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HomeMy WebLinkAbout020-1118-30-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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 Brunelle, M. Scott & Pat Hudson, Town of SST BM Elev: Insp. BM Elev: BM Descr~tiyn: / o o• o / o a• o .R mss rr7/ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ J ~ 1~n / ,n'!, V ~g cJ~~~.~/ ,~,.CiU/l Z (/ ~ Aeration ~ , A ~(/ ~ Holding TANK SETBACK INFORMATION TANK TO A _ P/}}L !~ Gil WELL ~;Q~L G. JG vent to Air Intake ROAD Septic ~ Jai , l~ / ~'2 IX~ZCI l s 3 2~ Aeration Holding PUMP/SIPHON INFORMATION (.~YX/1M,~v Manufacturer Demand GPM Model Number TDH Lift Friction Loss ys Bad TDH Ft Forcemain Length Dia. Dist. to= ell Sell ARSnRPT10N SYSTEM 3~ lC=,~ ~U.e,.._ ~~n.., ELEVATION DATA County: St. CrOIX Sanitary Permit No: 515045 0 State Plan ID No: Parcel Tax No: 020-1118-30-000 Section/Town/Range/Map No: 19.29.19.500 STATION BS HI FS ELEV. Benchmark Alt. BM~ Bldg. Sewer L~z~l~~ ~ s -- ,,~ SUHt Inlet / / ~/ ~ Inlet . 7r/ ~ 7. Dt ~ ~ / Bader an. Dist. Pie //• ~~ 9s GI Bot. System ._._. :o.~fi /r7. 9y ~. Final Grade ~I 4~ S ~ 'vv ~ ~S ~Y+~ ~, 99 St Cover to-a 1~/•~ ~ 2 x~,J - 3~~.~ ~ ~ qs io/. ~~ 10 ~ ~ ~~~ i BED/TRENCH Width Length No. Of Trenches PIT DIMENSI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ / 7~ f~/(! 3 SETBACK SYSTEM TO /L BLDG WELL LAKEISTREAM EACHING Man r: ~ yy~,, - INFORMATION CHAMBE i TOY Typ Of System: ~ ~ 22 ZS/ 7~ / Model Number: ~~~ nISTRIRl1TInN SYSTEM U - ead$r anifpl~i~0 ~ ~V Length Dia DiPtr(b) lion Pi e s Length r ~ X~ ~~ Dia ~ ~ S acing x Hole Size ~ x Hole Spacing Vent to Air Intake ~~ R vep[n mover Bed/Trench er x Pressure Systems Only Depth Over Bed/Trench Edges xx Mound Or At-Grade Systems xx Depth of xx Seeded/: COMMENTS: (Include code discrepencies, persons present, etc.) ~~ >yc 5 "~ ~ Yes ~ No ~] Yes ~ No '- Inspection #1: / / /~ Inspection #2: / /_~,~ Location: 874 Willow~e I Rd(Hu son, WI 54016 (NE 1/4 NE 1/4 19 T29N R19W) Willow Ridge 2nd Add Lot 25 Parcel No: 19.29.~9.5!~ 1.) Alt BM Description = ~~ ~1 W )l 7TH ~~~!-E'il~fi-6~1.. ~/~ I ,/,f 2.) Bldg sewer length = ~y ~ ~ 7fY ~ ~j ,S~!/Jw ~ se~~~ U>t ~ ~1-~~'"-~~-- - adG+/+'i~1 - amount of cover = ~~{~~~~ (~1~s ~~-~I,~-~ ~ /.,.mod ~~~~{ ~ -~v X02 ~'~tCPM--~ ""~ - - - -- Plan revision Required? ~] Yes No 9 I ~ Use other side for additional information. O ( ~~ '` ~ ~ --- ate Insepctor's Sig ature Cert. No. SBD-6710 (R.3/97) ~~ 1 ~~ commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ~' ~` ~ sco n s ~ n Madison, W l 5 3 707-7 1 62 Permit Number (to be tilled in by Co ) Sanitary Department of Commerce ~ ~J ~ 5 d 5 Sanitary Permit Application State Transaction Number ~~ In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Commerce Personal information ou provide may be used for secondary ProjectAddress(ifdiffIere,ntthanmailittg~p~dpyss) p ~ f C t~t ~I . y j" __ W t d ur tses in accordance with the Privac Law, s. 15.04(1 )(m , Stats. ~ ~~~ 1. :~ lication Information -Please Print All Information Property Owner's Name Parcel # Property Owner 's Mailin g A ddress Property Location 507\ u / ~ ~ /~ /~ ~7 W l ~ ®rJ./ / 1 (~ .~ / t ~A GT Govt. Lot ~ ~ , iJ V Clh State 'Zip Code Phone Number ~ ~~,, ~~ %, Section ~~ / w o~ /v .~ $-'7'®~ f .~`l~d/~ 7 <s =3~ 6 - l ~^O [~ ~ ~ Q trcle one T N; R =~ E or V~ 11. "Type of Building (check all that a 1 pP Y) Lot -~! __ ~,,~ I(7 1 or 2 C'amily Dwelling-Number of Be rooms ~ 1~~ ~ ~ B o~ _ Subdivision Name Gu~~l~o~ ~'d ~ ddP: • ~ _ ^ Public/Commercial -Describe Use ^ City of ^ State Owned -Describe Use CSM Number ^ Village of ~~,~ L d / 3 +s~- w /5 f15~-15 ~ E~ ~~-- - L7 Town of /~ ~ ~9 A ~I1. "type of Permit: (Check only one box on line A. Complete line B if applicable) :~ ` ^ New System Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B• ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New Ltst Previous Permit Number and Date Issued E4cfore Expiration Owner ~Ic of PO~V"1'S System/Component/DBvice: (Check all that apply) Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil a - ~~ Flolding Tank ^ Other Dispersal Component (explain) ^ Pretreaunent Device (explain) I_~'. Dis ersaUFreatment :area Information• _ ' fir- - a.:~ (f Design flow (gpd Design Soil Applicatio ate(gpdst) ersak quired (st Di ersa{ Area Proposed (st) System Elevation ' ' ao___ ~~ 8s7 8 z~. q y. o ~ ~'1. Tank Info Capacity in Total _ # of Manufacturer __ Gallons Gallons Units n ~ o ,'~, ~ New ranks Existing Tanks fi / ~ /.1 L C~ G J / d ~ c o v v ~ ~ ,a !__~ _ (/! ~,, a U rn ~, ~ ri. L G Septic or Holding Tank ~.: G boo ~G 2 6~ Caen a.~bf V t~O51nL ('hm„her ~_- ~ 1l. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number E~ ~~~ ~~~~ ~ r ~~~-S 2 !S -799 -33 P umber's Address (Street, City. State_Z-ip Code) ' _ ~~ 7-_ ~~ Ra6~~i-s u.~ ~-~o~.-~ - ~ 111. ('ounty/D~artment `se Only ~ppnrocd '^ )isappro Permit Fee _ Date Is ed Q Issuntg Age ,gnantre ^ ' $ ~~` ~ ~ 3 ~ 'l f Cl ..n ~ ven Reason ial j IX. t'ondit~~~~1~2casons for Disapproval //~ ~ 1. Septic tank, effluent filter artd 3, (~~~ ~S~L,,~.... ~~ V-~, G.rt- a dispersal cell must all ~g services-/maintained ~ / , as per management plan provided~by~pkNnbar. GO ~ ~ (~ /~1J / Z. All setback requirements mttsl be maintained---~1-- ~~~ C.~C~~, ~-~ cc, ~ ~ cY~. ~_~ c> ~ 1 ~ dC - _ _~-pa[ ~• _t - Attach W complrte plans for the system and submiYto the County Doty on paper not less than 8 IR s I t inches in size G O ~~ Sl3l)-G~9R (R. 01/07) Valid Chru 01/09 g~~~ ~. .~w ,~- ~ • f0~ t.~ (~ I 5 ~ ,. -~, ., ~ ~ ~ 10 967K~~~ ~a2zSl ~ t a~,o 3` ~ 3`L 3' ~~~~ ~~~' I G~ D B ~x;sf;Nl lm ~ ~-~~ ~~r f$I ~m~' ~ z ,, p eO1. p ~ ~,.,~~,~- ~~ w~ „~--~ ~ w ~ks~ ~~ c~,e _ T pis . ~~.~-.~ ~~ ~, ~5 ~ ~~ P~ ~~ ~ a.~--- ~ °~~ C~]CO P ~~ G` ~~ 3, 3~ ~ €~ ~y6o ~ S ti" ,Q,.~ ~"`~ 3` G 3~G 3' ~~~ .8- ~' ~. ,._---^- ~2 i ~~ ~~~ ~~ r8 ~-' ~; _~. . ~~ ~ a_~ a ~~ P..~- ~~ ~ ~~ ~- ~' a Q/ ~y~o i ~ ~ v~~, ~ 1~3. ~ ~ i l a~ o v~ w~ ~xSf.k~ ~® amp- ~ ~~ ~ Ji: ~. ~ o ~- w ~le~,,~-,- ~~~ i t8~ ' .. ~~,o _. ~ Ste- /.~_ ~a i ~ ~' p~-~ -n- t n ~- ,/ ~ ~, ~" G --- 3 , ~ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: 1/4, 1/4, Section ,Town N, Range W, Town of , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service ~ ~".~~ Did flow back occur from absorption system? Yes No ~ (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: ~QQD Construction: Prefab Concrete teel Other ~'~ Manufacturer (if known): ~(,~ .~,t~.. (ter,-t, Age of Tank (if known): ~ g 7B (License Plumber Signature) (Print Name) ~~ ~~- (Title) ~- ~o (Date (License Number) MP PR Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) ~t ~~~ ~ SOIL EVALUATION REPORT ~"""' + ~ ~ ~ t~ivision of taafety and 8uddirgs M axotdanoe with commas. Wis. acfrn. code Attach oanplete site plan «~ paper not less than 81/2 x 11 in sae. Plan muse bxlude. t~ not limited to: vertical and hariaor-t~ refierenoe. post (Btun• dnecxion and penceM sbpe• scats or ~. Horn,arrow, and location and r~tanoe b nearest road. Please print all Information. PasonN nrwm.,ion,roe ao~ m.,, b. rise tor:.oorwprp owoss t~ Law, s. taa (+f t~)• , y 5cof{ 3 ~,4T T3~P viVEGG6= Govt loc ~ v l- - p • /~8. 3 0 • oeo 1 2008 ` °~ ~ ~ N ~T. c I I FFI 1 E( W ~P~Y Owner's Lot # Block # Stld. t+lame or CSN~ 87 GU~IIOG~,7~:~~ ~ R ~ 2S Zvi//o!v RiD~ A•DOi,r. ~ state Code Phone Nunber a ~ ^ (Town raeares< Road ~~pSon) Gul s o~ca (7lS~ 3~• /oo n1 evil/ow' ~i ~ . p Flew canstrudion t~se: ~a~de~! t~Nanber of bedrooms code deriw3d desi~ tbw rave CD o ReP O pubsc or oo - Desca~: parent rr~etisl ~}ND O tJ-~ w11-~ - ?~ ~ Flood Play elevation if a .Generaloorm~ents -~-t•llS' ~ ~lo~~~.~.d Area.____ Spot..._._Tested suitable br ` ~ . ~~ ~f- Q~ ~ `( a Coflventbnal inground system (P.O.W.T.S.) ~ R ~d~~,t";~,Q © a a°'tt'° ~ ,~ ~ Ground surface elev. y~ ~ ~~ Depth fo ~rr~ng factor y `T 8 ~. Rate Horiao n Oeplh Dornirrarrt Redox Desoripdan Te7d11te Strrxxure Car stenos BOrxrdery Roo ts in. MtnseN <lu. Sz. Cord. Color Gr. Sz ~. 'E1011 l o- 7 / 3 ----- SiL ~ S,bic CS 3~ . CQ • 5 •5 yR S -. ~L. 2f ~~f'R c w ~ ~- . ~ 3 I •K 7•S --- SQL S i Q S - •~ ,, Z ~~ ° tlormg ~a •~'o pit Ground surface elev. n t)eptt, eo factor in. ., soil ~ Etoriaon Qeplh Donut Redoot Oesa~6ort TexCure Shtrcttee Come 8ourtdar)r .Roots GP DItlt 4t. GAurrseN (lu. Sz Cont Cokx Gr. Sz. Sh. 'EIlfJ:1 'Effp2 ~ ~ /D to y/Z 3 :---- ~ L Z Sb CS 3 ~ • Cc -. ~- lD • ~•S Z h ~fR C cv ! ~- •C~ 3 7 S l S b ntit,-F ' a, -- •~ 7.5 -_--- D • ,~ 5`~ • Et{lAient I<7 = tam > 30 < 220 mdl and TSS >ao < 1 50 mall • Etituent Ill = t30D _ < 30 mnlL and TSS < 30 mdl. c~ t~ante tie ~•~Z 0 ~E1Z7' 7,l LQR I C (~ s ZzCe 3 ?S Address Dade EvaNa~on Condix~ed Teleptrone Ntanber Ulbricht & Associates M~ 2 Y - ~. oo ~~s' ~ ~~ ' 3 y~ ~- „~. ,. _ _ _ u an s ~o ~ ~ ~ vin Hve. Springy Valley, WI 54767 ORIC~i4AL C~~pl~ ~o-~'~•P~' ~ oho • ~~~ ~• 3a ~~ pyop~cy D~ Parcel ID # d ~ © # ~ cro~td ete,-. ~ ~' 0 R ~ to tintilkg taaor ~/CP D h. Horlmon Dept Oor'nirtar~t Redorr Desaip4ion Texture Strtactrxe Cartsistertce Boundary Roots`. GF OrlE in. Mtx~se~ Qu. Sz Coml. Color Gr. S`z Sh. 'B~'t 'Ef~2 b ..~ ~ I D yR l~ - SQL z-fSb~ 3 ~ ~ ~, Z '7. 4 ---- G --. ,~ v. .1z. ~ ~. . M 4~ 0 ~X i i NG- w S l S ~ ~ # ~ ~ ~. ^ plc around ata'face eNv R Depth to tat~or in. soil Rye Fiaimon Dantl- Oorr~rtarU Redaor Oestsip~ort Te~u~e Structure Cor~stenoe Boundary Ruols GPDItE h 1 Qu. Sz Cant. Color Gr. S`c. Sh. `E1i~1 a ~~ ~ ~ Ground surface elev. R ib 6rrrN'itg: factor in. SoN Retie Horaeon Depdt Donwtant tiedcar Description. Terdtas Strtrt~ue Cart~enos 8ouwlary Rods in. aMsisell aw Ss. Copt Color (sir. Sz. Sh '~f#1 ~ 'Et>S2 ~1 _ _ (~ 8artrtg / - _ U °fAp~ R . ^ Pit Ground surteoe elev. n uapar ~ .raQ®~ •~ Textrrre Structure Carrsistertoe Boratdary i~ools d R sa Rata t~todaon Oepttt ti• Dorritarrt Ntrstse! orr e Qtr. Sz Cant. Color Gr. Sz Sh. 'Elf#1 'Et~2 . , '~•' . i. r t - .. ~ ,.., . ~ '~~ .. • 3 P~oPeRY l)xnter Parcel ID # Page ~ BorMg # ~• D ~/ D ~ t3round suriaoe slay " R ln. D~ih to g taclat `~ acai Flodao n , peptlt Uoniu~ar# Rsdwc TexGue Structuna Coe Y Rook`- t~ 01RE' in. Mures Qu. Sz. Cor¢: Color Gir. Sz. Sh. 'C-ff#1 •' 2 '~. --_-- L- -~ , M 4 ~ ~ ~Xi i~(r lv S l S ~ ~' CD (if4~-' S'aY ? ftj > ff-• d w ~O ~S - ^ a # _ ^ - f l G R th t cbor ~ f D P e ramd sur ace e ev. . o e ep ~ ~ . Hariaor r :Depth..: Darinant Redaoc Oesadptlon 'Texture Stru~fiie Car~te~roe Botrrdery Roots ta m in. tNtnseM tlu.5z Cart. Odor Gr. Sr. S'h. ,. 'E>f1~'1 'E~kt _. .• , ^ Pit t3ratsrd surieoe env . R to g'>acbor in. Bait Reba ttoriao n t]ep~ Donirrrarit Redaoc OesaipGoe. Te~ae Stcuc4aae Garrsi~eriae 8amrbary Roots in. 11A~afseB Qu. Sz Cart. Color t#r. Sz St , 'B~F4 u ' , --- O ~ - t3alrg ~ factor h h t O . ~ ~ C~,mrnnd surfeoe Meer. ~ R o epl Soi Rate i . tiot~o rr D Oorr~rd Redoor Texga+e S6udure ~noe Cass 8ousrdary Roots ' ' ' irr.. Mum. (~. Sz. Cant. Cator' (7 Sz S'h. ~ 1 ~ ,~ x ~ ,. ,, ' _. ,,, , , .~- . ~_ 4L ~~ _~ .~ U ~ ~~'~ a~Q~ ~,~= ~cno T U~N~ .Q ~ *- '' ~ac°°vu~ 5' (~ 5/a j(,~ 9~~^~ I~2•(7 a 1 f j~ ~ g, •~ 33 - e .. ~3 3.v p (D ~- ~~MS (~~ ~ ~ -~ T~~ of ~~~M. pooh Si1~ ~' /~~~ p~; V;2._ ~o' ~ ~~ ~~ ~' 7S j1 _~ s~'~~u~ ' ~' _~g_ a -g ~J ,~ to ~, ~,~y w~llS N oT~ ~ ~~ • ~6 i~ ~~~5 c a 3.D~ ~~ o~ S s-~ ~ -~ pR ~ c ~ ~" , ~~~ ~~~ P f ~~'~~l ~~~ ~`~ ~~ e~ ~ j ~/~t , I ~ 74 ~5 one c~t5 T s~pt~`c i ~~k d F %f.~1 ~NOCt//l~ s,'z.~ C~FSsvr+~ ,ooo ~~.~ ~'ONDi ~~ov -' -~a r3Q- ~}ssuti ~p t3o ~ ,l'C~4 /2 / ~~ - 2 4 ~ o = ~~~/~~ S~ i ~ ~~ ~s 31 ? ~ ~ ~ 3e ~ ~ ~r ~ s¢°,Q,53.. s6 s° y I r ~ 3$ O. , O , 6°z 9~, Z8 v f P ~ e 8 e o ? ~3Eo>~ 6 T o `,4~ ~9 N r ~ ~ ~ ~ ~ 5 ~ _ Z ~ ~ 4 o So ~ 1 ~ r ' ~ ~~ ~ ' p 2 l ZcIG.Co EAST 325. 33 P 0 2SO~ 14'l. 3-l' 221. co 3' {~ 2 ~ r' N ~ ~ 4 ~Q j ~ ~ J . 10 ~ Q (n f ~. N d ~ .. ~ ' ~ Q I ~ PLAT 'f 'C 0 ~ 250'- 2 S ~ ~, N : o N N sn..~a ~ ~ AS~ ~ r az~~ / ~ s gyp ,. so, ~: ~~° 5 eOy Q o~ s o• ` N ~1A l7 `ti ~ cn .. ' I'1 ~ ~ . ~ ~ ,,~~ 3312, e: \ ~ ~ _ .~ a S~ ~o,o~ ~ o ', 4t~p ~~ Ib ~ ~ 0~~~~_ ' ~ ', ~ ~~ ~ ~ ~ ~eo s~~~ ~ ~ tea' ~~ `a~.a4 ~ ~ I . 13 .. * lZ i7 ~ t ~ \ ~ 9 L ! . _~ 1 ~9 e~ PW ~~ J i tJ ~ ~ ~... T ~ , ;i, H 's: W S W 0 ~' '' to y ~' ~ ~ 0 ~ jj1 2 fCo Z r _ N d' ti p b ~~j't. Z. 3~ 9g.° i • . ~+ . o ~ `~ _- ^ Z 00.11 ~a ' ® 3 J _ v I /\ ...~_. r N o Z1 b'~, ~ ~ _ -- , ~ ~~ ~ Q 7~0 ....... pie-« .. - 9 _ _ 5 GG ° .• ° ~,t1 ~ - ®GJ1~O ° •~e~e•° • • • ~ ~ t . ~ ~~ .i Z' e i ...'F`a' ~ .. . ~~ ~ Q S.. • - - i i v ~. f ~~~~~T~ ~C~ ..,..~ w+. r,r. ~r rvw .~w.~.av n • tx DnA VF itlgWil Olin iVORi i~aDlf~ ~~ • it ~ [~~j i/'~i . __ __.. _ _ RAG#~T~R'~ C3F~=i~'.: ST: Ci~41a( ~ `' Pobert J. Johnson and Beverly A, Johnson! as his ~ orc~J~ -------------------------------------------•- - --- -----•-----------•--------------•--•-- Recd for Re wife and in her own ri~ht .............................................•---•-•-- - :. conveys and warrants to ... ~`~,._ Scor_C_.$rune•tle_ and__Patrlca I ~ ~"~~ t!s_ 1)~ s` ,~ .--_ B~4neI1~,._ husband._~~d__),rf~,,__~&_•~H~v~•vorshi g_ mars-tal______ ~'~'+~st~sc ; .................______-._______.. _. __. _. ____.__.__.. ..-....._. ... ..... .. .... ....__....__.._______.. RLTUAf! TC the following described real estate in ._._....Y~_e__Croi.X_,__________ _____„_-County, 5; State of Wisconsin: Tsis Psircel Ho i' Lot 25 Willow Ridge Addition i.n the Town of Hudson. ~' ,. ~ 3 ~~~• l .` ,~1 j ~. i~ i II i This __......s ................ homestead property. (is) (RSC2ti~ Es~ention to warrsnties: Rxict•ing highways, nacamn~~-a sort riv~hr~ nfyray nF rAr..r~l. ~' Dated this .__.4~th...... .. ... _ ............. day of ........'.`.~'.~..~.....J.unE'---...._....---- --..............-...., 2989.... ......... ........................................................ .<SEAL) ...._"!•..!~_--------..- ... ~~~-..(SEAL) ` ,;. Robert- J. Johnson ..................•-•-- --..._.__ ......-.-..-..............----y...~ ' ~ / --••---•(SEAL) ~-G.•t-f'-f~~-:._V~.,.`~~i,-..~.-~G-;'.G9~ L) + + ,;3everly-.-A.,`Johl~:zcn.- AZiT>iil*NTYCAT20N Signature (aj .-----•-------------------------------------------•---- authenticated this ..______dsv oS_________________________, 29_.____ TITLE: MEMBER STATE BATt OF WISCI.: :IN authorized by § 706.06, VPis. ;`tatsJ ~, ,~ _ T~i15 INSYRV MENT WAS DRAFTED BY _ - __Al~orney__-U:avirf •J. 1•atreen 6~i >c~crmri ~r • , Ilnris<:~n, ivl `t4U1(, (u~gu&.iu era rosy ire Bit i.nenLICACetl or BCK nOWIetlJS*etl. I56C11 n..A __ ,_____nS'. . ACHNOWLED4MENT STATE CF °~iSCCP:3iA: S•J __._S_t_.__Cx.os.r_..._-___-_.County. `J Peraonaity came before me this ...24~._....day of .iti flP ., }{y t, .-, ar~i2il Koix: rt: .i . 3f.~hnson and i;ever 1 ;• .1 . ~hn a..n i'1cf _~t:a ;.? and cr ~ Ff- to me known to he the person 4..... _.. who executed the fcragninv fr.st.r.:mar.[ ani qr:: nresct.~.i ~.= :ha ~_. _ ~. - ~. - :v:. . f - - ... cc _,~. ..•nn••.. ... r- ~ ~••~r.nxne rv. ii nor. ._.r r.<n~~~i w^. rt sign. ~!- _ .. lp STATP. P~:~R r1P P.'i cr'rf~ce` ~NL RI~s r~nf:,•w ti.. ~ _. SfOCIf MO, 1; ~O[]2 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner C~ ~ q-t- Permit # DESIGN PARAMETERS Number of Bedrooms ;~ ^ NA Number of Public Facility Units ~'1 IAA Estimated flow (average) ~J~ ~~ gal/day Design flow (peakl, (Estimated x 1.5) ~~ gal/day Soil Application Rate , ~ al/day/ft2 Standard Influent/Effluent Quality Monthly average* Fat`s, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD5) 5220 mg/L ^ Nq Total Suspended Solids (TSS) <_150 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) 5104 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 ~ gal ^ NA Septic Tank Manufacturer ~ ~ ^ NA Effluent Filter Manufacturer ~ ~~ ~ S'- ^ NA Effluent Filter Model ~~-- ^ NA Pump Tank Capacity gal A Pump Tank Manufacturer A Pump Manufacturer A Pump Model ~A Pretreatment Unit NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection D Other: Disper al Cell(s1 ^ NA In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) ,~ At least once every: ^ monthls) ^ year(s) (Maximum 3 years) ^ NA Pump out contents of tankls) ~r ~~ 'r When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cell(s) 3 At least once every: p yearlsl(s1 (Maximum 3 years) ^ NA Clean effluent filter At least once every: ^ month(s) ^ yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ^monthls) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ^ month(s) ^ year(s) ^ NA other: At least once every: ^monthls) ^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 corYibined 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. GMW (4/01) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s-. 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 cells) in one large dose, overloading the cellis) 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 PO,WTS: 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. It 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 ~ jll w ,~~ JrL ~/ t /~ I.-'~ Phone 7/.S = 7 y Name ~-~~~ ~G U i Phone 7 S ~'y q.- 3-3/Z~ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.2212-(b-(111d-&(f) and 83.54(11, (2) & 13), Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner C ~ „~ ~- f Permit # DESIGN PARAMETERS Number of Bedrooms ;~ ^ NA Number of Public Facility Units f8'I~IA Estimated flow (average) ~Q ~7 r•- ~ gal/day Design flow Ipeak-, (Estimated x 1.5) 00 gal/day Soil Application Rate , 7 gal/day/ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand IBODS) 5220 mg/L ^ NA Total Suspended Solids (TSS) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) <_30 mg/L ^ NA Fecal Coliform (geometric mean) <_104 cfu/100m1 Maximum Effluent Particle Size Ys in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~ gal ^ NA Septic Tank Manufacturer ~ ~ ~ ^ NA Effluent Filter Manufacturer ~ ~~ ~. S' ^ NA Effluent Filter Model ~~- ^ NA Pump Tank Capacity gal A Pump Tank Manufacturer A Pump Manufacturer A Pump Model ~A Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: NA Disp~er al Cell(s) ~ In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tankls) „~ - At least once every: ^monthls) (Maximum 3 years) ^ year(s) ^ NA Pump out contents of tankls) j< <r '' When combined sludge and scum equals one-third (Y3i of tank volume ^ NA Inspect dispersal cellls) 3 At least once every: ^monthls) (Maximum 3 years) ^yearls) ^ NA Clean effluent filter ~ At least once every: ^monthls) ^ yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ^monthls) ^ year(s) ^ NA Other: At least once every: ^monthls) ^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 cellls) 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. GMW (4/01) ST. CROTX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r,~c ~ ~~~ ,FJ~~ Mailing Address ~' 7 y W ..~Cr1~-ct~" ~ 1 RoQ Property Address CT~".Ze,~eM.- ~~ .~~©l`i (Verification required from Planning & Zoning Department for new construction.) City/State ~~c~. GcJ ~.. _ Parcel Identification Number 0~ O - ~ ~ O ~ ~ ©~ D 4 LEGAL DESCRIPTION '/ Property Location ~ I/4 , ~~ '/a ,Sec. , T _~N R~~, Town of 17~.,rt-6~.e~-n- Subdivision Lot # Z.S-. Certified Survey Map # ,Volume ,Page # Warranty Deed # ~ ~ ~ ~ I ~ ,Volume ~~~ Page # Spec house ye no Lot lines identifiabl yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities aze specified in §Comm. 83.52(1) and in Chapter 12 - 5t. Croix County Sanitary Ordinance. T'he property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standazds set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of beJ'drlooms _~ R - _ SIGNATURE OF APPLICANT(S) /~/~ DATE ***Any information that is nusrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** ~clude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (rtEV. os/os)