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HomeMy WebLinkAbout020-1413-70-000 (2)Wisconsin`Department of Commerce PRIVATE SEWAGE SYSTEM Safety and 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)j. 'ermit Holder's Name: City Village X Township Schock, Lonnie Hudson, Town of ;ST BM Elev: Insp. BM Elev: BM Description: ~Z Q-3 csi TANK INFORMATION n.. ~•r, TYPE MANUFACTURER CAPACITY Septic ~ ; ~ ~ ~~ I~ ~~r,i,.-.. d ~a~C.. F't Aeration Holding TANK SETBACK INFORMATION TANK TO P/L 5~~~ WELL BLDG. Vent to Air Intake ROAD Septic ZQ I 7J ~ 5 ~ 5 I Dosing Aeration Holding PUMPISIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System H Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengtjd' l No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ? Z S/ 6C /,~ J ~w ~C 1 ~ 3 ~e~L~.i~ j1 ~ ~- __ SETBACK SYSTt=M TO P /L BLD G WELL LAKE/STREAM LEACHING Manufacturer: ~~ ~ /, INFORMATION CHAMBER OR ` / 0.~ P7 Type f System:, ^ ~ ~~ ` ~ ~ ~ ~ UNIT Model Number: 4 b u ; DISTRIBUTION SYSTEM Sn,1~'.. tK.L:.,.J1 I.1-~.~sc ~~ Header/Manifold ~ f / ~ Distribution Pipe(s) ~ \ x Hole Size ~ x Hole Spacing \ Vent to Air Intake rr ~ Length Dia Length Dia Spacing ~ +~ t"~a ~^~ SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only ~` "`clJS Depth Over Bed/Trench Center ~ G t J ~~ Depth Over Bed/Trench Edges ` xx Depth of Topsoil ` xx Seeded/Sodded I- Yes ] No xx Mulched ~ -~ ~es No COMMENTS: (Include code disc encies, persons present, etc.) Inspection #1:~/ ~~ /~ Inspection #2: i /_ ..i' Location: 765 Martin AveC/H.u1d on, WI 54016 (NE 1/4 SW 1/4 20 T29N R19W) The Glen Lot 11 ~~ YParcel No: 20.29.19.2605 1.) Alt BM Description = ` ~ 4~ ~flJ~~" ~ ~~~ ~ f^ ~0~5 j~ ~/\ 2.) Bldg sewer length = s, 5 - amount of cover = n,~ -- -- _.. , ---- --- Plan revision Required? (~ Yes No T~ ~ ~Q / ~~ ~~ Use other side for additional infor~q~t. SBD-6710 (R.3/97) Date I Cert. No. ELEVATION DATA County: St. Croix Sanitary Permit No: 514825 0 State Plan ID No: Parcel Tax No: 020-1413-70-000 Section/Town/Range/Map No. 20.29.19.2605 STATION BS HI FS ELEV. Benchmark ,~ q ~ t / ,D~. ~ q,Z, ~ Att. ;~~.... ~ 3.5 ~~ Bldg. Sewer /b ~ ~~ ~/ St/Ht Inlet ~~ • 9~ ~( / / • 2/ SUHt Outlet ,/, ~ / ~~ D Dt Inlet ~- Dt Bottom Header/Man. 1 /~ ~ ~ ~~ • Dist. Pipe * ~/• ~ ~ ~ , Bot. System ~ ~ O Final G~ ~de ~ L ~ 1'!• ~ J ~ ~ ~ I ~ ~~ St Cover' ~ ~ ~ ~• / 9~ ` T T cammerre.wi.gov f~ ~ ~ ~ Safety and buildings Division 201 W. Washington Ave., P.O. $ax 7162 County .->-~ , ~/ ~ ~''A X j ~ c ~~ ~ S ~ ~ Madison, W 153707-71 i~led in by C°J r {to be f Sanitary Petmit Numbe ~ I9eparttnent of Commsroe T O G 5~ 7 D Z J y~~u~- Sanitary Pertr;iit Application StateTransa"`onNumber ~ ' " submissiatt of ti»s Form to the appro a gave n Cade to accordance with s Comm 83 21{2) Wis Adm , . . . . . , unit is requrced prior to obtaining a sanitary permit. Note; Application furnts for state-own Ni ' re oject Address (if different than mailing address) i submnted to the Uepartmenl of Commerce. Personal information you provide may be used Wr condo I pur<mses in accordance with the Privac~Law,s. 15.04{1){m), Stats. ,____ ~ 71v5 ~/'J.-tth Q,~/ V ~ y I t ~- l. Application Information -Please Print All infor t -- ( I _._' PropertyUwner's Name RE~~~~/ ~i~ ~~ ~'~ < h ~ ~ ~a Parcel ~ b2o ~ /~l3 - 70 - ooc~ Property Gvner's MaiiingAddress ~ JH~ ~ ~ ,}~~~ Property Location f ~~ yx~~ Govt. Lot ~Ciry, State Zip Code _ _ ~h~,~UN?Y ~''/~.,~G~' 'i~. Section ,2 ! ~ i ~ .7 ~ G' ~ Cl~ ~L~l .J ^~? ZONING OFFICE ` tt ere one) T ~ Jr N R L a~ _ l L Type of Buildlug (check all that apply) a„„ t.ot p _ _ : -~=--r-- ~ ~ Subdivisicm Name l ar 2 family D+rellint; - Number of Hedronms 1~,Os.aS i u Public/Commercial -Describe Use _'~/+?~',du'eltr++^- ~_K_~--'~- Q•'rog L ^ Stare Owned - Dcscri • l.lse ~ d,~1- w Z! ~- ZZ ~ CSM Number ti ~ ^ Village of i Town of ~~~~tL._ ~ - I lI1. Type of Permit: (Check an one box on line A. Contptete Iltt _ e li if applicable) ______ -1 A. .New System "-_-~r ^ Replacement System ~ _ _____ __ _ _ _ ^ TreatmgntlHolding Tank Reptacerrant t)niy mm-~~~-~ Y _~. ~ ^ Other rVi°diticaumt to Exisung System (explarn) ~ , t Previous Permit Numbicr and Date Issued ,~ Li H• ^ Pet•nut Renewal ^ Permit Revision ^ Change of Plumber II ^ Permit ?ransfer to New s ~ ( Before Expiration __ iLOwner ~ s ____ ~ V i . T ~y~te of POWTS System/Com~onenUDevice: (Check all that an ti > _ _ ~ ,, ~~ aa ^ Mound < 24 in. of salable soil KFN°n-Pressw•ized in-Ground Q Presswized ImGround ~.) RbGrade Q Mound ~ 24 in. ofsuitabie soA Holding Tank ^ Other Dispersal Component (explain) ____ eku~nt vice {explain) ~~ iL ~~ l V. dis ersal/`freatm nt Area Information: Y~ Desibn Flow (gp:S) Design Soil Application Rate{gpdst}~ D sal Area Required sf _ _ __ _ rsal Area Pro ~rd (st) SystemgF3 • •ation a V 1. Tank Info Capacity in Tats{ ii of _ Manufacturer Gallons Gallons (Jttits ~ ~ ~ ~ ( ~ ~ New Tanks Existurg 7aaks ~ `~ a ~ U // L/ ~O !d~ SZ 4V v,~ ~ tiV a Jeptic or Holding 'Tank ~~~~ ~ ~ ~ ~ ~r Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responcihiflty far installattoa ottUc PQVVTS s wn on the at{ached plans. ~_•----•~ Humber's Name (Print) Plumber's St$nature PRS Number Business Htone Number i i Pi umUer's Address (Street, City, State, Zrp Cade) V111. Count /Drpartrner-t Use Only _ Approved Disapprov Permit fee Dat Issue Issuirr gent Signature L`~50.Ob ~ J S og ~ w rv ^ k i l en ~son o en a - - ' lX. Condi~ ~.~~t~[teasona for Disapi,roval /~yy ,^~// ~+~ ~ ~dL, 1. Septic tank effluent filter and 3) Ir '(, JS ~ / ~:~^~a. ~ti.- ~ ~ ~ , l dispersal cell must all be'services /maintained as per management plan provided by plumber. ~ `'t'`- ~`~ ~~~ ~ ( 2. All setback ctaquirements most be mt~ttaihad L~-- -- ~~ ~,.w. r,Nti. r --,. ~r e'tltacl+ io eou+pletc plans u: the system and submit lu tt,r County Doty ou paper nut tens rUan 8 td x I I IncAcs in size SbD-6398 (R. OtlU7) Valid they 01/09 1 .~ v ~ ~~ ~jb ~ ' ~ S ~ ~~ ~ U 1J l~ ~~~ °' ~~ ~ . ~ ~~~ d ~L t c~ ~~ ~~ a ~~ ~ c> -- ~ ~ ~~ ,b 0 " CoIP a .~ ! ~ ~ ~ i~ O r~~ 'r ~~ t ,. ~ .~ ~~ 0 ~ a ~ ~ U ~ D ~ ,~~ ~ ~, ~ .~ r~~ '~ cv , ~~ ~ ~ ~~~ ~~' G` ~ s' ~~ ? ~ ~~ ~3k~. ~b o ~~~~ ~~, ~l~ ~ u; `~~ ~~."sTo ~a1 a 0 O ~~ z Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Cade Attach crxrr to she County plc plan on paper not less than 8%: x 11 inches in s¢e. Plan must include, twt not limited to: vertical and horizontal nference point (BM), direction and Parcel I.D. percent slope, scale or dimemsions, north arrow, and location and drst Please print al/ i ~ ~ ~ ~ ~;.~' Personal information ycw provide may ~ used for ary purpcues (Privacy Law, s. 15.04 (fj (mj ~, Property Owner 5 ~~ c~ ~t L ion 1166 page l ~ 3 Steel Soil Service St. Croix pending Date ~,~ //2 3~0 Sienna Corporation Govt. Lot NE 1/4 SW 1/4 S 20 T 29 N R 19 W ,, Property Owner's Mailing Address. ST C ,n~,Y ~ ~ \. # Block # Subd. Name or CSM# 4940 Viking Dr, Suite 608 ~n~; ;1N~=~ ~~ ~~ na The Glen City Stale Zip Code Ph City Village Town Nearest Road ~~%~ti MN 55435 9,5z-~-~btS.Y Hudson Carmichael Rd. /' New Construction Use: ~ Res'ldentiai /Number of bedrooms i Code derived design fkrnr rate (~ GPD Replacement Public or comrrrercial -Describe: Parent material Pitted outwash Flood plain elevation, if applicable na General comments and recommendations: System elevatron 93.20ft trenches~p~ and de~~to code 5.OOft bebw grade ~ /i ~ ~o ~S ' / d B2 - fib' -/ C'~c..1 f Ge- dk~SidP~ £3 .~~ L_J B~~ # --- B°nng Pit Ground Surtace elev. 98.20 ft. Depth to limiting factor 120 in. ~ A~j ~~ Horizon Depth Dominant Cdor Redox Description Texture Stnictun: Consistence Boundary Roots GPD/ftZ *Eff#1 "Eff#2 1 0-12 10yr3/3 none sil 2msbk mfr gw 1f .5 .8 2 12-24 10yr4/4 none sicl .2msbk mfr cs 1vf .4 .6 3 2^~_ t0yr4/4 c2c7.yr5I6 sicl 2msbk mfr di na .4 .6 4 44-120 7.5yr4/4 none cos osg l mvfr na na .7 1.6 (.Qb ~~ /20 ~ ~G~r+~-Qd 6.e 5~ `'a6 l.e l ' ,6e !~ ~-z.. ~L~sJ ~j~'1 s ~~ vY: ~-r , Sn~ aZtit~t~.~., Gaa~- -~ - / ',6.~l~rkJ -f (o d ~ /~-aws~,~ Horizion ~ has noncontiguous mottling Boring # Boring 120 Pit Ground Surtace elev. 98.20 ft. to limitin factor Depth g in. Applicatiar Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDfft= 'Eff#1 "Eff#2 1 0-11 10yt'3/3 none sit 2msbk mfr gw 1f .5 .8 2 11-25 10yr4/4 none sici 2msbk mfr cs 1vf 4 .6 3 25 12 ~ - 7.5yr4/4 ~~ none cos osg mvfr na na 1.6 << ~i0 ~~ /Z~ tttluent ~~ = taw ~ 3D < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BODS < 30 mg/L and TSS <~0 mg/L CST Name (Ple~e Print} Signature: CST Number David J. Steel l~ /Gx~-`^~~ 248956 Address Steel Soit Service ~/ Date Evaluation Conducted Telephone-Number 1564-CR G~ New Richmend~ Wt5401T 9/16/2002 715-246-5085 J r - Per-ope-rty~Owner Sienna Corporation Parcel ID # Pending 1 ~ 1 Boring # ,Boring ~J~ ilfj Pit Ground Surf~e elev_ 9LQ0 ft. Depth to limiting factor 96 in. Horizon Depth Dominard Gelor Redox Deseriptrcm Texture- S#nnture Consistence. Boundary. t 0-15 10yr3f3 none sit 2msbk mfr gw 2 15-47 10yr4f4 none scl 2msbk mfr gw I -~ 3 47 96 7.5yr4f6 none ms osg ml na ~l~n~.- a.~~ BOrin4 # -_ ' Boring. Page 2 of 3 Sod Application Rate toots GPDIft: *Eff#1 'Eff#2 1f .5 .8 na .4 .6 na .7 1.2 'Effluent #1 = BOD 5> 30 < 220 mglL and TSS >30 < 150 mg/L 'Effluent #2 = BODS a 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or ^ Honng # Boring Pit Ground Surtace elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominanf Color Redox Description Texture Stnrcture Consistence Boundary Roots GPD/ft= 'Etf#1 *Eff#2 Page 3 of 3 STEEL'S SOIL SERVICE David J. Steel 1564 Cty Rd GG CST-POWTSM Sienna Corporation New Richmond, WI 54017 Lic. # 248956 NE1/4,SVV1/4,S 2o,T29,R19W (715) 246-6200 Town of IIudson, St_ Croix. Co. (715} 246-5085 The Glen lot # 11 This soil e~aluatian: was coa~neted to satisfy a zoning requirement, it ma or may not be suitable for your use. The location of the test may or may not be as shown as perman~nt lot lines were not established at the time the soil test was conducted. ~~~~ ~(~ ~6i ~- ®= ~l~ ~tHr~-vrar~ ~~, 170! n ~ ~~el/utl D/OS ~1 _ cr8,~~'~ B2 . q 9'. 2.~ ~~- l~3= ~.oa$'~- N i i ---" ,- _ -~ .., . - , - ; i i -' -.. - , -r-: i ~ , - 55. A - . . ~ , ~g• - 63_ ~ _ ,' -- "- .. _ . " .. ,. E _ _- ,- ~ - -- _- ` _ _ _,. - _ , _ `` ~. ~ _ , - __ ~~ 57~ du ...-•. _ , ``Q 1 / ... .. .. .t ._:- . 1.. cam. 1 . '. ~ ~'Tfi , l^, ^`` 'H :£ a.... . . . y ' ,.x .' :: a j 1 '~ v l ~ + 1 i ,~.~... f` L.iµ.r. - \ i . _ 1 ! ' ~ ~ _ .~ a.~ n ,.. - .., .. ~ .,, .. ,. 1 i .ar y , , y ': 1 f s ~ ~~ ,L. .:, - - __ <. ~ • . . ,f t f; i. .^ . ... ~- .. a - i f f ~ 1 ~ 83 81 ~\ ' ~ ,~ 10 ~. . 4 • . ' ~ 1 y ~.- ; 1 - - ~ + ~ f N $8 , s 60 J i! ,. 0 ~• .. 1 ~ , ' ~ '\ ' ~' _ '. ... ,~ : ~ : 1 /~ 1 / 1 ' ,.. ~ y -- --~ ~, , . ,_ ~ `.. '^, + ~.. 1 ~ ~ ~: y~ r ;. ~a~ . ~~ .. :. ~ ~ ., j , '. , ,: r . ~ __ - ,. .,,, y . __. TJ ' _.._ ... , 1 .. ..~ ., .,,, ~~ ;~ t . 5. ... .. . _ ~ -: ;: , r _ ~ ~~ + 1 fl. ,. ,.. 1n _,. \ +\ ~ ~, ~j~ z~.* .. if f+, ` r~ l ~-~ _ 344r 1 1 ~ ' , 1 a '_a ~ . • ~~ L ~~ ~'`_ _ _. -. ... ! 1 . i - 1 ,, ` = , 1 ~ - v` _~ ! _ _ - - .. f' _- ~ - _ ..... ~--~ :..may . ~r r ~. _. _ a ' ` ~ -. -~ ~ ~ `~ ', ~' \ , . ~ ~ , ,. ._ ` 7... ~ ...... .. _. , ` .. a __ ! .. ` ~ ~ , ~ 1 + ` /' 293 . 1 ~ ~ ~ ~ 7 _ 1` 1 1 \ ~ / .. _ 1 1 . .,. .. ~` ! ~ 1 1. f i ! 1 ~ - ... ,i ' ., 71 ~. , .~ ~ I 1 1 ~ .N \ a : 1 1 ,fig ~. .. ~. ,'': ` 14 ' ~' ,a~ '~ ` 1 ~~ ,, 1 _- 1 ~` ~ 1~g 66 \ `1 ~\ ~ ` ~\ ~ \~ ` ~ ~ ~ 1 ~ ~ ~ 1 ~ ~ ~ ~ \ ~ \ ~ \ ~ ~ ~ ~~ ~ ~ 1 ~ \ ~ ~~ ~ ~ °'~ ~' ~ ~ ~1 W ~\ ~\ ~ ~~ \ r N N \ \ ~~~ \\ N ~ a r ~ ~ ~ ti ~ \ ~, ~ ~ J N~ ~ ~ ~ a ~ \ ~ m ~ \ \ n" ~ ~ ~ \ ~ \ .~\ \\ ~ \ .. N ~Q^. ~~x,G\ \ J \ ~ \ ;. O ~ M ~ ~ ~ w'~~ \\ \\ ~0~ //, <,.:; \ \ i 4 _ '~ ~ ~ i ~,. `~ ~ \ i~ ~ ~,,_ ~ \ \ ~ ~' ~ ~ ~ i } ~ ~ \ \ 50~' •o \ ~ , ,. \ / ~O 0~ \ / ~ ~ '~ ~ ~ ~~ / / / ~ \ b u X53 / / \7~ .~V .. ~ .,v.i"~ ,.:tea... ST CIiOIX COL'N'I'Y SEPTIC TANK MA.INTENANCI/ AGREEMENT AND QwN~RSHIP CFItTiFtCATION FpRivl Qt~VI1CT/131tV8C ~m `rim ~~'c ~ /-E ~ s cJ c~_i ~_. ~ ~= ~~.a-° Mailing Addrt.ss _-_ yam/ 7 C~,J,e~ -ri s~c:~- ~ -~~~n-ti ¢ ~-~•~~' S'~~ i _(^ Aroperty Address _ 7Cv `` ~~ ~- :~-~ - (Verification requiared~ from Planning Department for new construction) _... City/State ~-~c~v~ , G!~,~ Parcel Identil;ication Number ~~~'-~~~~ -zc -~'c_~' LEGAL Dk~SC)~ttk'~'ION '~ Property Location ~ '/., ~~'/,, Scc. ~~ , T ~ ~ N-R~1~V, Town of ,~i~.~S~ r~_-. St113dtv1Sl~n ~~~.,~. _ _ l~ yr d ~- ~~e~~~, _ ~ ~ ,Lot # /1 _ _ Certified Survey Itifap # ,,, Volume , Pagz tt~ __ _ ~Vgrranty Ueed # •,,,~_, _ ; Valtune~ ,Page # ~ _ ~. Spec house ^ yes no ~ Lot lilacs identifiable ~` yes ^ no S°~'ST~,1M )yiAiN~'ENAl~'~ Improper use and maintenarleeof your septic system could result in its premature failure to handle wastes_ Proper mattttenance consists of pumping out the septic tank every tluee years or sooner, if needed by a licensed pumper. what yott put into the system eau affect the function of the septic tank as a treatment stage in the Neste disposal system. Tl~e property o:vttec agices to submit to St. Croix Zoning Depattmetit a certification form, signed by the owner ar-d by a rnasterplrunber, jouruey~titan plumber, restrictedplttmber or alicensed pumper verifying that (1) the oa site wastewatetdisposal system is itt proper operating condition and;'ur (2) after uaspectioa and pumping (if necessazyj, the septic tattle is less than 1/3 full of sledge. Uv~~e, llre undersigned have read the above requirements and agrez to maintain. the private sewage disposal system with tlts standards set fo-~t}a,~l ' , set b Department of Cotttmzrce and the Departtrtent of Natural Resources, State of Wisconsin. Certifcatioo statin at your pti ,stem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da of t1t ee r expiration date. SIGNAT~CfRE OF Ak'FI.ICANT 01~~'NF.R Cl?RTIFYCATIOv I (we) certify that all statements on this fotin are true to the best of my (cur) knowledge. the property described above, by ~~irtue of a warranty deed rccoroed in Register of Deeds Office. ~~ ~.P ~~ ~C~~ac(' SIGNA 1.1LZE Or APPLICANT / / / ~e D.A.'f.E 1 (we) am (arc} the o~~~er(s) of l ~ i<< a~ DATh •'"*'** Any information thatis mis•reprisentedmey result in the sanitary permit being revoked by the 7_oning Department. '""'• •" Include ~~•itlr lhls application: a stamped aananty deed Eton: the I;cgistet o.f Deeds office a copy of the certified survey map if reference is made in the warranty deed . U _2952Pr~llg 1' eis431 KATHLEEN N. MALSH State Bar of Wisconsin Form 2-2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO. , MI RECEIVED FOR RECORD Document Number Document Name 12/38/2~A5 84:10PK MARRANTY DEED b'XEIMPT Ii THIS DEED, made between West Lake Builders, Inc., a Wisconsin Corporation RfiC FEE: 11.00 TRAAS FEE: 416.70 ("Grantor," whether one or more), COPY FEE and Lonnie R. Schock and Abit?ail K. Schock, husband and wife ~ FEE PAGES: 1 ("Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ("Property") (if more space is West Lake Builders, ]nc. needed, please attach addendum): t7t4 Crestview Lot 11, Block 1, Plat of The Glen in the Town of Hudson, St. Croix County, Hudson, Wt 54016 Wisconsin. As additional consideration for the conveyance between the Grantor and Grantee herein, their heirs, successors and assigns, Grantee covenants and agrees that o2o-1413-70-000 Parcel Identification Number (PIN) West Lake Builders shall have exclusive rights to make any and all improvements upon the property. This is not homestead property. (is) (is not) Exceptions t~oJ~warranties: Easements, restrictions and rights-of--way of record, if any. Dated ~ " ' ~~ (vim c (SEAL) * *West Lake Bu ders, Inc. (SEAL) (SEAL) • Signature(s) _ authenticated on s TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stet. § 706.06) THIS INSTRUMENT DRAFTED BY: Attorney Kristine Ogland ACKNOWLEDGMENT STATE OF W,<Jt9lJ11S~ 1 ) / /~ ~ ) ss. `~' t..fGo ~~ COUNTY ) - Personally came before me on I Z~~iv ~o ~-]*,,,,.,.~.•....,~ , the above-named West Lake Builders, Inot`` W1sc~lsiA., Corporation •'c~'~'•~~ • to me known to be the person(s) who ex8~ the- fore~i g instrume and ackno le~dged~ the same. : y ~ ~ _~ • -" r Hudson, WI 54016 * '` • •' '~' ,~` Notary Public, State of i3~ My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Roth are nut necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ®2003 STATE BAR OF W ISCONSIN FORM NO.2-2003 AUTHENTICATION • Type name below signatures. INFO-PROT" Legal Forms 800-655-2021 www.inioproforms.com POWTS 01NNER'$ iV~AI~~JAl. & MAiV~4GEM'ENT PLAN ~a~a ___ of Owner ~C~'~c1~/i ~~ ~~d~ ~~ Permit tt --_..-.____.__ _ Number of Bedrooms ---•--------. 0 (dA Number of Public Fa~rility Units _ + Estimated flow (average) ~ ~ ~` -~_ ___~, ~ ~ ald~ra Design flow {peak}, {Estimated x 1.5} (__~~~~ _.__._.._._._ b ~ o g~+ Sail Appliaatian Rate ~~-- - aaildayJtt~ Standard Influent/Effluent Quaiit~--y ^~~ Monthly aueFa~e"• Fats, Oil & Grease {FOG) ~ S30 mglt. • Biochemical Oxygen Demand {130D~} ~ s2Z0 mg/L !~ lVA _ Total Suspended Solids ITSSI a~150 mg/!~ }'retreated Effluent Quality Monthly average Biochemica! Qxygen Demand {gpp~} ~ s3Q mg/l. Total Suspended Solids {TSSI K3b mg; L Q NA _ Fecal Caliform igaom$tric mean} 51 {)° cfu/1 QQmI Maximum Effluent !'article $ize ly in dia. (~ NA Other: -- NA `'Jah;es typical for dUrnestiC wastewater ~ ;d .peptic tank tiffluertt. MAIhITfNANCE SCr•t~ntrr c Y8TlwM SAEClPlCA7i0NS Sraptio Tank Capacity ~„~S" ej ^ NA Septlc tank Manufacturer gal ~ t ~5~. ^ NA _ Effiuera~t Filter Manufacturer~~,c~ ^ NA l«ffluenc Filter Model ~~~~ ^ NA PtIrr1A Tank Capacity - ------ g ~~ ~ --------- ^ NA _~al Rutnp~ lank Manufacturer ~ ~~ ~,~, ~ p NA Pump Manufacturer G 0 ~r ~ ~^ NA 6ss.rmp Model -- __ - ^ NA ~rptreatmerrt Unit ~~ ~ ^ NA Q SandlCaravel Filter ^ Ftsat Filt:3r C] Mee:ranical Aeration Cl Wetland t~ piainfection __ q Other: Dita~ersel Ceuta} -~~~ Q NA L? ln-(around Igravityl 0 In•Ground (pressurized) C7 At-C3rada D Mound Q Drip•l.ine _--...~. ^ Other: fJthpr? D NA Service Event Service Frequency Inspect condition of tank(s) ----- - +.. At least ante ever y' ~ monthtsi ~ year{s} !Maximum 3 years; ^ NA Pump out contents of tanks} Wt-en cornbined sludge and scu m equals one-third {Y ) of tank voiurne L:3 NA ~~ 3 trrspect disperse! call{&i -----. __ _.~...~ _ ~ At }asst onea every: _ ~ ~ ^ monthls? ~~~^ -R^ " ~ yaartsi IMaxlmum 3 years} - ^ NA Clean effluent Fiiter At lea&t onpd evgry~ _ ~ _ ^ monthfs) _ ._._._~ --~ -_ ~ NA Inspect pump, pump controls & alarm ~ At !dear r{rtce every; r-~. ^ rnonthfsi ^ NA Mush laterals and pressure test ~At least nce t3v r ^ monthlsl _.._ y o +s ____._.._ ,~,,, ^ NA Oche+: _pV __.__. _..... _.. ~`~'""'-" ... At least once every: ___ -"._ -'- ^ monthls) r' - Q yearlsi ^ NA otner: __- ~ ...._. ^ NA mArty rcNANG~ 1N5TRUCTIONS tnspectians of tanks and dispersal cells shall be made by an inctlvidua) cgrrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; AOINTS inspector; P'QWTS Maintainer; Septage Servicing C?perator, rank inspections must include a visual inspection of the tanklei to identify #ny missing or broken hardware, identi#y any cracks or teaks, measure the valumo of combined sludge and scum and tochaak for any back up or ponding of effluent on ±ha ground surface. The dispersal cents) shall be visually inspected to cheek the. ~fflust~t levels in the observation pipes anti to chmck for any ponding of effluent. on the yround surface. The ponding o± affluent an the ground surface may ind+cate a failing condition and requires the irrrmediate notifYcaNon of the local rec~ulatary authority. Whery the combined accumulation of siudSe and scum in any tank equals one-third {Y3i or more of the tank volume, the entire contents of the tank steal} be removed by a Septage ServlGlnp Qperator ar+d disposed of in accordance with chapter NR 113, y1/isconsin Administrative Code. A.II vtha~ serrvicss, including but not limited to rho servicing of effluent filxers. mechanical or prassurixetl components, pretreatment units, and any servicing at intervals of 512 months, shall be taerformed by a certified PGWTS Maintainer. A service rriport shall be provided to the local regulatory, authority within 10 days of ccsmpletion of any service event. START UP AND OPERATION rryape ___-__- of ° - For new canstructian, prior to use of the PpWTS oheak trdatr'lmeht tanlCds) tqr the presence of painting products or other chemicals that may impede the treatment process and/or damage the di6~tgrsAl c011;s1. It high concentrations are detected have the contents of the tanks} removed by a septage servicing operator prior tp uaa, System start up shall not occur when soil conditionf;! are frosgn at the inf±ttrative surface; ' During power outages pump tanks may fill above normal highwatar levels. When power is restored the excess wastewater will be discharged to the disperse! cellfsi in one lerga dose, ovgrlAading the eAll{s) and may result in the backup or surface discharg® of effluent. To avnid this situation have the oontents of thb ptl~a tank rerttoved by a `septage Servicing Qperator pnor to restoring power to the eftluc~nt pump or contact a Plumber ar ppyt/7`~ Maintainer to assist in rnanua#fy operating the pump controls !a restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cell;. CfR ?I4t drive or park over, or otherwise disturb or compact, the area within 9 5 fast down slope of any mound or at-grade apiF ebsor~tidit areal. Reduction or sliminatian of the fopowinq from the +ate8teirratar a3tr~arrt tray improve the performancR and prolong the life of the f OWTS: antibiotics; baby wipes; cigarette butts; cwnddrrts; r ogitfan awab>t; degrease. s; dental floss; diapers; disinfectants; fat, foundation drain lsump pump! water; fruit and vegetable p•!alingas; gaAr>sot3ne; greasr~; herbicides; meat scraps; medications; cil painting products: pesticides; sanitary napkins; tarripgni; end vv4tAr soff~ndr brine. ` ABANDgNMENT When the POWTS fails ar6dior is permanently takers caul t3f aerViC9 the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Co~rrt $~,~~, ~iaGpnsin Adminis±rative Code: • AR piping to tanks and pits shall be disconn+9atsd sttd the abandoned pipe op9nings sealed. • The contents of ai! tanks and Rits shall be r~rrlwaad and properly cliaposed of by a Septage Servicing OperAtor, • After pumping, ail tanks end pies shall be axcpyated amd rernove~d or their covers removed and the void space filled with soil, gravel or another inert solid material, GUN71Nf3ENCY PLAN If the POWTS fails and cannot be repaired the fallpyvin$ measures have been, ar must be taken, to provide a code compliant replacement system: ^ A suitable replacement area has been evaluri!ted And mny be tatlltzed for the location of a replacement soli absorption eyeless. The replacement area should be pr¢te4tad frorh distcrrbfpnce and compaction and should not be infringed upon by required setbacks from existing and proposed etfpCturg, lpt lines Arid wells. Failure to proteot the replacement area will result in the need for a new soil and site evrrluatien tcs sateblleh a suitable replacement area, Replacement systems must comply with the rules in effect at that time, C7 A suitable replacement area is not available .due ~(~: a~eiback and7or soil (imitations, Barring advan;.es in F'OVJTg technology a holding tank may be installed eta 8 last raaQrt to repiad®-the failed F©WTS. ,1~~^ The site` as not en evaluated to identify a aukabie replacement area. R1pon failure of the POWTS a soif and sits lY eveluatian be performed to locate a sVttablpl rrfp(a~ar{tett~ girya, if r1o reptecarnent area is available a holding tank may b tails s a last resort to replace the felled Pt71NT~, p Mound and at-grade soli absorption systems may be -SconptrUCted in place following remove! of the biomat at the infiltrative surface. Reconstructions of such systems fnuet oomply with the rules in effect at that time. < G WARNiNO > > SEPTtC, PUMP AND OTHER TREATMENT TANKS fVlAY CANT'AIN 4.ET~A~. 4ASSES AND/OR INSUFFICIENT OXYGEN, DO NOT ENTER A SEPTfC, PUMP OR OTHER TREATMENT TAiYK tJIYDRii AMY G ~9Ct!(Utl37ANCE8. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY $E DIPFIrr;{j'{,T Q!! lrylp~yg~lg ADpITIONAL COMMENTS POWTS INSTALLER ANA NTAtNER __ Name ' ~~ t~~ IRt~ .,~ ~y~~0.~i~aR.~t:. Ne~)a Phony ? / ~ _. ,,~ $ '°v? J a ~ Phone - _... SEPTAGE SERVICING OPERATBR iPUMPER) ~ 0 A! I~B. ULAT4RY AUTHORITY Name ~ __.. Phone t'hone - This document was drafted in co-npriance with chapter Cornet B~.~Zt~tib,lliitlM$r(fl and 83.54(ti, (2i & (3}, Wisconsin Administrative CaAfl. STt4~iT uP ttaN® OPERATION ~Rr,~ ------ "' . for new ccrnstrvction, prior to use of the FOWTS ohee7< treatrttsnt tankla) for the presence of painting products ar other charnicais that m.ey impede Yne treatment process and/or damage the dieparsaf isPl#s), if high concentrations are detected have thq carrtenrs of the tank!si ramaved ~y a sapless servicing operator poor t4 uaa. System start up shall not occur when sail conditions era froaen at the infiltrative surface; ' touring power outages pump tanks may fiH above normal highwsier lgyai8. When pawar Is restored the excess vvasiswater will be discha.ged tcs the dispersal cell{$} ;n one large dome, ovrloading the cell{si and may resuk in the backup or sur#aca discharge of effluent. To a?rt`id this situation have the contents of fhb pW}},ip tank rpmoyed by a Septage Servicing Cptsrator prior to restorirg power to the affluent pump or contact a Plumber or pf)WTS lUlaintalr~ar to 8ssist in manually operating the pump controls 30 resters normal levels within the pump tank, Do not drive ar park vehicles over tanks and dispars~l celi~, Qo rf4t drive or park over, or otherwise disturb ar compact, the area within 3 5 fast dawn slope of any mound gar at-grade soil ebaor~atlort area. Reduction or elimination ~~f the following from lira vutfgt~jryptar strear» may improve the performance artd prolong the fifes of ffte POW~'S: antibiotics; baby wipes; clgareite butts; eondoirra; aoitfgn ayvebe; dagreasars; dental floss; diapers; tiisinfecianis; fat, foundation drain (sump pump) water; fruit and veg•tebie ppsiingay; gtlsc>llne; greaEC; herbicides; meat scraps; medications o~i; painting products: pesticides; sanitary napkins; tamriQni; and kvstt4r sottertgr brine. ABANDONMENT When the P4WTS fails andror is permanently taker taut t3f servi~s tho following slaps shall be taken to insure that the system is properly and safely abandoned in compliance wit;ti chapter ConSr» 83.3, 1Alieconsir Adminis+.rative Code: • Aii pining to tanks and pits shall be discannecisd fled the abandoned pipe apanings sealed. • The contents of all tanks end pits shall be rovptg and propArfy disposed of by a Septage Servlcin~t Oprrrator. After pumping, ail tanks and pits shad ba axefavatmd rsrrd cerndved or their covers removed and the void space filled with soil, gravel or another inert solid material, CONTINQIE:NCY PLAN If the POWTS fails and cannot be repaired the folloyirin~ h'sei3isilrta5 have been, or must be taken, to provide a code compl;ant raplacernant system: ^ A suitable replacement area has bean evaluated eind may be Utgized for the location of a replacement sal; absorption systarn. The replacement area should 6R pr4t•ctpd trorn tfistarbaAnoe and compaction and should not be infringed Upon by required setbacks from existing and proposed r>yt~ucturg; lot llnsp acid wells. Failure to protect the replacement area will result in the Head for a Haw soil and site evfilu~tivt- to eetablleh a suitable replacement area. Replacement systems mt,st comply with the rules in affect at that time. C7 A suitable replacement area is not available due Stt: >reiback andlor sail limitations, Barring advances in FOVJ; S technology a holding tank may be installed ea 8 last rasprs to rapiface the tailed FOWTS, N1~+i° The site' as not ran evaluated to identity a suitable tApleAfllfiJant area. RJpon failure at the °OWTS a soil and site evaluation be performed to locate a suitable rsplaCertlertt erda. if no raplacernant area is available a holding tank may b tells s a last resort to replace the Palled l'01NT~, ^ Mound and at-grade sail absorption sysratns may pp taconotriictad in place tollowing removal of the biomat at the infiltrative surface. Reconstructions of such ayst~rtts rntiet Damply with the rotes in effect at that time. < <WARNiNQ> > SEPTIC, PUMP AND OTHER TREATMENT TANKS NIAY Cf~lY1`AIN 1.~1' qt, Q~g~ AND/OR fNSU1=1=1CIENT OXYGEN. QO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT 7'~f11K tlNDBq"AIYIr f~~flC:i.~iCASTANCES. C?ti:ATH MAY RESULT. RESCUE OF A PERSON FROM THt? INTERIOR OF A TANK MAY BE DrPFlOt1'6.t ~~ tMP~l881$LE POWTS INSTALLER '~ : „ '. NTAtNER ^~ Name ~ ` (A~...~ L~v.~cf,.~ hlprf?a Phone "? j ~' , ,3 ~ q3 f aL~ F'h4rrd -~.~._~ _.. SEPTAGE SERVICING QPERATOR fPUMPERI D AI. S_ ULATQRY AUTHORITY Name ~ _ _ blame 5~-, e. Phone ~ ~ (` '~` Gp~~~„ f- . w~ .. This document was dr3ftep in co-npiiance with chapter Comm B~,aZ(2t,{b;itltt!}&ff} end e3.54(ti, (21 & (31, Wisconsin Administrative C.:or1s, ~ wvt. v• • SEPTIC TA*SK ~ PUMP CHAMBER CR S a aEGTIG~1 AND Sp£CSI'.:C~yTIO:v'S '+" CI VENT PIPE 12" MIN. ABOVE G~A~~ ~ 25' FROM DOOR, WINDOW CR FRESH AIR INTAKE FTNTSNED GRADD 4 " G I RISER ----~ 28" IN. 6" MAX. N L £'I' ~ (ice .r ~~ WATER TIGHT SEAI:S A b~p P R4V E D .•-~-^. 'i PE 3' ~ ~ ..,.~... it~TQ 54L Y D PUMP OFF ELEV . FT. I uEAT~E~pRoo~ JUNCTION 8QX APPkOVED WITH CONDUIT MANHOLE COVLR W / :PADLOCK ~ WARN?'NG LABEL ~ "'~---~-_.~-- ~- " MIN . t ` ° `-, .~.L • ~~ ~~ 3' GAS- `ti T~~HT~ SEAL ~ ALM ' ON t ~ ~ai ~ 3" APPROVED BEj7AZ~t4 ~~iDE~ TALK ~~ /APPROYEO JOINTS Wi3H APPROVED PIPE 3' OHIO SOLID SAIL ~~ RISER EXIT PERMITTED aNL! IF TANK M.4NUFACTUREF~ HAS APPROVAL CANCRiTE PAD SPECIFiCA~'TONS SEPTIC / DOSE . ~?"ANK MANUFACTURER : ~ 1'~.art.l~ AivK SIZES : wEPTIC ~ `~'.~ Q GAL. DOSE ~ CAL. ~i:AFt.M MAN"JFACTL'RER: .Lt1~~.~R.iE~.~ MODEL NUMBER: pl,~( 5W I TC H TYPE : ~~0.c PUMP MANUFACTURER: G~ MODEL NUMBER : ~ ~ d, SWITCH TYPE: ~zR~ PE~LfIRED DISCF~iARGE RATE ~~ GPM NUMa~R ~ QSES PER DAY : _w~ ______ DOSE VQLtJME Ih.CLUDwNC F LOWBAC K : I ~ ~ GAL . CAPACITIES: A = ~ INCHES = LI_~~,,,~GAL• B = 2 INCHES = ~ a, GAL• C = ~ INCHES = ~~ GAL• D - ~ 'INCHES = ~~O r~AL. PLMP ~ ALARM FIRING AS PER IrrLHR 16.23 WAC '.'ER'I'ICAL DIFFEREPICE BETWEEN PUMP O~ T' A~1D DIaTRIBUTIL~N PIPE . 1~ FEET + MINIMUM NETWORK SUPPLY PRESSURE . ~ FEET _~~-~ FEET FORCEMAIN X :`OFT/~.pQ FT. FRTCTZON FACTOR ~. ~' FEET ~~E7TA1~ D~Ft~AMIC HEAD = ~1~~:~-~~1 ~ E£T i.'rTERNAL DIMENSIONS OF PUMP TANK: LENGTH ,...- s WIDTH .---~'' ; DIAME'"ER ~---"" ~ ~ Cr,~l pee J SIGNED. _t' ` ~;~.,~---~-' LICENSE NUMBER: ~a`~ ~ DATE. ~...-~-. 1/88 ~~GOULDS PUMPS Submersible Effluent Pump ~- 3871 E~5 APPLlCATlON5 Spedfiwtly designed far the following uses: • Effluent systems • Homes • Farms • Heavy dory sump • Water transfer • Dewatering SPEtIPICATlL1NS • Solids handling capability: '!a" maximum. • Capadties: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'/~" NPT, • Mechanical seas: carbon- rUWry/ceramic-stationary, BiJNA-N elastomers. • Temperature: 104°F (40°Q continuous 140°F (60`C} intermittent. • Fasteners: 300 series stainless sleet. • Capable of running dry without damage to components. • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Auto- matic models include Mecfianiw! Plant Switch assembled and preset at the factory. PEATURE5 ^ EP04 !impeller: Therrnaplas- tic Semi-open design with pump out vanes for mechanical seal protection. METEitS FEET - -- 10 . ... 9 3p ,.__. 8 zs .. _ ~ ~ - ua s 6 5 d i ~ ar 0 ~ Ir 3 ^ EP051mpeller: Thermoplas- ticenclosed 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 ~' Gnadian Stesidards Association (CSA listed model numbers end in "F" ar "C".) Goulds Pumps is KO 906t Registered. GPM 10 12 m~/h Motor. • EP04 5{n le phase: 0.4 HP, 115 or 230 V, 60 Hz, 1550 RPM, built in overload with automatic reset. • EP05 Singgle phase: 0.5 HP, 115 V, 60 Nz, 1550 RPM, built in overload tivith autOmatlC reset. • Power cord: 10 foot standard length, 16/3 S1TOW with three prang grounding plug. Optional 20 foot length,16/3 S1TW with three prong grounding plug (standard on EP05). ~ 2000 Goulds Pumps Effective february, 2000 83871 0 1. 4 6 8 CAPACITY G,po~u_lds Pumps iTT industries i