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HomeMy WebLinkAbout040-1312-08-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division — INSPECTION REPORT Sanitary Permit No: 569540 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: City Village X Township Parcel Tax No: Delta Construction, Inc. I Troy, Town of 040-1312-08-000 CST BM Elev: Insp.BM Elev: IBM Description: Section/Town/Range/Map No: /Ob , f8 04.28.19.2038 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER r M,! CAPACITY STATION BS HI FS ELEV. Septic �J J � Z'�, Z Benchmark z + q •� /Qa, .( r Alt. BAN a G nor- 1 3. Aeration O % Bldg. Se er g 7' 9 Holding St/Ht Inlet 7.(P . TANK SETBACK INFORMATION St/Ht Outlet 7. ( �,` • 59 TANK TO P/t. WELL BLDG. Vent t Air Intake ROAD Dt Inlet Septic �0 N� J5 / Dt Bottom 7-10 J 30 Dosing Header/Man. 17.L I�p• Z Aeration Dist. Pipe -7 • L S. 3 9 Holding Bot.System `I. Z— '� Z .3 45 - 1 < 'E Final Grade PUMP/SIPHON INFORMATION 3•°I /d Manufacturer Demand St Cover Model Number TDH Lift Fric ss S s T DH Ft Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No.Of Trenches PIT DIM Nf= SIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 Z Ire J `� SETBACK SYSTEM TO I P/L BLDG WELL LAKE/STREAM LEACHING Manufactur INFORMATION Type Of System: CHAMBER OR y►A. 1 �A— //t_ UNIT ModtNumber 5^ DISTRIBUTION SYSTEM 4-1(0 = 3Z_ /0/0 S Header/Manifold it Distribution x Hole Size x Hole Spacing Vent to Air Int ke �[ Pipe(s) \ 56 J Length / Dia �" Length 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 jxx Mulched Bed/Trench Center 3 Bed/Trench Edges Topsoil j NISZYes � No Yes n No COMMENTS: (include code discrepancies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 524 Olivia Court Hudson,,WI 54016(NE 1/4 SW 1/4 4 T28N R19W) Cottage Meadows Lot$ Parcel No: 04.28.19.2038 1.)Alt BM Description= �'" GO J 4i`_ /N R--� �-- aG��, O ✓� 2.)Bldg sewer length= Z9 C -amount of cover= t Plan revision Required? FBI Yes o / / / C 53q •7� Use other side for additional information. Llp (11 /le / J � ______7__/ _ SBD-6710(R.3/97) Date Insepctor's Signa re Cert.No. PLO PL206 PROJECT Delta Construction d St. Hudson Wi 54016 NE 1/4 SW 1/4S 4 /T 28 9 N Troy COUNTY ST.CROIX ____ __ _ 4/29/14.._ 3 MPRS Shaun Bird 226900 DATE BEDROOM CONVENTIONAL XXX IN-GROUN ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32 IL BENCHMARK V.R.P. Top of iron pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL SYSTEM ELEVATION 97.0/96.7 4 ' below arade Vent �6„ Quick4 Standard 210' Scale is 1" = 40' of Cover Leaching Chamber unless otherwise with 20.0 ft2 of Area noted 7�� 5.6ft^2/pair of end caps 4' Long 12" 34" Grade at System Elevation B-3 All piping sh b R 30/34,within 10' of tank, i I edule 40. 100' �a 2-3' X ' cells with>` pa 1% SLope ntsr`� 10' 0' 4' T 100' 10' Pro 3 Bedroom House 100' B-1 290' Property Line Olivia Ct. G l `i Safety and Buildings Division County Rai 7� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) P R Madison,vvl 53707-7162 ,.( c�o�XQ� itary Permit Applica `T�`ion In 383.21(2),Wis.Ada.C ate,submission of this fn®to the sppropaiate governmental unit is o>>�a sW�y putt- Note:Application forms for state-owned POWTS are submitted to Projax Address Cif difirneat Chao mauling address) the of Safety and profeniaW Savim Personal information you provide may be used for scoondary OMDOW M accorda=with the Law,s.15.04(l)(ml Stats. 5 Z''� �l ✓:!� G�-1 L Aplikgon Infwasation—Please Print All Information Property Owaa's Name Parod a I 446- 131Z ~ e - 6`CHD Property Owner's Mating Address Property Location '0 GovL Lot ci1,,State Zip Code Phone Number y,,` ye, Sootion / �eacle one) T� � N; R EaW IL Type of Buildiag(cheek all at apply I.ot Subdivision Name or 2 Family Dwdit-Number of Balm �1 ,lam Block L�T c L ❑PublieC4sm aoial-Describe Use �JGlj LIy6U4Q. a ❑City of ❑state Owned-Describe Use CSM Number ❑ >MF or of'� M.Type of Permit: (Cbeck only one box on tine A. Complete line B if applicable) A system ❑Replacement system ❑TreatmenteoMmg Took Replacement Only ❑Other Modification to E—d-9 S9A!W(espy) —^ List Previous Permit Number and Date Issued V/� B. ❑Permit Renewal ermit Revision ❑Change of Plumber ❑Permit Transfer to New Before EViration — —+ own" (' IV. ofPOW PS Com neotMWvice: Check all that apply) I»�irotmd ❑Pnemuriud Dn-Grand ❑At-Grade ❑Mound>24 i of suitable sor7 ❑Mound<24 in ofsuitable soil 6Y31,1% �J 3 ❑Holding Talc ❑Offer Dispersal Canpooart(evlsiu) ❑Prohestment Device(tacplain) V.Dis reatment Area laformation: Design Flow(gpd) Design Soil Application Disposal Area Required(sf) Dispersal Area °°Elevation VL Tank Info in Total gy Crallons man units NOW Toth r s Tula 8 m L-I)/ �i v� iw c7 a Septic or Holding Tank Dosing(]comber VII.Respoosability Staten t-I,the aada*aed, poadbitity for tnsts"ties at the POW'I'S abowa oa the attached phtaa. r's Name(Print) rgnatcue MPAvM Numbs Business Phone Number``� 7 Phmti.�m ; <strcec,Cite state.tiP Co 1 VIII, o /De eat Use On ❑ permit Fee Date Issuin8 Signature ❑ Reason�fbr�D�.�W s 8 5 •one $ 3d l 4 DL CO aditic ±►coos for Disapproval ,` l 0 �O✓• I�f 1w'l 'tank,effkiant fitter and /`� ( Wt a► AAV Aispersel cell must all be services!maintained A riper management plan provided by plumber. r t 3, ' ett�pcl�rsgtticernents must be maintained f A&t d•n, . AUNA to amide plea.far the syshm and a&"to(Ye County 0J N paper not lees lira 5 w x 11 ideb"mfila l P SBD-6398(IL 11/11) j28 PLAN PROJECT Delta Construction RESS 206 2nd St. Hudson Wi 54016 NE 1/4 SW 1/4S 4 /T 9 W OWN Troy COUNTY ST.CROIX MPRS Shaun Bird 226900 DATE 4/29/14 BEDROOM 3 CONVENTIONAL >00( IN-GROUN ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32 BENCHMARK V.R.P. Top of iron pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE • WELL SYSTEM ELEVATION 97.0/96.7 4 ' below arade O j4' Long ent Quick4 Standard Scale is 1" = 40' Of Leaching Chamber 210' unless otherwise with 20.0 ft2 of Area noted " 5.6ft^2/p air of end caps 34" Grade at System Elevation B-3 All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. 100' 2-3' X 66' cells with>3'spacing 1% SLope Vents B-2 10' 4' 1 100' 0' T Pro 3 Bedroom House 100' B-1 290' Property Line Olivia Ct. POWTS OWNER'S MANUAL & MANAGEMENI PLAN Page . of FILE INFORMATION SYSTEM SPECIFICATIONS EOwner Septic Tank Capacity _ al ❑NA Septic Tank Manufacturer ! _ ❑ NA Effluent Filter Manufacturer 2 D.NA - --- DESIGN PARAMETERS Number of Bedrooms D NA Effluent Filter Model + NA' Number of Public Facility Units lA Pump Tank Capacity al. P A Pump Tank Manufacturer NA Estimated flow(average) O al/day __. _ — Pump Manufacturer NA Design flow(peak),(Estimated x 1.5) al/da p SoH Application Raise al/da /ft! Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA Fats,Oil&Grease (FOG) 1530 mg/L D Sand/Gavet Filter Q Peat Filter Biochemical Oxygen Demand (BODs) 5220 mg/L D NA El Mecharical Aeration D Wetland Total Suspended Solids (rSS) <_150 rng/L ❑Disinfection _D Other: __ Pretreated Effluent Quality Monthly average Di persal 1;ell(s) ❑ NA Biochemical Oxygen Demand (BODs) 530 mglL In-Ground(gravity) , D In-Ground(pressurized) Total Suspended Solids (TSS) :530 mg/L' D At-Grade O Mound Fecal Conform(geometric mean) 5104 cfu/100ro ❑Drip-Line _ D Other: Maximum Effluent Particle Size X in dia, . C1 NA Other. NA Other: — �— Other, .w NA `values typical for domestic wastewater and septic tank effluent. Other. - a NA MAINTENANCE SCHEDULE Service Event Service Frequency , Inspect condition of tanks) At least once every: D ear sus) (Maximum 3 year) ❑NA Pump out contents of tank(s) When combined sludge and scum equals one-third(3j)of tank volume D NA - — --- — D month!s) Maximum 3 ears 0 NA Inspect dispersal cell(s) At least once every: ears ( years) ❑months s) NA Clean effluent filter At least once every: ear(s, _ _ _ �� O month(s) NA Inspect pump,pump controls&alarm At least once every: D year(sj _ D monthls) E NA Flush laterals and pressure test At least once every: D years)—_ Other: — D monthls) NA At least once every: D year(s) Other: D NA i 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 ServiOng 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 or the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to checi: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(J)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordancz with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechar ical or pressurized components, pretreatment units, and any servicing at intervals of 512 months,shall be performed by a certified POWT3 Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of and,service event. Page_of 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 chemicals that may impede the treatment process and/or damage the dispersal celi(s). If high concentrations are detected have the contents of the tank(s)removed by a septage servicing operator prior to use. System start up shall not occur when soil conditi ons are frozen at the infiltrative surface. During power outages pump tanks may fill ab3ve normal highwater levels_ When power is restored the excess wastewater will be discharged to the dispersal cell(s)in one large dose, overloading the cell(s)and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of tht� pump tank removed by a Septage Servicing Ooerator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the Frump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cabs. 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; condoins; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scrap..; 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 seale'j. * 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 filed 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: `)Ff��uitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be prolected 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. ❑ 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 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/OF4 INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC,PUMP OR OTHER TREATiVIENT 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 POWifS MAINTAINER Name ��/ Na me Phone = J Phone 7 r, SEPTAGE SERVICING OPERATOR(PUMPERI LOCAL REGULATORY AU'T'HORITY Name ryv Name ` Phone ,—. — Phone ""-1 J � V This document was drafted in compliance with chapter SPS 383.22(2)(b)(l)(d)&(f)and 383.54(1),(2)&(3).Wisconsin Administrative Code. ST.CROI K COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownef/Buyer__Ivy; Mailing Address Property Address (V t'm required from Planning&Zoning Department far new 'on.) City/State Parcel Identification Number � � L&g L DESCRIPTION Property Location V, V4,Sec. T_aN R�-�'W.Town of�c� — Subdivision ,Lot# Certified Survey Map# ,Vc-lume ,Page# Warranty Deed# O 0 ,Vo fume Page# Spec house (`yes )no Lot line identifiable( yam J no SYSTEM MAINTENANCE AND 0VVT4ER CERTIFICATION Improper use and maintemnee of your septic system could result in its premature faikare to handle wastes. Proper maiataaanca consists ofpumpmg 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¢Comm.83.52(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 mdester plumber,journeyman phmnber,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 pamping(if necessary),the septic tank is less than 1/3 fiu11 of sludge. 1/we,the undersigned have road the above requiremGnis and agree to main.taia 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 WisconsizL Certification,stating that your s has bear maintained must be co feted and returned to the St Q= P septic system rep 8t County lannu►g Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our lraowlWp. Uwe amlere the owner(s)of the property described above,by virtne of a deed recorded in Register of Deeds Ofte. Number of bedrooms NAWRE OF APPLICANT(S) DATE ***Any iafozmathm that is nnisrepresemmed may result in the sanitary permit being invoked by the Planning&Zoning Department*** Include with this appl=bw a recorded warranty deed from the Reetipf Dees Office and a copy of the certified survey map if reference is made in the wwanty deed \b A County um Industry Services Division ` & ►`J 1400 E Washington Ave Sanitary Permit Nber(to be filled in by Co.) P.0,Box 7162 q zj� Madison,WI 53707-7162 % to Transaction Number d > ary Permit Application In accordance 'h6 $ (2).Wis.Adm.Code,submission of this form to the appropriate governmental is required pri�D mg a sanitary permit. Note:Application forms for state-owned POWTS arc submitted to Prote s.1 'fferent than mailing address the Duire p afety and Professional Servies. Personal information you provide may be used for secondary I I;J;Q f U ses irr rdanee with the Privac Law,s.15.04 1 m,Stets. I. A ligation•Information-Please Print All Information Parcel# rO Property Owner's Name Property Location Property Owner's Mailing Address � Govt.Lot Zip Code Phone Number �,/r�'/., _/ti Section City,State role on II.'Type of Building(check all that apply) Lot# Subdivision Name r 2 Family Dwelling-Number of Bedrooms 1 i� Block t� �n o" - ❑Public/Commercia 6k l-Describe Use ❑city of CSM Number ❑Village of ❑State Owned-Describe Use _ Town of Z III.Type of Permit: (Check only one ox on line A. C mplete ne B if appl' 17� ❑ tm T k lacement Only C1 Other Modification to Existing System(explain) A. w System ❑ Replacement System T en olding List Previous Permit Number and Date Issued B. ❑Permit Renewal ❑ C3 Permit Transfer to New Permit Revision Chan Owner Before Expiration IV a of P0 TS S stem/Corn onent/Device: tCheck all t t aMttl > ,5 on-Pressurized In-Ground ❑Pressurized In-Ground. ❑At-Grade ❑Mound_24 in.of suitable soil ❑ Mound<24 in.of suitable soil Gk4, ❑Pretreatment Device(explain) ❑ Holding Tank ❑Other Dispersal Component(explain) e, V.Dis ersal/Treat t Area Information: Dispersal Area Proposed(sf) S stem Eva ion �J Des)g Flow(gpd) Desi n Soil Appli'c�ation Rate dsf) Dispersal Area Required(s c 70 / Capacity in Total #of Manufac rer B ; Tank Info I ^ Gallons Gallons Units � v u New Tanks Existing Tanks pp � a`.0 :M3 Septic or Holding Tank Dosing Chamber . Responsibility Statement-L the undersigned,assu VII, ponsibility,for installation of the POWTS shown on the attached plans. Plumbe gnature Mp/IvfPRS Number Business Phone Number Plumber's Name(Print) Plumber's Address(Street,City,State,Zip Code r , �t! Z-0 VIII.Coun /De artment Use Only Permit e Dat Issue Issuing t Signature F'e g Approved $ /J 75.6c> 4 9 4 ❑ iven eason.forDenial new IX.Condrtj*V . sons for Disapproval 3 e t�e 1.•, 8eptir nk,etfluerit>glter and � ttJ fff���"` I°tilu.i l dispersal,cell must all be services/Maintaloj as per management plan provided by plumber, 1�A P(_^44_1 Q�� 7E:'?tAlFset{elk r.G941rernents+Host bts�xlaintailiFlid ills I orls to complete plans•for the syscem and submit to the County only on paper not less than 8 tlE x 11 inches in size Attach SBD-6398(R0313) Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 4/10/14 Owner:Delta Construction Location: NE 1/4 SW 1/4 S4 T28 N,R19W Lot 8 Cottage Meadows Troy System type: In-ground absorbtion system(conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Sheet 8-10. Soil Test I Signature r License number#22690 PLOT PLAN PROJECT Delta Construction ADDRESS 206 2nd St. Hudson Wi 54016 NE 1/4 SW 1/4S 4 /T 28 N/R 19 W TOWN Troy COUNTY ST.CROIX MPRS Shaun Bird 226900 DATE 4/9/14 BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 890 # of chambers 44 BENCHMARK V.R.P. Top of iron pipe ASSUME ELEVATION loo' Filter BEAR Filter ❑ BOREHOLE O WELL SYSTEM ELEVATION 97.0/96.7 4' below arade Scale is 1" = 4�� All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. unless otherwise noted 210' PL ic Quick4 Standard of Cover eaching Chamber ith 20.0 ft2 of Area M02/pair of end caps Grade at System Ele ation 34 101' B-3 Vents 00' 1% SLope 10' B.M.* 366' Property Line S 100' 100' 10' 10' Pro 4 Bedroom ouse 100' 290' Property Line Olivia Ct B-1 Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 101 Vent A/ Grade Vent 3' 411 3' f�30/34 Septic Tank 1 5' Long " 51 5' Long 111 3 6" Grade at System Elevation Grade at System Elevation Spacing 5' 2-3' X90 ' Cells Same on other end Observation tubeNent At end of cell A 22 chambers per cell B System elevations: A_97.0' B 96.7' I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Ca _ / S� aj ❑NA Permit# Septic Tank Manufacturer ! _ NA Effluent Filter Manufacturer_ � ❑NA DESIGN PARAMETERS - Number of Bedrooms ❑NA Effluent Filter Model �' . NA> kA -Pump Tank Capacity .,Q '!E._ • NA Number of Public Facility((nits Estimated flow(average) gaUday Pump Tank Manufacturer NA Design flow(peak),(Estimated x 1.5) 0 gal/day Pump Manufacturer — `:" t NA Soil Application Raise al/da Pump Model NA /ftz Standard Influent/Effiuent Quality Monthly average"" PretreatmEant Unit NA Fats,Oil&Grease (FOG) :530 mg/L D Sand/Gavel,Filter Cl Peat Filter Biochemical Oxygen Demand (BODs) 5220 mg/L 11 NA El Mecharical Aeration 0 Wetland Total Suspended Solids (TSS) :050 mg/L ❑Disinfection ❑Other: Pretreated Effluent Quality^ Monthly average Di persal�.etl(s) ❑ NA Biochemical Oxygen Demand (BODs) 530 mglL In-Ground(gravity) _ ❑In-Ground(pressurized) Total Suspended Solids (TSS) <_30 mglL D At Graae D Mound Fecal Coliform(geometric mean) 5104 du/100r;V" ❑Drip-Line _ D Other: Maximum Effluent Particle Size 3k in dia, . O NA Other. NA Other: — --- NA `values typical for domestic wastewater and septic tank effluent. Other: �'` NA m { MAINTENANCE SCHEDULE Service Event Service Frequency , ❑ om nth's) (Maximum 3 years) D NA Inspect condition of tank(s) At least once every: ear si Y� a) Pump out contents of tank(s) When combined sludge and scum equals one-third O of tank volume ❑ NA At least once ever I-]month+s) (Maximum 3 years) D NA Inspect dispersal cell(s) Y 0 monthr s) NA Clean effluent fitter At least once every: ear(s, --� O month(s) NA Inspect pump, pump controls&alarm At least once every: D year(s) _ ❑monthls) NA Flush laterals and pressure test At least once every: O year(s) Other: �M At least once every: ` ' 0 months s) NA 0 years)_ 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 or the ground w irface. The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to checir: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 or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordanc-3 with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mecharical 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 of TART UP AND OPERATION or the resence of painting products or other chemicals that $ tank(a) f p the For new construction, prior to use of the POWl S'check treatment ( ) contents of may impede the treatment process and/or damage the dispersal cell(s). ff high concentrations are detected have 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. of effluent. During power outages pump tanks may lar a dose, overloading loading the cell(s)levels. and may result in the k atck p or surface discharge ter will e discharged is the dispersal call(s)in on g Servicing er to the e avoid this situation haaPlumbbeer onPOWTS Maintainer to assistinymanuaAy operating the umrp controls to restore normal levels effluent pump or contact a within the pump tank. Do not drive or park vehicles over tanks and din soperlrcalls area.not drive or park over, or otherwise disturb or compact,the area within 15 feet down slope of any mound or at-grade Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life; 1bundat POWTS:d n antibiotics; baby wipes; cigarette butts; condoins; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; products; (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scrape.; medications; oil; painting 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 proper y and safely abandoned in compliance with chapter Comm 133,33,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 property disposed of by a SeptagH Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void Space filed with soli, 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 complian replacement system: �uitabie 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 ld not be infringed upon n the need required setbacks from existing and proposed structure,lot lines and wells. Failure to protect the replacement area will result n 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 aviiilable 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. 11 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 availrible a holding tank may be installed as a last resort to replace the failed POWi-S. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biornat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> ON TANKS MAY CTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT SEPTIC, PUMP AND OTHER TREATMENT T ENTER A SEPTIC,PUMP OR OTHER TREA714ENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK tAAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS_ POWTS INSTALLER POWTS MAINTAINER Name Name Phone IIJ Phone:1:2 SEPTAGE SERVICING OPERATOR (PUMPER LOCAL REGULATORY AU'T'HORITY Name n,� _y Name �•f. l�t� Phone _ — Phone '� j '2- This document was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f)and 383.54(7),(2)&(3),Wisconsin Administrative Code. f� 10 y LTE" CARTRIDGE INSTRUCTIONS Xis F i~gw It pry Iff UN tti<irsr c"M.arlta ON iWd of dw*Out k"to ar"M it is t*&",*d eRWW the a w"a ovaning. If 00%,""M A%r aaa n tnore wo*ilrte tbw teak Owsl U/b trot sutfaet or eoivent wand%%a)add'irllrna*plea"it lira UUtM 0410- b"xgP I Wwo the shwa is iYtib dry"tow*I tlw audet fslpa,ureaaure tlw fwigttr of*-hV&pipe vwnded to braes the niter to"ta*Mid well if tttgflkiy ties apub"W swalviau+w adds sauppelt.TY Whic support tswrthad.k not utfjwd, prepeed to sto fats. 5•YV.P•5 For k etallsdollo iltitFring t$a aprleMI suppia►rtalatat silo supp ot: SOMAMet weMt"vA inch plpe a"6 the sdblir cam. if side supper[methdil ib hot U11163e4,lrsafted to sbWp four. SeIv ait W6W the Met case nits tha Mhat wWW. tasart tf,o Idler cwtildga irrtu the Kaf s, 11MRSI1'r!I dawn bud than Offer 6&s Itrtu the bettoni uF the oawe. If a Wks WWI is otifr*d_ irrsrrt kAo t'ho filter arrd tack by tnrmeig - •41;;�, dodn"e 900. 1. yhe efouWalt taw sl.duld be t owed livery trans the r,Wtic table Is serviawl. 1. Opeh the oritlet samsm apewbrg to inrout the tank and Nor. s. Purnp the captie tsrrek an"wldek nukhg sure to rwrnme the r;lu"ti V Iey.,r to the hokum of the tank sad sot)tat the smaan and emuetil. a- tH l 4490 urlkw,tet I&Vet hes beew IVV*Mred below the invwt will thu � outlelt ppiipe,ffamnty Pup up ur.the filter hondle to dieivdge*a 't ch f vk,tiro QW6. 5. side the rarkwad up and m rs of the rasa fkW dadaisiy. 6, 111`A vAa swNtk cwtusteti to art Wwta is"at,We sw" rr aiioer(d be newsy by ba*A sg evurrtarduckwirm Wu glld denewd wM water only. r.'+l 7. Veldts how"t,the Wartrldd0 kni 45 silos flare.fiat surf3re facb&e dawn)ornrr t!w opmrbipw rlaatW off qNe+rei"us Wlth M Ane ' *Ay,waidtrg sure all a lawtell(at Is rinsed back Into th+y tank. �'`'" t 1 .wa _L VIl a. If V"aiwltsh Is udhicwl,niplgce by Il�sot'ft into Nbr atld turnb,p dadcM,ire Mr. 9. riasart am tli w aantridge beak ihta the CAW,)wax*dAm-omill lha Altar ludo;into the 1100061+of On i0.tseplata Wei macro this acrosi 9111Mlai10 On the talnlL a,� •_[i r i. 0l:`75 4N'RWll4 t,t' 'rI15Jtnrft':L +Y,ild4a 1" ,W W 7-WL#WT9kS(653 0 ST.CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM . Owner/Buyer- � im-- pJ e v Cam-- _ . Mailing Address "LO G +- Property Address �Z << �/� Co v (Verification required from Planning&Zoning Depattctbent new construction.) City/State Parcel Identification Number g* —/3 Z—0 LEGAL DESCRIPTION Properly Location E V1, SLJ '/a, Sec. T 2 �&N RJ�W,Town of T' o Subdivision 1,6 Lot# Cerd l[ed Survey Map# 'j `V� .Volume ,Page# Warranty Deed# (� 3,5 1� ,Vohmae Page# 0 Spec house (`yes Jno Lot lines idea ifiable( yam J no SYSTEM MAINTENANCE ANDS-OWNER CERTIFICATION ]improper use and maintenance;of your septic system could result in its premature failure to handle wastes. Proper maintanance consists of pumping out the septic tank every three years or sooner,it needed,by a licensed pumper. What you put into the system can affect the fiction of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§Comm.83.52(1)and in Chapter 12-St Croix County Sanitary Ordinance. The property owner agrees to submit to St Croix County Planning&Zoning Department a coon form,signed by the owner and by a master plumber,jou mayman plumber,rest icted phanber or a lick pamper 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. Uwe,the undersigned have read the above requirements and agree to mun.tak the private sewage disposal system with the standards set forth,herein,as act by the Department of Commerce and the Department of Natural Resources,State of Wisconsar. Cm tificafioa stating that your septic system has bear maintained must be completed and rahaaed to the St.Croix County Planning& Zoning Deportment within 30 days of the free year expiration date. Uwe certify that all its on form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property desearibed above,by virtue of a deed recorded in Register of Deeds Office. Number of bedrooms NATURE OF APPLICANT(S) DATE i ***Amy information that is reeemmed may result in the sanitary permit being revoked by the Planning&ZonW Depathtnent ''** Iuclade with this application a recorded warranty deed from the Register of Deeds Office and a copy of dw certified survey map if referee is made in dw warranty deed. (REV.OW PIN 686 S.F. N o�cP� FNS I a I EL =IRON 9115.55 54 Ac. ° �� 1 Q 1 \ 1 �naN r (n 1 I N 88'20'09" W 346.78' 1 1 1 uss� I I 153.16 _ -_ 193.62 1 1 3s.o'2a7.00' „s.s7 Z v;�R�ES N ff 10 �Ir W9:0 / S LOT 7 ��0 111 1 1 1 0 3 f 0 �� f 43574 S.F./ — -- — i �; f LOT 6 1 0 Ac. 1 1 LOT 1 ` Z a V) I N f N N 43572 S.F. 43572 S.F. ow 1 Cn ^ f n O7 1.00 Ac. f a coo c �'� � iCb 1 1.00 Ac. 1 1 w Z w f I �.a� ��i LOT �8/\50' .�\ HWE- 907.031c o p f o ^� °j y`�� 43567 S.F. 1 1 1 ,sue,'180- 909.0�w �s �r'o U, N I f z '2 2 ` 1.00 Ac. !' 1 u oo r' 39.43' ' _— \ 1 23.15' _114.31= ! sro. ®� n I o N 88'20'09" W 153.74' o ro �® " `° N 88.20'09" '�OT , LOT 91 so 2,98' �,C\r�� \ 43560 S.F. 1.00 Ac. \ 1 "o�a co.n B I o Mo \ 11 8 2 OUTLOT 5 I �o 233:5 58463 S.F. cp. " E \ -- W\ CO o 1.34 Ac. ----1—=° -°"s LOT 10 \\ i Lo congnvAnon um+enr O 43565 S.F. \ va.2759 P0.590 1 VOL 25547�� �r � 1.00 Ac.`50 WE- 9&8�4 0C' i m N \4625% 110 ,C8. /® 3 . LA I o LO T' ,13 °j LOT 5 0 0�, I Z I (n 1 1 43568 S.F.,-1a -- \ \ \ 1 1 I ` 1.00 Ac./- � LOT 11 43614 S.F. 1 ,ao' I LOT 12 \ 1 43577 S.F. \ 1 1.00 Ac. I I CO Im 910,32 43560 S.F. w \ 0. 1.00 Ac. 50'\ 1 / 100 I I i l80 191232/ / 1.00 Ac. -- - - 311.81' J i ' 152.63' 386.78' 184.88' \ --448.38=- --724.29=-I S 89'09'46" E 1262.72'--- LATTED LANDS I I 8905 6" w UNPLATTED LANDS I LOT 1 I LOT 2 0 N Z 1 CERTIFIED SURVEY MAP a o ul VOL. 3 PG.1720 N�,sue, U. 2868 P Oy 'i 81z 3596 KATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., wI DOCUMENT NO. RECEIVED FOR RECORD 08/16/2005 02:00PH WARRANTY DEED This Deed made between CORNERSTONE EXEMPT i PARTNERS,a Minnesota limited liability company, REG FEE: 11.60, Grantor, and DELTA CONSTRUCTION,INC., a TRANS FEE: 3120.00 COPY FEE: Wisconsin corporation, PAGES: 1 Witnesseth,That the said Grantor conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: RETURN TO: T1(/Yr �(p�3 y010 Lots It, inclusive,Plat of Cottage Meadows in the Town of Troy, St. Croix County,Wisconsin. This is not homestead property. TaxID# 040-1014-20-000; Together with all and singular the hereditaments and 040-1014-50-000 and $ � 040-1015-80-000. appurtenances thereunto belonging; and Cornerstone Partners,LLC warrants that the title is good,indefeasible in fee simple and free and clear of encumbrances except easements,restrictions and reservations, if any,of record. Dat th day of August ,2005. CO TO P RS,LLC (SEAL) Its: i AUTHENTICATION ACKNOWLEDGMENT Signature of as STATE OF WISCONSIN ) of Co yVfj W?artners, )SS LLC authenticated this day of August,%` GUQ�yi,,�" COUNTY OF ST.CROIX ) W Personally came before me this 15 t laay of August,2005,the TITLE: MEMBER STATE BAR OF Wst-0.Sl y'. 'v% above named O * ' of Cornerstone Partners,LLC,to me (Signatures may be authenticated or acla—V edged. Bd%%.not known the person who executed the foregoing instrument and necessary) 7�CC G aclatow d the same. N AUB\� THIS INSTRUMENT DRAFTEWA:' • . . • 'G02,r�D.Peter Seguin �i, OF V 5��l Loy) 74z4-- MUDGE,PORTER,LUNDEEN&SEeft!15.t. 110 Second Street,Post Office Box 469 Notary Public,State(expires): sjtt_11-200 5 . My Commission(expifires): 1 G Hudson,Wisconsin 54016 e a+ qEi Rol-, J' I 1 r 13 El DE `tf � � •t 1�ar Y'F o 3 r a r £'d 1910t, 60 AV 2L I 1\1 i A' 91 J ri CCL M.7_ 86910b6 60 AV A 0.1 0� i 0 I Ssi�- Sz7 i v � ' - • �Y '1 'J ; i 3 � � 1 47 s D 41 g•d BZG:ZO ti L 60 ady RECEIVED O Moonsin Deparbnent of JUN 2 x 2005 8 L t REPORT p'sge < of 3 Di+rision ofSaretyand ST.L =in 85.MOs. Adm. Attach oot o to side plan N ' F size Aida nMat Cody S T G Ro J X Nude.bA not&nW 10:veraCau and ha montel retbrerwe pokt a" direcOm and Parcel W. / persape.s�lead�rraceziOr>s,r�r�rarroa.a�dtocetionandoetor�u #raad. 1b- Abase print all lnAwmallorL f�a1e Ps�soavr nfomeMo ny-pwWanyu.uaeuraKSaoor�rrw•n P+opervowner PropertyLocelion ,Z `7 o D a f !�i�S- - Goof.Lot N� ua 5 W 19 s T Z$ a R I a E(orYQ Pwperty 3 C/2�&� area G S s o'r T e M-EA-aol4S code Number ❑cky ❑~ (&i'cnarr NearestRoad NvD3OW I W/ 1 5401� coY i DMA 421 0 New Oorrsiruc lon use:ER R /Nurtmer aft dro.3 _5— code deed desin flow rate �rs'o— -Z" o GPD OReplaomierd ❑ fttft or conmemiaf-DescrAw f nuderlei L O �p�!£-2. O fJ 6i+ mood Plain elevellon if amlicaW /r'r fL General corrww is and yo' S 5r 61A EaJ04Ee o Area 6 Spot Tested seitable br �• Z$ 421 t�y_ 6,7 r1-1 f�l Plt c�xrnasurraosele��Q'g7-i3. DeMrr� �r > W Apploollon Rob Had= Depth Dorriwnt Redo,Desaipdon Tendwe Sbuckxe Con dsterve Boundary Roots GPDAF in- F&RI e/ CkL Sz Cont.Color er.&z Stn. 'EW1 'EM2 0—l1 to&ep a/ - A 2 f jr m fr e 30 - • a 11•Z.l. tuYR *14 — Sic! in bX In fi a w 2J� •tv 3 5 © 5 ml - - .7 1-46 r/ ® Pft Grovrdsuriaceelev. O.7o tt oeptlrto mom f u ) 9 2- ia. Sol Application Rate Horluon Depth Dons Rado,Desaipean Too" Smx km considence Baundary Roots CPOW , h. fYhmgell (lu.SL Con L Color Gr.SL Sh. jr- loterz Zi-L 1l 2-m bK Mfr . 18 t oYR.19/3 510 2 M bX A4; C s A �,i 3 4 IoYR 416 sc-1 o, bK mf a W 14 •�t . 1a toYR � 1 -(V V r Efltuertt#1=Bw >3IT<220 rn and M:5 1so nQL 11 J A&%"AM- M Owen, Rk* ftnatrse CSTbkndw E r-j a u t—Ebc.-- k.s+T 59 9 3"q- Address '1 Date E m Conducted Telephorw Number Z 812 t rfi'�n' Arq* s�fZtJ3 k��,>✓�( W( S —13—os- 67/S 77Z-34` For issuance of permits and designing Contact: Ulbricht&Associates Ulbr icht & Associates Registered private wastewater consultant and MIMOM Private Sewage Consultants 2812 10th Ave. 2812 10th Ave. Spring Valley,WI 54767 Spring Valley, VVI 54767 715-772-3442 opiGiNAL i i Property Owner /3 J ,,tT''E�r Parcel w# t.�� -'1 01`4—10'00W paw 2. &- 3 F—S] dev.10 I I/ Depth t acot) n �Pet ri suae ii Horizon Depth Dort Redox Desarption Texture Structure Corufttence Boundary Roars GPOW im MunseA Qn.Sz Cont Color Gr.Sz.Sh 'EWI "E#t42 I 0-16 IDYR,,L/2. - !1 Zm bK Mf r GS .j+ .le .,B Il#'2b 10YR414 5G l 2rn bK M+r C S 2.0f .ft . (a 31 - S l J M b)(. rh f r w I r f Spring -�F 3S IUYrZs/s S d s rv� J - .7 i � b ` u ❑ pit Groumdsurface;eiev. ft. Depth to g factor n i Soil&OPkAmon Rate Horizon Depth Doff&k"Color Red=Din Texture Strurbure Cons�teruce Botany Roots GPIaUlF as # Qua.Sz. Cord.Cotor Gr:Sz.Stu. 'Em Borim# ❑ Groundsmfaceeretr st ❑ Pit Deptta In. 4 Rate HO'b u Depth Dm*mftCQkx Redm D ox"on. Texture Sl ui tse Consistatme Bogy Roars GAM CIM sz cad:color Gr.Sz sh. 'EM EIO&Q# ❑ Pit Grandsurfaaeerev ft. Depth to Waiting factor in Sol Amkxftn tie I* t m Depth Doff*mtCdm Redm Dora. Texture Stitar " CordMartce Boundary Runts GPM In. ata.sz. Cont.color Gr.SL Sh. 'ter 'Ef 2 Co?rrq ea P-46;E a of i M E'+too ws LD? $ 0 A = c.oa-rcwR For issuance of permits and des' ing Contact:Ulbricht&Associate Registered private wastew r consultant and M .° 2812 10th Ave. �•► Spring valley,Wl 547 715-772-3442 133=/dj, �f a. �. l oo' eo' 10 Z a tl-e�aV8 dt+2A: Tam 2-- /oo.e 9 �2 /Da.5$ 81- 41.97 Z 1 pi. tf 'am t_ loo.00 i 743 V2 " Its 5E-r z +ek5v C �i2�tDL� d 4°1.$-7 l richt &Associates Primate Sewage Consultants 2812 1 Oth Ave. Spring Malley, 1.;"41 54767 W o �LL o L,_ m 0 C3 7 0.z —d 1_-- — N I — I —O V A3�2 — 1� SONVI n01LL30 J — N lv ————— �z � — W � _ se — z 0 —6871 3 ZLr1.70 N 1 ill �a xo _——— ,ZS'B9£3„ZISUO N 4lO I-- _ --- —^--- --------- y __--__"_^� FwQa°� T LO F Wo°o :. 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