- 217 14' _ _ - -~ -~ ~ X7.21' -- _ _ _ -- - 111' oa -- -- - . 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