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HomeMy WebLinkAbout018-2005-11-000 n ~ p l ~ g 'D f) d m ~1 ~ ' j ci W a ?;, i ~~ i ~'~m I 3 "' '~ ~ ~ r: ~ Q 3 e+ ~ N 3 N ~ 1~1 n 3 c ~~ y ° ~~ V ~ ~ O ~ o O ~ I V of a 7 °' a co cn "s ` 1 ° w 0 ~ ° ~ ~ ° ~ °~ 7 N CIS rn f/1 O ~ O C v Si ° a ~ ° W ~ ~ a ~~ N ~ ~ ~ y a y ° ° o c~rrn N ^ a ~ w ~• I OOO~ ''' vy I o ~ ~ ~ o p ~ fN tR V! I o ~ ~ v v v ~ _ ~° ~ ~ a I ~ ~ j d ~ N m ~ m .. ~ 3 °- = .. I ? Z .. i ° C ~ Z I => ~ o > O ° I I o ~ o o ~~~ I y y ° ° I ° C .~ ~• ~ ~ I W ~ v a Z m ~ ~ ~ to o ' y D o A Z T ~ ~ .~ C a ~' 3 ~ I =. .. ~ ~ ~ w I W ~ ~ ~ ~ a ~ ~ .~ Z ~ ~ 3 r. ~ I I ~ y Z I I ~ ~ I ~ I ~~nc~m-+ D ~ m ~° ~ n I m o~ m m a ~ . °°°nn-o ~ c ~, ° i N ~ ~ a~-o o a I ~m °°°' m ~ m3° cn I ny . ~ w m c I ~ ~ mss<o°° ~ ~ ' ° '° ~v~~+,m 0 a o-, Qc m~ A ~~cm~~ `e ~ ~ ~ N ~ N fi N7N O, C~J~O `<" m a~ -°+~ A E ~ ~ ~ W - ~ ~ ~ n O • ~. s ~? p~ O A ~' a ti I I o m A :~ W ~ ~ CN O O ~ C °' ti WISOnSln Jartr.~ent of Commerce Satty and Esui!diny 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)]. Permit Holder's Name: City Village X Township Miller, Sam Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: Ob • D J " ~C ~~ .~ L3 rn. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic o Dosing Aeration Holding TANK SETBACK INFORMATION ~d~,lu-~ ~~ ~'~ ~'~ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~.7 ~ / ~ ! i ~' ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION I Manufacturer Demand GPM Model Number ~ ~ TDH Lift Fr tion oss System He TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ~ r~,(II~/ -~-~-~ DIMENSIONS V 3 ~ SETBACK SYSTEM TO INFORMATION Type Of System: ~~ r DISTRIBUTION SYSTEM :ngth ~ No. Of Trenches ~3 / 6 i h o_l f ?~ ~ 1b5~~ !?g' ELEVATION DATA County: $t. CrOiX Sanitary Permit No: 430467 ~ 0 State Plan ID No: Parcel Tax No: ry D ~ ~~ ~' G ~'z~ Section/Town/Range/Map No: 31.29.17. `~3 STATION BS HI FS ELEV. Benchmark Bm - -2.Za ~ z2v ~ao.a Alt. BM BrM y ('~1'y a~ ~ 3 96•B Bldg. Sewer 7.a ys SUHt Inlet .0 Z St/Ht Outlet 10 3 Dt Inlet Dt Bottom --~ Header/Man.. •t~ I~-.¢ j 2.18 / 00 , p Z ~ a it• ist. Pipe I j,,ea ~ 13 .ES' ~' 8'~3S Bot. System Final GradeSct ~, ~ h: ~- ~ ,~+ /~~ 2 /D/•S 0 St Cover ~ ~ ~ - z,~8 D ~ 6 a.S a 13~~ Z `19.a8' ~{ $ Jy•ibz. IS~t 97•S$ D~ PIT LEACHING Manufacturer: CHAMBER OR UNIT Mn~iPl Numha .-- Header/Manifold ~al ~ Distribution x Hole Size x Hole Spacing Vent to Air Intake i Pipe(s) Lengthia Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over BedlTrench Center Depth Over Bed/Tr des xx Depth of Topsoil xx Seeded/Sodded xx Mulched o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: CJ / 1 / 6_~iyY4( I Location: 1515 66th Avenue Hammond, WI 54015 (SW 1/4 NW 1/4 31 T29N RR 7~~hl~h L 1L 1~~~a r I Nop~3`1.17. 1.) Alt BM Description = -n~ ~.P/1 ~ ~ 10 / C~ r 2.) Bldg sewer length = '2, ~~C ~~ ~ ~m~ ~ ~ b-.~ 6v._. - amount of cover = .~ ~~' 4r_ ~~ i~~ ~~ ,ne / ~. ~-d,...p( P-~p G.~- t3M~ ~"'~" - - --- -- ------ -~ ~ - - - i -- --~ Plan revision Required? ~] Yes No ~( 0 6 _ ~ ~ -_~ Use other side for additional information: C~ ~~ ~ __ _ _ __~J Date sepctor's Signature Cert. No. SBD-6710 (R.3/97) ---- a Safetyand Buildings Division Countys~ C J© 1 x ~ .. ~ 201 W. Washington Ave., P.O. Box 7162 _ ,S~D~S~~ Madison, Wl 53707 - 7162 (608) 266-3151 Sanitary Permit Number (to be filled ili b - / ~~~ ~ u De artment of Commerce ~ ~ C 3~ _ / -- Sanitary Permit Application Sta" Plaa `°. Number ln accord with Comm 83.21, Wis. Adm Code,•paso~nal information you provide n,ay be used Cor sxondary proposes Privacy Law, s15.04(! xm) Project Address tf di8ertnt than manias add: ens; I I . Application lnformatlon - Pleasc Print All lntormat~oa -°-----~~ et -_ ~'FC'F~1~~~" b - ZGo S-//-~O Propeny Owner's Name Parcel fi Bias Sc~,vt c.. ~~~ r .. /' ~ Property Owner's Mailing Address Property l.ocatio , ~y / ~3 ©x `~ i~ / ,.ri~i,ii.,,v,.+. w- ~ .- 1 ~ tcJ ,,~~w r~,, Stctinn 3 Ci;y, State Zip Cod ti:.: ~ ~~ri$Fs V ~ S Q ~ ~ ( ~y~ ~ (/b "~ 7 ~ O G T ~ (N~ R~E l~ W 11. Type of Building (check all that apply) ~ ~ ~1 or 2 Family DwclUng - Number of Bedrooats CSM Nuw~tk; Subdivision Name ^ PubliclComntercial - Describe.Use ,,rte ~~ ~ ~ ~ ~ K~ r`°`~ $-a---~ haw.(oo.r5 '~(-b`~~.-{ ^ State Owned -Describe Use ^Ci ^Villa a Townshi of f~a-wv WO1.~ c~ h'_ 8 ~ P - 3` ~3~ ~ Lt lrs o !ill. Type of Permit: (Check only one boz on line A. Complete Une B if applicable) A. 1i~ New System ^ Rtplacetnent System ^ Treaunmt/Holding Tank Replacement Only ^ Other Modification to Existing Systen•~ - B • ^ Permit Renewal ermit Revision ^ Change of ^ Pemut Transfer to New list Previous Permit Number and Date lssuca Bcforc Expiration ~ Pl ~ Owner ~.~ - I v. [ ypc of YO WI'S 5ystcm: (Clskck all tbat apply) // Non -Pressurized ln-Ground ^ Mound > 24 is of suitable soil ^ Mound < 24 ia. of suitable soil ^ At-Crrade ^ Single Pass Sand Filtc~ 1 Cotsstructed Wetland ^ Pressurued !n-Ground ^ Bolding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ kxirculatin Synthetic Media Filar Ltachia Chatnber ^ Dri line ^ Gravcl-less Pi ^ ', `'. Dis ersal/T'reatmentAreer In ormatlon: ! I '"" .S /• .era Uesign Flow (gpd) Design Soil Application Dispersal Area Req ' (st) Dispersal ed (sq ~ st~rot Elevati "l ~ p0 / ~ ~ ~ } rJv ' ~_ ~ ~ 1'1. Tank Info Capacity in Number Manufnctura Prefab Site Steel Fibcr ?las.: Gallants Galloon ofUniu Concrek Construatd Glass ' Ncw llxiating Tanker Tarr ~~ S:riic or Hol~lin~ Tank r v /~ { ^ 1 Z 4'~-~ " ~. t/' /~ ~.: rook Tn: atmcm Unir ~ ~ Caine{ Chamlr_r ~ ~ ~ I'll. ResponslbUl Statement- 1. the tinders ned, assttnre responslblll for installation of the POWTS shown oa the attached plain. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business !'hone Nuusbtr t Plumber's Address (Street, Ciry, Start, tip Code) jE77 tt ~ t~ ~ ~ ~ ~S v~ ~ `fo/ - I ~ 1LL oun /Dc artment Use 0nl Approved ^ Disapproved ~+~' Peruut Fee (includes Groundwater D~Issu, suing Agen Signer e (: ~ _~s; Surcharge Fee) G~~^ , ^ Owner Given Reason for Dmial 7'1~b ~ 6 lL Conditions of ApprovallReasons for Disapproval ,,,/ A,~ _, ,,, J ~jt SYSTEM OVttr N E R ~ ~ Gt~ yy"'~" I'Y'iriti ~Gn , ~~ ~'~`' ~~~~ 1 Septic tank, effluent filter and ~~ t (~/ / ~l , dispersal cell must all be serviced~aif3ed _ as per management plan provided by plumber. ~ S~'~~" ~ t'%~C1~2 ~.~` ~i~"`~" 2. All setback requirements must be maintained ~~~~ as per applicable code/ordinances. ~ ~~~~ !~ ~~ GL~+~~'~'r'ir' Attach complete platy (W the Couoty nly)~f/or t6c rItem on paper n~ot~kaa~lhaa 81! I I luc6ef la rlxc 5BD-6398 (R. 01/03) - w ~~ l~ ~~ ~~ ~ ~. o~ ~~ ~~ g N ~ O ~~ ~ ,~ -- _ - --- ----- ° U1 V1 0 \ ~^ ~ / ~~ ~~ ~ ~' ~ ~~ ~ ~ ~ ~~ W x w ~.e ~ ,~ • r I~ ~ ~~ o o. ~ ~; a n ~ ~ ~ T r-1 ~ ~c r~ ~- ~ i,' 9 i ~, o n ~ ^~ ~ ~ ~ ~ e ~ ~ o n Z, L -~r-- .~ ~~ S n r\ v ~ a ``~ `1 c.14 o r ~-~~ L ~ ~ d \^V' ~ ~ . ~, ~~ ~,G '~' ,C ~, ~. hl a ~~. ~t ~ '6~ o ~ ~ ~ I~ ~ ~~ ~ ~~ ,lei; `I ~ _ ~ • 'fication ~~ ~ ~ ~~~-~ ~~~~ B1oD~f f user Sped S ~ ~~~~ 9~. ~~ -- ~~~oa S __~ ~s~ ~ oo~ ~~uo 00 c~c~ acs c~c~ .~ o0 iloo~ cn~e« T cnemex 4' Knockout Safety and Buildings Division . County ( C QA C 201 W. Washington Ave., P.0. Box 7162 , f r;, j ,~CO~~,~ Madison, Wl 53707 - 7162 Sanitary P 't Number to be filled in by Co.) De artment of Commerce (608) 266-3151 Sanitary Permit Application state Plan D. Number !n accord with Comm 83.21, Wis. Adm. Code; personal information you provide may be used for secondary purposes Privacy Law, s15.04(lxm) Project Address (if diflereut than mailing address) ~ 1. Application Information -Please Print All Information ..w .. -., ' '" " ~ f ~~ / / ~ JL iw; G ! fG~~ Cr Property Owner's Name T' Parcel # Lot # Block a Property Owner's Mail in g Address - .. ~ y Location op e rt ~ / ~ ~~ ~7 / .' ~ ( ~ ~ 5 % Section %. City, State Zip Code ~ e'Nltwnisfs ~ r ; , , V ~.lO /a / J ~~ ~fp 3 ~ "` Z 7~ ~ T ~ N; R' ~(cE o~) Il. Type of Building (check all that apply) / ^ 1 or 2 Family Dwelling -Number of Bedrooms L/ Su rvision Name CSM Numb~:r ~ ~ C ^ Public/Commet>;ial -Describe ~ G i a•• ^ State Owned -Describe Use ^City_^Villa e~Township of ~~ . ~ 111. Type of Permit: (Check only on bozo 1 ne A. Complete e B If app r able) ~ ~ ~ •• Oe~ - O O `~' New System ^ Replacemen ystem ^ TreatmenUHolding Tank Replacement y ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit T er to New list Previous Permit Number and Date Issued Before Expiration Plumber Owner 1V. T e of POWTS S stem: Check all that 1 Z' E 'l-s.r' ~ L~Non -Pressurized In-('Hound ^ Mound > 24 in. o unable soil ^ Mound < 24 . of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ `Constructed Wetland ^ Pressurized !n-Ground ^ ding Tank ^ Peat Fil ^ Aerobic Treatment Unit ^ Reciroulating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leachin Gha ^ Dri Line ^ vel-less Pi ^ Other (ex lain) V. Dis rsal/Treatment Area Information: O ~ ; • ~ a~ /Css~G-h Design Flow (gpd) Design Soil Ap icati Dispersal Area uir Dispersal Area Proposed (sf) g System Elevation L~ ' ~ ov D • ~ 9 ~3 95 eo VI. Tank Info Ca ity in N acturer Prefab Steel Fiber stic Gallons Gallons of Units Concrete ons ed Ncw Existing Tanks Tanks Scp[ic or Holding Tatilt ~ ~ Q Aerobic Ttcatmctu Unit Doping Chatnbcr Vll. Responsiblllty Statement- 1, the undersigned, ass reaponaib for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) MP/MPRS Number Plumber's Signet Business Phone Number • ~~~ ZZ~o ~~ ~z~ y~ ~~~z ~o Plumber's Address (Street, City, State, tip ) ~ ~ k~ /~ - l ~~O ~ o > ~ ~ ~ Q V11L Coun /De artment Use O Approved ^ Disapproved ~~Y Permit Fee (includes dwater Date Issued Iss ' Agent Signature ( S~anyrs) ^ Owner Given Reason for 'al Surcharge Fee) rn Z 7 V p f r ~~ ~/ ~.~ 1X. Conditions of ApprovaUReasons f DIsapproval ~ ~ ~~ ~ /'e ~ ~ SYSTEM OWNER: 3~ ar, s Ctest~tt ta,' m 1 Septic tank, effluent er and '-"'~~~ ~~~~ ~ ~ dispersal cell must be serviced / maintai~l rovided by plumber lan t ~'~ 1z r/ . p p as per managem ~ ~~ ~ 2. Ali setback requi ments must be maintained 8,~ ) as per applicable codelordinances. C,s.H,~ ~,. ~~ ~~ Cep ~~ .~f- ~~ i ~. ~. t Attach complete plane (to the County only) for the ayatcttt on p~~ no Icaa than 81/2 z l ] inches yp slzc~~ SBD-6398 (R. 01/03) ~ c7 r i h ~,a- ~2- "" ~~ ~~ Kevin Grabau Subject: Start: End: Recurrence: hammond--hidden ranch--soils at #--lot #2(#430466) & 11(#430467)--onsite with Mike McD Tue 11/11/2003 3:00 PM Tue 11/11/2003 4:30 PM (none) ~~ ~~~~~ ~'~ Z~~) ~ r~°'~~s ~f~Z ~ *-~ ~~ ~ 'y wv~` ~o~ ~~ ~~~~ ~~Jb l~~ /~ ~~,~~ n~~ I(.,~ a, d~ ~~\l ~a ~~ 11 l ~ ~~ F-~_-~ t 0 ~~~ ~~_~ ~0 r° w ~9 S~Z° ~~ ~ 1 I 1 ~ ,___- M ' N ~~ (1 e~Y+ __ M ~ O ~' ~~ 4 ~ ~ ~ s `. ~~~ ~ ~~ # .~ W o s N ± 3 ~ '~ a ~~~ ~ ~ n `, ~ ,~,.. Y V T ~ ~ a 3 d _` 4 ~~~ ~ w ~ ~ M ~ \ ~ ~: .~~~ ~ ~ M J M ,~ ~ S .{ M \ v. ~- \ N ~ ry '~ Q ~ ` U o _ 1 ~' _~ ~ ~ : ~ v V1 .`1 _ 4 0 a~ ~ ~ ~ ~I v _ v ~ ~~ ,~^ ~ V1 \ ~ J ~ J~ 1~ ~ 9 'S 3 Z° 9. GN ~ i 1 ~ l ~~ U ~~ ~ M '~ ~~~~ ,M V ~~M .-frSd~~ wrsconsin ~~,t ~ ~ SOIL EVALUATION REPORT Division of safety and Buildings ~ wiflr Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 i/2 x f 1 ,ida~ia~.P,lBrt. taust.,_.__.~ inca,de. but not IhrtfOsd b: verfkal and hodzorttai referon point ~ f10!f"q ~ Paroel ID. pert~nt sbpe, scale or c6mensions, north arrow, and an~~ ra~stt road. Please print ap fnihrm n. 7) ~n `l ~ Personal inrormat,on You Provide may)m used ra sscaMary asec (PLari. s{,t5~s {~ )Ym))- PropertyOwner ~~~~~ R J..1 O (o d ~ ~-y'~. I 1 City - Page _..L_ ~ $~.~'/z~r~~ Date ~~/2. t'C ,(~r,(~1l4 S ,3( T Z Q N R f ~E (or~ Name ar CSIMI# 1-~,ghlancQ 12anc~~,- [~ n Nearest Road ...., ~ ~ w l ~ 5~d~.S i (715) 7~~ sy~(~ {~ -'Y1 Y/1 oncQ ~ 1 S O~~.S~. (~ m vrl~ ® {~, Construction I~Se: [~ Residential / Number Of bedreoms _ ~T Code derived design lbw ram y ~~ ~/D ~ ~) GPD ^ Repiaoement ~ Public or canmereial - Oescrfbe: ~ Parent material ~. T ~' ~ Fbod Plain elevation fi applicable ~ ~ Gerrer~ owruneMs Sys-(-e rh ~e I e v i 9'~', p O and recommendations: ~~ ~~rfng# o Ground surface elev. ~ /' 1 y ft. Oepth to timitlng Tactor _.~--- in. Sol Uon Rate Horizon Depth in. 0-10 Z (o - 3 L~- ptt d B Roots GPOIff~ Dominant Cobr Mansell Redox Destxiptiat (lu. Sz. Cont. Cobr Texture Structure Gr. Sz. 5h. Conshtence oun ary •Eff<f1 'Eff#2 Borfng # ~ Boring Pit Ground surface elev. /C,Y~~ ~ ft. Depth b Hmitrcrg factor ~ in. Sol tbrr Ra Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GPDIft= 'EHfl1 ~~ in. Mansell Qu. Sz. CoM. Cobr , Gr. Sz. Sh. S ~ ~ I 076 0 ~Z - S' V yn r C r ~ -5H loyr ~l _ LS S 111(r~'r C w - , ~ /, Z ~ -r^~~ ~o~,r ~Sl Z - ;Cr - - - - .N ti • Ellkrent #1= 80D > 30 < 220 rnrg/L and TSS >30 < 150 rng1L ' ENklerK #2 =BOO < 30 mgll: and TSS <_ 30 mgK. CST Name (P Print) ~Q azure CST ~ Q m ~ lJYI!1 ` ~ - ~ Date Evaluatwn Conducted ~ elephone Number Address ~ ii ~ ~U~"'.~, ~n-v~o/~~, rel. ,S~/oz~S t~ ~~~ -03 7~s- 7~ d -oZ ~ ~ ~a (I Parcel ID # Ovmer ert P ~~-`i-- ~ ( Page Z of _~ rop y ^ 8ormg Borelg # (~ Grawrd surface elev. ~~r ~ ft. Pit Depth th --+-_-- m' Sob ~ Ra ~ x Consistence Boundary Roots GPDIIf ~~ Depth ~ Cobr Redox pn Textuxe ure Strut •Eff#1 'E1t#2 in. Murtseit t1u. Sz Cont Cobr Gr. Sz Sh. ~ yZ 90 io~i~ ylC~_ - L ~ s 1 ~ 7 ~' ~ ^ Boring # ^ Bormg - ^ Pit ;Ground. surface elev. ft. Depth to linithrg factor in• gp~ Rate Hor¢on Depth t~minant Cofer Redox Description Texture Sdudure Consistence Boundary Roots GPD/ff? Gr. Sz Sh. ~~ ~ff#2 in. MunseB Qu. Sz Cont Color ^ Borg # ~ Boring Ground surface elev. ft. Depth to Igniting factor in. ^ Pit Sod tiort Rate Fiorimn Depth Dominant Color Redox Description Terdrae Structure Consstence Boundary Roots GPDlfP in. Mrnsell Qu. Sz Cont Cobr Gr. Sz Sh. 'Eff#1 `Efli12 E #'1 = BODS> 30 < 220 mg1L and TSS >30 <_ 150 mglL `Effluent #2 =GODS <_ 30 mglL and TSS <_ 30 mgil. The Department of Commerce is an equal oppornmity sernce Provider and employer. If you need assistance to access services or nced material in an altercate format, Please contact the department at 60&266-3151 or TTY 608-264-8777. SBD-N330(R.ONOR) . , PAGE~OF~ T ~~ ~G> (( T OT# ~~ LEGAL DESCRTPTION SCJ ~-U~./~,,5 ~I T Z~ N.R. ~ ~' Elor~ SCALE: I"= 1 U ' BM 1 ELEVATION /G 6 ~ y BM 1 DESCRIPTION ~ Q a -~ ~ ~o~~C ~~`Pt -_- BM 2 ELEVATION ~ S(• ~ y BM 2 DESCRIPTION ~b(~ OS ~ ~~ T~O~ ~ ~~-~. SYSTEM ELEVATION ~`~, G U SYSTEM TYPE ~'U t l U ~ r'l Tr v v~.o. CONTOUR ELEVATION - k .S 0 J~ ~~n0~ ~ ~ ~ 4 6~~ SIGNATURE DATE ~ -/-S o 3 B'^ ~ ~ /&' ~ n F~e~eR- `~teoC ~ ~ ., CI B ,~ r l ' if fuser s ifications B1oD p~ 4 _____~ ~s' ~ c~c~ coo 00 00 00 ~0 °~o o° c~c~ coca oc~ o°~ °c-ov°' o°°°~o°°°OO cn~« coo c~c~ c~c~ oc~ coo o c~c~ ors "~'` O° °o°°c° 1 00 C~C~ CEO ~y 00 OO ~~ C=70 pG~ c:° C:° G~ 0 0 34' 4' Knockout ~ Universal End Cap ~` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _~_ of ~' FILE INFORMATION Owner S.I°r•yv~ yV(. ('~-~. >~,~. Permit // DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) al/da Design flow (peakl, (Estimated x 1.5) Ov al/da Soil Application Rate • ~- al/da /ft2 Standard InfluenUEffluent Quality onthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (RODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size YS in dia. ^ NA Other: ^ NA "Vpfues typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity '~ ZvV al ^ NA Septic Tank Manufacturer ~jE (S ^ NA Effluent Filter Manufacturer ~„ ^ NA Effluent Filter Model _ (gyp ^ NA Pump Tank Capacity al ~AIA Pump Tank Manufacturer NA Pump Manufacturer A Pump Model ANA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: [~NA Dispersal Cellls) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) O Mound ^ Other: Other: ^ NA Other: ^ NA Other. ^ NA MAINTFN~NCF SCHfFr]I II F Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ ea~ls~(s) (Maximum 3 years) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,1 of tank volume ^ NA Inspect dispersal cell(s) At least once every: '3 ^ month(s) (Maximum 3 years) year(s) ^ NA Clean effluent filter At least once every: month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ earls! ^ NA Flush laterals and ressure test p At least once eve ry~ ~ ^ month(s) ^ earls) ^ NA Other: At least once every: ^ month(s) ^yearls) ^ NA other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; 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 on the ground surface. The dispersal ceII1s) 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 IY,1 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and dispo$ed 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 IoCal regulatory authority within 10 days of completion of any service event. Page ~ of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemical that may impede the treatment process and/or damage the dispersal ce(lls). If high concentrations are detected have the content of the tank(s) 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 b discharged to the dispersal ce(lls) in one large dose, overloading the celllsl and may result in the backup or surface discharge c effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorin 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 are 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 th POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fa' foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; of 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 i 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 wit 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 compliar replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptio system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems mu: comply with the rules in effect at that time. ~ A suitable replacement area is not available due to setback and/or soil limitations technology a holding tank may be installed as a last resort to replace the failed POWTS. /~ T rf alua ' b e ai a ~f2 (74.118 i'71~ ~ ~ Barring advances in POWT ng tan p D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at th 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 NO' ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF ~ PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name L Phone ~ ~~, 2 POWTS MAINTAINER Name .Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S , C ( 20~Jl~U~ Phone Phone '~/S"- 3~(P_ (p (~ This document was drafted in compliance with chapter Comm 83.22121(b)(111d-&lf) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer s ~/L~~--~ Mailing Address ~ ~ x'~~S/ ~~ ak ~~ ~ ~SC~~,~ property Address s ~~rt~ I~V~ (Verification required from Planning Department for new ~tylS~ ~t ~ s ti e~ Cil) 1 Parcel Identification Number ©! $ - /! 8 ~~ ,m o ~ ~~/~ (~ U r ? F.(:Af. DESCRIPTION c~ ~ . property Location ~~ '/4,1~ ~ '/., Sec. 3 l . T ~9 N-R l ~ ®Town of /-~a..ye e Subdivision .~ ~. P ~~~ Certified Survey Map # Lot # 6 j Volume Page # ~--~- Warranty Deed # ~ '~ ~ ~ y Z-- .Volume o1 `~ ~ ~ .Page # ~- sG Spot house ~l yes ~ no Lot lines identifiable,'~1 yes ~ no ~.i.D.s ~M MAiI`i'TCNANCE ~ ' i ~ Improper use and maiatenaaceof your septic system could result in its premature failure to handle wastes. Proper maintenance oonaists of pamping 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 treahaent stage is the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner sad by a ~rplumber, journeyraanplumber, reatrictedplumber or a licensedpumper verifying that (1) the on-site wastevvaterdisposal systea- is is 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 sad agree to maintain the private sewage disposal system with the standards set: forth, herein, as sot 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 day: of the three year a iration date. F APPLICANT D(A-TS/ OWNER CERTIFICATION 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office. ~ 0~3 f A'TUJ, PLICANT ~= DATB ~ ssssss ~y information that is mis-relmseated may result in the sanitary permit being revoked by the Zoning Department. s«ssss as Include wlt6 this appUcation: a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if refevence is made is the warranty deed U 2y08P 256 STATE BAR OF WISCONSIN FORM 2 - 2000 Document Number WARRANTY DEED This Deed, made between Bruce J. Moll and Thomas S. Grantor, and Sam E. Miller, a single person ~~ 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:) Lots 1, 2, 3 11 2 and 13, Plat of Highland Ranch in the Town of Hammond, Croix County, Wisconsin. '739842 KA?HLIiEN H. YALSH REGIS?ER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 09/12/2003 10:30AM 11ARRAN?Y DEED EXEMGT 1< REC FEE: 1 i. 00 'TRANS FEE: 792.00 COPY FEE: CC FEE: PAGES: i Recording Area Name and Return Addres 1=t,~.~t F~ ~~ /~ / ~S6 f~ ~.~, w~Sy ~~v 01&1069-00-400 Parcel Identification Number (PIN) This is not homestead property. 6isJ (is not) Exceptions to warranties: Easements and restrictions of record. Dated this ~ ~~ day of ~ , 2003 Signature(s) authenticated this AUTHENTICATION day of ,_ TITLE: MEMBER STATE BAR OF ~ONSIN `tin (If not, $ TAMARA K. t authorized by § 706:06, Wis. St ~~ HERBST 2 THIS INSTRUMENT WAS ~~l;D BY .. ~y_ Thomas A. McCormack <<gtm~wm''F`w~e~G r -~'--- Baldwin, WI 54002 • Bruce J• Bruce J. Moll ` ~ ~ T +~ Thomas S. Aabv ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St. Croix County ) Personally came before me this ~~ day of ~..ni'- 2003 the above named Bruce J. M II and Thomas S. Aaby~ to m~fcrtov~,rt jb be the person(s) w~tcyexecuted the foregoing Notary Public, State of W.LSQONSI[N My Commission is permanet}t. (Knot, state (Signatures may be authenticated or acknowledged. Both are not necessary.) f Names of persons signing in any capacity must be typed or printed below their signati WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 2000 ,_•) INFO-PRO (800)855-2021 www.infoprofomu.com . C _ . .. ~ • ; HYIfE :~ .992:0' . "\ '24-:~.~ g LBO ELEVATION =990 ~~~ i~ ~~ .. • .. ;~ ~ dOO 4 ~3 N - ~ ~wr~-~-+~ ~ 5 --- 3 ~ ~ ... nNb ...~~~ V ~l~o U cr'~p ° ~M~JC4J 10 . • ` •' tJ.°1iie,v~m..~. . itOa .~ _ ~ . . . . . . . . • • ~0 11 0 ~_;~ ~ ~- i0- ~ S 89°39'38" W 363.01' ~ -1~0.'~ ' ~ - ~ ~ N89'39'38'E434.00' ~~ ~ .•.•.•.•., ,~.., 389'39'38'W434.43' - ~' ~ ~' ~~ ~...'. '~..~•.~.•~~~..~. ~ 930. 104.42' -' ~' , , _ ~ • ,. . N 89°36'38" E 363.01' c1 ~ ~ . • ...... , . . ~i ` ..... C~~I~tl° oa ~ ~ ~ 76,296. sa. FT. ~ .....~. . _ _ ~ ---------- ~ ~; LBO ELEI/ATtONa999. ~' . • . , .;.;. . • i BENCHMARK ~ ~• 3 ~ 3 • ELEV. ~ 101286 I .... ~ • ~i ~ ~ ~ ~~...... $ -- --- ~ DoT iZ ~ :~~~:.,...~.~. S 89'4875' E 6E.00' ~ ~ • 2 ~ ~ ~ W ....12' dOO 4 9 ~ ~s6 ACRES .. ~ , •~.. . $ ~~~ ~ ..- '.Hw ~3 ~ 67,711 S0. FT. i .. . hNVE =1000.00' ~ ~ ... z I d~~ ~~ ~° ~ ~ LBO ELEVATION = 1000 ~ i ,,••,•.;•;.•,,.:, ~. . ~ .. S 89'4875' E 311.02' ~ • ' • ' • S 89°39'38" W ~ ' . ~ :. : .:.:. : .:.:. ~~ - - -- - - ~ 106.76'` SOT 13 '~ ~~°y ;:~ :~:•:•:•:~:•:~:; 3 2.92 ACRES $ .:...........:.2 .- ,. 126,999 sa. I~ r. N ~• b HWE = 1001.00' ~•,•••••,••• ~~a r$ ,.....,,:~: ~... - - - - LBO ELEVATION = 1004 ~ ~ • • e ti ~~',',',',',~ 4G3G~C~4 ~ ~ CONCRETE _ ~ o FOUNDAl1ON ~ ' ' ' ' ' ~.,,, W ~ ~.,.. 489.18 \x•.'141 _ N8D'39'i8'E ~'~ SEE DETAL EAST - wESr 1M LNE N 89'39'38" ! • ao~ 9 ~ DEraL I (NOIT TO SCAI.Fa ~$ ~ >? ~