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HomeMy WebLinkAbout020-1409-03-000Wisconsin 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 Bast, Kernon Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~~d Dosing / (~ v Aeration ~~ V Holding _-; TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic I ~~,IYi 1 I Z/ ~a ~ ~r1 s ~ Dosing ~ S~~'-' Aeration - Holding PUMP/SIPHON INFORMATION Manufacturer G~4.~u~ Demand GPM o Model Number ! 1 , ~ F. TDH Lift Friction L s 1„` System Head TD Ft Forcemain Lent ~ I Di~ ~~ Dist. to Well SOIL ABSORPTION SYSTEM 2 2 P La~,l./ ~ ., l 1 ., n County: St. CfOiX Sanitary Permit No: 420702 0 State Plan ID No: Parcel Tax No: 020-1409-03-000 Sectionlfown/RangelMap No: 24.29.19.2561 ELEVATION DAT ~ STATION BS HI FS ELEV. Bench k r 1rGln.,~ ?•Q~ - I ~ (~J.~ ~ ~ ~ ~ S , Cc~ Bldg. Sewer 162.~i , D Q.Gi St/ t Inlet IoZ. ~D'3`J' SUHt Outlet Dt Inlet ~ w l 6 s ~(O ti ~ Z ~ .._~ Dt Both PIS ~. ~ - • 1 G Dist. Pipe, v~'S (J O `~ ~ ~ t~ Bot. System ~ I~ /~~ ~ l ~ l ~ `~ Final O~~ DOYY ~~1/ ~D,S.~ s~ / ~~• 6 S 5.0 7-q ~~~~ • ~ f 02 ~ ~ ] .-~1 ~,~~ BED/TRENCH Width I ~ Lengt I No. Of Tren es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ - SETBACK SYSTEM TO P/L BLDG WEL LAKE/STREA LEACHING Manufayture INFORMATION T Of S CHA UBER O / yp ystem: 0 ,~ 'ZS/ ~ ~ I Model Number: DISTRIBUTION SYSTEM - 7 lUo p%f Header/Manifold t h Distribution ( Pipe(s) ~ ~' / h t / ~ x Hole Size ,~'" x Hole Spacing Vent to Air Intake / Length Dia Lengt Dia pacing SOIL COVER --- - ___ x Pressure Systems Only xx Mound Or At-Grade Systems Only _~L ~t.(,'f7ti ~.tt~ 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 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~(/~~ Inspection #2: i I Location: 828 Hidden Lake Rd Hud~,s!on~, WI 54016 (NE 1/4 SE 1/4 24 T29N R19W) Boundary Ridge Lot 3~ Parcel No: 24.29.19.2561 1 J Alt BM Description = ~ST~~p VGI`~ ~Q~`' 81~~ -~~~~~~ 2.) Bldg sewer length = C Z 1 ~GM (,~ d ~.C/ ~ 6 1 ~,~ - ~(~~ ~ Q~~~-ti~0, ~ ~~ -amount of cover = ~~~~,~e~ J_c ~~ ~/ Plan revision Required? I~ Yes ~" No i r- l Use other side for additional information. ~ ~ ~ D~ I _~~!Z~`L.~%r-l.~- ~'~~!1/~~ _ i ~ -~' ---~ SBD-6710 (R.3l97) Date Insepctor's Sign lure Cert. No. an n.e„Fl~ w'sa iu~,e G ~` Safety and Buildings Division County • C{~ x ~ 201 W. Washington Ave., P.O. Box 7082 ?~ ~• ` ,~~O~~~l~ Madison, Wl 53707 - 7082 (608) 261-6546 Sanitary Permit Number (to be filled in by CoJ !~a O ~~ ~.. Department of Commerce Sanitary Permit Application State Plan 1.D. N tuber ,~~,4 In accord with Comm 83.21, Wis. Adm. Codesonal information ou vide may be used for secondary ptaposes ~y ~~C E IV E D ~~ Address (if di Brent than mailing address '~ ~ z ice ( .t ~2g ~ t e ~ - Z 1. Application Information -Please Print All information ~ ~' ~~~~• Property Owner's Name Lot # Block # lingAddress ZONING OFFICE wner's Mai O prop ert y Operty LocatloA ~~ ~. ft Q r -` T'~ ~,.Ik' ~ ~ ~~ y~ ~ '/., Section Z~ Number City, State Zip Cade Phone t ~Db~ L. ~~~ ~ ~O J ~ ~ - ~ p T ~ / N; R~E ot~) f Z ~ ~ I 11. Type of Building (check all that apply) ~C 1;~ -~/t/ ~ ~ W~tNI bdivision Name CSM Number or 2 Family Dwelling -Number of Bedrooms ti K~If4tLIq ~. ^ PubtidCommercial -Describe Use ^Vdlage ~1'ownship of Daa~l ^City ^ State Owned -Describe Use _ 111. Type of Permit: (Check only one boz on line A. Complete line B if applicable) A' New System ^ Replacement System ^ TreatmenUHolding Tank Replacement Only er Modification to Existing System list Previous Permit N umber and Date Issued B. ^ Permit Renewal ^ Permit Revision e of ^ C1»g ^ Permit Transfer to New Before Expiration Plulrlber O"'n~ IV. T of POW'TS S stem: Check all that a 1 Non -Pressurized ln-Ground ^ Mound ? 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recireulating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip line Gravel-less Pipe ^ Other (explain) • Z~ I3'lH 1 - • - ~ V. DIs rsaUTreatment Area Information: - Design Flow (gpd) Destgn Soil Application Ra sf) Dispersal ea Required (sf) Dispersal Area Propo~(sf) System lev on ~ - 5-~f ~So tm p.~ ~- ~~ $~F 9b.a R ib i er Plast c apnu~facturer J~} Prefab Site Steel F Vl. Tank info Capacity in Total Number ~~M, /j ~ D`~ Concrete Constructed Glass y~ Gallons Gallons of Units J (/ ~`~ ~i ° - _ , Ncw Exieting (~ Talcs Ta[Jca y1 f '1`a ~• / ~ ~. ~O ~ / i Scp[ic arFFeiditl$ l ob it Dcning Ctwmbcr ~ V Vll. Responsibility Statement- 1, the unde ed, assu r ponsibility for installation of the POWTS shown on the attached plans. siness Phone Number B u PI is Name (Print) PI 's Si MPlMPRS Number s t NZ Iy~P 13 ~ roZ = 2 - L~'f ~f lC1 p 1 . Zia Plumber's Address (Street, City, State, Zip ~' S'609 7n S `~' ~9r1 E E',~/p~t n~ i E Gvl ~ y ~ tS'i VIII ount 1De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued 1 mg Ag t Signature ( s) Approved ^ Disapproved Surcharge Fee) ~/ S` ~ 02~ 63 Q Y-P ~ , ^ Owner Given Reason for Denial ~%e-~^ c~ ~ I Conditions of ApprovaUReasons for Disapproval ~ ~ _ Attuft tc pines (to t6c Cou`ty~o he ayste on paper oot kss tlua I/2 s I 1 iac6e• is size / ~.~( SBD-6398 (R. 08/02) 1-~Lo 1 C'Y-vI-I`1 K-~I'lON k7M5r ~-- vorirrct -~~~--ter- •.•h,~ . ~ NE ~~ Z-'-E Z°I. L9 Tou~~ ~~ ~osovt T.L. Sinz Plumbing Inc. B~ ~ ~l o ~ ~ o~ ~ S~ 3~' ~'~'"'' E5609 708th Ave. ~ T 3 Phone: (715) 235-2644 Menomonie, WI 54751 ~T C.('o r X ~D . Fax: (715) 235-2592 No ~~ ~ ~~ = $O~ r ~vi-6~T ~~p~Iooo Cow~t3o Zrl~t.-c b~-l~o ~rl~ I~p~oNCµ-~iL Sct~~ 30 `ovwt~ O W~ ~ ~~~ ~ ~~ ~( Pte, 1. . ~ a~ s •62 ~ RI ~,wt~l loo. 2' ~ ~ 2N5T~-t~ Z 2,T1~ (~ ZS FDr'GP, ~~~ 5~0~ 1uF~~lfr S M1-.4~. n ,~, ~ ~3 ~~~ 3 IIg F..~ ~' oo w~ ~~-_-~ ~-1iwt.0 -- _ _.._. ~ oc~~S Soy S Sr~wc ~~ q~.o q,~bv ~'" Into i rte[-vt-~ ~~ 11 D N fSo~ r ~ Uo vt vice S~, e ~ ~~,ts i T.L. Sinz Plumbing Inc. Bo~~ o~ ~c o~~ 5~3~~ ~~'~"'~ E5609 708th Ave. ~ T 3 Phone: (715) 235-2644 Menomonie, WI 54751 ST Cry ~ ~ ~~ . Fax: (715) 235-2592 ~`~=Soy $~Z~oojz ~ ~ ez ai • 2" ~rt ~F z,~sra~-r-1 Z 2,7~ LS,ZS . , , Nn.w-t h ~~ ~ S t'x,v0 k+C~ f f r~-D~cGS o j ~ Gt ~j bl„+=~T ~GbD/loo Co„u.t3o - ~ ~'3 Z~~ bE-l~D rclf~Ge. ~ ~~(J~oticrc-~r~ SU-~L 30 ~ W~ 3 8~ ~ouw~ ~~ L,,~ oc~ ~ S S Sr~~ ~~ qG~o ~ ~q~bv ~~ W tA73i E t{PRlw1= LOCI ~ ~ .Tk.INCTIOt+ ti/R,.1s~vrwlG t i48~~ . ~ 4u,~cx a+.c.aw.iacT~ PIPC~ RB~EA ~ f U NDtSTU '~ ~ xpi"{ Sa1L Z4° x•A. t~ d~ 4° t~uwunu~ _.. ~ ... , ~ v~~ v~ s /.1st r "r„u.v op+'Kr7v~.R A Korx e~" Q~ ~ 5..~ c>tT ~ur-a ~_ ~AFF~.ES 40 PttG. a .~. at 3' a+To u+~~:•'tt~e~ NEC.TIOKS ~ `+•. a``~Q, ~ - ~vl~ ~ 0a~ .- (;F,7cJr~tO Lem. ~~o ~t , ~~ o ~ ,~ ~ ~„ to~rr.~Er~' . ~~ 83. ~ ~• 14•~ ~,/,.~,, SCPT~c t ~ SP T p DO S t w, ~-~ c. w~ T/~1.1..5 MAUUrACTU0.~R:~~~, - U11M6CR 4P DOSES: ~ .~~PER pJ~~ 7AAJK SizC : ~ Q~L°t - V~ GA,Ll.OUS • .DOSE UOF.4fME ALARM ~lA-JJJ1rACTL3R[Q; S d 1.>~ ti~Yd IASCLIlD1l,JG a-~L~GFi.OW= - -- ~ ~~. G A L L O IJ $ ~"~QOCL ISU,~=JC; . 1 e 1 ~r ~ CAPACITIES: As L~ 17 aWtTGN 'f'yP=: ""Q.++~~ wpb -.......~_WCHfS OR ~ W~1.0~;5 S s Z HUGHES OR ~~„ a~g (,A~L0~.:5 PUMA /'1AUU2<AC7llRCR: tC. MpDEI. -JUMDLR: ~1~8F- 30 V„`~ ~~ ~ 0 ~ ~? iSx: NES GR GAL LG+.~. JWITCK TdPR; AJOT~ PUMP A1J0 ALARM ARC 7J bC M11JIh1UM DISCiiA1RGC RAT ,_.,, 3_,~„_~~M INSTALI.EO pl.~ SE PAF~ATC CtKCE~r,; IERT~CAI. Qr-f[R[llt£ OCTW[Ctl Pul"1P Ord AUD DISTRIb1lTtOA} PtpC•, ~~ FEE7• -a~•I~invrt~~ t Mi1JIA'1UM ~CTWOfIK SUPP4.'~ rRE=~LiRli:.. . . .. ~ .. FECT '~ ~~ FEET or PORCC MA{N X ~.~~ ~ ~I~1o trEET ~l7 ioorcPR~LTtou 1'ACTOR. " ~ ~ TGTAL Q~IJAMtC NSAC +s oil • G ri ~'~ ~ ~'..• f>LE . 1 ~~,~ ~,L'~ ,~reR~,tA~, o~M~u4~ai.lE ~ar T11iJK: t,EAl6TH : W ~ b T N .,_,.,~~ ~ ~. Zd WdS0:60 I00Z ~Z 'hpW 860 €5=Z SQL 'ON Xti.~ ,Z .. iD Of PT K ~R~l ~ r~ t~ ~JN I 1SSl 1 I OS QS I d I 12lSO W02~d Pump/Motor Unit Submersible Automatic Model SHEf30A1 Horsepower .30 Fu6 Load Amps 8.0 Motor Type Shaded Pole (4 pole) R.P.M. 1550 Phase 0 1 Voltage 115 Hert: 60 Temperature 120°F Ambient NEMA Design A Insulation Class A Discharge Size 1-1/2" NPT (38mm) Solids Handling 3/4" (19mm) Unit Weight 30 lbs. Power Cord 18/3, SJTW, 20' std. Materials of Construction Handle Stainless Steel lubricating Oil Dielectric Oil Motor Housing Cast Iron Pump Volute Cast Iron Shaft Steel Mechanical Shaft Seal Seal Faces: Carbon/Ceramic Seal Body: Anodized Steel Spring: Stainless Steel Bellows: Buna-N Impeller Engineered Thermoplostic Upper Bearing Cast Iron Sleeve Lower Bearing Single Row Ball Bearing Legs Engineered Thermoplastic fastener Stainless Steel 9 30 6 ~ 20 s 3 10 0 0 Capadry-U.S. G.P.M. 0 10 ~ 20 30 10 s0 Olers/5«ond 0 1 2 3 Dimensional Data 3'4/2 5'd/8 (89) (, 49) a•-in (pia) 3'4 (~) NPT 3' /2 DISCHARGE (89) 11'-7/8 (301) 9'-1/2 (za1) s"a/a (250) P MP N 3"-3/4 (95) All dimensions in inches. Metric for international use. Component dimensions may vary t 1/8 inch. Dimensional data not for construction purpose unless certified. Dimensions and weights are approximate. On/Off level adjustable. We reserve the right to make revisions to our product and their specifications without notice. ~~ HYDROMATIC Pentair Ptunp Group USA 1840 Baney Road Ashland, Ohio 44805 Tel: 419-289-3042 Fax: 419-281-4087 -Your Authwizad laal Distributor - CANADA ISO 9001 Certified 269 Trillium Drive Kitchener, Ontario, Canada N2G 4W5 nvw.hydromatic.com Te1:519-896-2163 Fax: 519-896-6337 © 2000 Hydromatic® Ashland, Ohio. All Rights Reserved. Item #: W-02-6350 7/00 8M Details Pump Characteristics Performance Data ~ . ~!~ ~~ T . a~ ~tPP~~x • 3 5 Armes '' ~~=~i a/1 /~~~}-T /~E.tTf~l N(r~ II~ rMscons-n bepartmenl of Commerce SOIL EVALUATION REPORT Page , of 3 -ivislon of Safely and 9ulidings m accoroance won Comm no, ms. nom. wue County 5T ~/~ o~ ~ attach con, lele site Pian mull lan on er not less Ihan ©112 x 11 inches In size a p . p p p include, hul not lirnlled Io: vertical and horizontal reference point (E1M), direction and Parcel Lb. percent slope, scale o- dimensions, north arrow, and location and distance to nearest road. • • Please aria[ ail Infotma[lon. bate evlewe y sr~ '~ ~~1 /v r'ersonai inlorrnnlhn ov rovide me he used ror seconder nr oses rivet Lew, s. 15.04 1 m v n v ran 1-' r 1 11 11 G ~~ ' Properly Owner KEI~NoN 1~f1s1" ' ~INA~~~ 5 C perly Location e~ ~/ e ND S~ 114 $i~ 114 S ZT T Z7 N a ~~ ~ (or) W G oI Properly Owner's Melling address 9y8 Gg' /3~tR~~ Tz~ • JUL 2 2 2002 M .3 9lock !! Subd. Name or•66QQM11 C ii w ~~UND~'"y ~;~f~G - Clly Siate Zip Code ffvl~So n, t 1,c~1. ~ 5yo/lP Phone Number ~~~ a"•c~i~~ dy [] Village ®Town Nearest Road ~vf>SoN ~ I3~A/~,ups ~ ~ New Conskucllon Use: ~ Residential !Number of bedrooms 3 - ~ Code derived design Ilow vale ~SIJ ""' ty t3~ GF'b ~_) RepiaCement [] Public or commerctat - bescribe: I'arenl material _ /BASS ~(~f~ sy'¢.t~~~ Flood Plain elevation If appltcabie ~ n• General comrnenis d~.~~rA_ • and recommendallons: d'^ ~'>~~9- TtB~ S vi Ti4~ l_e. die i.~S~o uND Ce.uvR~..~i'o~s.~-_ 5 YsT~~r . ~~ ,~,~.~ tlortng a ~ Boring /od, ~ S ~. Pil Ground surface elev. ft. , Depth Io tlmiling factor in. Solt Apptlcalton Ftale Horizon beplh In. Uominanl Color Munsell Redox bescrlplion Qu. Sz. Cool. Color Texture Slnrcivre Gr. Sz. Sh. Consistence Boundary Roots GPD/fl' . 'Et(gt 'EfNi2 / a Cp /o ye 3~3 - L ~f shk •w~fi~ Cw 31~ • ~j • G Z lo• ~ /oyi2 y SSG /fShie ~-~+~i' GS ~ ~ . Z- . 3 / T S R SC. zfSk~e ~I ~~ ~-i / 5 _ 3~ • 7. S R -----. S~ I ~ ~ ~~R GS - . G ~ 7•S R n~Q . S ors oQ,e ~• Z ~Y (p.O r .~ 'l (.~ j~ - ~ S Irv -{~ ~ s . ~~ ( S(o, oY" - ~.Q,1? ~ 8orinq # Boring 7 2" b y /d 0 • ~ 9h I ~ 1 1Z9 PII vrouna sonata erev. n. vepm ro mm~rng raorvr • "'• Soft Appllcatlon Bale Ilo-Izon beplh Uominanl Color Redox Uescripllon texture Structure Consistence Boundary Roots 6'P UI(1: M', MunseO Qu. Sz. Cool. Color Gr. Sz. Sh. 'Elfin 'Ellil2 3 /oR -- ~ O c - •7 i•Z ~a ~e s - s o.. ~.e / • Z~ ,~+ ~.a' . ,6'~ ~ ,~ s ~ ~ , g' ~~ .g '~ ' Eltluent fli = gOb~ > 30 < 220 mg/l and TSS >30 < 150 mgll ' Eflluenl M2 = 8Obs < 30 mglL and TSS < 30 mg1L t CSi Name (Please Print Signature CST Number I 'RogERT- ~!/6RiG~iT ~.ZC~3ZS . Ihricht & Associates ~~ ~~-" ~~•-~- 7~ S • 38~ • ~l v S Private Sewage onsu 655 O`Neil Rd. Hudson, Wis. 54016 Go 7" -~3 ~. sP~~. ~~sr ~.~ s 3~ K /3/~5T rroncrty owner ~ 11 /D ~/ ~ D /D~ ~ • • /6a Z 3 ~~yyd S 1 - 1 Eoring !f U Storing ~! ~ Gr d f l r ~ parcel IU N ~~ Page of oun sur , hit ace e ev. _ fl. Depth to Rmiling facia In. l Iorizon bepih In bondnanl Color Redox bescripllon Mun n Texture Structure Consistence Boundary Roots SoN n GPIb/n~ Ra . so Qu. Sz. Cont. Color Gr. Sz. Sh. 'EtfN1 •EftN2 z o ~O ~O _ ~ i~ ~~ ~ ~ , y . ~ - l7 ~o~ SL a fshi~ ,~i2 cs /f . s , y~ __~__ 75 -' L /7~ ~f~ ~cJ -- Co s - S. d . d,C. i. Z Boring N^ U Boring U hit Ground surface elev. _ h. bedlh to IimiOna farln- tr. ,, Horizon Uepih mi U l C l Shc nppncalion Rale ln o nan o or Mu n Redox bescriplion Texture Structure Consistence Bounda ry Roofs GP O/4r . nso qu. Sz. cont. color Gr. Sz. Sh. •EfllN •EIM2 Boring !! U Storing , h h„ Ground surface elev. fl. he~n• r., a...rrr.... r,...... ,_ lorizon beplh Uominanl Col r R 8vN /lpplfcation Rale in o Munson edox Uescrip0on Texture Structure Consistence Boundary Roofs GPD/tl' . Qu. St. Cont. Color Gr. Sz. Sh. 'EItN1 'EIfN2 ,. ; Emuenl N 1 - 8OU~ > 30 < 220 mgll and tSS >30 < 150 mg/l. • Emuenl !!2 = BOb' < 30 mgl~ and TSS < 30 rngA. "I he bepaNmenl of Commerce is an cgoal npparlanity service provider qnd empMyer. If you need assistance to access services yr need material in an gilernale format, please contact the department al G08-26G-315) or 7TY G08-2G4-8777, snn.R~~e IR R,mr ~~" ~~ .,~ v ~~ 5 l l~N ~ ~` ~ ~~ ~j0~ S D ~ Gb T G/ ~~t/,2,- 3~y, ~ - ., Z N ~ P ~~ %~~ ~~ r 5 ~o, ~~- 1 o , ID ~ ~ 2 i~ ~ . ~q.3S i3 ~ ~ o,a ~ ~~ .~ ~ 3~ d r ~ ~ ; ~ ~i f° ~~~p~~ s 7D~ , Imo- ~ ~o . _„0 ~ j ~ ,,.,~,~ `~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN. Page of FILE INFORMATION Owner ~ ~,,. ~ ~~ Permit # ~ () DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ,0'NA Estimated flow (average) app al/da Design flow (peak), (Estimated x 1.5) ~{s0 al/da Soil Application Rate 0,"') al/da /ft~ Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent Quality Monthly aver age Biochemical Oxygen Demand (6006) 530 mg/L Total Suspended Solids (TSSI 530 mg/L NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ye in di ^ NA Other. ^ NA "Values typical for domestic avast/e~wla~t~ernand septic talnk~e~f7fluent. ^AAII~ITC111 A111f~C Cl~YCr1111 C !// /1 /Y/~/ / JK ! L~ /( SYSTEM SPECIFICATIONS Septic Tank Capacity al ^ NA Septic Tank Manufacturer "'~ O NA Effluent Filter Manufacturer ,~ ^ NA Effluent Filter Model pp ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer af~.tl'~ ^ NA Pump Manufacturer r ~~ ^ NA Pump Model ~:y ~F ~.p ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ~ ^ Peat Filter ^ Wetland ^ Other: O-NA Dispersal Cell(s) In-Ground (gravi t- rade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA GVr' wr -v•~~ Service Event Service Frequency Inspect condition of tanklsl At least once every: ~? ^ month(s) (Maximum 3 years) ear(s) NA Pump out contents of tankls) When combined sludge and scum equals one-third IY,1 ^ NA Inspect dispersal cell(s) At least once every: 3 ^monthls (Maximum 3 years) earls) ^ A Clean effluent filter s ~,~ least once every: ~ ^ monthls) yearls) NA Inspect pump, pump controls & alarm At least once every: ^monthls) year(s) ^ NA p ls) ~ NA Flush laterals and pressure test At least once every: earl l Y Other: At least once ever y~ ^ month(s) ^yearls) ,q 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 tanklsl to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals onRd-third IY,) or more of the tank volume, the entire contents of the sank 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. ,~ f , Page of ,START UP AND OPERATION For new construction, prior to use of the POWTS check treatment rankle) 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 ce(lls) in one large dose, overloading the celllsl and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist~in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction of elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails rep( ent system: A Suitable rt.,..,.__..._... _. __ ..__ ____. sys em. he replacement areas ould be protected from disturbance and compaction an sou a in ringed upon by q~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 si has not been evaluated to identify a suitab ment area. U on a soil and site I ~' valuatio us a erform~ a replacement area: If no replacement area is available a holding tank be insta ed as a sort to replace the failed ~OWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~ ~ ~, a f..r Phone ~ ••. '~,5'~ Z.lo~ on~~rrc ~~n11UTAtN~R Name (~. ~ (~,1 Z ~' ~ ~-- Phone ~ ~.. 3~.- ~ l~ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ,sr" r0 f X t;`' O t i~ Phone "j S"~ '~ (p - g~ This document was drafted in compliance with chapter Comm 83.2212)Ib)(1)ldl&lf) and 83.54(11, 121 & (31, Wisconsin Administrative Code. and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant Feh 18 03 D1:20p HonOe Excevati~-g [7151796-2519 p-2 sir c~a cw ~,iaT zc ~rANIC ~ O~ CBRTI'~CA'I'ION FORM Q_ r'~ ~- D'f ! ~Dri - r iat~in~ ddreas ~ ~"' ~' (2 ~, ~~~ ~~ dtes9 ~ Plana+o8 Dept fog truer N;oa toq„hoa ~ ~ ua ~ ~. Paeeel Identification Nuunber ~ ~ `^' ~ty/Stst a i ~ ~ 'I'X ~ ~ Z T,~ ! I~I-R-~-~-•~' Town of ~L-----~-- 'ropatY ~,ocation ~~'~'~ ~- y., Sx. _ c-~. C~ ._ _~ Y,ot # ~ r.. Survey Map # Volume . ^.«~ ~; Pie ~ O 1 --? ~~ ~ .Volume Wsnaa paed # '~'~ Lot tiaes id~cna5iable ~ Y~ p no spoo ho a y~ ~ °O taSa tsfd °f youx ce4p° ~ t~oda4 by tt Ucens~odpasmiPu~ ets~ Pi's out Ibe s~ptvc ttuAlc ew,ty ~ y~ ~ ~ ~ w~p. ~ ayatons. . qIR tt![ 8:e oC the aeptu tao1~ es a tceatmeut ~ . fbt>n. ~ ~ tbs owpcr ~ awsKx ~ to a~bmit b St. Cxo6[ ~ogtltat (i) lire ~'~° fall of oludae• joectpsymQa Plwabw ~d~edplwubea (~ neoessat7l)~ ~ ~ ~ ~ Mess ttndn If3 o~~g eoaditt~aa aedlor (x) aSot ~i10~'oa ~~ matnte~a the private s~6o dispos:i ~ ~~ r!~ is ~ u~:, V~nc. th+e 1~ave Head the abava~~ ~ the Ucpatlmmt °tNa ~l~ StR ~~o~l- ~~ Offioo dr•.tfua 3 ~~ - .s uc~+ m~ ~~~ ~labod and c o ~Q,.,,lulge. [ (wo) am (sre) tt~e owiuds) of ~r~rTP'IC~~4~Y ( ~ I (*"e~ eeiti~- that all ttakaxnxs oa this fotm~ t~cdod •~ of Deeds O!'fu°• d~bod abovo vitae of a wattauh' ~ ~ (~"~ ~ ~~ D/ti'T.....- g --- t beist8 cavclcrd hX t3us 7.06 qoa that is t~ti~-nP~oaO°~ ~'y ~t in the esdtary P~~ ••••• Ilay bofo~mi dR.~ ~m at Dooda afEtc~ •. ~d vrlt6 tbls aPPlleafloa: • ctamp~ rwaaca~Y od cocvaY P u ~et~,e ~ mado fa the patsaatY decd a Dopy of the eestlR . i~ ST~CTE BAR OF ~SCONSIN FOAM1-3W0 WARRANTY DEED Document Number This Deed, made between David A. Larson and Lea Ann Larson husband and wife Grantor, and Kornon s. $ast,andDonalda J. Seer-Bast. husband .,a ; ~P - Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum): That Part of EySE}r Sec/ 24-T29N-19W described as follows: Lot 3 of Certified Survey tdap recorded in Vol. 11 of Certified Survey P1apa, page 3151 as Doc. No. SdB751. 678ta01 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CRUIX CU. , MI RECEIVED FOR RECORD 05-03-2002 8:25 Alf haaat~uTr oEi:c EXE,'4PT t: REC FEE: 11.00 TRANS FEE: 1312.50 COPY FEE: CERT COPY FEE: PAGES: 1 Arcs Name and Retum Address ~F~ ~- 020-1069-10-100 Parcel Identificuion Number (PIN) Together with all appurtenant rights, title and interests. Thy is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements, and Restrictions of Record. Dated this let day of rtav 2002 . AUTHENTICATION Ry pVe Signature(s) - authenticated this day of i ~_ i /~ ~ \ 1 l ~ TITLE: MEMBER STATE BAR OF WISCON ;t•,tiv~~~~~ (If not, authorized by §706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Michael K Forecki Attorney ,~a~tu.c~ ~~~ o a~/c~c •David A. Larson 7 " eo Ann Larson ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St Croix County. ) ~ Personally came before me this last day of Mav _ _ 2002 the above named ~ David A Larson and ~.. a., T.~ to me known to be the person a who executed the fore o' inst~nt knowledged the same. + / a Not Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: Si natures ma be authenticated or acknowled ed. Horn arc Hoe necess --- -- -- - •Names oCpersons signing in any capacity must be typed or prinud below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 Homey Michael H Forecki 1830 Bracken Avt, Eau Claire WI 5 4 7 0 1462 7 T6046612.ZFX Phone: (715) 835-3029 Fax: (71 S) 8]5-4112 Michael H. Forecki Prod,eetl wiln'DpFarm^' lry RE FamsNN, LLC f 8025 Fiasan Mie Roeq Cliraon Ta«nahp, Mkhpan 49835, (9001387.9905 ~~ $ \\\ .b - ~ h ~NyN .- I~''JJ'',J''J J W 3$ ~~ *r• ~ Nri QO f7 f~~~ ~ ,' •. a~" ~ ~ pZ \ \ \ `OO ~ / ~~ q log ~'' '~~ o ~ ~ ~ ?~ I W ~ ~ ~ ,~ ~ ~ ~° ~ ~ ~~ ~ ~ ~: ~ CV~~p •.. ,\ , ~.' ''. .~ ~2!\ \ '. •LL' ~B9'S5l ,\ \ \, \ ~ \ ~ \ N ~ c~W ~~ Q ~ o ~p~ ~ NCD ~~~ ~~~ ~~ Q~°~ O g~ Q~~~ Z S9'9lE ~'~ ~'~ ~~ ~~ a' ~~ ~' 0 ~ i n..nlti u~'E'V£Z ~~ ~~ ~ e` c: ~ g ~ ~~ c:, ~ ~ is \ . . ~ ~ Y. \ r~ \ fA~2 .I. ,~ '~ ~ -~~~ ~ z ~~ a I- ~~ a~ s ~ ~ y,~ J N~ QU¢ ~`~~