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HomeMy WebLinkAbout020-1447-05-000 (2)Wisconsin Department of Commerce ~ _ . PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION s ~ (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, Town of CST BM Elev: Insp. BM Elev: BM Description: ~ ~ a ~ ~ Ls TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic t.~ ~, („~ ; e / Z S b F't, Pd ~Oc,~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 75 i ~ l/1 VI ~~~ L ~ _-. Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model N!.mber TDH Lift Friction Loss S Head TDH Ft Forcemain Len Dia. Dist. to eu SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 463431 L`h 0 State Plan ID No: Parcel Tax No: 020-1447-05-000 Sectidn/Town/Range/Map No: 15.29.19.2836 STATION BS HI FS ELEV. Benchmark 9'a3 /093 /~ Alt. BM `~. Gavw- 5 Bldg. Sewer 3 , zS SUHt Inlet ~ ~ ~~ SUHt Outlet , (1 Dt Inlet ~~ ~~ Dt Bottom Header/Man. 7, Dist. Pipe 1~'/ Bot. System C J /J rJ /d / / . 3 Final ~r~ade ..-- ~ ~ ~ ~ St Cover a. 55 ~-I ~~' 3 Z .~- ~Z-3'S BED/TRENCH Width ~ Length 3 ~ NQ. Of Trenches PIT DIMENSIONS No. Of Pits ` Inside Dia. Liquid Depth DIMENSIONS 3 4 ~~ r f ~ --- ~ `'~'~_ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~-.n , CHAMBER OR ' INFORMATION Type Of System: r ~~ ~~ p I UNIT Model Number: ^ U ` .. I~ISTRIRl1TIAN SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Ven to Air ntake ~~ r ~~ D `'£ Pipe(s) ~ '~~ ~ S a in th Di L ~ ~ ~e~ C ~'~. Length ia p c g a eng SnIL_ CnVER v Pro~~nro we4umc Anly YY Mnunrl (]r Ot.Grade Systems Only E'.A ,~ Depth Over Bed/Trench Center < ~ uL Depth Over Bed/Trench Ed~es ~\ xx Depth of Topsoil \ xx Seeded/Sodded ~es No xx Mulched Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 942 Pup Circle Hudson, WI 54016 (NE 1/4 SE 1/4 15 T29nN IR19W) Coyote Ridge Lot 5 Parcel No: 15.29.19.2836 1.) AIt BM Description = `~~ ~`~~ C~q,;,.~ ~ LOG~K~ 0 ~. 2.) Bldg sewer length = ~( CJ ~ - amount of cover = 3b ~ w %r~. 7 I g ~ 7 y L" q ~ ~ Yes _ _ II, /~ - •~ ~_- Use others de for additional information. _. Date w Cert. No. SBD-6710 (R.3/97) [~oD Safety and Buildings Division County ' 201 W. Washington Ave., P.O. Box 7162 5 , ~j(~p'~-rG COII SIII Madison, WI 53707 - 7162 Sanitary Permit Number (to be fine by Co.) r7 Department of Commerce (608)266-3151 u/ ~ i/7 ~~ Sanitary Permit Appl eat~6CEIVED State Plan I.D. I~u~er may,'/// In accord with Comm 83.21, Wis. Adm. Code, personal nformation you provide may be used for secondary purposes Privacy L , s15.04(1)Am) Project Address (if different than mailing address) ~ J ~ IV 1. Application Information -Please Print All Information ~ ~ ~~ ~ , ~' ST. CROIX COISNTY ' Properly Owner's Name ZONING OFFICE Parcel # Lot # Block # ! S zg ~ , t er's Mailing Address Property Ow~n L ~ Property Location j ~ / " ' ~~'/< S~'/< Section ~~ Ci ty , State Zip C od e hone Num ber , , f ~ /J (,~ / / / ~7 ~~(~ -P 2 Q 6 ~s ~JU ~ ~~ ~~ ~rcle e) T N; R~E o~ Type of Building (check all that apply) ~ / II . [~ or 2 Family Dwelling -Number of Bedrooms 7 ~ ~ J`~-~+ ~`~ _ Subdivision Na e CS Number ~ 4.''~ ^ PublicfCommercial -Describe Use ~'1dt)S2 ~ ^ State Owned -Describe Use ^City_ Vi lage wnship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - - ~ A' New System ^ Replacement Systetn ^ Treatment/Holding Tank Replacement Only ^ 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 ~~ 3 L f 3 IV. T e ofPOWTS S stem: Check all that a l Non -Pressurized In-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constrrcted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Fitter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter eaching'Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/TreatmentAnea Information: Design Flow (gpd) Design Soil Application Rat~(gpdsf) Dispersal Area Required (sf) Dis al Area Proposed (st) ~ s~m ElgvgYjoi~ / T-3 ; ~' ~ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank d i /~~-~ ` e ~ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for i tallation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' Signatu a ~ /MFRS Number Business Phone Number ~~~ ~ ~' aao 3S7 7~s-. a~g -~ Plumber's Address (Street,~Ci~, State, Zip Code) VIII. Count /De a+-tment Use Onl Approved ^Dis Sanitary Permit Fee (includes Groundwater Date Issue Issuing nt Signat e ( o ~ Surcharge Fee) ~ ~Q ~ ~ JI U n Reason iSflfenial ^ Ot IX. Conditions of Approval/Reasons for Disapproval ` ' L /~ - srs~ o~rt: 3 ~~ ~ I~7ea-. 1. Septle f`nh, e[lhlertt 1Nter and drpMSal ceN must all be sarvices !maintained __ ._..._ pit dlinapement plan ;~mwci= 2 AN sebadt requirements muss ;~- , . .. q her epolicahlA -~,iN ., , . . , .., Attach complete plans tto ate County only) for the sysrem on paper no, ,ess ,un„ o„~ x „ ..,..,,~, .., ~...~ o> ~ 30' ~8a SBD-6398 (R. O1/03) l'--1~~ ~_~odz~ o ~,~~ N ~y~ 7"- l ~ 9S. ~o r tea= y~So~ ~.3^ y73o~ T `~'= 9~.8or ~ ~~ = lam ` ~~~ / ~ ~~~ GfS ~, ~_ 1 i_9~ ti~ - RECEIVED ~ ' 'JUN ~' 6 2005 ~ Wisconsin Department of mares $ ~!. T10N REPORT Division ofSatetyand But s ST. CROIX CO NTY" Page ~ of 3 ~~ ZONII~~~ with m t15, Wis. Adm. Code Attach comPiote site plan on paper not less than 8.1/2 x 1 t inches in County lnctude, btatnotAmltedto; vettica! size. Plan-must ~iZl~ a . percent si nd hor(zontal reference point (t3M), direction and ope, scale or dimenslone north arrow, and Location and distance to nearest road. Part~e! I.D. ~.V a Zo - I~4~- aS - ~ b Please prln# all information. Personal information you provide by Date may be used !or secondary Durposes (Privacy Law. a. 15.01(1) (m)I Property Ov~rter Property Location e ~ rt G n ~j a. S ~ Govt. 1.ot 1/4 7/4 ~,~ T Z N R E (or)~ Property Owner's Mailing Address Lot # Block # Subd. fJartte or CSAA# ~ a~-~ State p e Pttane ^ DRY ^ Village ®own Alnv,~r R„~,r tit ~ c~ ~ C .'i-c- `'~" New ~ tJse: [~ Residential / Nt.tmber of bedrooms 3 _t~ Code der9ved desdyn flow rata ~ ~ U /(~ 6 y t3PD ^ Replacement ^ PubUc or c~rnrrterdal- Describe• _ Parent material _ f~(~ ~.. ~t ~ h Flood Plain elevation N applicable ~^ Vii/ /~ r. tt. mendations: ~ernrvfc5 ` ~ `r~~ Q~f'/,'~ 5 fir- 6~~r1'~~ tt Z Horizon ..Depth • - -- Dominant Color --..-.... _....w.,, .ter.,., .,~~_ ... Redox Desatption Texture Structure Cortsisterrce Boundary Roots SoN ksUon Rate. G ~. Munsep pu. Sz. Cont. Cdor Gr. St Sh. 'Etf#t 'Etfi1R2 Z Zy "5~ ' ~ r l Sty f Zw, sblc vri~.- c 5 I ~ ~ , ~ , ~o ®Pit Ground surface e1ew. /~ `/ ~Gt R. Depict to limitktg fader .,__ /3 5 _, in• c~ lion Rate ~ ~ ~~ ~ Horizon Depth Dominant Color Redox Desaiption Texture Strtlclttre Consistence Botxtdary Roots GP DIIi? Mt. Mansell tau. 3z. Cont. Color Gr. Sz. Sh. `Ef(#t 'EfflF2 1 v- L r~~ i3/z - s,`l Z~ ~ ,~ C 5 ~v ~-13 ~ -- 5 Ds vr- / ~" - 1 z • Effluent #t = BoD_ } 3o S 220. mdL and rss Sao < ts o mdL • Effluent #2 = BOD, <_ ao mgn. and T35 ~ ~ mplL CST tJuistbar - ~a -d .s- 7s-~~o -az ~9 Property Owner ~~ 5 ~ " Parcel 1D # ~ U t ~ '~ o f ~ ~~ ~r~- ~( Page Z of L ~' i ~ Pit Ground scxrace eieV. ~~ ~• --"~ n. vepm to ~urxuny ~auor~_~- • q M Hortaon Depth Dominant Redox Description Texture Structure Consistence Boundary Roots Soil Rate GPD1fs? in. Munson Qu. Sz. Cont. Color Gr. Sz Sh. 'Eft#1 `Etf#2 / -~~ 7 f G Z /_ ~ ~ 5 U~ L ~~ n~ ~J u t~t VIV«HiVI N7W plp~. It. Vp~lYI W IN IgYl1a /ONVI ql. Soil Rate Horizon Depth Dominant Redox Description Texture Strtxttue Consistence. Bourxiary Roofs GP D/ig in. Munsep Qu. Sz Cont. Color_ Gr. Sz. Sh. `Etf#1 •Eff#2 D ^ Plt Oround surfaoa elev. R. Depth to Amitirq factor In. # ° Sob Uon Rate Horizon Depth Domhtant Redox Description. Texture Stnxture Consistence Boundary Roots GP O1rf in: MunseN Ciu. Sz. Cont. Color Gr. SL Sh. `Eff#1 'EtT#2 Efiusnt #1 ~ BODi > 30 ~ 220 m~IL and TSS >30 _'150 mglt ' EAkra~t alt2 = BODE = 30 mgll, and TSS , 30 m81L The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access senricas or • need material in an alternate format, please contact the department at 608-2ti6-3151 or TTY 608-264-8777. sso-eswre.~ • PAGE ~OF~ NAME Cam'-C.~S I LOT# ~j LEGAL DESCRIPTION ~/a ~/a,S /$-T Z~(,N,R(q E(oR~ SCALE: t ~~ d BM i ELEVATION fQO. O BM 1 DESCRIPTION ~C a~ ~ 1 nn ~: ~G' e. BM 2 ELEVATION ~--- BM 2 DESCRfPTION u`- SYSTEM ELEVATION ~ 1 • `7 C SYSTEM TYPE ~'~/l u e ~f ~ o=La( (~ sb o~ / ~~ ~ ~+' ~ ~ i ~~ ,~ i ~ ° ~'v ~ ~y" ~~~' ,r, i ~ e ~, ~ G ,, ~ o ~ ~ o ,, ; ,~, mil' l'9~ES ~( C~ /~-r ~e ~ SIGNATURE f~~ ~/~,/~~'' ~- ~~ATE ~ - ~ ~ -G ;, Safety and Buildings Division County ` ~ ~ 201 W. Washington Ave., P.O. Box 7162 ,~CO~~,n Madison, WI 53707 - 7162 Sanitary Pemrit Number (to be filled in by Co.) De artment of Commerce (608) 266-3151 113 f ~ T Sanitar Permit A lic ti I.D. Number y pp a on p (('' In accord with Comm 83.21, Wis. Adm. Code, personal information yo providE~E~+ ~ J may be used for secondary purposes Privacy Law, s 15.04(1 xm Project Ad rs;ss if different than mailing address) I. Application Information -Please Print All Information 005 ~ 1 T C.IP C~ Pope Owner's Name ST ~ ZONING OF # Block # I .--- Pro wner's Marlin ~ ~~~ N~ E ~s i , S Zip C Phone Number _ ~, Section - t ~~~ (circle ~ ~ II. Type o wilding (check all that ap ) puj S ~ N; R E v s I or 2 Family Dwelling- Number ofBedroo u ivision a CSM Number ^ Public/Commeroial -Describe Use ^ Sffite Owned -Describe Use ^City i e ~o o III. Type of Permit: (Check only one box oa line A Complete line B if applicable ~ Z p _.. _ ~ ~ A. ~ New System ^ Replacement System ^ tment/Holding Tank Rep] ment Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Chan ^ P t Transfer to New ~~ ~~o~ Permit Number and Date Issued Before Expiration plumber IV. T e of POWTS S stem: Check all that a 1 Non -Pressurized Tn-Ground ^ Mound ? 24 in. of suitable soil ^ M < 24 in. of suitable soi! ^ At-Grade ^ Singte Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ P Fil ^ Aerobic Treatrnent Unit ^ Rxirculating Sand Filter ^ Recirculating Synthetic Media Filter king Chamber ^ Drip Li ^ Gra I-less Pi ^ Other (explain) V. Dis ersal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dis Area Required ( Dispersal Arca Proposed (sf) System Elevatio ay ; r ~ ~ 0 7 . _ 9 S ~ S-y . VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Uni Concrete Constructed Glass New F.~dating Tanks Tanks Septic or Holding Tank ^ts. ~sf~ soft Auobic Treatment Unit i Dosing Chamber VII. Responsibility Statement- I, the uaderaigae ' ' assume reapon ' ility for installation of the POWTS s wa on the attached plans. bet s e( t Pl is N bet B '~ P n N r lumbcr's~Ad City fate, Zip C ) VIII. Cozen e a ment Use Onl Approved ^ roved Sanitary Permit Fee (includes Groundwater Date Issued Issw Age ignature (N Stamps) Surcharge Fee) \ ^ en ial 017-- L 26 IX. Conditions pprova al r r t t SYSTEM OWNER: 3 ~ ~ ~ ~ u (, . n 1 Septic tank, effluent filter and ~~ _ U,~.,,,, C ~ (90 K ~-Qbt~ S ~`^^'- dispersal cell must all be serviced /maintained ~ ) as per management plan provided by plumber. ~ ~ Cent-~~ e't-~ ~~ZS-~D~, 2. All setback requirements must be maintained ~~~ Nt ~ ~- ~ ~~ o~ CSZ' as per applicable codeJordinances. ~.(.Q~~~~ ,,~ ~9aJ " "'""~ 1 g,r ~ l 3 Attach rmm~l.f..,1.... /t.. A.. n_.._~ GLE _- ~__'-_ ____v -..v~..........~ ~`u yn c uva ws wa~ V R`~~ 0'M--Vy~+i`^ t'om` J ~ "i SBD-6398 (R. 01/03) P1~, ,.Q~ verz`~ ;~- )bc~t n~ ~-~ %' . ~. 1 N ~,_ ao ~ , ~~ ~ '~,~ - _ Sao ' ~~ ~ ~jyl-a IDd.sa ~ ,. r'i s~ P~ T~a T~_ 9yay~ T a= ~3-5'~` ~~~~ ~~ ~-~D B~'~ asp q,,,e ~~~ ~'~-. .~+~ /;~- ~ f 9 yrN / ~. ~~~ ~/ ~aa~3~'~ N r ~'' a~' ~~ K~ _ _ ioa ' /~ "5~ -a - i on~- ©~ ,, ~~ ~~ ~~ q~y~ ay ~ ~, ys I/' ~v ~ ~ N _ _ _ +~r~~ ~,V 4 a ~ ~ ~~ ~ 9 ~p~3SO1L~~EVALUATION REPORT Oi~sior-afsafetyand sr c8~,. ~ ,~ ~ 3 Attach oornplele atte ptan on paper twt l t~Ktg~x 11 inches in etas. Plan must ode, but not lin>iGed b: vertical and froriaorltN E (BM}, d~tion and p slope, sc~e arm, north emow• grid tocsdlntt and distance to nearest road. P~oel l.Cl. ~I / s~~ !K do ~ - Please peri„t a-r Ir-forrnatfon. ~eviawea ~ ~°0 S/ 2 ~ t~ewwnt YMon~tion you o~+as mr w wsa txseoonorry a+-a~s car ~. ~.,so~ E~) t~l NW a S£ SEGT• I Properly Owner k~iPivo.v 13fFS ?~' ply ~ 1 q /9 ~ ~ r cwt. Lot , N lz 4{ar} w proPertY Owners ~8 Address ~Y GA • rBA~R G"~ ~`~ • Lot # 5-- Biootc # St6d. Name a t E.v N " Goo ~o Tom' ~? f®~f-~' ' . ff'UO.SoA~ w/. sy ~ '7t 5 3 8~ •-n't 5 ~ `~ ^' ®ra"r' r>ear~t i~oaa ttvr~so~ ~~~~~ adz - ~.~- user Residettliai t Number of bedieoens 3 - Code derived desi~ Aaw rate YSD „- ~ coo ^ R~ ^ Pubic or oorrrrreraet - Die: teacart rrsafarial _ 5~4,vd y a v T tJ~t- S~ F,o<,d Plaln elevation if a~ppi~6te it/ ~. cene~l t~«t>Ettert~ ~ ~ - ~'~- T~s~ iS su~'T~6/~ - co~v~v7~o,v,a-~ ~' o- ~ ~ T's , ~f ~ wvaw•M a•A•a.R i1c~.~~,~,r •a. WFIY~ W r~1RVI~j w41•w u a~. Horizon Deptlt DOrr>~18rtt i~0ed0rt Desaipion Texture 81nx~ure a 8drrfdary ~ ln. filet. Sz Cont. Gbior (3t: Sz Sh. 'EfflRi 'Et~2 Z D- o . S S -- S cs ~ ~ '2_. ~/ 7 - a 9 .2'{ s ~-/ 3 - ~~ a ~ ~ '`~~ ~ ~ 9 0 ~ Pit atotatrdaafaceetev. oa ~.. _ ~ a :>_ - sal - ~ HotiTOn ~ oomi~rt •~ ~ c ~. ~. sz. ~ ~ ~ sz. mot. 'mi'l Z <5 ~ ~ cs !~- .. 4 ~~ S' D • ~~ ` ~ 7 O -L i O ~ l R ~ ~ WY ~ .7N ~ !B7 N~f7L 8~ ~ 3aI l• 1Z 7N /r~~ ~ GNR~W t /f~i r' ~N/_ ~ N1/ ~ a~ Ta7.7 t JH 6 ~Y-- 2t ~ b ~~ cf~.i ._. j Z~ 3 z s Address Dale Evekieliort Cortdtxied Telephone Number iyOU. t5- ao-o3 7t5•"7~a•3~~z t~:~aia#~-~-~s cruets sewage Consultants 2812 10th Ave. ~j/V .s ~tQ TOT~4'G ~~ pa /~ Spring Valley, WI 54767 O Z Q . <D )..7. 2 O ~ D'tTa Z.o • f©,1.7. 30 • o~ zD • ioi7 . yo - aa~ ~E~tio.v T.~A-s T' .,,.. ..j '~~:. .. tt ~~ ~yo T~ ~lo~ Go ~- ~ S Parcel ro p 2..._ ,~ Pane of u Pit t3rorard surface elev. ~ . d ft Depth ~ Crn~ factor , ~` O ~. Sot Rate i~oriaon Depth Dominant Redaz Description Textre Struohre Cor~enoe Boundary Root GP OVff in. Mures Qu. Sz. Cont Color Gr. Sz Sh. •Eff#1 'E1f#2 / o • lZ ~o yR 3~ -- L ~ fs K. w 3 . S - 8 i ~R ~!z- ~ • o y y s~ ~ ~~e ~.s -- •~~ ~sy s ~ s -- .~ / Z • /w ~o ~2 --- s 5 ~ ^ ^ Pit Gnwnd surface env. ft Depth to rNnitirg factor ' in ~ ° ~'~ . Sat Rate fiorimn Depth Dominant Redwr Descriptan Texture Struct<rte Consistence Boundary Roots GP D/fE in. Murrse9 t1u. Sz Cont. Color Cx. Sz Sh. 'Et~1 'Eff#2 Grotatd suface env, fL ^ Pit ~ ~- tp 9 factor in. ~# ~ Sot Rde Horiaorr Depth Darrwrarrt Redox Oesaip6on. T S6rrct<re Coroe Boundaclr Rods in. MunseN tlu. Sz Corrc. Cator Gr. Sz. Sh. 'Ei~1 'EfkK2 ' Eflkterrt #1 = BC1D6 ~ 30 _< ?20 rrglL and TSS >30 <_ 150 rrgll. ' E1Huent #2 = BODs < 30 ngR and TSS <_ 30 rtgl~ The Department of Commerce is an equal rtrruity service provider a~ employer. If you need assistance to sacxss services or arced material in an alternate t, please contact the department at 608-266-3151 or TTY 608-2b4-8771. seaa3~otRS~oo~ ., .. T ~~ ~3 ~a ~. ~~ ~2 ~s~~ ~--'-' For issuance of permits and designing contact: Ulbricht & Associates Registered private wastewater consultant and plurr~ers 2$12 10th Ave. Spring Valley, WI 54767 715-772-3442 ., ~' a ~,o r C! " d ~~Z S~~ ,, S~ of Ya~ ~~~ ~ ~ ~~ O, Sa- ` la ~5 ~..D f ,3Y rtb +,~ ~' t fir" ~~ ~~ ~ ~~ ~~~ ~ ~ ~ ~~/ o _~ ~o i j . ~ ~.~ ~. /~ ay POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ( of ~'' FILE INFORMATION IOwner s2~~~ Permit # ? .3 ~ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) al/da Design flow Ipeakl, (Estimated x 1.5) ~ gallda Soil Application Rate , al/day/ftz Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) S30 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 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. IIAA1111TCIUAIUf~C Cf~YCr\I 11 C SYSTEM SPECIFICATIONS Septic Tank Capacity ~ ~ al ^ NA Septic Tank Manufacturer ~~ ^ NA Effluent Filter Manufacturer . ^ NA Effluent Filter Model - d ^ NA Pump Tank Capacity al NA Pump Tank Manufacturer A Pump Manufacturer A Pump Model ~ ~NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: L~ NA Dispersal Cell(s1 ~In-Ground {gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) ,~ ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month(s1 (Maximum 3 years) ~ year(s- ^ NA Clean effluent filter At least once every: ^ month(s) ~ year(s) ^ NA ^ month(s) ~(yA Inspect pump, pump controls & alarm At least once every: ^ year(s) TT`"'_ ^ monthlsl I~NA Flush laterals and pressure test At least once every: ^ year(s) Other: At least once every: ^ month(s) ^ year(s1 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(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 (Y31 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, shalt 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 Z of Z' START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellls). 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 dispersal cellls) in one large dose, overloading the cellls) 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 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. ~~ T alua ' o m9 ank b e a~ ~lZD1-~18 TfE1~ ~D~ /~/~ ~fVS772tl~ON ^ 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 ~. Phone _ ~j g ~ ~j- POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name Ste- ~ l b ZD~tIl~ Phone '7/S- 3g(~_ (p ('~ This document was drafted in compliance wkh chapter Comm 83.22121(bl(1-(dl&(f- and 83.54(11, 121 & 131, Wisconsin Administrative Code. ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNE~~RS``HIP C;:,RTIFICATION FORM OwnerBuyer @'1! Vl n ~l~~ Mailing Address oc~4 Property Address __. -_ (Verification required from Planning D partment for new City/State Pazcel Identification Number OZO - ~ ~ ~--os"-t~O C• 28'3(p LEGAL DESCRIPTION Property Location %.,:~ y,, Sec.l~, T_~N-R~W, Town of Zc~~~ Subdivision Lot # ~. Certified Survey Map # Volume .Page # Warranty Deed # ~ ~JC~ c~ 3 ~ Volume °~ ~ g 7 .Page # ~ ~ a Spec houseyes J~ no Lot lines identifiable Dyes ^ no SYSTEM 11ZAINTENANCE 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 caa affect the function of the septic tank as a treatment stage in the waste disposal system. The propertyowner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restrictedpiumber or a licensedpumper verifying that (1) the on-site wastewaterdisposalsystern 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 Zoning Office within 30 days of a year ex~tion date. /` SIG OF LICANT DATE OWNER CERTIFICATION I (we) 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 pr a described above, by virtue of a warranty deed recorded in Register of Deeds Office. _. , ~ SI OF CANT 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 U 2y87P 11$ STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Steven L. Bakken and Caye L. Bakken, husband and wife, Grantor, and Kernon J. Bast, married, Grantee.. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area 75m939 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 01!07!2004 12:35PN iIARRANTY DEED EXERT It 17 REC FEE: 13.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 2 E7tceptions to warranties: Easements, restrictions and rights-of--way of record, if any. This deed is in fulfillment of land contract dated August 16, 2002, recorded August 20,2002 in book 1952, page 549, as document number 687523 Dated this 6th day of January, 2004. B * Steven L. Bakken AUTHENTICATION Signature(s) OWt` authenticated this 6th day of Janu 04 L1b~~C Notary P Sons;n ~~ \(~ 1 * sta TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED 8Y Name and Return Address: Edina Realty Title, Inc. 400 S. 2'~ St. -Suite 11 S Hudson, WI 54016 412540 20-1027-4C-000 & 30-000 &20-00 Parcel Identification Number (PIN) This is not hdmestead property. B ~ ~- ~~ *Ca eL.B en ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CRO[X COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Steven L. Bakken and Caye L. Bakken, husband and wife to me known to be the person(s) who executed the forego' 'nstrtunent and acknowledged the same. fit-Q.1 ~;~u~- *Cheri Brown Notary Public, State of Wisconsin Edina Realty Title -Doug Berg My commission is permanent. (If not, state expiration date: 400 South Second Street #115, Hudson, WI 54016 3/11/2007 (Signatures may be authenticated or acknowledged. Both are not necessary.) •Names of persons signing in any capacity must be typed or printed below their signature ~3 WARRANTI' DEED STATE BAROF WISCONSIN FORM No.2-2000 U 2'i87P 1.19 EXHIBIT A The NE '/, of the SE '/. and the N W '/, of the SE '/., all in Section I5, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E'/. corner of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE'/. of said Seciion, 407.27 feet; thence South 89 degrees 08 minutes IS seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the azc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North Ol degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume 1, page 217 at the St. Croix County Register of Deeds Office; thence North 88 degrees 51 minutes 13 seconds East, along said south line, 570.78 feet to the point of beginning. St. Croix County Map Output Page Page 1 of 1 • St. Croix Count Ma in LOT4 ~ ~~ ` 110A4 E 4 ~. i ~ 357.63 ~ 56;8:4 570.75 X~ \' 119B-20 Hudson 15 ~ V~~IV~1'.V 119B-1 ~ ~~ . ''x., St. Croix County Planning Department 1101 Carmichael Road Hudson, WI 54016 Phone: (715) 386-4674 DISCLAIMER :The information contained on this map is advisory. Map accuracy is limited by the quality of the public records from which it was prepared. It is not intended as a substitute for an accurate field survey. AERIAL PHOTOS :Aerial photography is date-sensitive. Features that exist presently in the County may not be present in the photos. 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