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HomeMy WebLinkAbout020-1456-14-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division F INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township SOlber ,David Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: /o l3w~ , cbT TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~ ~~~ 5 .~,}-- ~ Z5 ~ ~`~ pv a ~ Z Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 7 75 i N19- 3d / ~ / Dosing Aeratio Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Mo Number TDH Friction Loss TD Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM County: St. Croix Sanitary Permit No: 479452 0 State Plan ID No: Parcel Tax No: Section/Town/Range/Map No: 11.29.19. STATION BS HI FS ELEV. Benchmark 7 35 /6 7.3 /cs~ Alt. B Bldg. Sewer ~ ~ , ~j ~~3 , ~ Z SUHt Inlet y. s2 f12,2'] ~,l.e~ ,oz .~s SUHt Outlet ~1.9Z ~Qz. y3 Dt Inlet ~ ~ Dt Bottom ~- Header/Man. ~ ~ ~ ~ 5 Dist. Pipe 9 $ ~/ 7, S 3 Bot. System /0.8 yb- 5 Final Grade St Cover~.• I ~ / ,~ ~ ~ ~a ~~~ + BED/TRENCH Width Length ! No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid D th DIMENSIONS ~ ~L ~ ~CeJ\ \ _ ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. r / ~' ~ ~ ' CHAMBER OR ~Q r I cc1 rJ" l. INFORMATION ~ Type Of System: C' J ~ ~ n /~ / V . /~ /l/ UNIT Model Number. r D DISTRIBUTION SYSTEM F...~- "/_:5 e~L.. `I.4, t-o~SLJ Header/Manifold ~/ Len th Dia 9 ~ ~ Distribution \ Pipgs)~ ~ P 9 Len th Dia S acin x Hole Siz ~ x Hole Spacing Vent to A' Int e 3~ ~C~v'~- / CAII CAVFR ., o.e~~~~.e c..~•e..,~ n.,i., ,.v 1111n~~nr1 nr ~f_(;rarlrs Systems Only i-Jd,.~,L. Depth Over i Bed/Trench Center ~ 35 Depth Over Bedrl'rench Edges ` xx Depth of Topsoil ~ xx Seeded/Sodded Yes No xx Mulched -Yes [ `' j No r COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 1046 LaBarge Road~eH-udson, WI 54016 (NE 1/4 SW 1/4 111T29N R19W) Sunset ~illsI 1st Add Lot 14 1.) Alt BM Description = ~~ ~ '~`~- ~oJ ~ C1n~w~r~,5 ~ ~o~ ~ ~ 2.) Bldg sewer length = ~jp - amount of cover = / ~9 ~ -~- ~~i Plan revision Required? ~...j Yes No ~ I I ~ ~ I ~J i Use other side for additional informa on. L _ _ I_~- _~___~ Date SBD-6710 (R.3/97) Inspection #2: / / Parcel No: 11.29.19. ~~ ,i ~~ ~_ `~~ _._ Cert. No. - Safety and B ' 'vision County , Cr Sf Washin Ave. ~~ ~ OI • iseonsin 537( ,~ a Sani Permit Number (o be filled in by Co ) Department of Commerce n 66x3151 U - Z ~~~ `~S Sanitary Permit Applicat ~ / ` ~ ~ ~ ~ ='17I1~ stet P-an LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal inform ion yog~rt~~ lX r 4(1)(m) C AUNT! s15 oses Privac Law d f d b Pr act Address (if different than mailing address) . y , may or secon ary purp e use ZONING OFFL ~ CE 1 Yte La Bois a Po. _ I. Application Information -Please Print All Information „t(" ~1 O h Ltd/ S ~O~t'o Properly Owner's Name ~ - arcel Lot # Block # a ~~ ~ y So ~~~ ~ b~, ~- o~ Qs Property Owner's Mailing Address perry Location ' Z ~ S ~ ~O V Q..n..-~lreatt /V~ Y,S~'h, Section ~~ City, State Zip Code Phone Number V O S ~ ~ ~ G+ / t6s~-33 - _ / /~ q Z / / (circle T N; ~E ll that a l ) ildi h k f B II T pp y a ng (c ec ype o u . 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Njmb~ 5 T ^ 5 "J~ ~ /'s Public/Commercial - Describe~/U[Lse /~ _ G~ ys Q~q•~y ~~yp~p~s'9 ( ~ ~+ V ^Village~Townshipof / So I' ^City 0 K i ^StateOwned-Describe Use 7 _ O - ~- III. Type of Permit: (Check only one box on line A. Complete line B if applicable) p _ p - O O A. New System ^ Replacement System ^ Treatment/Holding Tank Replacement O ly ^ Other Modification to Existing System B ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil . . ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In- olding Tank ^ Peat Filter ^ Aerobia Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Fil r thing Chamber Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersalJTreatmentAr~a Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area R wired (sf) Dispersal Area Pr posed (sf) System Elevatio ~ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Conswcted Glass New Existing Tanks Tanks Septic or Holding Tank / ~~('~ W ~ s Aerobic Treatment Unit W p 7 O C ` ~ • I ..~o'~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signa a MP/MPRS Number Business Phone Number /~'t`~-~'-~~ ~a.i 1 ~ z zs o 3 ~ ~ ~ z - 86r~ s z Plumber's Address (Street, Ciry, State, Zip Code)(('~ (~ ~ "r ~ ~ -l O o`-S t~ '~ O .r tic r ~ :. bl- VIII. Coun /De artment Use Onl A roved .-~ ^ D oved Sanitary Permit Fee ncludes Groundwater Date Issued Issuing ant Signature (No Stamps) pp ~ Surcharge Fee) ~~ r 0~ ~S ^ rven Reaso for Denial IX. Conditions o pprov 1 SYSTEM OWNER: ' 1 Septic tank, effluent filter 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 tm me i.ounry omy~ cur me syn,~,~~ o.. p..p~. ••~• ....,• "~ I SBD-6398 (R. 01/03) S ~r+s~T l-~~ lis ~sfi c~QO (Ti oN. LaT ~ ~ y A 1 P 0 1 ~ ~ c. Ldb4~5 ~. Roa~, w H ~o ~~ ~ .po..~ •, ~ ,Sa I b o ~S ~iyl~~c~,~. f~o.n~.s S ~~,~.T l-~~ lls ~s"r t~~D (Ti off. Low # ScAfe~.~/4'= /o~ P A P 0 ~ y 1 ~ y ~ ~-db4~s ~. Ro~~, ,~ O ~~~~~ ~~ w ~ RECEI~/!E ~~,, 1876 WisconsinDepartrnentofC mmerc~a~ E~3 ~ ZO(l~ S~IL EVALUATION REPORT Page 1 of 4 Division of Safety and Build gs A.C.E. Soil 8 Site Evaluations ' rdance w~h Comm 8S~, Vis dm~Code m acco -(C IX "'0 ~ ~T"~' '_ County Attach complete site an on ~ s 11 inch m size. Plan mu St. Croix include, but not limit ~ ' t (BM), direction ~ L,/' percent slope, scale or dimemsions, north arrow, and location and distance to nearest roa . Parcel I.D. Pen ~ from 020-1012-00-000 P/ease print ail information. Rev' Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ! ?- Property Owner Property Location Miller Homes Govt. Lot NE 1 /4 SW 1!4 S 11 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 868 Kelly Road 14 Sunset Hills First Addition City State Zip Code Phone Number -f City _f Village r+ TaNrn N~rest Road Hudson ~ WI 54016 715-531-0714 Hudson LaBarge Road 1+ New Construction D~~ N Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial -Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Recommend installing two trenches at 3' X 87.50' using twenty eight {28) 11" Standard Bio-Diffuser Chambers at elev. = 96.50' ~j ~ Boring # ~ Boring /~ Pit Ground Surtace elev. 97.77 ft . Depth to Limiting factor >112" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft~ in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0-7 10yr3/3 none sl 2fsbk mfr as 2fm,1c 0.6 1.0 2 7-24 10yr5/4 none sil 2fsbk mfr cw 2fm,1 c 0.6 0.8 3 24-29 7.Syr4/6 none Is 0 sg ml aw 1fm 0.7 1.6 4 29-112 10yr5/6 none s 0 sg dl - 1vf 0.7 1.6 H#4 contains approx. 10% gravel & Cobbles scattered throughout horizon. 1 Q, ~ {Boring # _! Boring 1 ~,) I Pit Ground Surface elev. 99.14 ft. >119" in. Soil Iicafwn Rate /~ Depth to limiting factor App Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 •Eff#2 1 0-9 10yr3/3 none sl 2fsbk mfr as 2fm,1c 0.6 1.0 2 9-26 10yr5/4 none sil 2fsbk mfr cw 2fm,1c 0.6 0.8 3 26-50 7.5yr4/6 none Is 0 sg ml aw 1f 0.7 1.6 4 50-119 10yr5/6 none s 0 sg dl - - 0.7 1.6 contains approx. 1096 gravel scattered throughout horizon. " Effluent #1 = BOD ~ 30 <_ 220 mg/L nd TSS >30 < 150 mg/L Effluent #2 = BOD < 30 mg/L and TSS <~30 mg/L CST Name (Please Print) Signature: CST Number James K. Thompson ~ ~ 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane. Osceol 154020 12/272004 715-248-7767 Property Owner Miller Homes Parcel ID # Pending from 020-1012-00-000 Page 2 of 4 Boring # ~ Boring i~ Pit Ground Surface elev. 101.25 ft. Depth to limiting factor > 125" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-5 10yr3/3 none sl 2fsbk mfr as 2fm,1 c 0.6 1.0 2 5-17 10yr5/4 none sil 2fsbk mfr cvv 2fm,1c 0.6 0.8 3 17-27 10yr4/6 none Is 0 sg ml aw 1fm 0.7 1.6 4 27-125 10yr5/6 none s 0 sg dl - - 0.7 1.6 ai~~(o-S?~/ s-~~ q 3 H#4 contains approx.10%gravel scattered throughout horizon. ^ Baring # ~ Boring _~j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ^ Boring # ~ Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS< 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. ' SOIL AND SITE EVALUATION 1878 Page 3 of a PROPERTY OWNER: Miller Homes PARCEL I.D.# Pendingfrom 020-1012-00-000 A.C.E. Soil & Site Evaluations REPORT MEMO Soil evaluation completed prior to plat review. Changes in lot line locations or building site may result in additional soil evaluations being required. Lot line locations must be verified prior to permit issuance and system installation. 1 . ^ So;l Eta./ua,6'a, p; E • ElevQ~~ -~ EXi s~ ~9 ~'e~ ~ oe /yl,•//cr fro~nc3,let /y S4nscf RQ~ ~'/B7G (~ 1 ~ 64n~ rr1 arK ~ e o f ~ i ~s /'~ba.~ ,Q ss wn, ed ', ~ ~ ` ~ ~ ~ `3 ~ ~ ~ ` ~ ~- ` ~ ~ ~- ~ ` ~ ~ ~ ~ ~ ,~ ~~ ~ t `~` ~` `~ ~~, 99.7' i t ~~ ~ ~~ 63 ~~ `~ S~oPE ~~ .Gh Nr` ~~ ~ ~ ~ ~ ~ ~ ~ . cJ- •~~ `~`1 -`~ ` ~1 O,l O~ O~~ J ~ ,~ O ~ /`~ \ d~,,~ 2/ Fe•~cc past. Eke = /~•~' Propascd / 4~~ K~ad P~. ~ o~ ~ Polylok PL-525 Support Stand Should you feel it necessary to add addi~onal support to the PL-525 filter, use asix-inch Schedule 40 or SDR 35 pipe to extend from the base of the filter to the bottom of the tank. The ext~n~on pipe needs to be anchored to the filter housing with one or two #1.0 X 112" SS screws. Anchor 1-2 Stainless steel screws through housing and intopipe. Use #10 X 112" -- 6"Schedule 40 Pipe Pipe rests on bottom of tank Quick4 Standard Chamber __..-_. SECTIUIV vltw !EFFECTIVE LENGTH) ~ I , _, 1 -_ - I ~ _ ~I~ ~ _ _ ~~~_ _ ~- _- l ~ _ alb ~~ _~~ I~~ 8 ~ ~ ~II~ -t- ~~.__-.__- -~__ - ~ ate- ®~I-~~~~~ SIDE VIEW MultiPort End Cap ~, ,~ ,i 'F F ~ f,~ [~ } 1 \\ ... \/ -, FRONT VIEW INFILTRATOR SYSTEMS INC. STANDARD LIMITED WARRANTY - ~. , , "a(.7 1 i b•Y Fnl; nlaie. wr:(1gP, antl nlhP,r aCCr.SSnry »:I It '.I rC1i'„ ... ~... - ..n: ', !f '.nh Lf'W!IF Irlfllralpf , n51rUCtnnS V w tlpl I t• I I.r :lt.Cn l,C nail: ~Ilal lhP. SCpIG pCrmISSSI IF,(l lnr ll C.rrn nrtl I Ov al `fi caMr law. IhP, warrMtlV Dergn Will bEgm l,l" Ily,' I :I.. .tl ~~ ~ .Ili n•ll I 10 pry L,'llydl Or n wrl nq el IS Cgrgprale Hn; tlntldrlr. . .. •. . l,r, r .I,(`I,ly rrna%;nr"Cal t)n,151pr UniiS tlClCrn,nCC`'I I I Il,:r~. •. ~. ... ,. . . ,•` 'C ~~v ~..:. ~, :!,N/nr n:t ~llgl <)n nl l,t'I1n \ . - r: ~V F~AI I IIF N S 1HPARA(~gAPH lal /,Ft( f:(CLl1:iIV 1Ir •, _ ' ~ .~, NC 111.!'~VJA.tI~ANC[S()F'MFR(:HAN'fA81L111'()171IiVl I1 r!, . ti„ .....- ..... ~ lit !a .• ;.~. n hn ^hnmprr ry^ rnn S nnrr lar.h n. by dn,,., I . ':"n ,:,A'- 1MI rf~ Iq I I'll aip I II ). I ~. . . r... .•~ d II:,. ',v rl r tl Cn, 15. p ~ hr:r r.,'nr itv .: I(t55e' rl .. " ~v < ~Ir : ii Ir I > me Unns nue In rurhndrv wrar I I , , -. '.1 ••( I n Ir alf n )Ihrr rnntlrl (r1S wh Cl, dre nnl rn I I I , n Inrl nr ,; II, r en rnSlr H:1 On$ Iht' PI,iCCmenl nl rnltr(:tlr air ,tl, ,~ - . '•'1 .: qr bOnr, n r,prnrN±r 5gmg PxCFl55rvP, wdlnr q ' ~ r ^: Ih- I , In ~ nl Irri Warranty 514i111)C vprl I Ihr Hnk n 1i 1, Irr ~ rr " ~-,. - I mat Ix... c~nsm,le Nrr a,v Ins. or nalnage to the Holner. In. ll ue::~ I 'al'~Ir.., .I ~Ir ~1nr r.. 1nV Ihrrtl •~.lrly. I~n t .Irl l~lral V/;r I i , ~ ~ ~ ~~ ` . ,. .I,d,r - ,n. c•.I II Irn. . ... - ~ t s. an'u"rc aon cable .. ~. - .. r -, ~.nn„r tv n in( r, •,Inr n I~,~ I , r,~l W.r~. :.., rr~ ..-~, ~.: .I..,,. .r _, -.,' 'nrn.' h, r. Ill alr,l A I.. ~ , _.~ ..,.. l,• „~~ . L. ,,., ,, Gnq,n air noadrn I ~ „ r . , d~ r.r .r\I .,nal ..,•mmvl•rx ul .he .., I~, II • (?. ~YST~ M C I N C Environmental Onsite Wastewater Solutions` B~Isiness Park Road • P.O. Box 'S8 Old Saybrook, CT 0647 860-577-7000 • FAX 860-577-; 00'.. 800-221-4436 Sfi.4At3: 5.336.01 I; 5,401.116: 1.n01 459: 5.'', ". / .;), ; ~.: Si4t? .1 ,.;.g3f1... n :1 ;9'. 2 M~ ',f.:1 O~her Oalenls Pending. .. 1 - ~~" ? c 5 dnV~ ndP.r are reglsl Ored Trademarks OI Infillralor SYSIemS .. II I io f 11 ~ rn '- v I;r21~ JS1BI't$ Inf, - it P.t -4 o Max CO. CO'llC,ur, COnlOUr Swivel C.OnnP,flion. MCroLI ar , I ' ~ ~ ' ~'~ I I •IrL,C [)1 Inlll/~1(,r S~SIP.ntS Inf. l~ Zn~3 n111 rdo( SYSIr?IT1C nC. 1 I"~.' I ~ ~~ ~~~ I nr ~,()rl(:; '' ' 'I k. ()II ..KCl11. ill (:k~l.l `; ~ . n .~:,K Quick4 Standard Chamber Nominal Specifications Size (W x L x H) ~~ ' " ~ e'y'~t ~ 1:34"~~x 52" x 12" Effective Length _ ` ~ 1 ,N. ~,~'- • } ; 48" Invert Height. ` ~ ~ ry~~` 8r, 1~ .~ °' PJIuItiPort End Cap Nominal Specifications ;ize(WxLxH) 34"x16"x12" 'avert Height 8" or 1.25" RECYCIEOOGFER POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _ of FILE INFORMATION Owner ~t~ i S C I ~~ ~ d/ -'ka S Permit # t / -7 ~ ~5-Z DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA, Estimated flow (average) ~C~O al/da Design flow Ipeakl, (Estimated x 1.5) O© allday Soil Application Rate . ~ gal/day/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG1 530 mg/L Biochemical Oxygen Demand (BOD51 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity Z~' ~ gal ^ NA Septic Tank Manufacturer l~as,iS~r ^ NA ,Effluent Filter Manufacturer ,~ ~ ' ^ NA a o Effluent Filter Model ~~- 5'Z S- ^ NA Pump Tank Capacity gal ^ NA Pump Tank Manufacturer ^ NA Pump. Manufacturer ^ NA Pump Model ^ NA Pretreatment Unit ^ NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal Cell(s) ^ NA ~(In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event - _ Service Frequency inspect condition of tankls) At least once every: ^ month(s) (Maximum 3 ears) ear(s) y ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ month(s) (Maximum 3 ears) -3 ^ year(s) y ^ NA Clean effluent filter At least once every: ~ .. ~ ^ month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ^ month(s) ^ yearls) ^ NA Other: At least once every: ^ month(s) ^yearlsl ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s1 shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 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 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede 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 to use. ' System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the ceII1s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents 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 a code compliant replacement system: A suitable replacement area has been evaluated and may be utilised for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a 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. ~ e ~V'' a asa as ~RO~IQIT1=~ Fo2~lEw ~o~JS?Zv~"rIOL~ ^ 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 INSUFFICIENT 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. ADDITIONAL COMMENTS POWTS INSTALLER Name ~ t ~ ~ ~p h4_ Phone (o) Z _ ~ ~ s _ ~ Z SEPTAGE SERVICING OPERATOR (PUMPER) Name Phone POWTS MAINTAINER Name Phone LOCAL REGULATORY AUTHORITY Name STS C~~( C~K Ze~K; Phone ~ / .~-3~'(0- ~(` $'O This document was drafted in compiiance yvith chapter Comm 83.2212)Ib)I t -Id-&If1 and 83.54111, 121 & (31, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHII' CERTIFICATION FORM OwnerlBuyer Mailing Address rn /L Property Address ~ o ~{ (o L ~. F3.;, i a~ m_ (Verification required from Planning & City/State ~ ~ ~ ~ o •~ ~ ~ Parcel ~Ro~~. ~-7o~nrng ,t~epariment for new construction-)-- -~ - ~-___ Taal ®r lion Number ~ Zo " ~d! Z ' oo • coo oz - /0/3- ~{o-oop ~ LEGAL DESCRIPTION / ~ //'' -~~N~~ "/ Property Location''/4~l,(~ '/4 ,Sec. ~, T ~~ N R~ W own of ~4~5© Subdivision .S u rl S Csr~ h~ ; ~~ s ,Lot # ~. Certified Survey Map # ~9 /S / S Volume O ,Page # Warranty Deed # _ ~ g 9' ~ ~ 3 ,Volume ~~ `f O ,page # Spec house yes no Lot lines identifiabl yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION S~ /$O Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What. you put into the system can affect the function of the septic tank as a'treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Planning & 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 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. Number of bedrooms ~_ r li l~ L SIGNAT OF APPLICANT(S) `~///C~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) l1. 28y0P 180 State Bar of Wisconsin Form 2-2003 WARRANTY DEED Document Number 11 Document Name THIS DEED, made between Miller Homes of Hudson. LLC. a Wisconsin Limited Liability Comganv ("Grantor," whttther one or more), and David D: Solberg. a single person ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space ed, please attach addendtun): t , Plat of Sunset Hills FSrst Addition in the Town of Hudson, St. Croix County; Wisconsin. ?99683 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , KI RECEIVED FOR RECORD 07/11/2085 10:iSA!! WARRANTY DEED EXEMPT # REC FEE: 11.00 TRANS FEE: 246.00 COPY FEE: CC FEE: PAGE5: 1 Recording Area Name and Return Address. THE RIVERBANK - P.O. Box 188 - Osceola, WI 54020 Part of:020-1012-00-000 & 020-1013-40-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated June 10, 2005 Miller H~ttes of Hudson, LLC * AUTHENTICATION ' Signature(s) Miller Homes of Hudson. LLC Bv: Same E. Miller, Member and Leo A. Driveling,, Member authenticated on ,.,++-unu,,,. . *B~E. Miller, Me ber *By: Leo A. Driveling, Member ACKNOWLEDGMENT STATE OF St. Croix ss. COUNTY ) SEAL) ~`~~~~' • ~ s ~'~~'ersonally came before me on June 10, 2005 *Kristina O land ~ 2 ' ~- ~~e above-named Sam E. Miller & Leo A. Driveling TITLE: MEMBER STATE BAR OE S N$~,tJ - *t¢ me known to be the person(s) who executed the foregoing (If not, = •~c • ~, ,' ?iAS and acknowledged the e. authorized by Wis. Stet. § 70~.Q~ B~~ .' y _~` p~`~. THIS INSTRUMENT DRAFTED BY:,'~~~~~~; ~OFtW~S~.`~~~` * Connie M. 'Gullixson Notary Public, State of Attorney Kristine Ogland My Commission (is permanent) (expires: f t~'' ~~~~t5 Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ©2003 STATE BAR OF WISCONSIN FORM NO.2-2003 * Type name below signatures. 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