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Wisconsin.Dep3utmer.Y Of J.nmrkerce PRIVATE SEWAGE SYSTEM County: St. Croix
i Safety and Building DiviSitiia
INSPECTION REPORT Sanitary Permit No:
453135 0
GENERAL INFORMATION (ATTACV-! 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:
Beer, Richard I Hudson Township 020 - 1433 -07 -000
CST BM Elev: Insp. BM Elev: T cription: Section/Town /Range /Map No:
l o� SS T 11.29.19.2695
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic , n A �-� Benchmark S 7 / • � S ��/�� �
Dosing J Alt. BM
�
Aeration Bldg. Sewer
•� � 98 7 5
Holding St/Ht Inlet 9
TANK SETBACK INFORMATION St/Ht Outlet �- d
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing � Header/Man.
Aeration Dist. Pipe R I c y t G�
Holding Bot. System
G �
l Final G ra e
PUMP /SIPHON INFORMATION t�h -•-,ems /\p r l� Vq �® z
Manufacturer Demand St Cover
GPM Z (5 3, O Z . /
Model Number
TDH Lift Friction Loss stem Head t
Forcemain Length Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width �/ Len l 2 No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ` a�
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM EACHING �pufaptu
INFORMATION r Q ( HAMBER OR
Type Of S l �_2 an l UNIT
Model Number:
IBUTION SYSTEM p � z jh j _p,.� e-)4 o
Header anifold Distribution / x Hole Size D ole Spacing Vent t it Intake Sy
_� � Pipes qc 't• �' levl
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 1 xx Mulched
B
tl
ed/Trench Center Bed/Trench Edges Topsoil
Yes No Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / /Q Inspection #2:
Location: 1068 David D W-n NE 1/4 11 T29N R1 9W) Mound View Estates Lo 7 Parcel No: 11.29.19.2695
1.) Alt BM Description= 57_, 60vo z Z. c� r7k ✓� �" �1GJ'
2.) Bldg sewer length = 10 t
- amount of cover =
Plan Use other l s de for additional information. Yes
.. No �_,
Date / Insepctors Signature Cert. No.
SBD -6710 (R.3/97)
1�
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Sati"ty and Buildings Uivisiun
I 201 W. Washington Ave., P.O. Box 7i62 5�cf Y'd f /(/,
�' Vlsivonsin j
Madison, WI 53707 - 7162 Sanitary Permit Number (to be MW in by Cc )�
De artment of Commerce (608) 266 -3151 3 - A f te
Sanitary Permit Application Stott Pin I.D. Nt/
i �
j In accord with Comm 83.21, Wis. Aden, Code, personal information you provide
j
may be used for secondary purposes Privacy Law, s15 04(1)( t i - ..Project Address (if different than mailing address)
I. Application Iufortnation - Please Print Ali Information
Property Owner's Na me pPar�l�
C � H.ock #
d e- ey 20 /qA4 �17�t- 0-�l
Property Owner's M ailing Address _.�. , Property Locati n •
i 1,.5 Gel
v�
City, Stan 5'G� la, /r/ k,5ecrlon 1
Zip Code Phone Number
(circle y oo �
II. T of Building (check all that apply) l� E � , T N. R orQYJ
or 2 Family Dwelling - Nwuber of Bedrooms _ Subdivision :Name CSM Number
❑ Public )Commercial - Describe Use f yhoa, �/,
❑ State Owned - Describe Use .__. ► C�C� (.t /� 2 Z 4- Z 1 d444.4 ❑Township of u �d s'o�✓
III.
Type of Permit: (Cbtisk only one box on line A. Complete line B 1f applicable)
I f New System C Replacement System ❑ Treatrnent/Hoiding Tank Repiacement only f ❑ Other Modification to Existing System
B• 0 Permit Renewal Xpermit Revision C Change of 70neerrm
it Transfer to New Lit Previous Permit Number and Date Issuec
i Bef ore Expiration Plumber
3 S�
� a�
��3/ � d
�N Type of POWT5 System: {Check all that apply) _
i XNon - Pressurized In- Ground [j Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Shigla Pass Sand Filter
Constructed Wetland ❑ Pressurized In - Ground ❑ Holding Tank C Peat Filter ❑ Aerobic Treatment Unit Recirculating Sand Filter
12
❑
Xecircuiaftil S nthedc Media Filter JELeaching Chamber 'rave; -Irss Pipe G salter (explain) I
V. Dls n&Treatment Area Information: — Q ,'
Design Flow (gpd) Deatin Soil Application Rate(gpdsf) Dispersal Area Requi (s o Dis sa rea Proposed (sf) 1 System Llevatio
i 7 g'� i fa; oC0
i
VI. Tank Into # Capacity in Total , Number Manufacturer ! Prefab Site Steel ; Fiber Plastic
i Gallons Gallons of Unite Concrete Constructed i Glass I
New Existing j
Tanks Tanks !
Septic or Holding Tank X a
Aerobic Treatment Uclt i
w
Dosing Cl
VII. Responsibility Statement i this Widersigned, assume responsibility for hAollation of the POWTS shown on the attached Ions.
Plumber's Na me (Print) Plumber's Si gnature 1P PRS Number Business Phone Number
Plumber'a Adds ea (Street, City, State, Zip Code)
VIIL ount !De tment Use U
I�Y Approv4d Q Disapproved Sanitary Permit Fee (includes Groundwater Stucharge Fee) O Date Issued sluing A& *t Signature
LL ry�i�-
F _
11 Owner Given Reason for Denial � 5z). � 0 / (p
�
IX. Conditions of Approval /Reasons for Disapp a! � � -� �--- - ---- -�
y� - 4- CS
441 - � - - -
Attach eompiste plans (to the County oely) for tba system on paper not iess em tU3 x ti wcbes in time
SBA -6398 (R. 01/03)
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w i :cousin Department of Payo of
connnerce SOIL EVALUATION REPORT _ / _ _-�
Ulvisicm of Safety and Buildings
in acxrordarrr.-e wiU1 Comfit 05, Wis. Actin. Code -
County Qlrb J
Attach complete site plan on paper trot less than 0 112 x 11 6rcires irr size. Plan must -
Include, bvrt not [limited to vertical and horizontal reference point (BM). direction and Parcel I.D.
percent 0lope, scale or dimensions, notOn arrow, and location and distance to nearest marl.
Please print all blforntatlon. eviewed Uat
Personal Information you provide may be used for secondary purposes (Privacy Lary, a. 15.04 (1) (in)).
Properly Owner Property Localiun
GovL Lot S4-- 114 Xlej /4 S T2 Q N It j E (o
Properly Owners Mailing Address Lot # E3kx:k # Sulxl. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ villaye N I own Nearest Road
New Construction use: l� Residential 1 Number of bedrooms Code derived design flow tale GPD
I] Replacement El Public or commercial - Describe:
Parent malarial ` d e tit lr, — _ —___— Flood Plain elevation if applicable
General comments
mid reconimendatkx .51 y, rs:
i
Bolng # ❑ Boring cf
1 Pit Ground surface elev. /G "_c �II. Ueplh to 11miliny factor -� in. --
- - -- _ Sol Applicat Rate
Horizon Depul Dominant Color Redox Description Texture Structure Consistence Boundary Routs GPDlI _
Ill. Munsell Qu. Sz. Cont. Color Gr. Sz. Sit. _ 'E1141 'Eff #2
.s 0 2n-,sbk m4 c-5 1 v-C _ `J
2 12- I0 5 r" 0 Zrn ,5b�,
3
Boring
Boring # ❑
Z ® Ground surface elev. it. Depth to limiting factor _ 1_ZQ — in.
Sol Application Rate
Horizon Deptli Dominant Color Redox Description Texture Structure Consistence Boundary Roots _ GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sit. _ •Elf #1 'Eff #2
-� I0 Tr31 — .5;1 2ri,5bk c5 l��' S -
2 5, ` -! 2na5b-� —rrrVr - C -
Effluent #1 = BOD > 30 220 nrg(L arid TSS >30 < 150 nrg/L ' Effluent 112 = BOU < 30 nig/L and TSS < 30 mg1L
CST Name (Please Print) Siyn lure CST Number
Address � V � z - � nd •led �� rep Number -ae
2— IY� r 4 c>Jc 5Zf025 C 7 1 0 ) 7tr o-6 2 7 `)
. t
property Owner -- -
Parcel ID It --------- - - - - -- Page - -- of
3
B oling # ❑ Boring
f Ground swface elev. I ` it. Deptlr to Gn►iGng factor 1 Z `f _irr• So n 3licatirnr Rate
horizon Deptlr Dominant Color Redox Descaiptiun Texlwe Structure Consistence Boundary Roots P D #F
•E(I /fGEII #2
in. Mulisell Qu. Sz. Cont. Color - Gr. Sz. Sh.
2 12 - 2� lO r - — s� cI Zrn cs `f
3 i 121 I0 ( - `f cQ
:3a 4
❑
Boring Boring
f # __
�_J ❑ Pit Ground surtac:e elev. It. Depth to limiting factor irr• Sun n lication Rate
tlorizar Deptl3 Dominant r-ok3r Redox Description Texture Skucture Consistence Boundary Ruins GPD #R
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. _ 'EI► #1 'ER #2
r� ❑
U Boring # Boling Ground surface elev. _,____ It. Depth to limiting factor _— in.
El Pit _ Sol Application Rate
Horizon Deptlr Dominant Color Redox Desciiption texture Structure Consistence Boundary Roots GPD #l
in. Munsell Qu. Sz. Cont. Color Gr Sz. Sh. 'Eff #1 'Eff #2
Effluent #1 = BOD,> 30 <220 mg1L and TSS >30 < 150 mg1L ' Effluent #2 = BOD < 30 mg1L and TSS < 30 mglL
7 6e Department of Commerce is an equal opportunity service p►vvicler and employer. if you aced assistance to access services or
need material in an alternate format, please contact lite department at 608 -266 -3151 or TFY 609-264 -8777.
SR6- 83301R.DD00r
NAtvIE: ac) h✓► V- _ LO I'll
SCALE:
BNI t DESCRIPTION: }op a -- ✓o- flQ"C ss.'l�
BM 2 ELEVA'l [UN. -- - _ -- _-
SYS "I'L'TvIL'•LEVi \'fl�)il:__��. � -� -
SYS "I'L "1'l' _�i.rs��✓ �!!'�°`( -
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SIGNA'T'URE:_
,
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T Safety and Buildings Divisiun j County i
2C1 W. Washington Ave., P.O. Box 7162 �`X
VISconsin Madison, W T 'IV _ Sa tart' Permit Number (to be filled in by Co.)
(608) 6.31. � ' S 3 3 5
De artment of Commerce 1
Sanitary Permit AppliCation A � R 1 S Z 1; 04 stn Plan hD. Number
In accord with Comm 83.21, Wis. Adm. Code, personal informati you provide
maybe used for secondary purposes Privacy Law, s15.04 Pro t Addr (if different than mailing address)
$ I. Application Information - Pletssas Print All Information
Property Owner's Na me Par r Let i
ftiG si pQ E? E;
Property Owner's M ailing Address petty ation
/X� r
City, Stare Zip Code Phone Number
(circle o
II II. Type of 8 iding (check all that apply) S � T N; R /� E o i
f l or 2 Family ing - Number of Bedrooms _ Subdivision Name CSM Number
❑ PubGclCommer l - eribe Use `� 1 9
State Owned - D ibo L Q ie I ❑City_ ❑Vitt e�'Township of
Z
III. Type of Permltt (Check one box on Iine A. Complete line if appy ble) 0 ZO - I`f 33 - o4-
A ' ZNew System ❑ Rop ement System ❑ Treacrtcnt/Holding Tank R lacement Only ❑ Other Modification to Existing Syhvm 1--
B. ❑ Permit Renewal Permit Re ' ion ❑ Change of ❑ Pe it Transfer to New 1 List evi Permit Num and D
Before Expiration Plumber Ow
RE V. TYVe of POWTS System: (Check a ll t t per)
j kNon - pressurized In- Ground 13 Mound > 2 . of suitable soil ❑ nd < 24 in. of suitable soil At- Grade ❑ Single Pass Sand Filter f
11 Constructed Witland ❑ Pressurized In- Ground ❑ Holding Tank Peat Filter El Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating S nthstic Media Filter Leaching ber G Drip ❑ Gravel -less Pipe 11 Other (explain)
V. I)tu rsaUTreatment Area Information: X I �
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal A a Required - 7
(.sO Dispersal Area Propas ystcm Elevation
GQa D a I Sa l. to t'3 i
VI. Tank Into 1 Capacity in Total E NEumber Manufacturer Prof !a. Site Steel Fiber PI astic
Gallonaallans I of Units ( Concrete Constructed Glass
I New Existing
Ter" Tanks i
Septic or Hoiding Tank
Aerobic Treatment Ueit f
Dosing Chamber �® ,•� J
VII. Res ibUit Statement - T the undersi _ �
Y . asatttae r ontlbUit for tlon of the POWTS shown on the attache d
gam. Y �►
Plumber's Na me (Printl Plumber's Si gnature P RS Number Business Phone Number ^�
Plumber's Addre ss (Street, C State, Zip Code) 1
VIII. Count /De artment Use Oal _
t�Approvgd 11 Disapproved 4 /maln y 8ermit Fee (includes Grout water Da Issued jss Agent Signatu (No Stamps)
l - rge Fee) <a C1 2�
Ow Given Reason for Den
IX. Conditions Approve r
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced
as per management plan provided by plumber.
2, All setback requirements must be maintained
as per applicable code /ordinances
I
Alum cocapleN pleas (to the County ottly) for the system on paper not kes then sla x it tnehes in lies
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of _3
Division of Safety and Buildings
in accordance *ft Comm 85, Wis. Adm. Code copy
�rci
-�
Attach c4nplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
_
indo4e, but not limited to: vertical and horizontal reference a {mint (BM), direction and parcel I.D.
petcent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print alf Lftff"ftff." Re Date ^�
Personal information you provide may be used rd artpWpo"s; (Privacy Law, S. 15104 (1) (m)). �`yL < UJ
Property Owner i Property Location
R C Y 'nCxrC� E') Gov Lot SLj 1/4A,1�114 S )J T Z`) N R J9 E(or
I OW
Property Owner's Malting Address Lot #, Block # Subd. Name or CSM#
ll C) v 12, °1 )Val Ufe Ls
CAy State Zip Gode N -- ❑City ❑ Vte Town Nearest Road /
l� n I JJ 540 (. c t / ' 1 0 u 11 L ,
[ New Construction use: Residential J Number of bedrooms _- Code derived design flow rate GPD
❑ Replacement ❑ Public or coonmercial - Describe: - - -
Parent material _— C -ti __ - -_ Flood Plain elevation if applicable _-- �� ft•
General comments e� eM 2 le- it DO c/ 4//,
and recommendations: / ' f �� �/t�irn✓
O
Fl Bon Boring # Ground surface elev. _ " 'uU ft. Depth to limiting factor _ I Z S i
Pit
® Sol Application Rate
Honzorn Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfP
in. Munsell Qu. Sz. _font. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
CS
2 10 31 I D S i e-
- --j - a /U r - 1 4 Ze, m5 m I
Boring # ❑ Boring , ' 1U
® pit Ground surface elev. 1 Q ( • - -- ft. Depth to limiting factor t 2 in. Applica Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDJfF
in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2
sic), 2m5LK m r c5 — �o
c 3 ,o
Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L
CST Name (Please f'pnt) Sig r CST Nurrber
Address
Date Evaluation Conducted Telephone Number
Property Owner _ � r
Boring Parcel ID # Page _ of
3 ❑ Boring
❑ # G ft. Depth to lnni6ng factor
CII�1 Grand surface elev. / 40 10 ' Sol Rate
4� Pit
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfft
Eff#2
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.
v f . 5 - g
yy r c` — _ —!k
3. 0
Z.
F-1 Boring # ❑Boring
❑ Pft Groumd,surface elev. ft• Depth to 1'mubng factor in. Sol Applicalkwi Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAF
in. Munsell Qu. Sz. Cart Color Gr. Sz Sh. 'Eff#1 'Eff#2
u
F1 Boring Boring # Ground surface elev. ft. Depth to limiting factor - in. Sol liar Rate
El Pit
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD(ff
in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. 'Eff#1 '011#2
' Effluent #1 = BOD > 30 220 mglL and TSS >30:S 150 mgfL ' Effluent #2 = BOD 30 mglL 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- 264 -8777.
SOD- 9330(R.07/00)
PAGE'� OF�
NAME: (3-e P LOT# LEGAL DESCRIPTION:
�1 /4 F/4,SAT2,
SCALE: 1 "= 4 /0
ELEVATION: A26.0
k
BM 1 DESCRIPTION: S-e V of
BM 2 ELEVATION:
BM 2 DESCRIPTION: 54c I t pod b
SYSTEM ELEVATION:
SYSTEM TYPE:
/j sys4
l
a -�
9G s 6
GNATURE: _ -_ � _ DATE:/- 0 — °
.. --- �....._..+� -�.:,. -- ..�ti+�.r • w � :ter L `- :r.. ,.D -L E ^ r r ' CA :\
v C I VZNT PIpE 1?" MIN, A$OVE GZADE E
1 FROM DOOR, WIN:)OW Olt dE+ kER
FRESH AIR INTAKE JLNCTIONO 8Gx APPROYED
• ,. 'KITH CONDUZ ,
F.NISHEw GRAPE `SANHOLE CGSER
W! PADLOCK g
4„ Cl RISER -- .....WARNING LABEI
as "tlsv. Ls
LL
1 i
WATrR TIGiiT SEALS GAS- ; ;
TIGHT, '
p
,
A , ROYED
pPR SEAL P
OYS3 +1 JOINTS WITH
'IPE 3' 8 !A Lm APPMVED PIPE
)RTO S,"!L TD i +
yCJII. ("�` ON � � 3 ONTO
P UMP r ELEV , C SOLD, SOIL.
x ' O FT. , - ..,..i
D } RISER EXIT
o PERMITTED CNLY
IF TANK
MANUFACTURER
3 "" APFR' V ED $EDDING UNDER TA?�TK HAS APPROVAL
SON ."RETE PAD
E *CA T. NS
DOSE
y ANX MANUFACTJRL"R: h'"►iMBER C OS£S PER DAY
DOSE -I;rdrd
GAL.
.r.0 VCt. J.Mr II�cw%NG
%LARM MANUFACTURER:
MODEL t�JMSFR: CAPAD .q s I:tiCiiES o ..: ..GAL
SWITCH TYPE:
2 . I v GAL.
MANUrACT'um:
MODEL NUMBER: C = ,,. INCHES = J_( GAL
SWITCH TYPE:
+ D i;IChES = . 12 1 a GAS.,
EQUIRED DISCKARG£ R.AT
-•L .�P:• PUMP E ALARM W 4'R1NG AS PER ILHR
CAL DIFrER 16.23' '+�'AO
EXT ,:NCE 8E.
MINIMUM NE'Y'WCRX SUPPLY pR� Gr �' AND DZSTAT BU i I ON PIPE ,2
4
FEET X SSL °RE < rEET
.,...�.. FORCLMAIH K ,
i'�1 x Tt 13 4 F . , r. T. T QN FAC" „ 4 00 FEET
- :..,w. , FR. TOR 7 FErT
OUL DYNAMIC MEAD x �
ERNAL DZM '.+~ T L i p .. , FEr
�'1� +t�tiS
WIDTH rW- ; £TER
aw
./ra.
wLU RF 501L TE5 T 1* ?A'E A
Goulds povu *, wr
.. SubmarMble --
�- Effluent rump
�� EPO4
t 71 t EP05
._.MUM • Futmsrc:1p sines •
P" ipnee for » who ral. g ; , t ,^ • me* Nowi�,on
• L'+bie of nnryn4 �4tOrta wQ eticiM,t sRnt INIt
dbm� d Not try.
i 1u1 �NNN; Avegmk fu ud =0 wNh P dk
» 7 sump ' EI~DI C,4 HP nOM( A�11tlP w0IW WAft A dtm4nt
• nth �1 Y, op al, 1550
� MIM1/ MAN
in ow.1w rkh o-d 1w • bust (alts: b o e du
E c fnet, pefelt d td fltld of ead wdiel Rt,
• i tI v, _p I MP. SH ap t 1144 ; pet wd bwer
�N: It04 W f'�.13SG iPM, HA he�+N duty bW t�trfnq
bust;
i Solos � i terra � We • TNrmo.
�.• rr+�d�wm. » wt. l0 tact Rik �"a0M dwdp n
• fit: uD � $ GPM. ilr 0,164 SJTp c br AM Y LMTIits
= bpd! �+dr. up ' 2f Pr. ** oft P" Imundii p10iN;�oA.
1 t'/d' NPt NUO. d0Mong 20 toot V ■ ELI I IMr. �'M■r»MA�iAiou�y,;
wl: cubes.
Ip!!�� ♦ �� 7 I � �W w th pule fo =A %W mods! numbtrs
IUNk 1 Viers, I�an O% ;frog 'mPtoW pWwWae. end tn'r pr - AC - .) nC
ths = W *"W=Av2pd
IR comftww PMW*g
o
per
wow am* t
ownporwft 4 3Q
n0 b�hy. so
G40mMe .rip to 00 GPM, ;
T919 how ft l it NPT
flu an
c is
1 04 5 F (4 = 1Q
M
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i try siauiCa p�++� rn», r 1!
-� �ric�fr4�
STANDARD CHAMBER
Quil Standard Chamber 48" -
(EFFECTIVE LENGTH)
®r
8" 1
SIDE VIEW
SECTION VIEW
MultiPort End Cap
I F
Tu�
16
I Ion
SIDE VIEW TOP VIEW
FRONT VIEW
A.,
Effective Length - 48" Invert Height - 8" or 1. 25"
invert Height g°
INFILTRATOR MC—S—TAV-Pil UK1-1ED-WARRA-NTY
"I thin of each "he"'i and plate, "edge 0 oll accessory rra-f.ctlui bry Inlituall,or ( "torts'), tyltiV, 111(aled anc' 1,ffraji
n a leachfield of sq col sapil sys tem j r, accordance wIll'u,511talpi '81mol "w arranted to the original cimfei,
t h at !
�,,4er "J is 'I'd "`rkirtninship for one year r"r tire date that Ili all Permit Is sallied (or file seplic systaui containing ft Ul provided, however.
if I septic Perroll l required by applicable law, the yvignal period will begin upon this dole that Installation of thitisenhi system , on rXinerteric
,Ja 0 wi Its wan-ty nq 'its. Holder ril notify Infiltrator in writing at As Corporate Headquarters 10 Cid Sat/wook, Giinnedlct;! within fifteen 05)
Of imp aiww dell Infittrator Witt so ppy
^ excludes the cost of remcnial and/or installation of in@ units.
O
Infill Rablilry swift WIwIlooll Jolts lot Uril!s delemill by Infiltrator to be Covered by the Centred W,
(11) 1 HF" 1 .11vill WARRANTY AND HEMEDIM IN SUBPARAGRAPH (a) APE LX(A-UlSVE I 1 11 RF. AMr NO C)rHEV WARRAl MTH RESPEC
TOTHEUNirs i','CIIDINCMC)lk4PLIEDVVARRANTIESopk4ERCHANTABILITY(IRF;T�IESSF,iRAPA!iZIC
,d th, -wris other (ban Infitirall The, 1-ii War V does
lc) I III,, War rally Shall i void It any pall Of the ol—be, system u, m anufai SYSTEMS INC
l exic-nd to inclOnial conseclustri special or daniages. Intilt-ator. lil not pa;mkslu for parrallies or ww'dso oani wrins ore all f o rt h r1i "
( lu l: ]-a C,4 Environmental Onsite Wastewater SoluWl n
k—J"061 and profits, labor andnritteriall overhead costa, or Olher losses or owl it,,u—i by this HC* or any third party. Spur fit i— Llhr Warranty are d ama g e rt,�l W.oly
aft arli In
eration, ac I rill of
! U
in '. , a to the Units I_ 1. 0 ,j., ya , yves, a n d tear, say
ro ni 1 11. Units being subject to vehO lode
O traffic Or CMIN CcvOl ,in l whit" not psTmilled by tit, n
tilt, sIruCA m ral the 6 Business Park Road • PO. Box 768
olhourn ground opyWs set forth in the Inetalation instruci the placre of jorlprore Metal "Ito the system containing it. L 1i failure of
III Units 01 the rel improper system dug to proper ailing or rnpropor tiring, ", i ,,s Vt . vriliflatfir ( USIA i nomirle, ' '16 475
any other �qrij �not caused by Infill 7 Limited Warranty shail be -id it I" H li 10 com wgh ,,, ojj p Is ,1 1, ln
Old Sa
We, gntv. I ybrook, CT 0
S
a er in nor event i Inli he r0firioni for any loss or Ishii 11, 110 Ho he 1,; thud party Msull ii Installallon or ship- 360-577-7000 - FAX 860-577-7001
Furth
nis" "i 6
, or from any product liabil clawl of Holder or al third pa For lit-
� ll ile Conti required by state and hoal : odes ' a
� dfes ar olint
't ariplicatitelay4i and li 'S i i Ine Units Must 139 Installed 11 accordani 800-221-443
or retaliation instructions.
(1) -i Hol No i d tibreseni of it has the Afrotry, to irttani it extend this Limileb Winal No wwo,irtypil 10 arty party oliT, than the
er.
TV show repi its $9 Standard Umi Warranty ofted by l.nhjj A L imited number of states a cot jj
h ave d,t1 warranty require-
,eri X or i,li Contact Infilrator's Cmorporalq Hisadquarl in ( Saybrook, Ownrti pilot to such pucf,ssa, to obtain a
,
nFY 0 !" nPollill warranty, and should carefully read that wainardy poor to the oururai "Ji
LJ S. Patents, 4,759,661; 5.0117.041; 5,156,488; 5,336,0 5.401,116: 5,401,459; 5,5111,903; 6,716,163; 5-588,778; 5,839,844
Canadian Patents: 1.329.959; 2PD4.564 Cher pati pending.
Irfiltre.tor, Equalizer and SideWinder are registered trademarks Of totil(ralo. Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc.
is a registered trademark in Wei Contour. Conti Svrsl Connection, lutcrol-eaOing. P&yluff, SnapLyci Chamberglaaci RoaiLi QuicitlCul QuickPlay
and 0LIl are trademarks of infiltrator Systems Inc, 0 2073 Infillralor SySI@MS Inc. Printed in U.S.A. 001 12GIHP-o
POWTS OWNER'S MANUAL & MANAGEMENT PLAN page of
F FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Tank Manufacturer 0 NA
Septic Tank Capacity Z _Cj al D NA
Permit # Septic
45 - 3 135 -- r
Effluent Filter Manufacturer � NA
DESIGN PARAMETERS C] NA
Number of Bedrooms 9-/, 0 NA Effluent Filter Model dc'l
Number of Public Facility Units A Pump Tank Capacity al O NA
Estimated flow (average! � � al /da Pump Tank Manufacturer ,r s e y , ❑ NA
Design flow (peak), (Estimated x 1.5) 4 al /da Pump Manufacturer [J NA
Soil Application Rate slide /fttp Modal QO 0 NA
Standard Influent/Effluent Quality Monthly average" Pretreatment Unit NA
Fate, Oil & Grease (FOG) 530 mg /L O Sand /Gravel Filter O Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg1L 0 NA o Mechanical Aeration 0 Wetland
Total Suspended Solids (TSSI 5160 mg /L O Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Collis) O NA
Biochemical Oxygen Demand (BOD 530 mg /L n- round (gravity) 0 In-Ground (pressurized)
Total Suspended Solids (TSS) S30 mg/L ❑ NA At -Grads 0 Mound
Fecal Coliform lgsometric mean) 510 cfu /1 OOmI M Drip - Liens ❑ Other:
Maximum Effluent Particle Size yi In dia. d NA Other' O NA
Other: 13 NA Other: O NA
"values typical far domestic wastewater and septic tank effluent. Ott: O NA
MAINTENANCE SCHEDULE
Service Event Servios Ftequency
inspect condition of tanks) At least once every: 3 ear(s1 a (Ma>Rimum 3 years) O NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal collie! At least once every: r m zn ths) (Maximum 3 years) ❑ NA
,7 (s)
Clean effluent f)kw At least once every: `h(a ) E3 NA
inspect pump, pump controls & alarm At least once every: �--- monthis) O NA
d saris)
Flush laterals earl sari and pressure test At least once every: y) O NA
s)
Off` At least once every: 0 ma j(Q 0 NA
Other:
O NA
MAINTENANCE INSTRUCTIONS
tnspections 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 Maintalner Septage Servicing Operator Tans
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 eeil(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondin
Of effluent On the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmen
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.
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1 06ed
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSED CERTIFICATION FORM
Owner/Buyer y
Mailing Address
Property Address ��� g a.
(Verification required from Planning Department for new construction)
City/State , Parcel Identification 1ltunber
LWAL DESCRIPTION
Property Locati V4, 1� %4, Sec. T�N -Rh_W, Town of -
Subdivision M t,�� � -
U y e.� ( �Z/ Lot it
C.erNffed Survey Map # ,, Volume
Wa non Deed # �
t3' Volume . Page #
Spec house ❑ yes�ino Lot lines identifiable ❑ yes ❑ no
MMTEM
Improper use and maintenance of your septic system could result in its prematumc failure to handle wastes. Proper maintenance
aoo:ists 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 f faction 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
masterplumber. Journeyman plumber, restriewplumber or a licensedpumper ver*ing that (1) the on -site wastewater&Vosal 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.
Vwe, the undersigned have mead the above requirements and agree to maintain the private sewage disposal system with the gtandar&
set forth, hemiry as not by the Department of C.ammerce and the Department of Natural Resources, State of Wisconsin, Certification
stft that your septic system has been maintained roust be completed and returned to the St. Croix County Zoning Office within 30
days of the throe year expiration date.
SIGNA OF APPLICANT
DATE
O,�R CER�_ATtnw
I (we) certify that all statements on this form are true to the best of ray (our) knowledge. I (we) am (are) the owner(s) of
the property descn'bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
Si(3NA7'URE
OF APPLICANT
DATE
«• «fss Any information that is ttiis- mepresettteduuy result in the sanitary permit being revoked by the Zoning Department.
se Include with this application: a stamped wartuity dood from the Register of Deeds office
11 copy of the certified survey amp if reference is made in the warranty deed
DOCUMENT NO WARRANTY 9111
Bog 4 6 0 G STATE OF WISCONBU -WORM 9
30005 Teti RAat MIUMM FM aoo. DATA
Tms IIwE n=z. Made by — Leonard J. Beer, also Rr- GISTERS OFFICE
mown as Leonard Be er, a- si nglp man S T. CROIX CO., WIS.
Recd for Record tWs_6 1_ __
grantor of St.- (; r n i X County, Wieoonain, hereby conveys and warrants day of _ APTi1 _ _ _ _ _ A. D.19_7
to Richard T.. Rppr and Ji:ppi ne 11 Reer hival»n at__ a. - M ____ M.
and wife as font tenants_ /1 i_
of St Croix RETIRE T•
County, Wlsoondn, for the am of
OnA Dollar and nther valrrahl- consideration
the following tenet of land in St _ rroi X County, State of Wiacoodn;
The Northwest quarter of Section Two (2), excepting therefrom: Commencing
at the Northwest corner thereof: thence South 159.6 feet; thence Easterly
40 chains to a point on the East line of said Northwest Quarter (NW 4)
which is 121.3 feet South of the Northeast corner thereof; thence North
to said Northeast corner; thence West on the North line of said Northwest
Quarter (NW -) to the point of beginning:
also
The Southwest Quarter of the Northeast Quarter (SW k of NEiI); the
Southeast Quarter of the Northwest Quarter (SEA of NWT), except a parcel
o land described as follows: Commencing at the Northwest corner of said
S heast Quarter of the Northwest Quarter (SE4 of NWT); thence East on
the.North line thereof 815 feet to the place of beginning; thence South
33 feet: thence East 100 feet: thence North 33 feet: thence West on the
North line thereof for 100 feet to the place of beginning; also an easemen
for roadway purposes 20 feet wide on the West side of said excepted
parcel; also a right of way easement over the roadway as now traveled
in a Northerly- Southerly direction over the Northeast Quarter of the
Northwest Quarter (NEB of NW-,;), all in Section Eleven (11);
all of the above located in Township Twenty -nine (29) North, of Range
Nineteen (19) West.
also
The Southeast Quarter of the SouthwestQuarter (SE;~ of SW4) of Section
Thirty - five (35) Township Thirty (30) North, of Range Nineteen (19) West.
Subject to easements and highways of record, and containing 275 acres,
more or less.
Grantor reserves the right to live in dwelling house on premises for his
natural life.
Subject p to mortgage to Federal Land Bank in the sum of $11,450.00, which
gra llY WTLNESSyVFIEKEQF; a said greaaetor 0 — hereunto set his hand —and seal— this 2nd
day of A pri I , A. D., 19 �0 . �-
SIGNED AND SEALED IN PRESENCE OF
Leonard Beer
(SHAT.)
(SEAL)
J W. Hughes
G
G " 1 I` I , � (SEAL)
Ruth A. Johnson (SEAT.)
STATE OF WISCONSIN, 1 —
St _ Crini x County. } sa '
Personally came before me, this 2 nd day of Apri . A. D., 19-7-
the above named Leonard J Beer, also known as T.P onard Bppr, a ci ngl a man
to me known to be the person _who executed th !1; fta;ne and ackn?qKedged the same.
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