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HomeMy WebLinkAbout020-1376-10-000~ o a ~ ti y ~ 4 ao C h O N n N oii ,o d c m •~ N •~ r~ V •~ O r`1wV r O W FBI i~r Glt .~ C~ A ~~ _rn ~ Z ~ N ~ ~ c t7 o Z V ~ ~ N FZ- ~ N N t4 a~ N ~ O A a N J U O ~ o c, CD N H ~ ~ O ~ ~ y N -O 7 O ~ 2 it ~' ~ ~ a a m .~ ~ ~ 3 tia~ .D C LL 3 3 ~ d Z y E O a m c Q ~ a C ... b e N ~ N .- •C `-' 7 ~- N V n. o O O Q z m z N R G d a ',fig 'oca` "'aaa 3 0 0 0 ~ N N _ r ~ ` N C O O f6 J N d y lL O +~~' ~ y C rn c E Y rn M _ O) m ~ O is .~ d a a ,~ c ~ ~ ~OmC~ 3 O c 0 ~ c o ° otS v v > _ y~i v N E . N ~ ~ O 0 y ~ ~ 2 y L '~ a o~ ~Ec 7 'o fq Ip C L dJ 'O U N C ~ N O C y w ~ O L O ~ -' O a 7 nv ~ ~ E o 'ov y ` ° N ~ ~ C N ~ 3 - ~ n a~ m ~' ~. 0 0 ~v o o ~ ~ o_ o 'o ~ m` O _ O C~ •y O~ N O Z C (0 ~> C O O C ~ ~ O ~ L C O 7 ~ ~ c°o ~°Q Eo.° m ~ N 3 c~a N ~ "' --°o `.' O. ~ ~•_ N m a~ o c c O ~O ~~~ Q a d ca ao my ~~~'n c N N .~ N Q' N T N m` 3 O) a ~ m v v ~ ~ a~~i } ~ ~ Y O ~ 'j O m r C 01 Q A (n c C O ~j y ~ d d O w N Z ~ 4. 0 .~ U O Z "O M C O U .o z N 0 _U O z N a m fl ~ ~ v a °o C 'O N R ~ C ~ N d ~ i C N t} .I I ~~ f d Buildings Division County t ` ~ ~ 2 W. ington v ., ox 7162 ~, ~seons~n Ma 1 3707 ~~ ° Sanitary Permit Number (to be filled in by Co ) Department of Commerce ~~ ( 8)2 -3151 ~ fj S/ c1 3 g ~- Sanitary Permit Appli ti _ State an I.D. Numbe~ Wis. Adm. Code, personal inform i n you provide ` In accord with Comm 83.21 ' , may be used for secondary purposes Privacy Law, s15. (1 xm~ / _ t-KUi,~L ,.„ Proje t Address (if different than mailing address) L Application Information -Please Print All Information ~,.,=?F~;~ ~ / /j k Property Owner's Name # Parcel # Lot # Bloc wner's Mailing Address Property O n ~~~ /2 ~/_~ / Pr operty Locat / _> (!J ~ / . ` C , Y S,~ '/. Section ~ /" ~. City1State_r ,~ ' _ ip Code Phone Number , , /Q~ Type of Building (check all that apply) II . L/ Subdivision Name CSM Number ! or 2 Family Dwelling -Number of Bedrooms ^ Public/Commercial -Describe Use ^ State Owned -Describe Use ^City_^Vi ge wnship of III. T ype of Permit: (Check only one box on line A. Complete line B ifapplicable) - ~~ A. New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal Permit Revisi ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plwnber Owner _// .-.. - ~. ~ IV. T c of POWTS S stem: Check all that a 1 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-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/TreatmentAreo Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sfj Dispersal Area Proposed (sf) System Elevation , ,.~ ~~~ gs ~ ~c 9y VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Ezisiing Tanks Taiilcs Septic or HoldinL Tank 7O~ t7t ._ / Aerobic Treatment Unit Dosing Chamber O ..~ C~~ / ,,.-. VII. Responsibility Statement- I, the undersigned, assume responsibility for in Ilation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signa re P PRS Number Business Phone Number ~~~ a ass` pis - a 6 -- ~ ~ P wnber's Address (Street, City, State, Zip Cod ) ~~ - ~ ~~a U. ,~ ..s i ..~.. ~l o VIII. Coun ~/De artment Use Onl pproved ^ Disapproved Sanitary Permit Fee ('ncludes Grou rdwater Surcharge Fee) ~ ~ Dat Issued 9 ~ 7 D Issu' Age~No )~ ^ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval ~ ~~ ~ S~i.S~l ~.L~QK4x-t/c~t.-. d~za' 3/2/6 ? , d.~ ~/~/aa, rl ~~~ s Athch complete plans (to the County only) for the system on paper not Tess tnan out x u mcnes m size ~t~t SBD-6398 (R. 01/03) ~- /~- N~ u-~-~ ~ y ~- ~- /5 ~ ~3r~ ` i°o j ~~' 5~'~. ~_~n~ ~~a ~~ = 9y ~~ P~ ~~~~~ 1 ~_ ya ~~ io 5 uu~~ ~~ ~ o ~r~ ~GOULDS PUMPS APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability; '/~" maximum. • Capacities: up to 60 GPM. • Total heads; up to 31 feet. • Discharge size: 1'/z" NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA•N elastomers, • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 1 15 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EPOS Single phase: 0.5 HP, 115 V or 230V, 60 Hz, 1550 RPM, built in overload with automatic reset. • Power cord: t 0 foot standard length, 16/3 SJTW with three prong grounding plug. Optional 20 foot length, 16/3 SJTW with three prong grounding plug (standard on EP05). 2' 2003 Goulds Pumps EHeciwe July, 2003 8387 • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- maticmodels include Mechanical Float Switch assembled and preset at the factory. FEATURES ^ EP04 Impeller: Thermoplas- tic semi-open design with pump out vanes for mechanical seal protection. Submersible Effluent Pump .. EP04 & EP05 Series ^ EP05 Impeller: Thermoplas- tic enclosed design for improved performance. ^ Casing and Base; Rugged thermoplastic design provides superior strength and corrosion resistance. ^ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic cover with integral handle and float switch attachment points. ^ Power Cable: Severe duty rated oil and water.resistant. ^ Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING S~, Canadian Standards Association ,_ File # LR38549 Goulds Pumps is ISO 9001 Registered. :.... z I _ ... _._ EP04 5 1 _ L_ I t :.... .... ~~' _ i a_ ~'~ ~ _ 0 00 10 20 30 ~_ 40 SO GPM ° z 4 6 8 10 ~ 2 m~/h CAPACITY Goulds Pumps ITT Industries COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of cover, Access Opening, not top of cover, must extend to a point no greater must extend at least than 6"Below Finished Grade 4" Above Finished/G ade . ~ , Co,erwith WCA'rNEi ~ ~ Y~ ~~~~ ~~ 's,~~(~ '~sAP~?'' Lock n Device ~x/ ~~ J ,$9,Y /ZpP Zl'l (typical) Finished Grade N /Z .MiN,/~ vm ---- ~ ~6N/~- . Min. 23" > 30 ~ ~42 h ~~ Access Opening o i2. 1%15U~ Min. 23" Access Opening ~ Ouh:t tsffluent Filter ~ ~ lv/'rt11f ~'o/C S~'~ ~ .Union ~¢peoYE~ ~/PE ,3 PT, Inlet baffle ~ ~ ~~ ON`1z~ .SOS-/D S`O/L i ~ ~I i Pu p 3 "Sa+--d or~ r-avr-I an~yy un~+l~(~ c,~i~h ~eh-~r 2•, rawer shah Pdc~ps Two ComparTment SepticlPump Tank ~~ J, _ _ _ ~~~ o ~ ~~;de /~~,(r 1 SPECIFICATIONS TANK MFR: ~~~-~ DOSES PER DAY: TANK SIZE: SEPTIC /,~.i~ GAL. DOSE VOLUME: o~C~ (~ GAL. DOSE Cep GAL. (INCLUDES FLOWBACK & <20% OF DWF) ALARM MFR: G, CAPACITIES: A = ~ INCHES = GAL. MODEL # G. Switch type: ,~.~-~~ B = 2_INCHES =~_GAL. PUMP MFR: C = r G INCHES = ~Ci ~ GAL. MODEL #: _ L / ~ ~_ SWITCH TYPE: ~.9„ i D = ,S~ INCHES = ~oS GAL. REQUIRED DISCHARGE RATE ~ 5_GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) _ _ ~, ,~O FT. MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) = + ----- FT. __y_~_FT. OF FORCEMAIN X f, /~ FT./100 FT. FRICTION FACTOR ...... _ ,.,~ ~ FT. TOTAL DYNAMIC HEAD (TDH) _ ~ ~ FT. INTERNAL TANK DIMENSIONS: LENGTH ;WIDTH ;LIQUID DEPTH 3 MP/MPRS SIGNATURE: / LICENSE NUMBER:~,~ Q ~i 5 ~ A ~~~ . ~scons4n Department of Commerce SOIL EVALUATION REPORT Page „~of~ Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Code County ~ i Attach complete site plan on paper not less than 8112 x 11 ind~es in size. Plan must ` include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel LD. x~ percent slope, scale or dimensions, north avow, and location and distance to nearest road. Q ~ -~3 Flo' 1 v-OCJ~J Please print all information. by / Date ~S Personal inforrnatiar you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~~ GG~(/1~/n.- ~ ~ 6 Property Owner Property Loption ~ ~ X L~ ~~ Ll ~ Govt. Lot 5~/ 1/4~(jW 1/4 S /~ T Z~ N R / E (or~l 'roperty Owner's Mailing Address Lot # Block # Subd. Name or CSM# ' ~(~ s(.v ~ee -!u S a r vt~ amity State Zip Code Phone Number (]City ^ Vllage ~ Town Nearest Road ~(/~ ,~~ w (s ~z ~-s~~o ~-v r~ F~azr a '~ New Construction Use: [~ Residential / Number of bedrooms ~ Code derived design Bow rate G O (~ GPD ] Replacement ^ Public or commercial -Describe: 'arent material 4 Flood Plain elevation if applicable /~/ /~ ft 3eneral comments S~~{-ems ~ (-e J' , ~'3, £S RECEIVED and recommendations: ,/)~_) ~ l ~ ~ ` ~ ~ ~ ~ d /~2~ .S 57~~'--~ A-T~J . D of ~ MAYS 2002.2 ~' 9d' ~ ~'''~ T. ROIX COON 1 I Borna# ^ Boring ~y~ ZONING OFFICE r ~t _J U¢ pit Ground surrace elev. L.~,~ n v n. ueprn ro nm,ung ,acw, .~c..i ,,,. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. •Eff#1 'Eff#2 Z tZ 3 to r/ -- S, ~ I Z wt~sb ~ r c 5 - . (o RMlnn # ^ Boring /] H I~ ~, iii ~-1 (~ Pit Ground surtace elev. 7 ~`~ D ~ rt. uepm ro ummng rac,or ,n. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate GPD/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ~ o-! Z ~6~ r 3!z S~' ~ ZrYlab~ h'~ ~ ~-~ (J-~ ~ ~ , ~ Z 1 2 3 1o r/ -- S, ~ I z rn~b k Y/1-~~ c S - .~ 3 ~-- ~ r /l -- vas o -- - ~ z y ~ • Eft)uent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mgiL - tmuenr ~~ = rsvu5 ~ su mgr,_ ana , as ~ ov uny~ CST Name (Please Print r ~t~tature ~ / CST Number Address Date Z!I ?~ ~YI'% ~~• Sd N~.r 5-~-{-. W ~, S~~/off'.: 3-ZS-o Z ~~/.S~ yy~- y4~~ SBD-8330 (R07100 Property Owner ~r~ ! ~ s ~ X C , Parcel ID # /O T / V Page ~ of _~ 3 Boring # ^ Bonng ~~ ~~ ~ pit Ground surface elev. ~.. ft. Depth to limiting factor in. Soil AppGgtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft~ in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#t `Eff#2 1 a ~3 ~a- r3 /z --. S," ( Zwla~ 1 v-ti ~ G.S I u~' ~ s ~ f 7 v I /QL ~ / ~~i ~l' '~-~ ~ ~ 1 ~ ~ ~ / r 50 yZ // a r y~~ - os N'l ( -- - ~ ~ / ~ ~, - ~ s ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ^ ~~ ^ pit Ground surface elev. ff. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlft2 in. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 = BODE > 30 < 220 mgit and TSS >30 < 150 mglt_ ' Effluent #2 =GODS < 30 mg/!. and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider aad 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. SBD-5330 (R07l00) PAGE ~ OF~ NAME h rU ~ ! S L-7~C', LOT# /C~ LFGAL DESCRIPTIONSw ~ ~Vu// ,~ I~ T ZQ ,N,R, ~ ~ E(orL'~ ALTERNATE ELEVATION ~ 3, ~y CONTOUR. ELEVATION - !UU .-SAO p ~ _.~. ~ S ~a / y ~" .~-= ~~-~ ~~ ~f~~~~" ~~ ~ r~ a i N ~ /~~ D~ c v~ w ~"y ~- I C ~~ ~ ~~~ . ~~~ ,~,~, o ~ ~ ~~° ~ ~~,~i~ ~.. _.s ~~.~ ~ ~ S~ %"~-- ;~ GNATURE ~~ w~-~ ~ ~ ~~ - ~~,s ~ age, vo DATE ~"'~'" 0~ Wisconsin Drpartm t of Commerce PRIVATE SEWAGE SYSTEM Safety and Buil ~sion ` 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 Bast, Kernon Hudson Townshi SST BM Elev: Insp. BM Elev: BM Description: ~ ,~ TANK INFORMATION ELEVATION DATA county: St. Croix Sanitary Permit No: 404939 0 State Plan ID No: Parcel Tax No: 020-1376-10-000 ~i 3~zS/6 sow ~~ TYPE MANUFACTURER CAPACITY Septic ~ ~ _. ~~ Dosing ~j Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ .t ~ ~ ~~ ! ~, Dosing Aeration Holding STATION BS HI FS ELEV. Benchmark 5 E t Alt. BM A, Bldg. Sewera,f- N~ IL,~~ ,ao S Ht Inlet i3~~ b ~©. (c0 SUHt Outlet Dt Inlet '~ ~ Dt Bottom H~ea-dTe~r/M1+an. ~l'iIWM~?~~r~{YP)1~1 LC' ~X7 '7 J~ LL p 9c~, 0 GI t. Pipe Dis ~ .~o - ~~ ~ ~;~~ ot. s m ~n~r /O. D C~ : 0 `15.5' Fin/a~l Grade V' L C ,7 5. (,) ~ / J• StCover/'a [ ~ .t, b'Ity/rl ~ 7~~ 7 g~/ s PUMP/SIPHON INFORMATION i~l'u~nd.~~ ~ ~'Y~/~ ~~-2..-~~( Manufacturer ~~ L-n S and IY G Model Num r .~-- ~) - Lift ion Loss System Head TDH Ft orcemai Le ~ Dia. Dist. t Well o ~ ~T C(lll ~RS(1RPT1(1N SYSTEM ' 3~ ~D~ BED/TRENCH Width ,~.? { Lengt No. Of Tr ches ~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ a q,3'~~? -~ ''~-"" SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~ CHAMBER O _ I 1, / INFORMATION Type f System: / ( / ~ 1 ~ ~ ~? ~ l i~l '~ Model Number: ~ ~ ~' ] n ~ Vn47 7 ~ r)ISTRIRIITInN SYSTEM ~ tlo~,,~-{-t//',L,<or~/. G`; non i~ Header/Manifpld / R Length~_Dia Distributio ~: - At ~ ~ Pipe{s) ~C~, Length ~= ~`~ Dia~~ Spacing x Hole Size '~..- x Hole S acing _~..-.-"'. Vent to Air ~. S(~II CnVER v Prccmmn Svc4omc rlnly YY Mnund Or At-Grade Systems Only ~ c~~,,~, Intake r. ~ ~ ~ c~ S' ~. Depth i, Be rench nter ~ ` ~ Depth Over Bedrrrench Edges xx Depth of Topsoil xx Seeded/Sodded i i N xx Mulched u No ~~~ I Yes ~ t I o ,Yes Li, ~ ~. COMMENTS: (Include cod~~crepencies, persons present, etc.) Inspection #1:~/ ; ~ / ~ -Y Inspection #2: / / f Location: 969 Fraser Lane Hudson, WI 54016 (S 1/2 NW 1/4 14 T29N R19W) Sweet Grass F/aJrm t 10) Parcel No: 14.29~./1~,9,.,2~271~~~, ,,/ 1.) Alt BM Description = ~/~J ~ ~-6K-~ ~1L ~/~J/tt Z~iv~__"""~M1~~r"'-`"~ 2.) Bldg sewer length = {~ ~ .{7,--}~n~L- ' L~ ~G,~,~ ~l G,/03 -P I// ~p r2l/I.s?~, t ~ t"~'o~"^ ~ ~' y~ - amount of cover = ~ U~ ! /Yt~ ~~ ,J~ , Lam, ~ --- - r -- , Plan revision Re uired? !. ' ' !D ` I I q Ye ~ ~1 No ~ i'~ 7 I ~ ~ (~ i~ Use other side for additional in mation. I ~ h_._-. I __ _ _ ~~~!___ ' '~J ,_ - D ~ Insepctor's Signature Cert. No SBD-6710 (R.3/97) /~ p J~~~ /~.~ ~~ ~/6 Safety and Buildings Division CO1°h' 5 201 W. Washington Ave.. P.O. Box 7162 ~ c ~ ~ ~seons~n Madison, wI 53707 - 7162 ' Address De artment of Commerce / ,3 L !/a !~-GL~.~... ~. Sanitary Permit Apphcatlo ~~' Permtt Number ~~9 39 ~`" " ht accord wid- Comm 83.21. Wis. Adm. Code, rsonal info Pe ~ / ~q J ,heck if Revision ^ C ma be used for ses Priva Law 1 m I. Application Information -Please Print All Information ~;~ r'' ~ ~~ "~ ? , ~ttite Plan I.D. Number , Property Ownei s Name ~ Parcel Number ~ G..- ~ ~:^ ~ ~ ~ ~ o o -13 7~ 6 - oa ~ ,~ 1 Property Owocr's Mailing Address roperty Location P ~ ~~ ~ tJ ~ !'~, 2L3fMM1tt1 ,~~; + i CC J Si ; S T N, R E StaOe City Zip Code Pho~ Number ~-., ` , Lot Nut,~ber Block Number ~ ~a / , ~ 1 ~vE ' Subdivision Name CSM Number U~~ cu Yo ~ 7/,~. S~a~ t.Sc,,~,~ Crust. II. Type of But~ding (check all that apply) .~,5 ~ 5 ^City (,~1 or 2 Family Dwelling - Nutnba of Bedrooms ~- ~°' ^Village ,~'ownship /^ public/Cotnaurcial -Describe Use _ / - 5 Nearest Road to Owned y rti,..~. -~,~.,~-~ ~,~4 aq ~ ,_ . oo . Type of Permit: (Check only on box e A (numb ring sch a for internal use). omplete line B if applicable) A. 1 New 2 ^ Replacement System 3 ^ Replacement 6 Addition to For Co m Tank ON stem B. ^ Check if Sanitary Permit Previously Issued Permit Number -~1 IV. Type of Permit: (Check all that apply)(numbering scheme ' r internal use) \ 44 Non-Pressurized In-Ground 21^ Mound 4'7 Sand Filter ^ Constructed Wetland // „Qn ~ , /~ Una ~ ^ prey ~~ound 41 ^ Holding Tank 4$ Ingle Pass 51 ^ Drip Line b~" 45 ^ At-Csrade 46 ^ Aerobic Treatment 't 49 ^ R ling 30 ^ Other V. D' tment Area Informati on: Z' ' ' sign Flow (gpd) Dispersal Area Dispersal Area n it A lication Percolation Rate System Eleva Required r ~ ~' pr°p°sed ~p' . Elevation (Gals./Days/ Ft.) (Min./I~h) ~j f ~. Tank Info Capacity in .Tots! Numbe Manufacture Prof S' Steel Fiber Plastic Concrete Constructed Glass Gallons Gallons of T New Existing Tanks Tanks Septic or Holding Tank Q b ~7 - / g r (,~ys.L Dosing Clamber VII. Responsibility Statement- I, the undersigned, a responst"bility for tion of the WTS shown on the attached plans. Plumber's Name (Print) PI is Si RS Number Business Phone Number ~ ~i~ 0 3s 7i.5 " ~ 9 Plu ~ Address (Street, City, ~ , Z' e) ~ ` Z~-~.~~' ,~S~6c5 VIII. Count /De artment Use Onl anitary Permit Fee (includes Groundw ter Date Issued Issuing Agent Signature (No Stamps) ,Approved ^ Disapproved Surcharge Fee) tip ^ Owner Given Initial Adverse .~ ~I ,~ Determination sappr°val 'ko S2 - `~`S ~ ~ Sivr'~-~9+~~ ~'„~c ~~v,p t IX.S ond~it~ ofof p~ ens°nsrf°r'D ~ Q~ ~i _p_ ( / ~ ~ cr~ ,J~-~ S ° `~ S_ °~' e ' ~'~Q~ iq N4At dly,d ~ W C `w„-~ ~ lcb^`~S ~`^*"~--~- r,na~ ~e~ ~ "1`Y " C,r,Q~ c-~_ (°~'o' (/ ~ ~ ~ n- ` r ,~Q rl ~+ ~ i ~ _ ., 1. f _ t ~.. ~ . _f_._ . ~. n ~ 0 6.. n ..V ~ I~ R/~ a i _ i:.. ..,nlJ(latpl C ~~' ~~191MR-6U'~~ VW~J~Ia~ ~ ~c._..e..~ ytltwv ~ - - n ~--~p ~ ~ em oa x (uchea size ~ ~c.~,..H.w~e~n~a~'I`e~ts . SBD-6398 (R. OS/Ol) 1- !s `~ ~ !3l'~ ! ; boo ~ ~'" /% ~~~~ !'~ /~ ~ ~~ ,~ S y,°~ 'a~ -~ao ~ ~~• ~~i~ N~' ,,~~ ~' Q~ ~~,,•i !1r X y,~ ~, ~~ r li U vv v o aa~ 3s~ S~ 96. a 7 o ~~~~/ `~nriscons~7h Department of Commerce SOIL AND SITE.,~VALUATION Pa e ' of Division of Safety and Buildings ! 9 Bureau of Integrated Services in accordance ~,Cothfn~88~09, is. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inche iq„s{2e PI unty include, but not limited to: vertical and horizontal reference poi (BMj, directi~rr~ r~ ~- C , ,~ percent slope, scale or dimensions, north arrow, and location a d distance to nearest road. Parpel LD. # ,~ n r~ ~ ~, APPLICANT INFORMATION -Please print all inf rnfafion `~ ~,-;'' ' RoVi wed by Date ~tiN~.,(~ Personal information you provide may be used for secondary purposes (Privacy taw, sGt~~+t~~~T.~r Property Owner Property LocaUpn,' c.-~ ~A YL..~. S ~ o -~""C ,~ Govt. t:ot 1/4~wii4,S ~ ~-( T .~ °j ,N,R ~ 9 E (or) i~J Property Owner's Mailing Address oi'#""' Block# Subd. Name or CSM# 135 -7r'. iv S~-~ ~ ss City State Zip Code Phone Number ^ City ^ Village [~] Town Nearest Road /~ 1, ~l `{O(ln (~~ 5 )5`-f9- `t 1s~a, r ~--n . New Construction Use: .Residential /Number of bedrooms ~- ~ Addition to existing building ^ Replacement // ^ Public or commercial -Describe: Code derived daily flow CD~f~ gpd Recommended design loading rate ~ ~ bed, gpd/ft2 ~ trench, gpd/ft2 Absorption area required bed, ft2 ~S~ trench, ft2 Maximum design loading rate ~ ? bed, gpd/ft2~trench, gpd/fl2 Recommended infiltration surface elevation(s) ~~' ' ~ 7 ft (as referred to site plan benchmark) Additional design/site considerations ~Lf • 9 ~ ~ Z 7 Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u = unsuitable for system Cis ^ u I~ s ^ u ~ s ^ u ®'s ^ u ^ s L~ u ^ s C~# u ~l1Af1T w~~ vwvn~r ~ wry rimer vr~ ~ Horizon Depth Dominant Color Mottles Structure i d B R t GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. stence Cons oun ary oo s Bed ,Trench o-rc io f I - w..~, ~. w~~C.. c 1,~ ~ , S : 6 2 rz-HL to / 4 r, w.ab w^F~ L _ •~ •~ - I io 1 D / ~' Yrs. ~ •~' . ~ • 2'{" , ~S~a~ ; Remarks: o-rt l0 3 4 "' S ~~ tom, t~-- G ~.s~ -S ;,b Z tzwo d y y - ~ ~,,- ~- _~ 3 a-~n to / 6 - o ,~... ~ - .~' ' . ft" Remarks: CST Name (Please Print) Signatur Telephone No. Address Date CST Number 2~ 1 '~- ~~ . Son-.QrSe~ " IUZ--S ~(-`~-OU Z5 3~ PROPERTY OWNER ~~ c1 ~ SOIL DESCRIPTION REPORT PARCEL I.D.# Boring # ~~ Ground elev. ~ . K7 ft. Depth to limiting factor min. Boring # `t Ground elev. X1.77 tt. Depth to limiting factor n9 in. Boring # Ground elev. ~_~ft. Depth to limiting factor ~in. Boring # Ground elev. ft. Depth to limiting factor in ,~.. Page ~ of Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench ~" to ~ ""' ~~ , z w~-t~l~ ~ F ~5 ~ ~ ~ . c Z ~-3fi o ~ `~ - s , l ye rn r-; ~5 - t5 ' , G Remarks: '! b'' ~ il7 ~' L5 ~ ~ .0 Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft'` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench 1 to y ~` w~-5 N.. ` C$ -~ .~' ~ . ~ Remarks: ' Remarks: SBD-8330 (R.9/98) f ' j ~ a PAGE 3 OF ~j NAME s'~'U~-4- LOT# ~D LEGALDESCRIPTIONSE '/oNu1'/a,S1N TZ9,N,RlR E(or)(G~ SCALE: I"= ~~)C3 ~ BM I ELEVATION /Go . U BM I DESCRIPTION~o~a,(r I ~, ~,K_ (~~ p~ lat ~/Gaa~ BM 2 ELEVATION ~ y. 9 BM 2 DESCRIPTION~yo ~- ~TV~ p;~s I«~hw/F/a~ SYSTEM ELEVATION qG ~ Z ~ ALTERNATE ELEVATION q ~ ~ /~ CONTOUR ELEVATION /~/( _+- I K . ~r1 • . Ei3 I ~ pe't' i '^ !35 ~~t • pz /- POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFbRMAT10N Owner Permit # ~ ~ 93 DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) Qd gal/day Design flow (peak-, (Estimated x 1.5) ~~ al/day Soil Application Rate ~ gal/day/ftZ Standard lnfluentlEffluent Quality Monthly average* Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand (HODS) 5220 mg/L ^ NA Total Suspended Solids (TSS) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (HODS) <_30 mg/L Total Suspended Solids (TSS) <_30 mg/L ^ NA Fecal Coliform (geometric mean) <_10° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA 'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~ ® al ^ NA Septic Tank Manufacturer ' ^ NA Effluent Filter Manufacturer r ^ NA Effluent Filter Model ~ ~ O ^ NA Pump Tank Capacity gal ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Cellls) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA eeerwrciueiur~ cruFn~u F Service Event Service Frequency Inspect condition of tankls) At least once every: ^ yearls11s1 (Maximum 3 years- ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ yea~(s-1s) (Maximum 3 years) ^ NA Clean effluent filter At least once every: month(s) ^yearls) ^ NA Inspect um ,pump controls & alarm P P At least once ever y~ ^ month(s) ^yearls) ^ NA Flush laterals and pressure test At least once every: p yea~ls11s1 ^ NA other: At least once ever Y' ^ month(s) ^yearls) ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) 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(s) 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 nedv 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 tankls) 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 dispersa{ cellls) in one large dose, overloading the celllsl 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 manual{y 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 utilized 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. ^ 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 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 POWTS MAINTAINER Name Name - Phone ~ . .-- Phone SEPTAGE SERVICING OPERATOR (PUMPER- LOCAL REGULATORY AUTHORITY Name Phone Name c~7~. t~,p--6sc Phone 7/S' ~ ~ - 8 This document was drafted in compliance with chapter Comm 83.221211b-1111d1&If1 and 83.5411-, (2) & 131, Wisconsin Administrative Code. ST CROIX COUNl`Y SEPTIC TANK MAINTENANCE AGRBBMBNT AND OWNERSHIP CERTIFICATION FORM Owna/Buyer .. Address ~'~'8~ L~~'~~C ~O. ,~~~ ~`sf o%~ ~~ Proporiy Address (Verification required from Planning Department for new constntetton) v- G"tty/State ~/~~~ ~-~ Parcel Identification Number 52,E i~ - l 3 7 <o - )d _- a0 C~ EGAL DES ON Location ~~ 1/4, /~ GEC ~/, Sec. ~ ~ . T~N ~ ~w. Town of ~~_~2~ Property ~~~L.e•~~- a~,~~ .Lot # ~o Subdivision ~r./ Volume ~ ..Page # ~~ Certified Snrvey Map # O watnran~- Deed # ~~,~ 7 ~..~ 3 ,Volume / 7 ? Page # Spec house yes ^ no Lot lines ideatifiable~es ^ no SYSTEM 1VZA.INTENANCE Improperuse and maintenanxof your septic system could result is its pnmaturefailuteto handlewastes. propermaiatenaace 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. t a certification form, signed by the owner and by a The property owner agrees to submit to St. Croix Zoning Dep~eII mast~rPlumber, ]oumoymaaplumbcr,rat<ictedplumber or a licensedpumper v°rif~nng tit (1) the oa-sitie wastewaterdisposal system is in proper operating condition and/or (2) after inspoetion and pumping (if necessary), the septic tank is less than 1/3 full of sludge. i~ 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 da of three year iratio te. -~- ATURB APPLICANT DATE OWNER CERTIFICATION the owuei{s) of I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are} the grope descn'bed above, by v" of a warranty deed recorded in Register of Deeds Office. 7f- ~ S r~~.-- -~n DATE T[JRB OF APPLICANT «««««« «««««« Any information that is mis-represented may result is the sanitary permit being revoked by the Zoning Department. «« Include with this application: a stamped warranty deed from rho Register of Deeds office a copy of the certified survey map if refenmce is mach in dre warranty decd ~~(.1724~~~E 198 I STATE BAR OF WISCONSIN FORM 2 - 1998 657333 • WARRANTY DEED - :: ,~t_~N H. WF1L5H firb':STEfi LF DEEDS Document Number .. ~ . CFtslx?; t:G. , WI " itECEIVED FOR RECOFD This Deed, made between - .5-c~-~001 S':'~ Af" - RTCHART) Ct STQIjT anr3 Tnp1gT p Rmnrtmr • _..2ltlgband and Wi fPF WF:nrif+hlY vEEI' Grantor, '- '~ - - and and noNAT.t)A .T CPFF.R-R~.ST_~ _.__ ~;.; j =E~; terra and and wife,._ _ Tiii,NSiEF FEE: 627.30 c~06JiiVG =cE: 11.00 -.--. 1~M j~~: i _ _ Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate fn St CrOi~~ County, State of Wisconsin: ,,:.;:a,~.~..,r,::, Lots 8, 9, 10 nd 11, Plat of Sweet Grass ~~ Farm, Town o Hudson, St. Croix County, Name andRetur"sw[xesg Wisconsin. ~~(- C 020-1376-08-000 020-1376-09-000 This i c not homestead properly. (Is) (is not) Exceptions to warranties: easements, restrictions, rights-of-way and covenants of record, day of September 21 st Dated this 2001 , ((~~ c ~ ~ ~ ~ (SEAL) ` ~ UV~D.~.d)~ • y (SEAL) / - t P Stout J " u;.-harA n_ Stout (SEAL) -- an _ - - (SEAL) s AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. CroiX County. authenticated this day of Personally came before me this 21 St day of _~e~,emh r ,2001 ,the above named Rir•harA n Stout gnA TanPt P_,._ t t TITLE: MEMBER STATE BAR OF WISCONSIN If ~ ' • ~ ~~ ..« C ~• ~~ a S Nt - ---- - - -- _ ._ to me known to be the person $~ who executed the foregoing ( not authorized by §706.06. Wis. Scats.) THIS INSTRUMENT WAS DRAFTED BY t d ~C nP.yM~It J ~ vnG~ e and acknowledge the same. ~7 aFL] ___ -' Janet P. Stout =*~~'~, ~ ©~t~ 1353 A ~ ~ ~ ~ -~ - HudSOn, WI 5401 6 Notary Public. State of Wisconsin da te: n tio My commission i permanent. (If not, state expira ~ y ~ ~ ~~-f•) ~Q (Signatures may be authenticated or acknowl edged. Both are not -- • necessary) • f~mnes of yersons signing In any capa<Ity must he typed ar printed below [heir slgnauue. STATE BAR OF WISCONSIN Wisconsin Legal Stank Co.. nw. WARRANTY DEED FORM Ne. 2 - 1998 Milwaukee. Wis. i l~/ luJl~a U U vl~J9_t_r ~a csr~v ----------- ~ M[vlpdQ44C~© ~©~ O~I[n`~L~D ~ ~ OO 4[~C~G°3~3 I -------°--------------- I ---------------------- ~ ~ I ~~ NORTH -SOUTH 1/a LINE SECTION 1a I 800°14'1 TE 1707.Ea Lei ~ --- j ~ >•ooti~ors ~MS.st ~os.oa . _. I_t_ r o . J .A. . 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