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026-1167-15-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No C GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: 7 City Village X Township Parcel Tax No: Marek Construction, C/o Todd Marek Richmond, Town of 026-1167-15-000 CST BM Elev Insp. BM Elev: BM Description Section/Town/Range/Map No 27.30.18.1317 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER t CAPACITY STATION BS HI FS ELEV. Septic y. 3 Benchmark , Alt. BM $r S Aeration Bldg. Sewer Holding St/Ht Inlet y 7 G~, TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. i Vent to) Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System O ~ PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover 1 GPM .~s/• 37 Model Number I~• 4,T 7'L/• TDH Lift Friction Loss System Head TDH Ft µ4 _ Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM t, BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth r DIMENSIONS - SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture, 4 cT L INFORMATION Type Of System CHAMBER OR it UNIT Model ~Number d 4.~.. ~ ' t', ?j' ~ rf' ~ 1 ,p-`C` Ca'AJ • CJ~ r ~ i`rJ DISTRIBUTION SYSTEM Header/Manifold tj TDpt,s(islbution x Hole Size e Spacing Vent/to Air )ntake LengthDia ngth Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil IS Yes L No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1393 126th Street New Richmond, WI 54017 (NW 1/4 NE 1/4 27 T30N R18W) Lundy's Preserve Lot 15 Parcel No: 27.30.18.1317 t ~ 1.) Alt BM Description i 2.) Bldg sewer length amount of cover = 47 0 Plan revision Required? ❑ Yes No u ] w Use other side for additional information. Date Insepctor's Signature Cert. No SBD-6710 (R.3/97) i Pow 4,eP ~`z YAA q (v 320 L pQ v~ ~r 1 CV~Af~ r ~i Q c LL, vi ~U Soil Test Plot Plan Project Name Environmental Holding L.L.P. Shaun d Address 706 19th St. S. Hudson Wi 54016 G M #226900 Lot 15 Subdivision Lundy's Preserve Da 5/24/004 N 1/2 NE 1/4S 27 T 30 N/R 18 W Township Richmond F ~ Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation 79.0/78.5 - * H R PSame as Benchmark Alternate Benchmark Top of Survey Iron @ 96.0' B.M. Alt. B.M. 320' Property Line 300' B-3 40' 83' ` 30' 10' ' B-1 100' Property B-2 Line / 5% 8 } Slope A Please note:Soil test r" was done to satisfy county zoning requirement. Soil Scale is 1" = 40' test may not be unless otherwise suitable for owners desired building noted location. Property Owner Parcel ID # Page of 1131 Boring # Boring Pit Ground surface elev. q 35, C ft. Depth to limiting facto 12-0 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 °10 vx r y -710 Boring Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 s r f l ~ F J _ Baring F-1 Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description- Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 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. SBD4310 (8.6/00) Soil Test Plot Plan ' Project Name Environmental Holding L.L.P. Shaun d Address 706 19th St. S. Hudson Wi 54016 M #226900 ~5124104 Lot 15 Subdivision Lundy's Preserve Da N 1/2 NE 1/4S 27 T 30 N/R 18 W Township Richmond 4 Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post System Elevation 79.0/78.5 *HRPSameasBenchmark Alternate Benchmark Top of Survey Iron @ 96.0' B.M. Alt. B.M. 320' Property Line 300' B-3 40' 83' 30' 10' 446' B-1 100' B-2 Property 5% 81' Line Slope ~k 1110 v Please note:Soil test was done to satisfy county zoning Scale is 1" = 40' requirement. Soil test may not be unless otherwise suitable for owners desired building noted location. i t VO~. County ECE' V E J ° Safety and Buildings Division 4 C p~ v _ r ID S 201 W. Washington Ave., P.O. Box 7162 Sanitar) Permit Number (to be filled in by Co.) Oil 1 MAR 0 Madison, WI 53707 2 G Q ~j CfaUNTY V, ST. CROIX scot COMMUNITY i ary Y"Tl rmit Application teTransactionNumber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), State. j 41 z 1. Application Information - Please Print All orm ll ( 10 Property Owner's Name Parcel # u ~ .3 0 Z6-1(t 7- _-~ov Property Owner's Mailing Address Property Location `7 0 2 Govt. Lot , 13 1 City: State Zip Code Phone Number kJ Section Z I / J J / )'7 7 Z U T N; circleE 3C ff) IL Type of Building (check all that apply) Lot # $4 or 2 Family Dwelling -Number of Bedrooms Subdivision Name Block # U. N yf t2 5 ~G2(/E ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of ❑ State Owned -Describe Use NCZA--ca W1 go =Town of f h(- ~1'l o ti~ 3 b~- Zo+-w~- e r III. Type of Permit: (Check o thy one box on line A. Complete line B if applicable) 26 A. XNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ~ Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner S ' l? Z -7 / om onent/Device: Check all that apply) IV. Type of POWTS Svstem C .Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ ther Dispersal Component (explain) ❑ retreatment Device (explain) V. Dis ersal/Trea ent Area Information: !Design Flow (gpd) Design Soil Application Rate(gp Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 7 J f Z lrv Z GrZ> 7 7 7 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units i U New Tanks Existing Tanks o w °n C~ c U v 5.5 Septic or Holding Tank (A) Dosing Chamber ! vn ~L ) VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the PORTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MPIS Number Business Phone Number r c r y ,z, Z Z(, 273 f ~Y9 9' PlumberAAddress (Street, City, State; Zip Code) l~ ( L_ (,,v 1 ~i 1 1 VIII oun /Department Use Only Permit Fee Date Issued Issuing nt Sign re Approved reapproved $ " ` ^x iven Reason for Denial 5 ` 6 GJ 1 b a IX. ConditAW-"t*Reasons for Disapproval 7 .,~~1_ 1. Septic tank, effluent lifter and dispemiii cell must all be services / rnaintainec' rte" a as per management plan pro~iided by plumber. W1 2. !1 setbeGlc requiter tents mast tie rlairttKired as per apple able code / ordinanm. Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in sue SBD-6398 (R- 11/11) County Safety and Buildings Division R ( x 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) SP' K Madison, WI 53707-7162 OFs,oN~~ State Transaction Number Sanitary Permit Application in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary /39-15 12-4 A, purposes in accordance with the Privacy Law, s. 15.04(1 m , Stats. 5 1. A lication Information -Please Print All In mat* Property Owner's Name Parcel # Property Owner's Mailing Address Property Location / © gU ' ZZ- Govt. Lot (15) W. Lz~ ~ AV t~ C/i~tyl, ,S/tate J I / I~ ) Zip Code Phone Number (circle section ~Z 7 v l:. W R 169me t4 b U) 1 01 -7 Ph `15-- 3 z z_ z- Iv T / N; R c E on& H. Type of Building (check all that apply) - > Lot # / Subdivision Name 1 or 2 Family Dwelling - Number of Bedrooms Sr P/ L/~~► d~ /F 2 L S y~ V r^' Block # G El Public/Corrrmercial -Describe Use vlZ 7,92014 ❑ City of C C ❑ Village of ❑ State Owned - Describe Use I ~DEVF~OR Town of I G -1a ,al Q III. Type of Permit: (Check o y one box on line A. Complete line B if applicVOnly 'ANew System ❑ Replacement System ❑ Treatment/Holding Tank Rep❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Ch g f Plumb t ransfer to New Before Expiration 4V- T e of PORTS S stem/Com onent/Device: Check t W^ply) w5 -Non-Pressurized d In-Ground ❑ Pressurized In-Ground ❑ At ade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVTreatm t Area Information: Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (sf) / System Elevation 7 ✓ zv~ 1 Z.vv f~ 7TS U '77 -5 VI. Tank Info Capacity in Total # of Manufacturer Z Gallons Gallons Units n ? °o New Tanks Existing Tanks D ro 2 n n L U c. Zw lOd Septic or Holding Tank -2 Dosing Chamber D o t VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MPS Number Business Phone Number bo L~r~ AJC-Lsvj 226,19 7 715 - 273 Plumber's ddress (Street, City, State, Zip Code) w t a County/Department Use Only Approved Disa Permit Fee Date/Issue Issuing A t Signature S 3 Own e`u Reason for Denial 11 / IX. CondilyJ'h+takReasonsfor Disapproval 31 f~✓r~ ~J_/ ~O ~(d✓~ ~1G•-✓ °i""¢-°`^~ 1. Septic tank, effluent filter and J k~ ' a ego , r / ' (,t~- S tea'` TP..tia ce, ^`a~f~• dispersal cell must all be services /-maintained as per management plan provided by plumber. 2.. Alf Seftck requirements must be;maintait)ad as Per aflppliCable Code / ordlk- 41CE8. Attach to complete plans for the system and submit to the County only on paper not less than 8 112 z 11 inches in size SBD-6398 (R I1/I1) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Q p 1-gA-e2 I Owner's Address: 110, 0.4~r1( Z Z;5 , Legal Description: /l1 Y 2 AJ, C:::. f1,q 5~ z 7 f 3U / Township: "Oe rJ County: 5,t C LLD J Subdivision Name: L r,,(./L)0 y /I ~,f--tz V Lot Number: l j Parcel ID Number: Page 1,' Index and title /U C;a_ u ~ct-Z:5 U Page 2' Plot Plan , TJ`}~t.,~C Crtv~sl S~~ Page 3; System Sizing & Cross-Section (`tr ; Z ra 4Ar CLk Page 4 Filter Specs ~ Page 5! Maintenance Information Page 61 Management Plan Page 71 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 91 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: a~'IL ~C[,License Number: - - Date: 3-- L 7 fey Phone Number Z? 3 K Y K,5z- Signature Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 t~ . ~io 1 z l.a~ 1 ~~NCrs P tM0C P,L-+ (v si k SS Co,jg'4` ~~kf s J 3a " 8s 1~ Soil Absorption System Cross Section f--- ft 7 i ft 4" Schedule 40 Final Grade PVC Vent Pipe 7 `l With Vent Cap ? 7 ft 7 7 7 Leaching Chamber ~ ft System Elevation - ft ftft Soil Absorption System Plan View So ft aft { i i1 ft Leaching Trench 1 Chambers 4° Dia. Trench 2 Vent Or Observation Pipe Header T rench 3 E Leaching Chamber Specifications Manufacturer And Model J AJ f-I C ¢-a &R &U4 e Ir r /C EISA Rating.. ZV_ sq ft per chamber Soil Application Rate gpd/sq ft gpd Design Flow Soil Application Rate +O EISA = v Chambers 3 rows of ® chambers each. Page of 41111C z~ewnes A 00V300/600m,, I! The original ZABEL® Disc Dam Filter was patented in 1959. The 12" series filters have been filtering wastewater longer than any filter in the wastewater industry. In 2000 Zabel made the best even better by introducing a complete redesign of the original with more great features and finer le ql\s of filtration. A 100-12TH Series The A100-12 is the commercial filter chosen by more engineers and installed in more localities than any other filter on the market. The reliable performance and flow rates from 3000-6000 gpd allow this filter to be utilized in almost every application. The new ZABEL Versa-CaseT" is available with built-in reducer and outlet hub that accepts either 4" or 6" SCH 40 pipe. The A100-12 Series is also } popular in many areas for residential use due to its high quality effluent and large capacity. Independent research has shown the A100-12 decreases TSS by 50-90% r a * and CBODS by 20-40%. Filtration Available lengths 20" 28" & 36" ka t >r ~ t <y qFf~ ~ I w s § r 'ac ya°t`~i {.4Cc tam 'g'ay A300-12T M Series ° µg y~ Yd s ' rr Long heralded as the ultimate grease trap filter, the A300-12 provides 1/32" filtration and has been shown to reduce FOG by as much as 50-98%. The A300-12 is w also used for onsite wastewater systems which require x:t .t , a finer level of TSS removal, such as laundromats and 9 J 1 wY aw* dog kennels. As with all ZABEL Filters extra filter r cartridges are available to speed service time and allow offsite cleaning of the used cartridge. VVr I{~ y 3 1/3Z Filtration x ~2 ~,ti w~c~vEsa ~ aAvailable lengths 20'; 28" & 36" A600-12TM Series d' The newest addition to the ZABEL Filter line incorporates the proven performance r a~ x, of the disc dam design with the finest level of filtration available on the market. KIMThe 1 /64" filtration of the A600-12 provides optimal filtration levels for those 4 x F. unique applications with very fine particulates and suspended solids. Every A600- ~12 Series filter includes the exclusive SmartFllter® Alarm switch to alert the owner y u " fir. of required maintenance. yyY,, t 1 J,}~rl k~ .,,a , 1 ~64 Filtration For further technical information. ~Available lengths 20", 28 & 36 ..x` 3 www.zabeizone.com 050103-244 POWTS OWNER'S MANUAL MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS. Owner Septic Tank Capacity O al ❑ 1 ' Septic Tank Manufacturer ❑ t Permit X Effluent Filter Manufacturer Z /-t ❑ f DESIGN PARAMETERS ❑ 1, Number of Bedrooms ❑ NA Effluent Filter Model -/00 ❑ NA Pump Tank Capacity U al ❑ r, Number of Public Facility Units Ck' G"i *icr,i` Estimated flow (average) al/da Pump Tank Manufacturer 1%j - Design flow (peak), (Estimated x 1.5) C gal/day Pump Manufacturer c ai o ❑ N s Pump Model ❑ N Soil Application Rate b _`7 al/da /ft ❑ N. Standard Influent/Effluent Quality Monthly average' Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (SOD.) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) S1 60 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NI Biochemical Oxygen Demand (BODE) 530 mg/L X In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA [3 At-Grade ❑ Mound Fecal Collform (geometric mean) 510` cfu/100ml [3 Drip -Line ❑ Other: Maximum Effluent Particle Size Yin die. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: p earth(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume ❑ NA Inspect dispersal call(s) At least once every: 3 ® year( s(s) (Maximum 3 years) ❑ NA month(s) Clean effluent filter At least once every; /01 ❑ ® earls) ❑ NA ❑ NA 1 -7 At least once every; 3 1 month (s) Inspect pump, pump controls & alarm Flush laterals and pressure test At least once every: ❑ month(s) *3 ear(s) O NA Other: At least once every: 11 month(s) 0 NA Other: • ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calls shall be made by an Individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintalner; Septage Servicing Operator. Tank inspections must include a visual Inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent qn the ground surface. The dispersal call(s) shall be visually Inspected to check the effluent levels in the observation pipes and to check for. any ponding of effluent on the ground surface., The. ponding of effluent on the ground surface may indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y,) 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 th~,servicing•of effluent filters, mechanical or pressurized components,.pre;reatment 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. GMW (4/01) cal START UP AND OPERATION For new construction, prior to use of the POWTS check treatment al cell(s)for If highrconence of centra tons rare ctsetected ha~ehtheccont nt that may impede the treatment process and/or dphordto use. • of the tank(s) removed by a septage servicing operator 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 b sch discharged to the dispersal cell(s) in o contents of the pump-tank removeddby may result In the backup or a Septage S rvicing Operatorfpriortlo restoerin~ effluent: To avoid this situation have the power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t 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. dental perforance and -p of gi t ec life of fate Reduction or elimination of the following from the wastewater stream may improve the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degeaseerherbicides; floss; diapers; dimedications; oil; foundation drain (sump 'pump)' water; fruit and vegetable peelings; gasoline, g 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:- -0 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 now soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be Installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area Is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed In place following removal of the b)omat 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 ASEPTIC, 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. i ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 0 5o-1V Name Phone S - Z 7 3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 7S6A-Jf•v v Name S-7~ CG~o~~C ,/zd^J/"LJ Phony 2 7 3 5-57 Phone T 6 Q This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.64(1), (2) & (3), Wisconsin Administrative Codo. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer (D D /,74 ,qatrx 'to Mailing Address C1 jC Z Z /j C- (C 4vtv'✓ 13 3 Le Property Address re_eP - (Verification required from Planning & Zoning Department for new constru t n.) City/State (A) A,(GE{ 13® r JO Parcel Identification Number. ' 7 LEGAL DESCRIPTION Property Location Aj '/S N /4 , Sec. T 7361 N R~W, Town of ~ ( c 0,/A c f2 Subdivision Plat: Lk (fL 5,7 .0 Utz , Lot # Certified Survey Map # , Volume Page # Warranty Deed #(before 2007)Volume , Page # Spec house4yes 0 no Lot lines identifiableX'yes o no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after 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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a w~aranty deed recorded in Register of Deeds Office. J Number of bedrooms 7/ -/lk" SIGNATURE OF APPLICANT(S) DATE * * *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) ~uuu 03!16/2014 20:48 FAX i i' ~ N00'26'46*W 30ZSr ik If ell, i g r i ~i~ ul y~ r to µ ~ !o r w9x "ITT f rEAST -too;44 ' 4 100 ro a v r~ .-t • F _ cC > r b ' 4 r+n ~ E r i r r n'irr" Std " ~Mi"g°, r , rt , : uick4 Piles Standard Chamber Side and End Views U 48" j. (EFFECTIVE LENGTH) - 34"-~ € r a~ Plus. All-ire.-One 12 Encap Front, Side and End Views 11.2" r 13" 8" INVERT 8" IN~ ERT 5.3" INVERT 18.2" l 33" ---I ~4uick4 Plus All-in-Cne Periscope DUICK4 PLUS ALL-IN-ONE PERISCOPE- (360'SWIVEL ) \ OUICK4 PLUS 12.7" INVERT 6 ALL-IN-ONE 72 5n 9„ ENDCAP Quick4 Plus Standard Chamber Specifications Size (W x L x H) 34" x 53 x 12" (86 cm x 135 cm x 31 cm) Invert' Height 0.6", 5,3", 8.0", 12,7" s Effective Length 48" (122 cm) (1.5 cm, 8.4 cm, 18.5 cm, 22,6 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Units"), when installed and operated in a leach"leld of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against delective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights. Holder must notify Infiltrator in writing at Its Corporate Headquarters in Old Saybrook, Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units, (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT ; ' TO THE UNITS. INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE h (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty I N F I LT R A T O R x 'Y does not extend to incidental, consequential, special or indirect damages. Infiltratgr shall not be liable for penalties or liquidated damages, including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. s y s I e rn I n c, Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units: the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing 6 Business Park Road • P.O. BOX 768 the Units; failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation: or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook, CT 06475 terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's installation instructions. 800.221.4436 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.infiltratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. a ~3 Y x r ~ -.~.yai >y zy 3p c~~c~l b~ t i r ~..5r~ 5 < ° r i, ~ c'rt 5,;•~ 4 1t '"~~yEt r x '+'3ts +'r o-~r G" 5 ~t r { ~ r i r 4 d r a~ ~ t 5~ n a~ rY' n2 a~ a tea, TM .fs^ ~~'ar . ~a•'dm`s~z.,rs+~aa'a'+~~,x~a;'~',:M.-aw » U S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,7781; 5,839,844 Canadian Patents. 1,329,959; 2,004.564 Other palents pending. - Inliltrator, Equalizer. Quick4 and Quick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. 0 2009 Infiltrator Systems Inc. Printed in U.S.A. PLUS0510101SI-2 Combinatio.n SeP•r ic--Tank and 1 vQ PLFMP CHAMBER CR055 SECTION AMD SPECIFICATIOMS VEIJT CA?' WCATHE'R Pj 00F JUIJCTIOIJ 50Y 4'C.I. VCIJT PIPC APPROVED LOCKIMC, lTO' FROM OOOIC, MAIJHOLE COVER w1v yv/ARNIsJG <_1~8EL diN00WOR FRC5H CouDVtr ~Nsp 101J PIPE ALP WTAKC r s ~ w / rYt Sz-11 s tt~ G'r-P i ' ~ I ~ le'Mlu. I,LC T PROVIDE I ,AIRTIGHT SEAL. I III ~ ~ III APPROYED JOlul APPROVED JOIMT ZP1$~1 Ftl~~ "i W~C.I. PIPC OR Tank constZrUCtiOII I III I w/C.T. PIPE-~Pj I I I shall comply with ALAR M ILHR 1;3.15 and 33.20 a j i I . I I ou C I I ` OFF 0 CONCRETE BLOCK R15ER E:XIT PERMITTED OIJLy IF TANK MANUFACTURER HAS SUCH APPROVAL~3,~D~ REDOING 51PTIC f 5PECIFICATIOUS DOSE TAWKS MAUUFnCTURCR.: ~1iZ5T--7Z C-ajC IJU/KBCR OF ppiy TA1JK SIZE : ~ ZD y A.LLOIJS DOSE VOLUME f j~L ALARM MA►JUFACTURCR: G SS,ELQ2.O SL(~ 11~ IWCLUDIIJG OACKFI.O7W: Z. OAL~Ot~s r`10DCL IJUMBCR: 10L Nw CAPACITIES: Ac CHCS OR GALLOlJS SWITCH TtiPL: X'1-4 4 _ 8 = z- IIJCHES~OR TL L G~LLOUS PUMP MAIJUFACTURCA: 3 4 6CA ® C; IUCHES OR ,~yZ MODEL MUMDER; L•ALLOU5 D `---tGL~ 1AiCHE5 OR f Z 3' b G,lLLO1J5 SWITCH TYPE: - ~f lJOTE: PUMP AMD ALARM ARE 1-0 6L MIIJIMUM•DI5CKARGE •RArE_;___Z GPM INSTALLED OIJ 5EPARATC CIRCUITS yERTICAL plfFeRUJCC DETk[i PUMP OFF AUO,DI5TRIBUTIOw PIPE.. VEF,T'ICAL DIFFER r /'""'MUM NETWORK SUPPLY PRESSURE FEET FEET OF FORCE f1AIN X f o fLFRICTIOU•FACTOR.-I FEET TOTAL OyQAMIC HEAD l FEET As per,manUlacturer gal/in.