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HomeMy WebLinkAbout020-1407-09-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building l7ivision INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). ermit Holder's Name: City Village X Township 3ast, Kernon Hudson, Town of ST BM Elev: Insp. BM Elev: BM Descript~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ J Z C~ Dosing ~ , Aeration ~ ~ ~ J / Holding TANK SETBACK INFORMATION TANK TO L W~ BLDG. Vent to Air Intake ROAD Septic 7 ~ 1 ~,.~. / ~ Dosing ()"n, Aeration Holding PUMP/SIPHON INFORMATION ~7'YlI/~tc.~f~, Manufacturer Demand GPM Model Number TDH Lift Friction Loss m Head TDH Ft Forcemain Length Dia. Dist. to well c~111 ARS(1RPTIC~N SYSTEM ELEVAI IUN UAIA county: St. Croix Sanitary Permit No: ' 479373 I/f~ State Plan ID No: Parcel Tax No: 020-1407-09-000 Sectionlrown/Range/Map No: 10.29.19.2556 STATION BS HI FS ELEV. Benc~a~ / ~ ~ ~~ ~ ~ p lU.~U Alt. BM ,/' ~D ~ 2 y~~ ~ Bldg. Sewer , / S~ ~1 d ~ U S ~ Ht Inlet ~ I ~ ~ ~~, St/ t Outlet ~ /c5 Dt Inlet .~.--- Dt Bottom ~~ Bader/Man. ~ ~ r ~~ ~~ Dist. Pipe~",y~~-p 5/~ ~ ~l Q d.5' ~~ 7 S- Bot. m ~•~~ 93. ~ Final Grade ~P~y S ~_ ~ ~ ® ~ D 0 St Cover ~ i ( __--- ~ ~ ~~ .7s- W BED/TRENCH Width f 1 Lengtk No. Of Trenches PIT DIMENSIONS ~^ No. Of Pits__ Inside Dia. Liquid Depth DIMENSIONS ~ ~QQ L~ 2 DD o0 7 ',~. SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM AC ING O M curer INFORMATION CHA uNER Type f System: ~ ~~ ' ~ ~® Model Number. -h~~ ° 37 UTION SYSTEM l (n / . ~ II.Irfl'Y .~-~nru_ - l.~ti~" Gl (1/~d r/ (/`~/r-</' Heade anifol~ Distribution ~ ~ ~. x Hole Size x Hole Spacin Vent to Air Intake ~~ / Pipe(s) acing ~ (/ S th ~ Di L `""~/- / 2 Dia Length p a eng C/111 t'/1\/RR ., o...~~...., c.,c~e...~ n..i.. .... 1111n~in(! ('lr D-_(;rada Svstamc Only Depth Over ~ ( Depth Over ~ xx Depth of xx Seeded/Sodded xx M Bed/Trench Center ~ i] Bed/Trench Edges Topsoil ~~~ Yes [] No _, v~ COMMENTS: (Include code di pencies, p ons p ese , e c.) Inspection #1: / / Inspection #2: / / Location: 721 Zephyr Lane Hudson, WI 5'401n6'(SE 1/4 NE 1/4 10 T29N R19W) Shepherd Park Lot 9 Parcel No: 10.29.19.2556 1.) Alt BM Description - a /J O~IytQ~1U?~X~-#" 2.) Bldg sewer length = Z Q - amount of cover = .' ~ 7 4 ~~ Yes ~~ ~ ~ ~ ~ 1 II- -- ---- ------ ---- _~ Plan revision Re wired? ~ i -G~~n _ // _ ~ _~ ~~ V Use other side for additional information. -__~_~~~ ~ _ 't-(/X-4C.- - Date Insepctor's Si ature Cert. No. SBD-6710 (R.3/97) 0 ulched O / Ei~, [~ Yes - J' i Sam _ ZOl W. Washington Ave., P:O. Box 7162 ~ ~' I S~II SIII ''~ l ~' ~ ~'i M~ ~ fi0ed in by Co.) -1aty Permit Number ( W ~ ( 8) ~`M1 .~ ~ - - 7 ~ 7g De artment of Commerce Sanitary Permit Application ~~ ~ Plaa LD. Nttmber ~~ In accord with Comm 83.21, Wis. Adm. Code, personal inf 'on you provide may be used for secondary purposes Privacy Law, sl 04(1 xm) ject Address (if diffettstt tfian mailing address) ~,; t ", ' %~'t`~ ~ I. Application Information -Please Print AU Information ' F'' :. ';... a:-- 7.2 7..s' 2 Property Owner's Name Parcel # Lot # ~~ T Property Owcer's Mailing Address ~Pefhr Location ~ saxion / D ~/z r~. /~/~~~. City, State Zip Code Phone Number , , RI~E T ~ N / . Type of Bnild g (check all that apply) II , ~ ,~ 3 o f ~ ~r . ~ Subdivision Name CSM Number n u.., (t }'1'or 2 Family Dwelling - Number of Bedrooms 5 J ^ Public/Commercial - Descnbe Use ~ ~ ~~ ~~ ^ State Owned-Describe Use ^City ^Village ~'['ownship of'~~~~ III. Type of Permik (Check only one boa on line A. Complete line B if applicable) A' flew System ~-~ ^ Replacement System ^ Treattnent/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Trtnsfer W New Last Previous Permit Number and Date Issued Before Eagriration Pltunber Owner u 7 IV. T of POWTS S m: Check all that a ~}'Idon -Pressurized In-Ground ^ Mound >_ 24 is of suitable soil ^ Mound < 24 in. of suitable soil ^ Ate ^ Single Pass Sand Filler ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculatitg Sand Fitter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Ltne ^ Gravd-less Pipe ^ Otlta (explain) V. D' ersaVTreatment Area Information: jz' / - ~ ~ 0 r ~ • Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required sf) Dispersal Area Proposed (sf) / System lion 7 // ~J-7•~ / Y.o / c-~ ~-Z VI. Tank Info Capacity in Total Number ManufaAruer Prefab Site Stcd Fiber Plastic Gallons Gallons of Units Concrete Construcxed Glass Taoks Turks ia-t! ~ r/ Septic m Holding Tank ~ v ~ , ,G;<' Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the rod sesame respoasib' ' r urstallation of the POW1S shown oe the atlaehed pbtas. Plumber's Name (Print) Plum i •I~/It~RS Number Business Phone Number Plumber's Address (Street, City, Stu Zip Code) .~gz~~ ~ t~v ~ - o r- ~fTv-- VIII. Coon /De artment Use On Approved Disapproved Sanitary Permit Fee (includes Groundwater Date L4slt' t Signature Surcharge Fee) ~ O ' 0 ~ /D /Z a for Denial Ut. Conditions of ApprovaUReasons for Disapproval SYSTEM OWNER: 1. 'Saptie tSMt, aiMlmt NNer and dispersal ceN must all !~ services ~ as per marapentent plan provided by pwmbsr. 2. AN sslbaCit raqukements must be maintained as per trpplicabie code /ordinances. Attach wmplete plum (to tae County Dory) for UI! systeor on paper riot rns man eus z a ^ mcna .o arc SBD-6398 (R. 01/03) Fager#y Plumbing ~z211so 2828a P:"IcKenaie Rd. Sp~aner~ Wt 5480 (715) u35-9609~,~ ~~ ~~~~ ~~~~ x Fogerty Pitembing #221180 28288 14cKenzie Rd. Spooner Wt 54801 (71~) G35-9609 ~~ ~~ ~~ T ldr ~ q /o~/%s' ~ctl~ /`t' ryo ~ d~/ _- ~•aq , T~ of ,~w.vr 6~~ ~ a ~srR,~c~~ ~' ~ ~s7lfi~d~ x = aet~w~ • = ~tWD L•T GK~~R ~ ~ ~`E• ~ = ~ 2,R7 ~L_ t•T• 9~ic y' CU 9y. i ~~ ~tT ~. ~, W r ~ ~ ~-3 ~ -~ ., ~- i -, _'--- x-2 q`GT. ~ ~~ i S~I'E ~ r ~~ ~i ~ ~` l , _, ~rFlE'C. ~E'MKE~ /~ ` ~S.w+'tti~ c,~~ F~VcE, x y wu=uY Attach complete site 1~ ~+ !>~ nat less 1lt~t 8112 x 11 irx~es in ~` _ indnde, but ~ limited to: vertical and hori¢onfai reter~e l~ ~J. ~. Parrxt t.D. B 20... - D - end percent slope, scale or ~mer~ons, nom aRrana , ar-d 1~a1~n a~ ~ Please prim#a!1 " ~~- ~ ;,~„~,lo,~rmayae,e~ltar _5,~. hl~~ /~ / a~ Property awe , i i ~ t,ac _ Property OwnerstNarlt'n9Ae~ress ST..CftOfXCOI.iN `~~ ~ Subd.t3arneor ZONING tJFF[C - ~ City State ~" Cade Phone Number -- [) CDy [~ VAta9e Q'T°wn Newest Road ~ 7 K/ Gdt ©li X7/3 ) ~$Ei' 7775 G/ B/~ ~ zF_ /~ 2 L 'Near Construction t1~: ~ f t ~ bedrooms ____~____ Cade d design Dow rate ~ OG __ GPC ~ ^ Put>Aic rn coerur -Describe' .~// ~ri....t c-s~ - FtOOd l~ i~ ft' Parent material Bl~~ ~••. •~~ •• ' 1, 2 General corm L y ~ , ! ' /V~-- PJ' ' ~.J ' ' and Cm~vvi.(/~,L'~'A//t ~ 7~ /~1 ~9 ~ ~ Ground swface elrw ~, R >3~ ~ facto< ~ ~ /~' Soil AppRrs~tfon Rai /lt= tiai¢art Depth DarronaM Redar Textrxe S Corgi 8aunda<y Roots GPD Color Cat Sz. S'h. 'Elf~1 `Effti2 Sz Cont tl . rr. ~ l / - // _ 22- ~' SG ~ rl rl 2 p ~ sur>~~ Q.s-.~ ~ ~ ~ ~- ~ ~~ ~ tiaizan t}epfh In. oarn;nart Calor M!NlSBtt t Qrl_ .SZ. t~ Cam ~ s Gf $Z .~1. c, - rE~ ~EtT#2 / -- ~~ C O 3'2 - ~ ~ '- fz L yrs ~ Ott s ~ ~ C S -" ~ -- ~' 2 a ' ~ i~ .~. ~~.~, ~~~ ana-rss <sOm~L-• - Eigttent #1 = B013s > 3u c F1r7 ngn. ana r a~ +s+ .• .,w ..qp.. --- ~T (1'~ Prinij ~"'~ CST Ntrrpber .r ~^'~+ .Z 2 Ly ~¢ r Tekptwne Nurrrber '~ Fe~gertY Pt~tenbin,g & Perlr T 'ag " D~ ~~~ ~ 7!S"~S 96~~ 28288 McKer>~ie ~~ y S ~~~s~rr, ~ s~{d'°! any o,r~ l~.ftT of ~ paroellDtf ®_.~ --~-~~~-~~~ Page of ~~ ~,~,_ Qf. ~~--~ ~~ -~ E ~ ~pppb < 3o mgA. and Tss _< 30 mglt. De artment of Commerce is an equal opportunity service provider and employer. [f you need assistance to access services or The p at 3't31 or'I°~1t' (~pg-264-8777. need material in an a{tcrnate format. please coin ~ ~°t J peon to fnii~9 i~or---~--" ~,,~~ra°°r-n ~>D~~ -" yip-p~OlR.6100) E ~1 _ aop, ~ 30 < rzo ~+~t. ~~rss >30 < 15o mgll FogerEy Piumbing #221180 28288 P:4cKenzie Rd. Speoner, WI 54802 (71,5) 635-9609~y cJ ~ ~/ °~ ,~~ts r Ldr # q ~o~i%s' sc.K~ /" _ ~o ~ d~qc/ _ jai ~ A~ Of ,~,i-N~-- jU~ ~m AF.~Y ~ v x = ao~srpG . = ~avc ~r ~u-~e ~'cs'c. ~eavc~ ~x ~y Romer. f4*~' ~s' r-~ 9s: y Y- 3 Qt. ~ ~° ~~s,~ ~__ --~_, x-2 x- s ~' `-.. (s~urt~ ~"-~ ~r~vcE~ x-r ~~ , ~~,, qS.o~ _$ _ _ m O _ ~ O ~. a n `~ A. C a _ ~ ca 0 ~, ~°e m A o O ~ c ~" ~. n ~' , e ~ ~~. ~ a ~~ -' _ . - 'r; ~ '+_w, _~ ~ ~~ '~= 'r f ~~ 'i tt -. «. L.'" +{foe .: j~_ _ _1 ` ~~ ': _ ~'~ .. 'i _ .v ~Y'~ _ i-- _ ? v .- _ - - _ ..~~ ' r r'-~ . 0 ~® F! ~` ~~ i~ _ A 0 y-' ~ ~~ i c~ ~- `-~- . -- ~. N b p. p. ~• s 4 i f ~~ ~~ i i i f 1 { ~. R ~~ m _ O A m ,, K t'! r• ~_ ry o ~ Ft"-+ 0 ~^^' ~"~ ~+ V1 l 1 '~ N ,V O N O ~~~~® v ~p N 01-~`n~ w~~ ~ ,~~p~ ~0. ~O~ ~ yrjy R G- n ., ~ ~/ ox 7 P.O. B Washington Ave 201 IW ~ ' mo't`'-" ' ~~ W ., . ~~~~~~~~ 'Sn, ~ ~~~ Sanitary Pcrmit Number (to be fiDed in by Co.) ' ~ ~ - De artment of Commerce P State Plan I.D. Number Sanitary Permit App cat~g ~,~ ~ ; ~:~.! tron f' robe ~ orttaa P y In accord wilt Comm 83.21, Wis. Adm. Coda, n may be used for secondary purposes Privacy , sl~t~4X COUNTI' Address (if different than mailing address) I. Application Information -Please Print Ail Information L~ 3t ~rG Parcel # Lot # Block # properry-Owtter's Na ~~ 2 S Property Owner's M ailing A properly Location ~~ ~G ~ ,~ _ 54.~~_'~,Saction ~_ City, State Zip Code Phone Nttm fAt? / T Y~IV 7~s` ~G ~~~5 T ~~, N~ R~E l~) Type of Boil ' g (check all that a y) ~ St~~,,,~ Il . Subdivision Name CSM Number , ., ~ LM' 1 or 2 Family Dwelling -Number of Badr _ ~~ ~ ~ ~ ^ public/Commercial -Describe Use -~ -" - / ^City ^V illage ~ownship of ~1-lJ/~~i~/ ^ State Owned -Describe Use III. of Permit: (Check only one box on ' pe Ty A. Complete e B if applicable) A' ~ / i~ New System ^ Replacement System Trea olding Tank Replacement Only ^ Other Modification to Existing System \ -List Previous Permit Number and Date Issued B. ^ Permit Renewal ^ Permit Revision ^ f ^ Permit Transfer to New _ Before Expiration Plumbe Owner .d ~ lip / ~ rv. Type of POWTS System: (Check all that 1) 1' / - T 4^'Non -Pressurized In-Ground ^ Mound > 24 in. of sti a soil Mound < 24 in. of suitabte sotl ^ At-Grade ^ Sin Pass Sand Filter ^ Constntcted Wetland ^ Pressurized In-Ground ^ oldiag Tank Peat Filter ^ Aerobic Treatmertt Unit ^ Recirculating Sand F'dter ^ Recirculating Synthetic Media Fdter ^ Leaching ^ Drip ^ Gravel-less Pipe ^ Other texplain) V. Dis aUTI'eatment Area Information: Design Flow (gpd) Design Soil Applit~tion Rat f) Dispersal Area (sf) Dispersal Area Proposed (sf) System Elevation X57 / ~G'y. d - t ~. -z s:. ~ VI. Taal: Info Capacity in Total Number Mamtfactu Prefab Concrete Site Co>gwcted Steel Fiber Glass Plastic Ga)lons Galt of Units New Tanis .Existing Tanks 2~ 3~-L /tt /db Scptk or~i~etdltlg'T'Snk ~' ~- d / t/ - Aerobic Treattttettt Unit Dosing Chamber VII. Responsibility Statement- I, the' detsigtied, assume rt'sp~b for installation of the PO shown on the attached plans. Plurttaer's Na me (Print) _ Si tore -la&'/MPRS Number Busittess Phone Number _ Fogerty Pfu>'rlbing ~ ~,z J T/~- .;'s- 9Lo P~LSSet~f Q. ~ Code) _ 7/S-~i3.S = s 1 ~'t'o F/1X ,- _ - r- v.~- ~6 c WI 54807 ooner S . , p VIII. C - 7v - ~ ~ ~s Grarndwa[er Data Isstted Agent Sigttature (No Stamps) mc Sanitary Permit Fce ~ h Q~ Approved v Surcharge Fee) _ Q ~ U ~ ~ ''~`~l' S ' ' ' ^ Owner Gi Reason IX. Conditions o v SYSTEM OWNER: 1 Septic tank, effluent (Ilt®r and dispersal cell must all be serviced /maintained . as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach complete plans (W the Comfy Daly) for the system m paper not less than 81/2 x 11 inches io size Fogerty Plumbing #221180 28288 !l,~cKenzie Rd. Spcener, WI 5480], ~ F®gerty Plumbing #221180 2~32£?~3 !`.~cKenzie Rd. Spis neP. WI 54801 n o I ~ ~ P U ,^ ~ 1 ~ i n v ~~ \~ ` ~~ Q: h ~ ~ I 3 ~~ ~ i ~~ ~I~ a Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page ~ of • in aeon ~rn ~w nw i ~.~m u n w, ma. rwn ~. vwc County C ~ YO 1X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must , inGude, but not limited to: vertical and horizontal reference point (BM), direction and Parcel l.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. p , 1 0~ _ p 9 - ~. 2 ST6~ Please print all inf rma r`~11, Re 'ewed by Date Persa~a~ ~tom~ation you psoviae may be uses for seco ~,+~es`~f +.1s.oa ~) tm))• ~ ~ f ~ ~,6D3 property Owner Kerr APR 2 2 20 Pro Location vL of s~ 1/4 $~` 1/4 S A O T 2~ N R ~ 9 E (or Property Owner's Ma(ili~ng Adddress Zi "l~ O ~~ ST G O PUNT Lo~ Block # Subd Namee or C~ City State Zp Code Ph umber flY ^ ~Ilage ~ Town Nearest Road ~' New Construction Use: (~ Residential !Number of bedrooms Code derived design flow rate !~~ ' G_ d ~ GPD ^ Replacement .(.. ^ Public or oommeraal - Describe: Parent material S~ ~ T 1 C~, ~~ Flood Plain elevation if applicable ~ f~ ft. General comments 5~5~-.e Wt_ e( e. U ~~~ Z L'S and recommendations: Q' e Boring # ^ Boring (IQ ~ .•\ ~ I S1 __~ ~ pit urouna surrace elev. > >~ c1 ~ ~-. vepu~ au ~u~um~y ~o~w~ , ~ v ~~~. Soli Apptiption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Eti#2 ~-~~ lp 12 -~-- - ~ i I 2~~ m-~ ~~ I ~ . ~ . ~ 2 l~ I ~ 2 ~ ~S - 5 -~' -gig ib 1 - ms ~S - - . ^i r. Z ar_ z ~' / ~ s•Sv `~'$ 8 ~~~ '/ I Boring # ^ Boring t! ~ c, ~I /~~ ___( ~„ Plt ~~~ sunace elev. ~ l~ v ~ ~4 ucpu~ w iuiau~~y ~acw~ ~ v n~. Sal Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. '~ff#1 'Eff#2 ~ Z -Ids 1 D r ~ to ~ 5 ~ rn I - _ . -l ! . Z ~--q~c.~ ~f3.2 -Z ' Effluent #1 =GODS > 30 < 220 mg/L end TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ~~ Signatu~ CST Number ---- Address Date Evaluation Conducted Telephone u r Z ti3 g'o *'~ S ~' Sov~ersef w( S-No 2S' 7,~ ZN~ yoo g- Property Owner GS~ Parcel ID # Page ~ of J Boring # ^ Boring I' ~J i Pit Grou nd surface elev. ~~j,,-~- n' Depth to linuting n. factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Struchue Consistence Boundary Roots GPD/ftz in. Mansell Qu. Sz. Cart Color Gr. Sz. Sh. ~ 'Eff#1 'Eff#2 5 S I ~-1t~ 10 ~ 3I k ~ t Z rr~ m-~r c ~ ~ „ , , 3 Z -~~a 1 ~I .- ,~, ~,~I - - . ~7 r . z ~-,ys. ~ a.f' RS'. 2~~ 3 . ~v ~ Boring # ^ Boring ^ Pit Ground surface elev. it. Depth to limiting factor in. Soii Appligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 in. Mansell Qu. Sz. Copt Color Gr. Sz. Sh. `Eff#1 'Eff#2 Boring # ^ Boring ^ Pit Gnwnd surface elev. ft. Depth to limiting factor ~. Soil AppGption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 in. Mansell Qu. Sz. Copt Color Gr. Sz. Sh. 'Eff#t 'Etf#2 • Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL 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 608-2fi4-8777. SBD-8330 (R07l00) L SCALE: 1"= LIO BM 1 ELEVATION ~(~ ~- O i " BM 1 DESCRIPTION -~o~~ Sf ~ ocQ BM 2 ELEVATION ~ q S~ / BM 2 DESCRIPTION ~~ C3-~- ~c~ ~~t-e -~~ ~oc~ SYSTEM ELEVATION ~ ~~ Z ~ ALTERNATE ELEVATION f ~~ Z a CONTOUR ELEVATION ~ ~ ~ ~ ~ ~ ~ ~ - ~ ~ SIGNATURE PAGE 3 OF 3 to ~ ~C, / 4 ~. i ~ - c ~~~trf Eo N~OZ X00 ~~ . d.~+Y~rM CV viW AN #~ C~ O N Ov ~ N ~ a U ~' o ~u ~ ~U ~ ' ~ , o v a O ~ ~AA vl -O V O ~, a ~' are a rd a :m w~ V O N ~ I .~ y ~ ~ t~ ~ ~{ ~l Y ~ f ~ 3 m w n e _ ~ '~ U • 1 N fi; ~. p. .~ J cri ~ 1 '~ ~ ~~`~~' . ~ ~~ ~ ~ .~ ~t ~. U ao 0 O O v ~~ v ~. __ _ ~ ~~~: .- Y, . _ . _~ ~ ~ 9 V ~ _ .___-._ ~- ~ _ ~ 'i~1-:'- ~' ~ 1 f ~ ~~ ~ ~~! „R ~+ ...~ • ~Q/ . ' • ~ .~~ I I _ 7. ~ f~f ~_~ ~ _~~ f ~~\ ~ ~ _ ~~ ~j _ - ~ _ ~ !~ _ i t _ ~ ~ _~ 1 ~ -a - ~ . t - '~ -Q ~n 8 _~ W m Q+ m b m Qt 0 U ~~ wV W .~ tl. m m O ~~ _ I'V W I a7 V VVIVCtf a7 IVINIV~J/~iL Ot ~YIMr11M~7L-rr~~-~~ ~ ' ''^'~ rayn ~ ~i -,~ c u~cna~A77/1w1 Owner ~,~~~ CA/!l~/T~_ - Permit # `~}~q-3 ~-3 vca.v.. ~.•..,.....~....,., Number of Bedrooms ^ NA Number of Public Facility Units _ ~NA Estimated flow (average) p' aUd Design flow )peak}, lEstanated x 1.51 aUday Soil Application Rate _ gal/day/ftZ Standard Influent/Effluent Quality Monthly average Fats, Oil & Grease {FOG) 530 mg/L Biochemical Oxygen Demand IBODS} 5220 mg/L ^ NA _ Total Suspended Solids (TSS) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD51 530 mg/L Total Suspended Solids (TSS) 530 m9~ ^ NA ~- Feca! Coliform tgeometric mean) _<10' cfu/100m1 Maximum Effluent Particle Size Y8 m ilia. ^ NA Othec: ^ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event ~7~l~aN ~~v~~ • -_ Septic Tank Capacity ~j-d ~ ^ NA Septic Tank Manufacturer lii, ~-- ^ NA Effluent Filter Manufacturer /SG ^ NA Effkient Filker Model ^ NA Pump Tank Capacity al ~ ~ Pump Tank M~ufacturer [i NA Pump M~ufacturer (~ NA Pump Model ~'~` Pretreatment Unit a NA ^ Sand/Gravel Filter ^ Peat Filter - ^ Mechan"~cal Aeration ^ Wetland ^ Disi~ection D ~~= Dispersal CeH(s} ^ NA In-Ground (gcavrty} ^ In-Ground (pressurized) ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: ^ NA ether; , ^ NA ether; ^ NA Inspect condition of tank(s) At least once every: Pump out contents of tank(s) Inspect dispersal cellls) Clean effluent filter Inspect pump, pump controls & alarm Flush laterals and pressure test Service Fregttettcy (Wlaximum 3 years) ^ NA When comb'med sludge and scum equals one-third IY,} of tank volume ^ NA At least once every: ^ month(s! 3 yeazis} pNaximum 3 years) ^ NA ^ month(s) ^ NA At least once every: ~ . ~ earls} O monffiIs1 -~A At least once every: ^ year(s} ' ^ month(s) (2 NA At least once every= ^ yearlsl ^ monthlsl _ ~ NA At feast once every: ^ yearls) Q NA MAINTENANCE INSTRUCTIONS one of the followutg licenses or certifications: Inspections of tanks and dispersal cells shall be made by an individual carry'mg O ator. Tank Master Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Paz 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 pondmg of effluent on the ground surface. The dispersal cellls} shall be visually inspected to check the effluent levels in the observation Pipes and to check for any ponding of effluent on the ground surface. The pondi~g of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be perfomned 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. .: `~ Z ~ . saHT UP AND OPEW4~ION For new construct~eur, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impec~'the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior tQ use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above nomnal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cetlis) and may result in the backup or surface discharge of effluent. To avoid this situatwn have the c:antents of the pump tank removed by a septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump! water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. _ ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a septage Servicing Operator. ~ After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or, must be taken, to provide acode-compliant replacement system: A suitable replacement area has been evaluated and may be utiC¢ed for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and shoukJ not be infringed upon by required setbacks from existing artd proposed structure, lot fines and wells. Falun: to protect the replacement area will result in the need for a new soil and site evauation 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/OR INSUFFlCIENT OXYGEN.-DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. e.. ' _ #221180 -- c en e Spooner WI ~~~ (715) 635-9609 ~ POWTS INSTALLER POWTS MAINTAINER Name I (~~~~ Phone °~/S! w3 ~Ol~ - Name - - Phone - ~Pt'ACs~ SERVICING OPERATOR !PUMPER) LOCAL REGULATORY AUTHORITY ~ y ,- I~ame Name l71 ~~ (x ~~ T~J j bhnn~ Phone ~tr - 3~6 QD his document was drafted in compliance with chapter Comm 83.221211b)11Nd1&Ifl and 83.54(1), i21 & (31, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer _~~/1~ Je~i~T' - Mailing Address 9S/~ 1_wc,Ps-,t,~ Ji~c.~'ot~ ~~~t- J'yolli Property Address ~-~/ Z, (Verification required from Planning Department for new City/State Parcel Identification Number DZG -- /Nv7- ~9 -mom LEGAL DESCRIPTION Property Location .5,~" ~/., ~~ y,, Sec. /a • T~~N-R,~V~, Town of ~~t/~llvl~ Subdivision Sl/f//~-f~ iJ.~/2x ,Lot # _~. Certified Survey Map # ~ Volume --~ ,Page # - Warranty Deed # ~S/, /p / Volume 2.S 33 .Page # y~ Spec house ^ yes ~o Lot lines identifiable Cages D no SYSTEM MAINTENANCE Improper use. and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a liccnsed pumper verifying that (1) the on-site wastewaterdiaposal system is iri 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 maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. - / / SIG ATtJRE OF ICANT DATE OWNER CERTIFICATION I (we) certify that aII 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 warranty deed recorded in Register of Deeds Office. / / SIGN OF A ICANT DATE- ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** _ ~- ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed - 'STATE BAR OF WISCONSIN FORM 1 -1996 WARRANTY DEED LV„elson. husband and wife. Cxantar, and Keeton J_ Bast and Dort~da J 8o~-Bast. husf~~rxf anc! v~ Grant®e. Grantor. fior a valuable consideration oornieys to Grantee the following described real estate in St. Croix County State of VYisconsin (the "Property'): Rts'l3IST&8 OF DB,EriS ST_ CROIX CO. , MI BECSIy1r't't FQx ltS:CUIiD @3I08/2005 12:3®PM MARRAIITY DEED _' EXEaP7 i t2FrC FEE: 13.00 rftst+ls Fire: Zips. ee COPY FEE: CC FEE: PAGES: 2 Burnet 'Title 7550:Fratace A~ . ~- First Floor Edina. biN ~ `a _~O.1009 20 000/ 020 1010 80 000 PanCel IdeM[fieMlon Number (PIN) This ~ homeatesd property. (is) ps ray See Exhibit A attached hereto Together with all appurtenant rights, title and interests. Grantor warrar~fhat the title >io the Properties good. indefeasible in• simple fee and free and clear of encumbrances except Dated this ~ day of ~g„ t C_ _ ?_004. _ (SEAL) (sEAL) Rodney G. Nelson elson At)THEN7ICATION Signature(s) (SEAL) authenticated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (~ rtut. authorized by §706.06. Wis. Stets) THIS INSTRUMENT WAS DRAFTED BY Coldwell Banker Burnet 1301 Coulee Road i-tudson, wl 54016 4-22so6 (Signatures maybe aufherdiCated or adcrwwledged. Both are not neoeasaiy.) ACKNOWLEDGMENT State of Wlseonsin. (SEAL) i ss. 3t. Croix county 5-~ carne befonES me this ~~ day of .~4 the above narrred Rodney G. tVeteon and Marv Bg,M R. Nelson. husband and wits _ tD ma known to be the person who exerxited the foregoEtg iristrurnent and advrowledge the same. .- Notary of Nly commies is t~ to expiration date: NOTARY Pust.tc .) PAM a SPENCER NOTARY PUBLIC t3TATE ta/-R OR WISCONSIN Wisconsin Legal f31®irrk Co, Inc. WARRANTY DEED FORM No. t -1t/9tt Milwaukee, YVis. L LLO ~ U J H 7 O ' - \~~ 3i ~ .I i I I~ ~ v \.J m i ~~ ~~ ~• AE'Zb£ 3.1Z,8Zo00N W ~. Q O N 0 tV ~ V ~ a ONE N t0 w m I~ ~~~~~ ~b S~~~e %r ~a fs b ~o ~d,, M: ~bE ~I ~e N ~LE'L£Z ~~ W ~V~ w ~ a'` 0~ J IQ ~N N ~ ~ ~ ~ ~i~ Z U t ~~ ? ~ U ~ I ~ O o U / vw w m ~ / ( /+961 H1.!!ON) ~ Z_ ~T ~. ~ ~ZS'OOZ 3. 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