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HomeMy WebLinkAbout020-1398-14-000Wisconsin Dept3riment of Commerce PRIVATE SEWAGE SYSTEM Safety and Buil(!ing s' ~ ' INSPECTION REPORT GENERAL IN, TION (ATTACH TO PERMIT) Personal information you proe~ide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi ST BM Elev: ~ Insp. BM Elev: BM Description: ` ~ ~ . d ~ 5' ~,~ CXA~ l IIhD./ '+4NK INFnRM~TInN FI FV~TInN D~TD TYPE MANUFACTURER CAPACITY Septic ~- Zao Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 7 ~ P ~ Sb r ~ / Dosing Aeration Holding STATION BS HI FS ELEV. Benchmark ~.o~ loz.o ~~ ~ r Alt. BM Idg. Sewer ~[ f•~ q ~ I~'~ St1Ht Inlet SUHt Outlet ,j .2~ ~/~ . ~~/r Dt Inlet Dt Bottom Header/Man. „Q . 9l) ~[ ~~ r Dist. Pipe /S , 23 ~ . Zd ' Bot. Sys m Q •3L • 3 ~ .3v q 3. ~/ r I Final Grade ~~ w:~( ti z . 0 99.03, St Cover , . 82 QO . ZOr (~`~ 0l•~3 (sb_ v ` County: St. ~'if OiX Sanitary Permit No: 420598 0 State Plan ID No: Parcel Tax No: 020-1398-14-000 aa~ a~~~ PUMP/SIPHON INFORMATION Manufacturer ~ Demand GPM Model Number TDH Lift rictio oss System Head TDH Ft Forcemain Length Dia. ist. to weu SOIL A RPTION SYSTEM REN idth r Length No. Of Trenches DI ONS ~ ~. ~~~- /2 ` INFORMATION Of Systerrf: -., P/L BLDG WELL ~ ' ~' t ~ > Sb/ DISTRIBUTION SYSTEM PIT CHAMBER OR ~,r(~( UNIT Model Number: r ~ _ /t /~ ~ Head / r, Distribution x Hole Size x Hole Spacing Vent to Air Intake 1.~ Lengt~~ Dia 1 Pip Length Dia Spacing ~- SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes n No [] Yes [~ No ~_ COM NTS: (Include c e disc pen 'es per on resent, etc.) Inspection #1: / ~ In pection~#2l_(tl~~[~ ~~ ~..~~ ~~s ...~~ rte: --~. ~~~ Location: 819 Ross Road Hudson, WI 54,0,[16 (NW 1/4 SE 1/4 22 T29N R19W) Pheasant R of 14 ~ Parcel No: 22.29.19.2474 1.) Alt BM Description = t ~~/~`~'y`'~' ~~~~ ~~~ 2.) 61dg sewer length = Z Sr t'r ~~ mount of cover = ($ +~,~. , `~~ed? ~I Yes No ~ n_ ~ / ; - - ~ -- i bnal information. ~-~IJ- Date Insepctor's Signature Cert. No. S'aietj- and Divieiae ~- ~ . 201 W. ~f/ _ . ~ ~ ~~D oe ent of Commerce - 1 ~ V `v ' ~ • ~ ~ ~ •a~i Wig ~ ~~ 9. /~ ~F l~1 ~~ - * ~ y w ~ ~ Limo. s ~ g ** ~ y ~ ~\ T ~ ~p ~ \ _ - * ~ A~opaq YR7w/O ~ ~ ~ ~ ~ ~ ~ a~ p (~ ~~ WY6 ~ ~ ~ ...,.+ ~ * ~ ifR u.lype of s~.`Id~ ~ mrt ~phra oe~ o -~~ - o sm~ o~ea 2~,~c~ ~ ~ ~ ~~ Neaest~oad - Z c~'~tr 3 ~ .s --2 S' 1J. - IIi. Type of Pam ~ aaljr aHe 6m~ ae Yea A. Namr~ is for aoieand oaf (t7eerpi ele Yee B, ~ appiica6le-) A. 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I I ~ i ~' y ~~ S ~ d q ' ~ O - 1 Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance witli Comm t35, 41ris. Adm. Code County - Attach oorrrplete sib plan on paper not less than 8 112 x 11 inches ~ sae. Plan must indude, but not Nrr>ited to: vertical and horizontal reference point (8M), direction ar-d Parce11.D. percent slope. scams ~ dimensions, north arrow. and location and distance to nearest road. Please print all information. ~ Parsonei irdormalian you praiide may be used tor~eCilnf$ryPwP~ lP~•Y ~. s. 15.04 (1) (m)). ~,~.' o~ Location . ©~/ Gbvt t.ot N 114 Sc v~ -s ~ Property Owner's IlAailing Address l.ot # Block ~ Subd. Name or CSf~t6F ciey state zap code Pnone IVrrmber ^ city ^ v~age own wr ~ --` _..~.... ~~ _ ~ _ ic/ Page _~ of ~ ~f~/o3 ~ , N R ~G~ E (orb Sic. Nearest Road [I~'Nevv Construction Ilse: [~Residentiat 1 Number of bedrooms .~.~_ t %~ d~ ~ rate (OlJ ~' ^ Replacentertt ^ Pubic or oommerdai - Describe: - Parent material ~T-~~i~ft - Flood Phdiri eleratian ~ appira6le ~f.~f - f General oorrirrierits ~ ~ . and r8corrinieridaitions: S~-p'.~'~*+ •c'~y: 9.3 s ~.rr/- ^ eoruig i ~~ # Pit Ground surface elev. f'8D tt. oeptn ~'riniting factor > //Z. in. ~gtlon R~ Horixari Depth Dominant Color Redox Oescr~iai Texhrre Strucdce Carrsisterice Boixidary Roots GPD/IN ai. Munsea t]u. Sz. Cant Cobr Gr. Sz. Sh. 'Eff#1 'Eff#~ 2- '- 2 G ~ S- ,. ~-- - / - .._. ,~-- i ~. D S~•~ Y3• o # ~. C,romidsurbceelev.fl. D~~tto~:r. ~~ GPDrft~ Horizon Depth in. Dominant Cobr Munse6 Redox Description Qu. Sz. Cons Odor Texture Struc>rse ~. Sz ~- Consistence Baxidary Rents ~~ ~f ~ D Z c F - 3 _ r -- . ~. 6'f . 3 z w . Z • Eitlirent fi'1 = BODs > 30 < 220 nipll and TSS >30 < 1 ~, Narita ~) 50 nigh t i1e2 = BOD, < 30 nglL and TSS < 30 ntpll^ - ' CST Number .~ ~i~ Foe lumbin & Perk Testin ~ E ti0" CO"d'r~ Teleptiaie Nurttber g rtY 8 6 O,rFs~ pi's L~s.= Q~9 9R9RR MrKPn~ia Rri G/"? ~~'~ ~f1L ~r5'/-Yo2 x0~ ply per ~~' Parcel ID # d.=O - l.3>D~.; /Y ~D- Page ~. of 3 Pit Ground surface elev._ ! L fl. Depth to 9 tailor } //~ in. Sai Rate a# Horizon Depth Dominant Cobr Redox Desaip6on Texture Stnx~re Caraslstertce Boundary Roots GPDlfE in. Mansell Du. Sz. Cont. Cobr Gr. Sz Sh. 'Efflfl 'Eff#2 ~ _ '._--- 2 ~ _ - .L toS-. 0`'~ p . 0 ~ Pit Ground surface elev. fl. Depth to IKniUng (actor rn- c~,pq Rate # ~~~ -. xture T Smx~ae Consistence Barmdary Roots GPDJtf tiorimn Oepth in. Dominant Cobr Munse9 Redox Description (]u. Sz. Corn. Color e Gr. Sz. Sh. 'Eff#1 'Eftl12 ^ Bonrg ~~ # ~ Pit Grourxt surface elev. fl. Deptfi ~ g facer ~. Soil _ Rai3e Fbrizon Depth in. Dominant Munsefl Redox Desaip6on tau. Sz. Cont. Color Texture Struchre Gr. Sz. Sh Cor~stence BotmdasY Roots 'Eff#1 'Etf#2 'Effluent #i = BOD, > 30 _< 220 mgR. and TSS >30 _< 150 mgll. 'Effluent t'YZ =• BOD, < 30 mglL and TSS < 30 trglL The Department of Commerce is an equal opportunity service provider and employer. ! f you need assistance to access services or need material in an alternate format, please contact the department at 6086=3141 or'f~'Y 608-264-8777. - sea-e~ota.sroo) o N ~ ~ ~ M ~ It i. ~ n ~ ~ y ~ ~ ' A ~ ~~ O ~. a 1 0 !.. 1 1 '~C I I ~ W ~. , f/~ ~ '~f ~ ~~ ~ ~ ~1 ~~ ~ N ~ ~ W~X~~ m ~C ~ - = N ~~ O~ ^ ~~~ ~ 7f p m z ~oo~l Eoa~~~~ ~ c ~~ d-~ 'b d.-r ~S~M rc'C~'f~ ~N ~ y ~ V i ~~ ~) m#~ p~ "d j N Iii 00 a" •~ i ~~1~~y ~ ^I N N ..~- j V ~ ~ i-I f Q r ~ V C~ 7l [ ~ O ~~ •i j.. _.. .. ....._. ~ ~ \ ~ •,1 ^^ i ~~ \ ~ ~~ x~~ ~ .\ Qr ~ i ;. 0 ~ ~ r ~~ ~ - .--a -_ . 'V ~ 1 ~ • _ r-, o _ ~ ~ \\ - - 1 ~x~--'~~ 1. ~ - ;• .~:~..~ ~ - ~ q. ., /~ ... ~ ~ } ~ _ _ _ •- ~ ~ . . b •-~ ~ _. r~~~ j ~ i'v - . v 0 ~ ff ~ ! .~ N _ a3 } ~ ~„~ of ~' ~' ~ ~ •1~~ ~~ O ~ F a~ U ~^^ W 0 b Q 3 a~i a U b y U N O .~!'-" O R Safety and Dt~aaoa Ga"r°'i~r _ . O. Hux 7i0~2 P sl~toe Avg W 7Al W . .. » . ~nsin - .. ~ ~- - is~r '~ , De rt~ent of Commerce y v 3 ~o~ ~ S ation it A p t /w' 8 pp c erm Sanitary Zo m aooot~d aat clam. aszl, wi:. ~.. code. pe:sod io[oiaaaio4 you ptaride D Ciecit if iisevt+ioa ~. Ate. ~~ r+t:ar A>< REC~~ sdt~ Pha Ln riA.at>Z~ Pro~etU-ours w .~ ~ z ~,~~ pEC u ~ ~ ~ 8 - f -~ . ,a .2 ~~ ~ Prq>mgrOwaer'sb[ ~ ~-(. CROix CO'S~ ~ Y NG OFFICE ~9 N R ZOM . ~ !f !t• c&p. Stae Zip Oode Plwee Wuwber Lot Hlock ' I~ t ~ 1 aeBem ~ ~~Y ~E Dyilpee O Sane Owned iJse /Je.,~'G r ,¢ III d et ~~ Nest road Z c,~cts 3 ~ ~- s" ~~ • ~. iII. 'Iypc of Pettit: ~ att goe A. N~baiu~ is tear iaderaai >Ioc ~. ~ -) A. 1 2>] ~ 3O laepiaoe~aewtof 6[7lidditioato, ~, B. t3(~ack if Sae~ry Remit Pic+rioasti issaed • t~imnbcr IY. Tie d P01~t'1' S t~Ue~ ~ mat is dor mta. o ns s3" Woa -re~a~ m-t~oaad al n i~ - a a 1~ 22 ~ Ftiessutiaed la-c>~oimd 41 ~ Hoi~ 1'aat 48 Pa4t 51 4g O At.(~~ 46 ~AeruUic lY+ealmeat kgcitaalatiog v. w~ ~ Desi~a ~- ~U Ata Ara ret~caitlioa vI. Tadt Info C~it9 is Taal Pte6b Site GaBoas Gailaaa of trloa~aete New ~t 77sks sepic or itwiAr*a.t ,~, ....- .2Ad l lie - .~' v ~e cane. ~ ~ - - 4 t4a attatne ~ ~ ~a6tloa at tre a6w~ w ~e vl L. p~~ ~~~~ p ~ Fogarty Pleueribills'e Peek r.~'" 7o~tiaber 8mi.esspiaoaelcaobrr z~// 8~ 7i~ ~7Y~"3!s'~ Plambers ss , zip ~ f - C~e~ ~~/~tt r~ . ~ J4fi{/.R ~- C/~(.+(. ~~ 1"~0~ YIQ. U9E _ 0 ~~~ ~ ~~ ~c. ca~iana of fr r l rev as.a~ ~ sue.. e•~,u~t,eK.7C"a~. ~ a~ ~~ S ~,s. ~- - 1 lltfae~ ~ phis a• ale atry !rr lae~(i, a des a: sna mu=11 ova ~ ~ _ -~ A~ ~~ ~ .,..A. r -..- 4 Y a ~~ ~1:~~ ,. '~ ~ ~: V ~ g r' d ~ ,~ *~~ ~ `' m 3. 1 ~ A ®• x N ~ ~ s ~~ ~t u ~ t, b ~ P 0 0 !h h ti ~ ~ v ~ c b 1 ~. ~ ~ ° ~~ N ~ 1 ~ ~ a ~ ~ ~ .ti ~ ~ ~ o ~ :i o O ti y ..'v N O ~ (T~ ~ 00 A ~ ~ ~ 0 ~ ~ N ~D °10~ ~'°~ ~ r~+a N Al e N h 1+ w x h~ o ,. ~.. A'i ti ~ ~ .~ ~ • ~ 3 ~~ ~° ~ ~ `~ 1 -. p. ~ ~ ;'1 ~ ~ ~ 1 ~ .. 0 ~ w ~ ~ . . 0 ~ ~C - ,~ ~' a N tJ ~ I r :~-- ~~o ' ,, '` ,y ~ 'r ~' ~ ~< ,~~ ;~ f~ ~ 1 ~' s f } z.~' 1~ „~ ~, r ~• ' w~sconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of Division of Safety and Buildings :...,.......a.,....~ ,..:a, r,......, oG ur.., na... r...a.. - -- . s < Attach complete site plan on paper not less than 8 1/2 x 11 inches i size. q~- ~ Gtr ' ' include, but not limited to: vertipl and horizontal reference point (B ), dir ~ V E '~A~ Pa I I.D. percent slope, scale or dimensions, north arrow, and location and di tance to nearest road. Please print all information. JUN 0 3 Z00 Revi e y Date Personal information ou rovide ma be used for seconda ur oses (Priva Laav 04 (1) (m)) s 15 ~ 'Z/OS/O y p y ry p p . , . . Z Property Owner ~e. / n,0 ,~ ~ c) ~ ov . of ~,~;,Vt 1 /4S t, 1/4 S Z ~ T Z N R ~ E (or~' Prope rt y Owner's Mailing Address # Lot Block # Subd. Name or CSM# ,% e ,/ / r City Sta a Zip Code Phone Number ^ City ^ Village [Town Nearest Road ~~~ l.cJ( S a~ (7/S) 3f~Cv-7~7 So/t ~a5 ', ~ New Construction Use: ~ Residential /Number of bedrooms ~~ Code derived design flow rate Ll, SG l ~o O d GPD ~~ ^ Replacement ^ Public or commercial -Describe: Parent material d v-~-t.u ces l1 Flood Plain elevation if appligble /~ / ~ ft. General comments r/ ~ ~ p U land recommendations: -SyST~ Vh ~' v q`S~ ~y~. ~f~ev, tS: acs 1 ^ Boring Boring # ~~Q/) Pit Ground surface elev. ~ ft. Depth to limiting factor lld in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~~ q`f- ~ S`f o Z Boring # ~ Boring ~' pit Ground surface elev. ; aU ft. Depth to limiting factorlZ/ in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 /D /a/3 Z - S~~ b mfr CS 1v~ • ~ ~ yo-IZ rh,5 ~ - - ~ ~- ~ ~ 5's'' 9~• 20 `Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L "Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST N me (Please Pri Signature „~-~~~' CST Number __ a m _~--, .~ ~ ~-~.~--- - - Z S3 3 0 Address Date Evaluation Conducted Telephone N tuber Z F/ 3 S~0%'~• So /,,v~S.~-~ , t..r 1, S/az-~ / is - a Z_. 7/s; a 1 Property Owner U Parcel ID # ~07L' /~ Page ~ of 3 Boring # ^ Boring pit Ground surface elev.~~ ft. Depth to limiting factor /z ~ in. Soil Appligtion Rate Horizon .Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 t Q- IZ la ~~L - s~ ~ ~a.b In. r GS , .r ~ 8 2 ~ / /~/ ~ S,' a r C , S- , ~ -126 ~ h2.5 o s 1'~ l -.- , ~ /, 5-s z i• Z ^ Boring Boring # ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 • Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BODS < 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 need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R0~/00) . , ,4 , PAGE ,3 OF 3 T M ~o.S T LOT# ~ ~"~ LFGAI, DESCRIPTION ~w ~S~ 14 ,S 7~ T Z ~1,N,R, 1 ~( E(orX~/~ SCALE: 1"= ~-IO BM 1 ELEVATION //~~, U BM 1 DESCRIPTION o ~ ~ ~ ~a~d u ~~ f BM 2 ELEVATION f ~ SU BM 2 DESCRIPTION ~~ o -F ~ ~ ~oncl~~zJ ~` f' SYSTEM ELEVATION ~ S. U U ALTERNATE ELEVATION ~/S, O ~ CONTOUR ELEVATION ~fi / ~- N ~ Z~ x~ ~'n/ 60 n 7I~~ G1 7 ~O ~~ °~~ -~- :--^~ ~. ~> DATE ~ - ~ e~ --E'J~ SIGNATURE ~,~~ ~~ , A a~ -~ U T~ ~ V O r .Ha ~~.y Q ~~ •O U a~ e morn ao .e: ~o~~~ d~~~e~ ,~+N v -'J d#ap mss ~o ~ on1o ~~ ~~ 0 N O 'O 4~ a~ b .~ .r w ~ -_ ..~ Ii fl ~ ~ ~ .. .~ ~ .o _ _ ~ ~ a o u `~ ~ ~ ~ •~ c" ii w o/~ b4 4"' - ~. . W ~` ` ~ ~ j~_~~~ ~ v ~- ~~ N .~ ~ ~ + Q `` . .. ~.... °' ~ 3 c 0 ~ ~,;~ . i ,. ' -- ~'' ~ i a _~ i.~. ~ - ~ ., i .b ~ .. '~'• .c "~"'~:' ~'.'.:~ .-.. -c~ . ~ .. _ ~~•,. t.. a -d ` • ~ . .. . r - ~-. ~~ '~, ~ . , Q ~,~,. :~.•.. .. v ..-. - -.:N-.• . .. ~.~ t _ ., " `'" '. .. ~' a .E-+. j •~ ~ ~ o.~ p„ ... .v ' ' ~ . ~ .~. ,.. ~ ` •o ~~- ~-: o ~ -: :~ '' ~ u ~ u n ~~J ~, .~ ~'~, p' ~~ ~ w .. ... .~ ~ ~ ~~ .~' w N O o ~ - - 8 ~ . ~ *i #~~ .; .h' ,t~`~ ~ Z~B ~ ~ n ~~ . y.• .. ~ !t .. ~; i ~`~`* e ..u. ~> ~~. .~ ~ :~' ,~ .~ ,. ~~ • M POWTS OWNER'S MANUAL & MANAGEMENT PLAN ~ ~ of Z-' pESIQN PARAMETERS Number of Bedrooms ^ NA Number of Public Facifty Units ~NA Estimated fbw (average! m0 aUday Design flow (Peak(, (Estimated x 1.5) aUday Soil AppGcatwn Rate ___ . L aUdaylft2 Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOG) 530 m9~ Biochemical Oxygen Demand (BODSI 6220 mg/L ^ NA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODb) 530 mg/L Total Suspended Solids (TSS) 530 mgJt ~ NA Fecal Col'rform (geometric mean) 510` cfu/1 OOmI Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. cveTeu sar.~_1RCATIONS vSeptic Tank Capacity 2 ~ al DNA Septic Tank Manufactwer ~ j~ ~- S` ^ NA Effluent Fltex Manufacturer ~L O NA Effluent Filter Model _ - Q ^ NA Pump Tank Capacity ~ ~ ~ Pump Tank Manufacturer Q NA Pump Manufacturer ~"j •NA Pump Model QrIA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ ~~'~ ^ NA Dispersal Celtlsl In-Ground 19rovtY1 ^ At-Grade O Drip-Line ^ ~ ^ In-Ground (pressurized) ^ Mound ^ ~~~ Other: ^ NA Other. ^ NA Other. ^ NA MAINTCNAIY(:t Sl:l'ftlJUl.t Servu;e EYent ~~ FfequCnCy Inspect condifwn of tankisi At least once every: ^ monthlsl tMazrmum 3 years) ~ earls) ^ NA Pump out contents of tankts! When combined sludge and scum equals one-thins (Y3) of tank volume. ^ NA Inspect dispersal cell(s) At least once every: ^ yeartsl sl ~ 3 years) 3 q NA Clean effluent fitter At least once every: ^ month(s) ~ ' Z yearts- ^ NA ^ month(s) -A.AIA Inspect pump, pump controls & alarm At least once every: ^ year(s) ' ^ month(s) Q NA Fd~sts laterals and pressure test At least once every: ^ yearis) Other: At least once every: ^ month(s) ^ yeartsl ANA Other. Q,NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the foQowing licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector: POWTS Maintainer; Septage Servicing Operator Tank inspections must include a visual inspectwn of the tank(s) to identify any missing or broken hardware, identfy anY cracks or teaks, 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 IY,1 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, pretreatm~~ units, and any servicing at intervals of S12 months, shat) 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 ~of ~- ~I~~r~UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) 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 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 ce111s) in one large dose, overloading the cell(s) 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 shalt be d'+sconnected 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 utifaed for the location of a replacerneni 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 swcture, 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. If 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. #221180 $oooner 1N1~'I POWTS INSTALLER POWTS MAINTAINER (715) 635-960 J Name I ~i~-t Phone S"_ ~ ~~ Name ~' ,~' Phone ~ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ~jl . ~~rX ~~ TAN/ Phone ~(r' This document was drafted in compliance with chapter Comm 83.221211b11111d1&Ifl and 83.54(11, f21 & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer l~~evvd ~ Mailing Address Property Address (Verification required from Planning Department for new constructi City/State s5/Dl¢ Pazcel Identification Number O,ZO --ld s'9- FG DQ'J LEGAL DESCRIPTION Property Location /~~/ '/., ~~ '/4, Sec, 2,2 , T2p N-R~«~, Town of lily/JSG~/ Subdivision Certified Survey Map # Volume -' ,Page # Lot # ~ 4" Warranty Deed # li 2 7.S / d Volume !,~ 3 / ,Page # y33 Spec house O yes lino Lot lines identifiable L9'yes O no 1~ ~~~ F 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 master plumber, journeyman plumber, restricted plumber or a licensed 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. ~~~ ~~ . SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described abof~ve, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE ****** 'Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ~- ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed m '• 153 F°5~ X1.33 • STATE BAk~~\'V~~~'~9 Docume:uNumber` WARRANTY DEED This Deetl, made between Marie A. Shimon, a single person, Grantor, and Kernon ,1. Bast and_Donalda J. Speer-Bast, husband _ and wife, Grantee. C;ra»tor, for a valuable consideration, conveys to Grantee the following described real estate in St. C_r_oix _ County, State of Wisconsin (if more space is needed, please attach addendum): (See Attached Exhibit "A") 62751 O r;AiNLEEN H. WALSH f•;IEiS:iSTEF: OF DEL--DS `.~1. CFQIk CU., tJI RECEIVED FOk kECORD ~`~8-0?-?~JOv 3:00 PM AAkkANTY OEEO EXEMDT !I t:EkT COPY FEE: COPY FEE: TkANSFEk FEE: 846.00 R=CORDING FEE: 14.00 PAfiES: Recording Area Name :u~d R~u~ l:, 1 1 1V A l,ii2r };streen0& Oglantl F.O. Box 359 Hudson, WI 54016 ozo-f a>9•so-ooo Parcel Identification Number (P!N) This is not __ homestead property. ~) (is nol) Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. OM Jul Dated this ~ d day of y 2000 . AUTHENTICATION Signature(s) Marie A, Shimon, a single person, aumi O of July _ 2000 ~ Mar'ie A. Shimon ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. ___ County ) Personally came before me this day of _ _ ~___ __ , ____~ the above named c ... - y : r~ . J(rystill3 >D1. --- - ----. -- - --- _ __ _ -- ;~ ... $ TI'l~••• ~E~4'I'ATC l3AR OF WISCONSIN /I~ vv• _. - - --- -- ----. - to nre known to be the person(s) who executed the foregoing t autho ~ § 706-OG, Wis. Stats.) ~ instrument and acknowledgctl [he same. THIS INS"fkUMFNT WAS DRAFTED L3Y ~ ___ __ _ ' Attorney Kristina Ogland _ _ __ _ Notary Public, Stale of Wisconsin Hudson, WI 54016 ___- _ ___ ____ ---- -- My Commission is pcnnunenl. (If not, state expiration date: (Signatures maybe authenticated Or acknowledged. Roth are not necessary.) __ ) • Names of persons signing in any capacity muss be typed or printed below their signature. imo.maro~ Vroressiooe~s Company. Fora a~ lar„ wi s•r;>: rE uAx oN~ WARRANTY DEEU w Isconsl~ aoubss-zoz, FORM No. 2 - 1999 ~Y ~o~ 1531PAG~434 EXHIBIT "A" A PARCEL OF LAND LOCATED IN THE NORTHWEST QUARTER OF THE SOUTHEAST QUARTER (NW 1/4 OF SE 1/4} OF SECTION TWENTY TWO (22), TOWNSHIP TWENTY NINE (29- NORTH, RANGE NINETEEN (19- WEST, MORE FULLY DESCRIBED AS FOLLOWS: Commencing at the East Quarter corner of said Section 22; thence North 0 degrees 02 minutes 57 seconds East along the East line of the Northeast Quarter of said section a distance of 40.00 feet; thence North 89 degrees 57 minutes 16 seconds West 750.00 feet; thence Westerly 450.47 feet along the arP of a 905.17 foot radius curve concave Southerly whose long chord bears South 75 degrees 47 minutes 19 seconds West 445.83 feet; thence South 61 degrees 31.minutea 54 seconds West 135.86 feet to the point of beginning; thence continuing South 61 degrees 31 minutes 54 seconds Weat 150.12 feet; thence Southwesterly 297.89 feet along-the arc of a 740.00 foot radius curve concave Southerly whose long chord bears South 49 degrees 59 minutes 58 seconds Weat 295.88 feet;. thence South 53 degrees 22 minutes 28 seconds East 409..87 feet; thence South 0 degrees 15 minutes d6 seconds East 687.10 feet to a point on the South line of the Northwest Quarter of the Southeast Quarter of said Section 22; thence North 89 degrees 57 minutes 16 seconds West 1269.89 feet along said line to the Southwest corner of said Northwest Quarter of the Southeast Quarter; thence North 0 degrees 16 minutes 35 seconds West along the Norr..h-South Quarter Section line a distance of 1296.23 feet; thence North 89 degrees 50 minutes 17 seconds East 651.01 feet; thence North 0 degrees 11 minutes 41 seconds West 22.40 feet to the Southwest corner of the Certified Survey Map recorded in Volume 7 of Certified Survey Mape, page. 1891; thence North 89 degrees 50 minutes 17 seconds East along the South line of said Certified Survey a distance of 651.09 feet to the Northeast corner of the Northwest Quarter of Southeast Quarter;~thence South 0 degrees 15 minutes 46 seconds West along the East line of said Northwest Quarter of the Southeast Quarter a distance of 129.99 feet to the point of beginning. ALSO Subject to that part of a 66 foot wide easement reserved for Euture township road included in the above described parcel, said easement being 33 feet equidistant and at right angles to the following described reference lroes: REFERENCE LINE NUMBER 1 Commencing at the East Quarter corner of said Section 22; thence North 0 degrees 02 minutes 57 seconds East along the East line of the Northeast Quarter of said section a distance of 40.00 feet to the point of beginning of the following described reference line: Thence North 89 degrees 57 minute's 16 seconds West 750.00 feet; thence Westerly 450.87 feet along the arc of a 905.17 foot radius curve concave Southerly whose long ct,ord bears South 75 degrees 47 minutes 19 seconds West 445.83 Eeet; thence South 61 degrees 31 minutes 54 seconds West 285.98 feet; thence Southwesterly 297.89 feet along the arc of a 740.00 foot radius curve concave Southerly whose long chord bears South 49 degrees 59 minutes 58 seconds West 295.88 feet; thence South 38 degrees 28 minutes 07 seconds West 100.00 feet; thence Southwesterly 381.99 19 ~, . w 2.1 s ACRES 95,291 SQ. FT. 11NIMUM BUILDING LEVATION = 910.00 ~s ~"E 962.92' 1T 2.02 ACRE 87,895 SD. FT. IINIMUM BUILDING LEVATION =927.5 H.W.L.=908.0 ate, ,,,4 r~, ,~ ~O ~. ~SF~,~G ~~. ~F ll•~ ~ ~,~ 250.00' ~ / ,. ~~ , 16 2.05 ACRES 89,377 SQ. FT. 4.07 ACRES 177,359 SQ. FT. MINIMUM BUILDING ELEVATION = 910.00 N 15 i 2.03 ACRES ~. ~ ' ~ ~ ~ • . 88,529 SQ. FT. ~~` '. . \ ~ • ~ N89°1745`E 294.55' ~ y~ P~~ ~ ,f /`" .\ _ ~ C5 ~ \ \ .. / ' ~, ~ \ ~ N89°12'45"E 513.59' a \ -' ~~ ` i 'i ~' ~ ' ' i ~ ~ ~ I -f'=- 2.09 ACRES ~ ~ I 91,038 SQ. FT. ~ ,~ ~ ' i OF ~ ~ ~ I ~ S89°12'45'W 504.78' \\ ~1 r' ! ~°--`66' E E ~ SItt~L.E DRI~WAY; `. ~ COR IN ~. LUIY~ 1814, ~AQE ~ , , ~/ ~ ~RTFtOF ~ ~. ~ I .~~ t: , ~' ~, X '`x 506:11' ~ x '' ` x 45 ~~1h i 268.72' eo' TEMPORARY CUL-DE-SAC EASEMENT TO 6E REMOVED UPON ROAD EXTENSION. JD3 ,O~G9CLD ~ ~7 CO`tr C;1L~G°~~ I ` . ~ ~~ w W o w z _ . ~ I~yl V O `Ua_ e c~ O NI $m~ ~ W g r h r ~ i -x--- M~n1G 01wIG 1 OF 2 SHEETS "y. -as ~er:-:_ 0.~0 ~~~ ~ 5~~~ "q~`~ Q~~T~ ~l~ ~ z.~