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HomeMy WebLinkAbout020-1398-10-000Wisconsin Departr~:ent 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)]. Permit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi CST BM Elev: ~ 8~ ~?' Insp. BM Elev: ~ ~ BM Description: ~ • ~ • CsT F,w~, - TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~~- I ~O© Dosing Aeration Holding TAN ETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , (~ `~, ~~ ~ Dosing Aeration Holdin PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model N ber TDH Lift Friction Loss System Head TDH Ft Force in Length ia. Dist. to well 'OIL ABSORPTION SYSTEM BED/TRENCH Width Leng1 DIMENSIONS ~ ~ SETBACK SYSTEM TO INFORMATION Tvoe Of Svsten DISTRIBUTION SYSTEM ELEVATION DAT county: St. Croix Sanitary Permit No: 420687 0 State Plan ID No: Parcel Tax No: 020-1398-10-000 Sectionlrown/Range/Map No: 22.29.19.2470 STATION ~ ~~ ~H~ FS ~ELE~ ~ ~ ~~ . Benchmark Alt. BM Bldg. Sewer /Q~2 I ~• SbHt Inlet ~~ 3g,. • ~ 1 SUHt Outlet Outlet , ~ ~ ~ f2 t . Dt Inlet Dt Bottom Header/Man. ~•~ I Dist. Pipe Bot. System }o . ~9 )~. o ' ~q 9S•9 ~ FinalG~ra~de ~~ _ b~ ~() ~~ St Cover SIB ~ o(.s2 (2~ a~"'rj'fp • 2S iL (J ~ ~ GZ • Std ~ ~..ir- ~Q.wq`l'~,S . No. Of Trenches 'rIT DIMENSIONS No. Of Pits Inside Dia. BLDG WELL ~ Gf(~ CHAMBER OR ~~ I I ! t C~ - UNIT w~ P y Header/Manifold i~ Distribution x Hole Size x Hole Spacing Vent to Air Intake ~Qi Pip Length Dia Length Dia Spacing ____ _- SOIL COVER x Pressure Systems Only zx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Ed es g To soil p ~ ~ Yes No `~ Yes ~ No /' OG~M~N ~S~In~cluSJe goys discre n ~~ rso s present, etc.) Inspection # • t~ /, Inspection #2: ~ca,,,,tio~~n: ~~8410`Ross RdriHurd{s"on, WI 54016 (NW 1/4~E 1/4 2 T29N R1 W) Ph asant Run 1st Lot 0 Parcel No: 22.29.19.2470 1.) Alt BM Description = ~~ ~ ~w ~.~~~z ~t '~ Cfl,~~ 2.) Bldg sewer length = ~` s ~ ~ ~~~ • C~~ ~'~ ~~l'D _ ~„t` ~~ 3 j ~~ f~ ~~-~~Dl c~-s~~.~d1 ~ Plan revision Required? ', 'I Yes No s ~ ~ / ~ 2~ 11 Use other side for additional information. _ - -- -- ~ ~__ ~~/~'~-~~ -~ / -~ SBD-6710 (R.3/97) ~ ~ S Insepctor's Signature Cert. No. _ ~. Safiefjr atd Buildings Division C~ 201 W. Washington Ave., P.O. Box 7082 iscansin - .~ ~-~ De artmeflt of Commerce ~A~it! Per>oit Nmd>v Sanitary Permit Application ~ o ~~ ht aocotd frith owmn 83.21, Wis. Atht<. c«le. wa l~~ • ^ Check ifRevision ~ ~,~ ~ _- L App4cation iafoamatian - Pkt~e Piist All ~ ,:: g `,_ ' " ~ State Pion Ll). N f~' Property Owaa s Na me 2 ., ~~, ' wed Nuaaber _ .- -mom Properly oteaer's as ailing Address ,. ,: . Property Loeadott ,aQ1 a . .., -_"`."`"°. lfti~ 511 S T N. R T.y- Code Phtaae N~ Lat Number Block Nambar Subdivision Name CSbI Ntunber ~ II. Type of tCbeck au mac app.) ~/ s ~ or 2 Family Dwen®~g - Nmeber of Bedrooms y `{ DrZ •F~0'y/ ~ ~CLi-~ 2/(% 3 - acsty ~ '~ pV ~ ~=1'• rt~'~'.e - t ~ o PubliGCamnaertaat -Destatbe flee Z.~ri1~G O state own~l sj/~.t~~itySt~ ~.~<t J~rv/~s' Neater Road III. Type of Permit (Check ot~ otm box ao line A. Numbering cs for internal nse.) (ComP kte ~ B, if app~We-) A. 1 S 2 ~ ~ Systetrt 30 Repboarteacof Tacit Od 60 Addition m S Far C~ the B. OCheck if Sanitary Permit Previously Issuod Permit Number Date Lssteed Ty~e of POWT System: (Clack a8 mttt ap~pl9. Numbering ~ for internal tie.) ,3 /72G3DJC~l E3S W 1 p ~ ~1 ~ ~j ', IV ~ 44 IiNoa -Pressnrimd Ia-Grouod 21 o irtotmd - 47 o Sand Filter 30 0 (b~n~od wWsad 22 0 Presstuiad bt-Grotuid 410 Holding Teak 48 ~ Sit~le Pass 510 Drip Lice ~5~~ ~/• // 45 0 At-Grade 46 DAetobie 1Y Utz 49 0 Rpciraba~ 30 ~ Wirer i Y. Area Infosmtttl ott: Design Flow (gpd) Dispersed Area Dispersal Area Sob Appiicadatt Systeta ~ Final Glade Raprircd Proposal Ra~lC,~s-/Days1S9-R.) T ~'- ~ ~s.7 F. YI. Tank info Capaaty is Total Number Maaufacuu+er Prefab Site Sled Fdrer Phtst~ Gaibas Gallons of Tads CaeACrese Gonsonrceed Glass tre+r F~isriag Tanks Tech vII. ResPotrt~i8ity fit- Y, rot: tom, ataamte tlon of ibe PavPiS slha~wn ea the atraelsetl Pbmoleer's Na me Fogerty Plumb g & Perk estl~ ri ~ >~ 6f'l . 8 z 7 y9"3 i Pltarrber's A ss > ;Zip I - .3• - Spoon~r~ WI 54801 ~ C~"CL- ~SF ©~"~/O~ v>II. use Approved ~ Owner Given Initial Advesae Y Permit l=ee rrreltrdea Grormdwata /Gig ~) IIL. Contliti~s of A~prov salons for Dural ~6_ ~/__yy~ ~y~.~~ ~ ~7 _ Q/ ; r ~y~ ~. mod. s~..~, s~ ~~~~~, ~ ~ /~ ~~~~' ~ ~ ` `~ c~- ~l~p~e .L.OT-S vsr ~!l~2~ ~~.P~GLc~ ~ ~Q~l~GT-) ~n f2! ~ ` 2 l~urn.~h/ $tuQ~L i~ d•~' (J ,-1~.~%ti4,~.- l-~DhtL~Own.Orc/ lv~t ~~ /v! ~~~ ~ ` AttaeY ~p~ plant Cdtfat7 ady) for system m paper not less ilue El/2 s: 11 lathes i• r ~ ~ _ ~ ~ //^^'' p ~J® ~ ~ n {~ ~ ~~ ~~ ti w~ H - ~ ~ {,~y, ~ ~ ~ wd tl ~~. ~ ~) ~ y ~ ~ ~ ~ `~ ~ ~ .` ` ~~ ~ ~ ~ ~ - ~ p© I~~ ~~ ~- ~ ~ ~ n {~ ~ M 1 1 ~ ~_ •~ - 1 p 1 A } v ~h N ~~ s 0 o V - t ` ' r ~ f I ~~ ~~ .- .., ... -- ~~ ! ' s~ :~ 0 \ ~ ~' y~ ~ ~~ N i ~p ~#C~R Q1~ ~N~ W ~ --+ ~-~ ~C I~~W 0a' ~0~ l ~ 'y A . ~ ~ ~~~ ~ 1 i `C O to c u ~' ~~ ~~ b ~yy P~ r p~ ~ i Ly ~ IG_ H ~, O 0 y ~ o ~ b C1 o, ~ c~ ... C ~ ~ C ~ N ~~ ~ u ~~~ '~~,7 y. a ;~ W ~~ h~. . fn pNp '!1 '~ ' \ N ~ 7 ~ A 1 # W ?' ~~ ~ ~-~ ~C O ; O~~ e ~ Q ~oo~ ~ °- °° 1~ c~ n• O~ ~' O ~• ~ CD n ~ v4 ~ O d CD ~a O ,. ~ :~ 0 ~n 'b H O~ (IG ~ ;~ ~ ~ ~~ ~ ~ C ~ ~ ' ~ N s „ ~~ „ Jr __ .: _ :,. ..- .. ... ~ ....., v ~~~~~~ 1 ~. ~. ~. .... ~ (.:~, ~ ,'. r~`yyY I. A . V~. ' ~ ~ . ~. V . _.. _ _ .. _ ... _ _... ~ ~~.;C7:. :.. .. ~ n :. ~ ~r ^~ ~~.. ;. .. ~! _ ._ __ __ .~ ~~ ''~ `~ . ~ . r ,~ .~ ~ .p. a cu~ . ~ 0 a`3 ~.~.. N ..~. •.~ . .. ~ vl. . . .......... . • . .. h. . , ,, ... \ r~~ . .,. . ,.. _.__ . :.,:. .~ ,~. : W ~ c~. o ~ ...'.~. ~. ,o 1..~..:~ s .. . ._ ~ ~~• ~~ ~ ~r ~ ~ 1 . '. ~ - .. ~_. ._....... ~' ~' _ \~ C .. ...•~ :.. ~, to , : .. J I ~~ )i trn~ o~ cor~eroe SOIL EVALUATION REPORT ~ ~ ~ ~ 3 ,~,-~ Bum in acx:ordanoe wiUi comet 85, v+hs. Adm. Code county C ~i complete site pMan on paper not less than 81R x 1.1 inches in size. Plan must Jde, but not flrnited to: vertical and horizontal reference point (Blur). direc~iorl and .Dent sbpe, scale or dimensions. north arrow. and location and distance to nearest . P/ease print all information. Reviewed by Date . Personal iniorrnaiion Tarr vrwide mar be naed for secondary prrpoaes (Prit-acr t.aw.:15.04 (1) m)). ~ N owner ~ r - ~" __ _ Go~rt. lot ~ T' X Z T Z N R E (or~ 'ropertY Owner's AINar Address LAt # ~Q_~ ~ - ~`~ _ _. :-ty State Zip Code .Number ^ (;ity ^ Vfllage ®, Town t Road a ~~ ( -~~ New Construction lJse: [Residential l Number of bedrooms Code derived design slow rate ~ d GPD [].Replacement ^ PubGc or conxnercial - Descr~e: Parent material ~ V-fZ,u ~ .$ Flood Plain elevation if appl'~cable R recorrlrrleridations: S~ s~ +!/~ ~ ~ S 3 D- .~- ~__ Q ® Pit Ground surface elev~ • ~ it Depth to frcr~ing facxor / ~ U in. - . - Soil AppGgtion Rate Horizon Depth Dominant Cobr Redox Description Texture Struc~lue Consistence .Boundary Roots GPD/R: in. AAunsefl (lu. Sz. Cont. Cabr Gr. Sz. Sh. _ _ •Eti#1 . 'Eif#2 ~0-2 ~} --- s. ~ 2 _ ~~ - r ~~ .. --- 2.#~ 9 ~ Ground surface elev. $ • .Y R Deptn to linating factor I ~ ~ in. ~ .. _ _ . ... sod AppGption Rate Horizon Depth Dominant Cdor Redox Descriptior- Texture Sure Consistence Boundary Roots GPDRtz in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 f l~ lZj _ i I ~. ~r e S v _ 5 2 -21D ( S 1 -fir ~c. ~ - 5 3 ~ ~~ - -- - . -1 /. 2 3 • Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/l. and TSS < 30 mgll CST Name (Please Print) ~ natur~~ 25 Number Address Date Evaluation Conducted Telephone Number 2t13 ~~+h S~-'- _ Scnr>erse~ , t~l 5`fc~2__S__ 1-10-OZ ~~ 5 -Zy7-~oo~ Properly Owner ~~ ~arod ID # O T ~~ s ~ if . 1 2 3 ;, ~ ~ of in. Boring # U ~~ Ground surface elev. ~ ~• 2' C~ f<. pepth to IirruWg factor ~ Z ~ soil , Rate ~} Pit h Structure Coru;istence Boundary Roots GPD/itr Hor¢on Depth ~. pomir-ant Color Munsefl Redaoc pesaiption Qu. Sz Cont. Cobr ue Tex Gr. Sz SR 'Etf#1 ~ 'Eti#2 ~ - ~~ I2 ~ '~ ~ cg ~~ • 2 _" ~) ~ ' - ~ ~~ ~ •~ q c L ~ ~ f f v ~# o ~ Ground surface elev. tt. ~a~ ~ factor ~ Ftorizon Depth Dominant Color Redoa Desaiptlon Texhue Structure f;,orisistienoe Boundary Roots in. Mansell t'lu. Sz Cunt Color Gr. Sz Sh. •EtT#f2 1 ^ Bonng # ~ ~ ~ -Ground surface elev. ft.. Depth. to Lrniting factor ir-. _ Sofl Appflcatiori Rate Str h ra;istenoe C BoruWary Roots GP D/R2 D~~ in. pt.~ Mur~se8 Redox Descriptior- Qu. Sz Cont. Color Texture uc re Gr. Sz Sh. o 'FJf#'1 'Eff#2 'Effluent #1 =GODS > 30 < 220 rnglL and TSS >30 < 150 mg/l. • Effluent #2 = BODS < 30 mgll. and TSS < 30 mglt. The Department of Commerce is an equal opportunity sen'ice provider and employer. If you need assistance to access services or need material in an alternate format, please contact the deparhnent at 608-266-3151 or TTY 608-2fi4-8777. sso-asw cu.mroo~ ~ f ~ • J PAGE~OF 3 NAME Bci.S ~" tOT# /l~ I F(TAT DF4('RiPTinN.(~ttJ /~S~ ~,S Z-T T zq ,j~,R,~~oriW/ SCALE: 1"= ~0 BM 1 ELEVATION l00•d BM 1 DESCRIPTION -~,P~ty~~~~l Qom, (~ " ~,,g ~ BM 2 ELEVATION q q, Rp BM 2 DESCRIPTION~oQ~~' $-(,ec~ Qad (o `` ~i4 ~ SYSTEM ELEVATION CJ ~- as.3 ALTERNATE ELEVATION q?J'a0 CONTOUR ELEVATION 48 S~ ~J7, ,~ ys ~ ~3, _ N •zZ ~ ~ 6~ ~ I b ~m ~ Po . ~,S a Qs S 4 ~~ _ ~$. ° 2 Qf~rw~`~l ~( bn` ~-~ z~~ , ~qo ' SIGNATURE ~ - DATE ~ - L o - a ~ Ro`Qt t ~ 5 ~- ct n {., Wisc~nnsin Cfarbnent of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page ~ of m a~woance rvnn uxrun oa, rvu. rw~~~. wuc County C ~ Plan must er not less than 8 12 x 11 inches in size n on a l Att l t it h . p p a e p ac cornp e e s include, but not linrited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest P/sass prirrt all information. Reviewed ~ Date Personal information you Provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) m)). J N ~ 3 f' 6-3 p~riy Oar Property lion ~ Govt. Lot W T X ~~7'i Z T Z N R E (or}~ Property Owner's Mani Address ~~ ~ LLa-~ e ~. Lot # +O ode a Number State Zip C City ^ City ^ Village [,Town Nearest Road 1 ~ 11~a New Constnrction l1se: [Residential / Number of bedrooms Code derived design flow rate ~/.~ %/ 4 d GPD ^ Replacement ^ Public or oommeroal -Describe: Parent material G V a .$ f=lood Plain elevation if applicable tt. General comments S ~ ~ ~"~r' t!/C V ~ ~ 3 Q and recommendations: ~`~- C/G U . ~ 3' Ud M ~~ ~` ~'~"'11-'/G~~Q-t'/2-c C~-c~ ~ f 3$ - ~~ t, Boring # ^ Boring esq. Q ®Pit Ground surface elev. 1 ~ • ~ ft. Depth to limiting factor ~ / U in. Soil Application Rate Horizon Depth Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ -~o is BIZ - - I 2 ~ g ~ Y , 5 . io-2 ~+ - s' 1 Z m c5 ~- 8 2~ i ~--1 --- _ m5 - ~ ~• Boring # ^ BOA Q .~~-~7~` P~d Ground surface elev. ! $ ~ ~J-' ft Depth to limiting factor I_~ in. Soil Application Rate Horizon Depth Dominant Color Redox Descriptimi Texture Structure Consistence Boundary Roots GPD/ftz in. Munseli Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 I lr~ IZ~ 2 i I Z.rr~ ~r ~ S v 5 Z c -ZCo (~ ~ - S' I ~r c~ -- . `~ 3 ~ ~o - m -- - . ~ I.2 `1~ ,~ = 3~,~`, ,, ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 _< 150 mg/L " Effluent rf'2 = t3VU5 < 3v mgrL and 15S < sv mgrs CST Name (Please Print} 'nature ~ CST Number -l 253 e~ _____ Address Date Evaluation Conducted Telephone Number 2113 ~p+h ~-, _ _ ~1->e_~Se~ ~ X11 S~C~ZS J -10-OZ ~l ~ 5 -Z y7-~1o0~ .,~. Pr Owner ~, T Parcel ID # operty ~J-~ ~D 7~ ~~ Z ~9e ~ 3.. Boring # ~~ ~ 7' 2 ~ ft a factor ~ ~ -~ in limitin th t D . ~ Pit Gnwnd surface elev. . g ep o Soil Applica tion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bourxiary Roots GPDfftz in. Mansell Qu. Sz. Cunt Color Gr. Sz. Sh. 'EN#1 'Eff#2 ~ 1~ ~2 -- S• ~ rn r ~5 1~ ,5 , g 2 ~ i I r ~s /' • ~ I C2 ~.S ~ ~5 `_ '.~ 1.2 Q 9h.- ~f ~'d'u n ~ ^ Boring • • - - ti ~ .~- K,- - 0 - -- :. - , ._ ,~ .~., -t.- ~ ~ - -- 0 D - Boring # ^ Pit Grarnd surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dwninant Color Redox Dessaiption Texture Structure Consistence Boundary Roots GPD/ftz in. Mansell Qu. Sz. Copt Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ Boring # ^ ~~ ^ Pit Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stnrchue . Consistence Boundary Roots GPD/ft2 in. MunseG Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mglt The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 ar TTY 608-2648777. SBD-8330 (807/00) PAGE~OF 3 NA_MF. 8QS T T.OT# ~~ T.EGAT. DE~('RIPTION.IiW /~5~ 14_,S ZZ T Zq ~LI.g~ ~ ~ Fdor~ SCALE: 1"= ~0 ~ ~,--_--- BM 1 ELEVATION l00•y BM 1 DESCRIPTION ~aQo ~ f~(~5~~1 Q~ (a ~ ~,4 ~. BM 2 ELEVATION q q, ~p BM 2 DESCRIPTION aoQ a~' S~c( eQd ~Q '`~h SYSTEM ELEVATION ~' S • 3d ALTERNATE ELEVATION R?J'°O CONTOUR ELEVATION 98• •~ '97. ~•d ,.A ~ n~ a~~ 3Z /~•L~ ~,~,~ ;' ~ Sao ~ -, y ~4, - _. rs--- ~2 ~ SIGNATURE, b ~_ ,~,r~ q$.7- ~~1 t ~~ ~~ ~+ _ -- l ~~~ ~~~~ Ccr~~~ ~~~~-; ZoU~ ~ road -_~ Ro`p~~~5 ~.-att. DATE ~ - L o " o ~ .~ < ._,' ~. PAGE ~ OF 3 NA_1yIE ~~~ T LOT# /CS T EGAI, DESCRIPTION.fht1 ~~~ ~ ,S ZZ T ZR ,I~,R, ~ ~ E(or~I SCALE: 1"= ~(0 BM 1 ELEVATION l00•y BM 1 DESCRIPTION -{~, Pe .~ ~~(5-~ ~~ Qad, (a ° l~; g t~ --•. BM 2 ELEVATION q ~~ BM 2 DESCRIPTION~Q 6Iz' 3-}~c~ ~Q~ (9 /~_ SYSTEM ELEVATION ~' S • 3y + ALTERNATE ELEVATION ~ 3' ~ ~ CONTOUR ELEVATION 98• s-z~ X97 ,$d ~•zZ b ~S a ~$.S f. a- ~2 SIGNATURE ~ ~ DATE ~ - z o - a ~ ~o'QeC~S ~'cct~~ ST CROIX COUNTY ~~ 2 D (p ~ '~- SEPTIC TANK MAII~ITENANCE AGREEMENT AND OWNERSffiP CERTIFICATION FORM OwnerBuyer ~~rkOh OrxS Mailing Address Q~/~ ~/~~~'- ~ ~rs~.r/ u~. Two/G Property Address - v " (Verification required from Planning Department for ne construction) City/State Parcel Identification Number ozo _ i3 9P -io - ~,EGAL DESCRIPTION property Location,.t/ul %., .~~'/., Sec.~L , T~~N-R~_W, Town of ,~~~DSor~ Z~~7 ~ r ~ .Lot # /D . Subdivision -- Certified Survey Map # ~'"`~'- ,Volume .Page # "~- Warranty Deed # l.Z 7 .~! O ,Volume Page # 3 Spec house ^ yes ~o Lot lines identifiable [J yes ^ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mast~rplumber, jounneymanplumber, restrictedplumber or alicensed pumper verifying that (1) the on site wastewaterdisposal 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 standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~ 1 ~'~ ~- / l1 ~i a3 SIGN OF APPLICANT DATE OWNER CER CATION I (we) certify that all statements on this form are true to the best of my (our) owledge. I (we) am {are) the owner(s) of the property descn'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGN TORE OF APPLICANT DATE *s**** rmit beia revoked b the Zo D artment. ****** Any information that is mis-represented may result is the sanitary pe g Y t~ ~ ** Include with thls application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made is the warranty deed ~~ ~ INwRManoN Ovmer Permit # ~ 0 r>FCCrsw peReM~s Number of Bedrooms O NA Number of Public Facility Units ~NA Estimated flow (average) ~~, al/da Design flow Ipeakl, tEstimated x 1.51 ,~©Q aI/da Soil Application Rate aUda /ftZ Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOGI 530 mg/L Biochemical Oxygen Demand 1130D51 6220 mg/L O NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand iBODsI 530 mg/L Total Suspended Solids ITSSI 530 mg/L ^ NA Fecal Co6form (geometric mean) 510` cfu/100mi Maximum Effluent Particle Size Ys in dia. ^ NA Other- ^ NA "Valdes typical for domestic wastewater and septic tank effluent. POWTS OWNER'S MANUAL & MANAGEMENT PLAN cv_c~ sPECIRCATIONS Page ~ of ~"~ Septic Tank Capacity ~~t7 O NA Septic Tank Manufacturer O NA Effluent Filter Manufactures ~G O NA Effluent Fker Model ~ ~ ~ Pump Tank Capacity ~ ~ ~- Pump Tank Manufacturer ~ N~- Pump Manufacturer (~ ~NA Pump Model 17 J~A Pretreatment Unit ^ Sand/Gravel Filter ^ Mechan"ical Aeration ^ Disinfection D Peat Filter ^ Wetland ^ Other: O NA Dispersal Cell(s) In-Ground )gravity) ~ At-Grade ^ Drip-Line O NA O In-Ground (Pressurized) ~ Mound O Other. Ocher: ^ NA Other: f7 NA Other: ~ NA MANY 1 CNAIYGC .7GflCNN6C Service Event Service FcY Inspect condition of tanklsl At least once every:. ~ ~~Isl (Maximum 3 Years) ^ NA Pump out contents of tankis) When combined sludge and scum equals one-third 1Y31 of tank volume ~ NA Inspect dispersal cellls) At least once every: ?j ~ y~earn(s (sl (Maximum 3 years) ^ NA Clean effluent filter ~-.S ~]~-~"~ At least once every: ~ "' Z ~ yearls-sl ^ NA Inspect pump, pump controls & alarm At least once every: p yr ~i gj s) ~A O monthlsl Q NA Flush laterals and pressure test At least once every: ~ yearlsl Other: At least once every: ^ month(s) ^ yearlsl ~j NA Sher. ANA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following 1'x:enses or certifications: Master Plumber; Master Plumber Restricted Sewer: POWTS inspector; POWTS Maintain; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal celllsl shall be visually inspected to check the effluent levels in the observatwn pipes and to check for any pondicig of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing cxuidition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY3I 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 POWT$ Maintainer. A service reenrt shall be provided to the local regulatory authority within 10 days of completion of any service event. 1 Page Lof 2 . iaNT 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 celllsl. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shalt not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fi5 above normal highwater levels. When Power is restored the excess wastewater will be discharged to the dispersal celt(sl in one large dose, overloading the cellls! and may result ai the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prwr 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 drnre or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Redyction or etunination 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; fnrit and vegetable pilings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesf+cides; 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, ail 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 faits 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 tines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluaYwn 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. w L The site h s not been eval ted to identi a sukable replacement area. Upon ~~ure of the,P soil and site ''" luation st be performed o locate a suit le replaceme re If no rep cemerlt,a[gl~ available a ho ~ may installs s a last resort replace the fat POWTS ^ Mound and at-grade absorption terns 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 ANOlOR 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 DIFFlCULT OR IMPOSSIBLE. SEPTAGE SERVICWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORfTY Name Name~j 1 ~ (X ~~ 'C3~11J Phone Phone ~'(S - This document was drafted in compliance with chapter Comm 83.221211b11111d-drlf) and 83.54(11, (21 & 131.1Afacor~in Administrative Code. Spooner yt(I rditAt (715) 635- ~ POWTS INSTALLER POVI/TS MAI ~ Name 1 (Z~~ ~ Name Phone S'.- - ~~ Phon -- ~ j - O f 53 ~ P"5e `1~3 - ~ STATE BAR~W~~I~BEt~~9 Document Nomber WARRANTY DEED Tdis Deed, made between MaHe A. SbUaon, a single person, I Grantor, and Keruou J. But aad Dtwalda J. Speer-Bast, husband and wife, Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): 62751 ~ i•:t3 i HLEEN H. WALSH REGISTEk OF DEEDS ST. CROIX EO., tiI RECEIVE!' FOR RECORD Od-O~-Zt700 3:00 PM illltr 1-EEIt EXE!1PT N CERT COPY FEF: COY FEE: . TRANSi'ER FEE: 86.00 R`CO.4DIM6 FEE: ' 1~f.00 PAGES: 3 ~~8 Arw (See Attached Exhibit "A") n rct:s t t tvA OG LAND Zi1z, Estreen & Ogland F•O. Box 359 Hndson, W1 54416 oxo-los9so~0oo 2'v- 'Z~~ L 1. ~2°~ Pared ldattifiedioa Number (P1M This is not himoeslead propcny. Ot) (is tmt) Exceptions to warranties: Easements, restriixituts and rights-of--way of record, if any. Dated this ~ d ~• day of July 2000 • + Matte A. Sltiwaa a AUTHENTICATION Signature(s) Marie A. Shimoa, a single person, is Kq "'' y-, day of July 2!100 w ACKNOWLEDGMENT STATE OF WISCONSIN ) ~• County ) Personally came before me this day of the above named Ra' c~,~,rr~`~'_ TlT~' ~1'ATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing auth ~ § 706.!16, Wis. Stats.) ~ instivment and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristian Ogland Notary Public, State of Wisconsin Hudson, W 6 My Commission is pcrmanart. (If not, state expiration date: (Signatures may be authenticated or acluawkdgcd. Both ate not raxessaryJ ~ ') Names of persons signing in aay capacity must be typed or printed below thcu signature. anan~w+ada..~s canoe~y. 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