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HomeMy WebLinkAbout020-1447-14-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety artd Building Division • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Bast, Kernon Hudson, Town of ;ST BM Elev: Insp. BM Elev: BM Descri tion: l~ fpm - c5~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ (~ • D r.... a 8 P~eration ~~ Pat -o~ ~ Holding TANK SETBACK INFORMATION TANK TO P/L W ELL BLDG. Vent to Air Intake ROAD Septic Z I - `` ,, N~ l0 3+ ~ ~ / Dosing ~ 1 ~~ 7 / Aeration Holding PUMP/SIPHON INFORMATION Manufacturer \ ~ ~ /~ ~/ ~ Demand GPM Model Number ~~ TDH Lif~'. Friction Los O 1 System Head TDH Forcemain Length ~ Dia. ~ ~~ Dist. to Well ~ ^ SOIL ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: 463310 0 State Plan ID No: Parcel Tax No: //// } 0 ~ ~7 / ~~ . SectionlTown/Range/Map No: 15.29.19. a ELEVATION DATA STATION BS HI FS ELEV. Benchmark o,s~ ~aa~5 i~~ Alt. BM ~ I 97• / Bldg. Sew r 7. ~~ 9 3.3Z SUHt Inlet 9.65 fib. 8S SUHt Outlet ~ ~ Dt Inlet ~ ~ Dt Bottom I ~. y s Header/Man. ~~~ c l5• Dist. Pipe S.~ ~. q~ ~ 7 . z Bot. System b • y ~, 93• b ~. z Final Grade Z .a 9~s • S st covaU 9 7 BED/TRENCH DIMENSIONS Width / Length i ~Q' d-~jZ ~ O No. Of Trenches z ~l-e~C~•~ PIT DIMENSIONS \ No. Of Pits Inside Dia. ~- Liquid De\ SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturers. ^l ~.~dh Type Of System: ff i~ /~ ~ 7ia~ ~ /~ ~~ UNIT Model Number /,~ t 5,~ DISTRIBUTION SYSTEM E l~C. '~G,.S =~ ~O°~~ Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ~'] / // Pipe(s) ~ ~ ~ \ ` ~/Gd c~Sp,~, '/t Length~_ Dia Length Dia Spacing Sflll ~nUFR v Drnce~~ru Svo+nm~ Only YY Mnunrl nr At_Grade Systems Onlv Depth Over / Depth Over ~ xx Depth of xx Seeded/Sodded xx Mulched ' Bed/Trench Center ~ Bed/Trench Edges Topsoil ~ 'Yes No Yes No , ~~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ ZeJ / +~S Inspection #2: --I_--J_-. Location: 668 Pine Timb r Lane Hudson, WI 54016 (NW 1/4 SW 1/4 15 T29N R19W) Coyote Ridge Lot 14 Parcel No: 15.29 19. 1.) Alt BM Description = ~~ ~ JQ~_ ~~; ~ ~- ~~ d/\/~ ~ ~ ~u~ 2.) Bldg sewer length = ~ ~~-~-- //`~~ '- '1\ 11' - amount of cover = ~~ i/ ~ _ _ (J ""'~ _ _ ? ,Yes ~~ / ~ Q _ __ _ __ _ _ _ _ - Plan revision Required . ) No ~ le ~ I d ~ ~ ~ '" _~ Use other side for additional in ormation. _~ _ -__.- - Date Insep is Si ture Cert. No. SBD-6710 (R.3/97) ' Safety and Buildings Division County ~ ~ 201 W hington A O. Box 7162 ~ ,SCO~~,~ A~a It on, WI 5 07 - ~~~ 26 3151 ~ Permit Number (to be filled in by Co.) Department of Commerce Q Sanitary Permit Applic n ''A, !~ ~, In accord with Comm 83.21, Wis. Adm. Code, personal informatio p1a. ~6 da 'Y ,J ~r f state Pla I.D. Nu may be used for secondary purposes Privacy Law, sl x.04(1 m ST C RO Project ddress (if different than mailing address) IXCp rr - I. Application Information -Please Print All Information OFFIC Q ~~ C~ Property Owner's Name Lot # Block # Parcel # ~~~ Property Owner's Mailing Address Property ocation >', L~ /~ ~''/< ~~ Section ~/ City, State Zip Code Phone Number , S~0/ 7i ~~ ~ircl~ ~~ ~~ / [~ T ~ N; R E ol lI. Type of Building (check all that apply) ` ~ J ' v Mr ~l or 2 Family Dwelling-Number of Bedrooms ~ ~ ~.~t. ~Jb ~ Subdivision Name CS Number // ^ Public/Commercial -Describe Use ~nA ~/4 r~ 1'Se t ,_ ^ State Owned- Describe Use ^City_ Vill To nship of III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) A' ew System ^ Replacement System ^ TreatmenUHoldin Tank Re lacement Onl g p y ^ Other Modification to Existin S stem g Y B• ^ Permit Renewal ennit 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 1 ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constmcted 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 (ex lain) V. Dis ersal/Treatment Area Information: ' Desi n Flow (gpd) ~ Design Soil Application Rate(gpds~ Dispers Area Required (s~ Dispersal Area Proposed (sf) System Elevati n / ~ ~~ ~ ~~ ~ VI. Tank Info Capacity in Total Number Manufacturer refab Site Steel Fiber Plastic Gallons Gallons of Units n Concrete Constmcted Glass New Existing y /~ ~~/ Tanks Tanks ,o t Septic or Holding Ta~ilt f 'l~ ! !JI f / O j / \ Aerobic Treatment Uni[ Dosing Chamber 8~ v~ / ; ~,C--• VII. Responsibility Statement- I, the undersigned, assume responsibility for in tallation of the POWTS shown on the attached plans. Plumber's ame riot Plumb Sign re /MFRS Number Business Phone Number J~ 1eC~i~ ~ao3s 7 pis , a~8 ~ Plumber's Address ( St~ree~t, City, State, Zip C e) ~ t' ~ ~ i ~~ / VIII. Coun /De artment Use Onl Approved ^ Disa ved Sanitary Permit Fee (includes Groundwater Date sue Issuing Signatu (N tamps) ^ Surcharge Fee) ~ ~ g a5 Own Gi eason nial . IX. Conditions of Approval/Reasons for Disapproval t C_,,~. SYSTEM OWNER: -y~ Pv 1. Septic tank, effluent filter and ~ dispersal cell must all be services /maintained ~ par management plan provided by plumber. ~ ~ sew rents must be maintained as par ~ppNcebM cods / pdin>Irtcas. Attach complete plans (to the County only) for [ne sys[em on paper nor Bess loan oac a „ ..~....~~ ... ~.~~ ~~ SBD-6398 (R. Oll03) ~.~ iy ~.~r~ ~-~. r~n,~ EOMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of coyer, must e~dend to a point no greater than 6" Below Finished Grade Coyer with ~CA'rl~ Locking Deyiee ~ ~ (typical) DUI LD!/v(a SEW ~~ > 3p PT ~.~Z /~ iNSUL~ PIS 0 Min. 23"Access Opening Owlet Effluent Filter ~ Inlet Baffle 89~' Access Opening, not top of coyer, must ndend at least 4" Abaye Finished Glade . ~IV/~~r ~PPi2e~D CA ~ ~ /Finished Grade IIZNlN 1Nr//'h Um r Mm. 23" Access Opening ~ Z "~/~ 1~bipC~/hA~~ ~ lvr~! if ~'Ai~ S!~'E ~i ~ Union ~,eoVE.A ~/P~ 3 Pr ~ .a,na, oN`Ta SoLia .Soil 3 ",Sa,---d ar ra.~-~ ~n~99 unal~er w~~Lh ~2h~r 2"/o+luer ~'Qh Qd~'ps Two ComparFment SepticlPumpTank ~~ ~ ~~~ on Ov~side GC~I~) SPECIFICATIONS TANK MFR: TANK SIZE: SEPTIC / (~ GAL. DOSE OD GAL. ALARM MFR: MODEL # l+ Switch type: PUMP MFR: MODEL #: E1~0 ~ SWITCH TYPE: B = _2_INCHES =~_GAL. C = ~ 3~INCHES = GAL. D = INCHES = ~ a .O~ AL. REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) _ ~ 3O FT. MI IMU~VI NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) _ + ~-- _FT. ~D FT. OF FORCEMAIN x ~FT./100 FT. FRICTION FACTOR ...... _ + FT. TOTAL DYNAMIC HEAD (TDH) = G ~ ~ ~ O FT. INTERNAL TANK DIMENSIONS: LENGTH ;WIDTH ;LIQUID DEPTH MP/MPRS SIGNATURE: LICENSE NUMBER: ~ / • O7G~d~S DOSES PER DAY: DOSE VOLUME: I ~ GAL. (INCLUDES FLOWBACK & <20% OF DWF) CAPACITIES: A = ~~I'Pd"CHES = __Q~GAL. APPLICATIONS Specifically designed for the following uses: • Effluent systems ~', • Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: '/4" 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: 1041E (4010) continuous 1401E (60x) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 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: 10 foot standard length, 16/3 SJTW with three prong grounding plug. Optional 20 foot length, 1613 S1TW with three prong grounding plug (standard on EP05). 's: 2003 Goulds Pumps Efieclive July, 2003 83871 • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models 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. METERS 10 9 a °a ~ W x v 6 }S 0 a 4 0 r 3 z 1 0 ~1 ~~- ~ 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 Canadian Standards Association S ~ File #1838549 Goulds Pumps is ISO 9001 Registered. EET -------. 30' . -- S GPM '~-zs zs zo ~ ~..- .- 15 __ a - EPOS P04 5 00 10 _ 20 I~ 30 6 8 cAP,aclrv ,~ 4G ~0 GPM 10 12 m'/h Goulds Pumps ~0~.. ITT Industries Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 County ~ ~ ~~ ` Maatson, WI 53707 - 7162 i i Sanitary Pem-it Number (to be filled in by Co.) n seons (fig) 266-31 (~ 3 3 ~ v Department of Commerce State Plan LD. Number Sanitary Permit Application 0 ~ _ ersonal information you pro e Adm Code Wi 21 3 . , p s. , . In accord with Comm 8 may be used for secondary purposes Privacy Law, s15.1>4(1 xm) 0 Project Address (if different than mailing address) I. Application Information -Please Print All Informatio ~ `j" ~~ ~ 1 ~ a ~ r . ~ _ / Pro rt Owner's Name ~ ~ y ~~ r L ~ ~;~ ~, ZuO~ Parcel # ~ t # Block # ) ~ !~ -~ ~ ' ~ V~ s Pro Owner's Mailing Ad ~:;~;X.C~U~NI~'~ 5 i ~ Prope Location ~ ~~ d , ~ ~-~C~, ~-.~ ~' ~ ~ ~ r FFICE ~- GI(%, L~'., Section City, State p Code Zi ~ ~ t - L t .~-- / { ,J t ~ ~ lC- ..~ fn l l ,1, °] C~,• R~E ot~ ~.~~ S ` I .Type of Building (check all that apply) ~_ ~/ ~ CS Number Subdivision N ` ~~~ `if. or 2 Family Dwelling - Number of Bedrooms ~ ' ~ `~~ ~ ~ ^ PubliclCommercial -Describe Use ^ State Owned -Describe Use ^Ciry_ V it{age ownship of ~ t lit. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System ^ Replacement System ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ permit Renewal ^ Petmit 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 sll that a 1 i '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-CiRund~4 I;Iolding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ ~ Recirculating Synthetic Media Filter ~ hing Chamber ^ Drip ine ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/TreatmentArea Infortation: Z ~c ~~c,~~_~_ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dis I Area Required (sf). Dispetp~ .+..,a , .u Stem/Eleva ion Q ~ ~ t ~ ~ ~~~-~~ ~ T_ L ~ r ~.~ 7 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 5 ~ (~S G ~ t~~l~it-'.Z Aerobic Treatnxnt Unit Dosing Changer VII. Responsibility Statement- I, the nadersigned, assume responsibility for i Ilatioa of the POWTS shown on the attached plans. Plum r N me (Print) Plumber's i ature MP PRS Number Business Phone Number _ Plumber's Address (Street, City, State, Zip C~°~ /~,L _ _ VIII. Count ~/De artment Use Onl pr Sanitary Permit Fee (i eludes roundwater Date Issued 1 suin gent Signature o Stamps) roved ^ isa A p pp _ _ Surcharge Fee) ~ ~~ _ O ^ Owner Given Reason for Denial I~. Conditions Approva ~~I 2\ ~a I 1 ` „~ _ ~ Q_ ~ (1 ~ ~ 2~C 'l ~'e JJ O ~ r` " ~~ ' , ~ ~ SYSTEM OWNER: 1 ~ ~ 1 Septic tank, effluent filter and dispersal cell must all be serviced I maintained ~'~^ as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. Attach eompxte pwat tto toe a.ooory onryr rur ...c qs.c....... p.r.~...... F.....-- --•- - -- ---- .~(= , ~/ ~~ `(T n '% ~~ ~. SBD-6398 (R. Ol/03) 6 `~ Q x 1 I~ ~-,~'-~, NU ~ -/~o .~~ ~ ~,~ #i / D~ ~ ~/7 !/ ~/,~ r ~ i~ ZJ ~3~' ~~ 1 y,o~ ~ °~ lea ~ ~ . S ~~ ~~ ~ ~ Ta-~a iii=ysy~~ ~ ~.-- r- a = ys .- ~, ~oPv ~'~ya ' 95- ~ ~` V 'v ~~ ~„~ 1 ~3 i ~ lzs ~~~ `~ ~~M e 1~ ~--~ /R~ // y i ~. ~ ~~ ` ~ ~~'"ya _, 5 ~~ i3 ~ - ~~~ . ~U ~~? ~~ #~ i~ l~-.. %3~t ~ o~ y y,o,~ ~ S ~ ~s ~ ~ ~=~` ~3~~ T--~ - ~~ ~- ~ ` ys ~`, 95 " r ~ , • RECEIVEC °.d.~~ vWsoors~Depetttnentof SOi,L EVALUATION REPORT +oivisian~se~rand i1FC ~ c~ ~,,,,... CZ..\ 1 3 Qe9e of - Y, ~~ ~, ~ ~. rns..,~,. ~ ca.~y S T c ~ O I ~- Aaacn oompleresite lan a e6aotl P(an must 1/2 x 1 t in alas p p p ~g, . ~ ode. r~ nd yea eo: t~. , and paw t.~. SF~ t~ `0 uJ ~ pen~nt slope, sc~de « d~tanoe to n nrad. Please print aIJ lnfwmation. ttev(eMred ~ t~ Pe,aani tnto,mdion you gowde aar w used rorssoonaary o,*P~s (Pr~gr ~-«+. s. +5.04 (+) (,~> /V w p S£ SEGT• [ Y~1eC ~1 d kE/@/VO,V /~rT/' 7'' pr~pe~tyioc~o~+ Gorf. tral /VW /~~^ 1ra•'w ita 8~7 T ~~ N (2 ~~ ~i{o~ w F'ropetty O+~'s ~8 ,p ~ Lot # 8tottC it Stbd. Name or CSI~r EiV N S'fate Code ffUD.So,~ tr>l • s'iotG ?15 3 8h •-~~5 ^ (may ^ v~age ®Town Neen3st Road hf vOsa~ r3~,C,~~ ~~ - ~~ ~ use-.ltd R r t~.nt~o~ aea~ooms ~ coae ae~aa desi~ ~- rare 'yS4 -- Co a'a c~ ^ RePt ~ Ps+bGc a ~rnerrai - Descx(be: ParenE mata~ -5fLVO / 0 y Y Gllf-~c~. Flood t~ir- ~ a~x~te ~t! it. a°a'ar'ent$ ~ ~'ff TZ'S7~ /S SU/•T/Pt~/-~ ~0~ i1`/v %fJfjPQU~cJ~ Gov vim- ~r'O~J~4'L- ~. D . W . T • S , t i1,~ a gy..3 ~. '>/l0 L • , f ~ 1~ c~toeirw stx~aoe aev. n uepu~ ~ Arram~ racer n. 90iE Re1B ttori'aon Oepth Oa~M tlsdoot Oesaiplion Texture 8sucture (enoe t3ourbary /loots in. 1 Qu. Sz. Cord. Color C,r. Sz. ~. 'Ef~'1 'E.>f~2 ~ o•I~ /aye 3 ~ ~ fs ~' ui 3 y ,~ • ~o ,Qs~~ ~ Sty / 5,6~ v ! . z • 3 ~ ~--- G S • 7 /. ~ o • /o S ~• . o ~ i ~Y ~ p~~ e°",~ a ~~ ~ Pit ~, (n. tidur>sell C/ ~/n $ur,aoeelev. ~ / • 7 ytt. C tom, _ Qu. Sz. Cont. Odor -- ~ b for ' ~~ in- - ~ Rare ~,~,, ~ Sz. Sh. -~+ o• /o ,P~13 L fs~6~ ~ w 3 ~ •~ ~ s~ ~~ . o ~ ~---. S D ~? 4S• n Y~ 9 -N ~a.8 ~ . ' ~tM1611t ~ ~ 1~ ~ 3Q '~ 220 RIQiI. and TaS X30 < 1 90 mgA. ~ F1Ruerrt ~ = B(3D ~ 301r1~, erld TSS ~ .•~ ~ C~`T `~ N~`t~~-r- ~t ~b ~~ cG-~ - z z ~ 3 z s Address Dete Evakx~l'ion Condrx~ed Telephone Numtx~x Private Sewage Consultants p 2812 10th Ave. SIN •5 /~o12 T47~L, of O 0 /~ Spring Valley, WI 54767 Z D • to ~.~7 • ,Z o • o-a-a o • 107 . 30 • o~ ~...o • i©z7 • yp • ~a~ ,, `~ +i ~R~vo,v T3r4-s ~ Gd ~`- ~ h' ParcellD ~ e°""91f ~ ~7 ~~ O Pit Grow s<,rfaoe e~,-. ft. oeoth ~ rr~na ratter > y'~ ~. Z 3 Page of Oeptli Dominant ~ Ram in M l Redox Oesaiption Texlune Structrre Cons Boundary Rods GP t?1R' . usse Du. Sz Cart Color Gr. Sz. Sh. 'Ef~fr 'Erfr{2 / Z ~/l~ D • i6 yR ~ ~o yie ! ~--- L /L 2 s~~ /fS e~ ~ f,2 v ~ c 3 f ~ . Z ~ , 3 '3 0 • S o ,2 7 - ve~~ ,,,r,-~aQ L ,.S f p as ~ .~ . ~ ~ , U~# ~~ ^ Pit Grotmd surface elev.. _ it t~rr. r, ama~, rte,. . ~~0n ~ Dominant R _ _ _.. _~ Ram in M edox Description Texdxe Structure Cara~st~xoe Boundary Rotes GP DVt! . unseA Glu. Sz Cont. Cabr Gr. Sz. Sh. '~1 'Etlit2 # ~ ~9 ^ Pi- Ground StafAOe elev. it. >b fbriitina facer L, --- -' Sol Rate ~~ ~ ~~ Redox ~P~n- T Struchrre Cone Botmdary Roots GPIMf in. Mur~sel t1u. Ste. corn. Color Gar Sz. Sh. 'Etlft I 'EtffE2 ~fAuent #t = Btms > 3a _220 mgll. and TSS >30 < 150 mplL • Efluent #2 = BODs < 30 mgll. and TSS < 30 mglL The Department of Coaunerce is sa equal opportunity service provider and employer. If you need assistance to access services or aced material in an alternate fotrnat, please contact the departrrunt at 608-266-3151 or TTY 608-2648777. saa-uw~espo~ .4 . c~ ~ "r ya-~- 1 T~ ~, o~ - ~ ~~r ~~ ~, ~ ~~ p ~ ~--- Y t~ ~ ~ ° ~~ v~ ~~ 5~ ,~ Z ~ r ~ ~ Y ~ ~- , A ~~ ,.--~~ J~ ~y ~ ~~ ..-~,' ~,r~.._ a ~g.D ~~ o' a ~ '''S ~+ ~t ,y~o ~~ \ \~ For issuance of permits and designing ~ Contact: Ulbricht & Associates Registered private wastewater consultant 2812 lath Ave. Spring Valley, WI 54767 715-772-3442 ~,~~e : / ~~ 3 0 s .~1 = ~av r4~v~ s ~' ~~~-~ ~a~t3~ x s o~ ~~ ~~ ,.. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~'' FILE INFORMATION Owner L Permit # tf (~ 3 31~ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units NA Estimated flow (average) Q CJ al/da Design flow (peak-, (Estimated x 1.51 (~ b al/da Soil Application Rate ~ al/da /ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (RODS) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent duality 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 did. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity S Q al ^ NA Septic Tank Manufacturer ^ NA Effluent Filter Manufacturer f ^ NA Effluent Filter Model - ~ d ^ NA Pump Tank Capacity al ~A Pump Tank Manufacturer A Pump Manufacturer A Pump Model ~ A Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~A Dispersal Cell(s) ,~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: q Other: q Other: A AINTENANCE SCHEDULE M Service Event Service Frequency Inspect condition of tankls- At least once every: ^ month(s) (Maximum 3 years) earls- ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY,1 of tank volume ^ NA Inspect dispersal cell(s) At least once every: monthlsl (Maximum 3 ears) ~yearlsl y ^ NA Clean effluent filter At least once every: , ^monthlsl year(s) ^ NA ^ month(s) A Inspect pump, pump controls & alarm At least once every: ^ year(s) ^ month(s) NA Flush laterals and pressure test At least once every: ^ year(s) Other: At least once every: ^monthlsl ^ year(s) NA Other: I~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 IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be 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 ceft(s1. 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 cell(s) 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 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 ing ttank ~~ e ai ~ 1T~~ ~C~ ~ I~fVS77811~tn~1 b fZD}~1'd ^ 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 ~ _S - ~ ~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name s'(', C ( bU ~D~l~ Phone ~/S- 3g(p- (p ('~ This document was drafted in compliance with chapter Comm 83.22121(bllt11d1&If- and 83.54(1-, 121 & 131, Wisconsin Administrative Code. Nov 12 04 04:47p. LISR RNN KROLL 715-246-5700 p.l ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C'~RTIFICA^i ION FORM OwnerBuyer ,~~y2iYD~ ~~~ v Mailing Address ~~~ '~ ,~~~~/`~/~ ~ `~~ Property Address (Verification required from Planning Department for new City/State ~~~~, fi/~ Parcel Identification Number C~ G ~-~ ~ ,~ 7 - ~b UC~CJ LEGAL DESCRIPTION V ~ ~ ~ Property Location /_.~J~('/., ~ ~ t/,, Sec. ~ T~N-R~W, Town of . ` Subdivision ~ ~~ ~i.~ Lot # /~ Certified Survey Map # ~- .Volume '- .Page # Warranty Deed # ~~ 7 (~ / , l~ .Volume ~~„~ Page # Spec house yes D no Lot lines identifiable D no SYSTEM MAINTICNA.NCE Improper use and maintenance of your septic system could resalt in its premature failure to handle wastes. Proper maintenance consists of pnmgsing out the septic tank every three years or sooner, if needed by a licensed pumper. What you pat into the system can a~oct the function of the septic tack as a treatment stage is the waste disposal system. Tate property owner agrees to snbmii to St. Croix Zoning Dcputmcnt a certification form, signed by the owner and by a masterphmzbcr, journeymanplumber, resttictedplumber or a liceasedpumper verifying that (1) the on site wastewaterdisposalcystem 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. Uwc, the undersigned have read the above regntremeats 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 Nattual Resources, State of Wisconsin. Certific~tioa 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 three year tpirati , date. I p~ S G AT[JRE OF APP ICANT DATE OWNER CERTIFICATION I {we) certify that all statements oa this form are true to the best of my (oar) knowledge. I (we) am (ace} the owaer(s} of the pro arty dace ' ed abo e, by virtue of a warranty deed recorded in Register of Deeds O{i'rce. /~ S (iNATtJRE OF PLICANT DATE «...~«« Any information that is mis-represented may result is the sanitary pernrit being revoked by the Zoning Deparnaeat. "««s«: •• 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 warranry deed V~`~g~ ~~. 1Zo Document Number STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Kernon J. Bast, a married person, Grantor, and Kernon J. Bast and Donalda J. Speer-Bast, husband and wife, as Survivorship Marital Property, 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 75094ta KATHLEER H. MALSH REGISTER OF DEEDS 5T. CROIX CO., MI RECEIVED FOR RECORD 01/07!2004 12:35PI1 YARRAHTY DEED EXEMf~T # 8M REC FEE: 13.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 2 Name and Return Address: Edina Realty Title, Inc. 400 S. 2nd St. -Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights-of--way of record, if any. 412540 20-1027-40-000 & 30-000 &20-00 Pazcel Identification Number (PIN) This is not homestead property. Dated this 6th day of January, 2004. * ernon J. Bast AUTHENTICATIQNBCOWn Signature(s) G~eC1 P a~~C' 0 h~ authenticated this 6th day of Jag TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Edina Realty Title -Doug Berg 400 South Second Street #115, Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing fn any capacity must be typed or printed below their signature ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Kernon J. Bast, a married person to me !mown to be the person(s) who executed the foregoing instrument and aclmowled the same. ~ ~~~ *Cheri Brown Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 3/11/2007 ~3 WARRANTY DEED 'STATE BAR OF WISCONSIN FORM No.2-2000 ~~~ I. , W1/4 CORNER ~ ~ ~ EAST .WEST 1/4 LINE OF SECTION 15 SECTION 15 x x----x---x 3ss'64' x x386.82' x---'x x x x LO 2.16 94205 x x ~ F o~ ~'a `~ ~ LOT 12 ~ x ~~s~ 3.65 ACRES ~ ~~ 158947 SQ. FT. ~ ~ x z x/ ~ LOT 13 3.18 ACRES ~~,~ ., S 13s393 sc~. F-r. ' o :' '. u, ~• ~~ ~' ~. _ , % •. ,. .` ~~. ' ~ •. , /, ~' ` / ® ~ /" ~' : ~. _~ %~ .• '~~ BENCHMARK ~ ~p /-/ ~' ;' ~- TOP OF 1"IRON PIPE ~ ~.'~' nn ~ 1 ~~ ~/u i ~' / ~ oC'~ ~ - ~' ; ELEV. =868.62' ,~ ~ /, ~ ~ ~ ; .. (I( ; `R. i 9~` 1 i ~• ^ _._._._._. / 1 , 1 / +G . ,~' i A ES / .~ 2.05 ~ , h I Q. Ff. , 894 r .' , /- i ~ L.B.O. - ~" o o /- n ~ ~~ ,. ,- ,, ~ N ~ ~~ ' ,~ /, ,,. ~ ~ i , i ' /' i +m ~ ~O. , I y~ ~ ~ ~ ~ / ?j ~ o ~? J i ,' ~ j ~' ,. ,. o i ~ Z c~i r- /- ,~,' ~ 2.43 , - ~; .. / , o - - , ...__. . ~! /- ,,, ~ ~ `~ ~= a 6~ , /- '1 j ~_ o /- (~~~ _ _- _ / 1~~1 _~_ .y fly ___x---fix - '~"E --' _ ' ,, LOT 16 x a 7.72' , - ... ~ ACRES _ 3.45 _.__ -- -- -- I 0 d ' i , 5014s sc~. F r ~, i ~ 80' RAD TEMP..._.. wo ~ L.B.O. =882.50 ~ ; ~ ....CUL=DE=SAC ,i ~~ ,..........~ ' BENCHMARK j -~- -~'~~ / TOP OF 1"IRON PIPE fJ ELEV. = 875.44'