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HomeMy WebLinkAbout020-1395-18-000 (3)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division • INSPECTION REPORT GENE~2AL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Carria a Homes Inc. Hudson Townshi SST BM Elev: Insp. BM Elev: BM Description: ~ i a~- 6 I ae g~ S TANK INFO ATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic 5 I asa Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic y ~ ~ ~~ / 2(~l ~.. Dosing G~tiwfll Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand M Mode u TDH Lift n Loss System Head TDH Ft Forcemain ngth ia. Dist. to Well SOLL~ABSORPTION SYSTEM 1141(k~.._~'..er5/'~~'re.H~, county: St. Croix Sanitary Permit No: 430157 0 State Plan ID No: Parcel Tax No: 020-1395-18-000 Section/Town/Range/Map No: 25.29.19.2412 STATION BS HI FS ELEV, Bench` ar ' ~. ,L D I . Alt. M Bldg. Sewer (~,g5- • a~1 SUHt Inlet ~.$D D q !(~•0 St/Ht Outlet 9.40 • ~~ ~ Dt Inlet Dt Bottom Header/Man. ID• ~ 9~•sz, Dist. Pipe ~ ~O. O ~. ->;'L~ f Bot. System I •Z 1•Za - Z ~ , Final Grade 0'Lt St Cover ~~Ys" a - , /~ t BED/TRENCH Width ~ Length f No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~r ~ ~` SETBACK INFORMATION SYS EM TO /L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufac,r~: (`M'r Type Of S stem: Z1 x 'TT J ( / .,. ~ UNIT Model Number: I Z // . h DISTRIBUTION SYSTEM (La/1o ~d1 K• O• W.) Header/Manifold (~ Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes Length Dia Length Dia Spacing 8 SOIL COVER x Pressure Systems Only 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 ~ No i x . r~r ~ Yes ~] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: V~~~~3 Inspection #2: '~-_---,:.~ Location: 837 Prairie Meadow Hudson, WI 54016 (NE 1/4 NW 1/4 25~T~2,9~N(R~19W) Scenic HiIIs,Lot 18 1.) Alt BM Description = ~. ~~ W'G'lytYtdl~ ~f` S~ P ~ '- s~,~ •',"'"'rL` ~`~ 2.) Bldg sewer length = ~~, ~Y,~.,~, 'at,.~_ ,~fl - am~ ny t of cover = > 3(d ~ ~. 't~'~ ~5 lr'el~~ n e i qulred . ~_ Y s ~o ' D /~ ~ Use other side for additional information. (i_____~ _ _ Parcel No: 25.29.19.2412 G-,IL v'r'/ ,~ -L-~~a - --1 Ce ~, u ~ ~ s ' ., SBD-6710 (R.3/97) Dat ~ ` ~~~ 1J~ ~ natur~ ~~ Safety and Buildings Division Cori' .,+~ S ~ ~ ~ 201 W. Washington Ave., P.O. Box / GYO~ X . lseons~n Madison, WI 53707 - 7162 P~ Site Add~r/ess ~j~ 2`~ ' 3 ~ P~ De artment of Commerce / r b ~ Sanitary Permit Application ~~' Permit Number In accord widr Comm 83.21, Wis. Adm. Code, personal information you provide ~~/ S2 ^ Check if Revision 7 ma be used for seco ses Privac Law, a15. 1 m I. Application Information -Please Print All Information --.-_ ,--_.~._ .._,.. State Plan I.D. Nutt ~[ ~' Property Owner's Name ~ 1 Number ~ ~Q~~.~~. ~ ~~es ~. ~ i p2~ - lags-/~- ~ Property Owner's ' ' Address roperry Location . ~~ f~~ - Y ~cx..d8. ~ ~~;,~~ :. '~ J',i•Sa? To? N,R ~ City, State Zip Code ~.~,.._„ - t Number /~ Block Number Subdivision CSM Number II. Type of Building (check all that apply) .3 o2,ri,d Bd2~ / B~I~tati•~ OCiry ^ 1 or 2 Family Dwelling -Number of Bedrooms ~ 'S~d ~ ~g~ ^ Public/Commeroial -Describe Use pp // i1d7TOwnship t~~.sv.tJ ^ State Owned ~ ~f ~ ,~ ~ ~ ~ / ~~- Nearest Road 2,n III. Type of Permit: (Check only one box on line A (numbering scheme or internal use). Complete 1rne B if applicable) A' 1 ~ New 2 ^ Replacement System 3 ^ Replacement of 6 ^ Addition to For County use stem Tank Onl Ezis ' stem B • ^ Check if Sanitary Permit Previously Issued Permrt Number Date Issued N. Type of Permit: (Check all that apply)(ntunbering scheme is for internal use) ` ,..,~ / ~~" ' " "" 44 ~ Non -Pressurized In-Groin 21^ Mound 47 ^ Sand Filter SO~Constructed Wetland 22 ^ Pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line /~1 ( z~// z 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 ^ Other ,3 , V. D' rsat/TSreatment Area Informati on: Design Flow (gpd) Dispersal Area ./ Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed ~~ Q / / Raoe(Gals.lDays/Sq.Ft.)/ (Min./Inch) IIevation OY o / M1Y ~o ~ ~S ?~' 7 8 s ~ a o ~s ~~~ o r ~ , ~, 'l'ank ~'o Capacity in Total Number Manufac tu rer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks ~ r I ~ /l / ~ /' Concrete Constructed Glass New Existing /.L2 /~ /O ~ 1 / ~ V Tanks Tanks Septic or Holding Tank _ f W~ ~~~, ~, Using Chamber LtJ.` L° /~. "l- VII. Responsibility Statement- >y the undersigned, assume responsibility for lion of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature RS Number Business Phone Number .: a %~N,.~a ` . a a 2 q` Q d !S = ~`C' 3l ~ ~ Plumber's Address (Street, Ciry, State, Zip Code) 6~d s~;~ z~ ,r d a~ ~ ~ G 6" VIII. Count /De artment Use Onl Approved ^ Disapproved ~~' Permit Fee ('includes Groundwater Da Issued su' ent Signs 'o Stamps) ^ Owner Given Initial Adverse Surcharge Fee) ~ ~~5~ ~ / s/ Q ~^ ' l ~2~ Determination G ~~ ~ '^~ . Conditions of Approval/Reaso ~or Disapproval t ~O ~~~ ~~'G~~~ ~~~ ~ /d,,r ~ u-ae- E~'Q ~ ~'-`'~`~ rhos ~ u~-~W7s /~I~~ ~-~a~, ~ ~li~u'~~ ~ ~ ~.t~o-ati z ~,~ plete plain to tpe C y) for the em on paper not I 81/2 x 11 lathes In size SB 398 (R. OS(~~~~~ ~ 3-~. GaYTl cc~_ !0"O.'7'+ ~ y y~~ .Le f /L 3G+-'.y.'G- - f~' /--f `- %_c~w.w c9 0 f7~1.~-sCS/.~/ T "`f ~~ o~/ ~ . b - ~-~ n~ .B3~xS~r ;,~~ 6 5 2$ ~~~,~ ~© t~~ ~~~ ~~~~` _~~ b ~~~ ~ k 5i~y S: tc ~ ~ ,. ~ w~ f = ~4 ~_ ~ 1 ~ .t~uG 14(x_ ~3/~ ~- 1 ~ ~~~ ~Y a ~ s~- G~~'j'"f ate- tE~Of9'a ~ y'' F~~G e ~ /~.5~+~°.ys'C= ~Fi~ ~` / G!*~// cs P~ ~l.~sQS/~ T _ -_, ~ __ ~~~b ~~~ a,8~ s ~ ~~ ~~~/ r ~- chy~ ~i ~~~f a •B3~x8~p~,,~~ 6 ~%r~ ~g G ~, r^ ~~~~ ~~ ~® D~ G ~1 ~~ ~ ~~ ~ i~ ~~w ~° ~ 5=.,~ s.` tG ~~~ ,~4 Qy v ~W~ ~i~1 ! 1 ~~ uc tDr SEPTIC TA,~iK ~ ~'UMP CHAM? R ~~ ~ECT:TON AtJD SP£CIFTCAiTGtvS _.___--- ._r______--- ~" CI VENT PIPE 12" MIN. ABOVE GRADE ~ MiEA~'HERPROOF JUNCTION BOX APPROVED >_ 25' FROM DOOR, WINDOW OR WITH CONDUIT CKV~R ~PAD~ W FRESH AIR INTAKE O / --WARNING LABEL FINISHED GRADE 4" C I RISER ~ ------ _,_ ,}~,,,,,..,._ ~ „ MIN . ~, ~~ 1.8 " I N ~ ,,,_,,, 6 " MAX . : • ~ ~r , ~~ ~ CNLET ' fr ! , WATER TIGHT SEALS ~ GAS ' TIGHT ~ 4~ VApPROVED A SEAL ' ~ JOYNTS WT7'H ..,,.f._ ALM , APPROVED PIPS ~PPROYED 8 , ~ ~ SON ~ 3' ONTO 'IPE 3' ~F"` ~ , SO~.ID SOIL INTO-SOLID TOIL PUMP OFF ELEV . FT • ~ ~ ~ OFF ~'~ RISER EXIT PERMITTED ONLY D IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECSFICATIONS SEPTIC / DOSE TANK MANUFACTURER: G/ ~~ ~r NUMBER DOSES PER DAY: TANK SIZES: SEPTIC 1as-d GAL. DOSE ~8~ GAL. ALARM MANUFACTURER: .ra ¢~ MODEL NUMBER: ~ U SWITCH TY F£ : e r _„_,....,_ DOSE VOLUME INCLUDING FLOWBACK: 159' GAL. CAPACITIES: A = ~ INCHES = _J~ GAL. B ~ 2 INCHES =GAL. PUMP MANUFACTURER: _,,,,~acr/~'.~' C = ~ INCHES = lG.._._S GAL. '"~ MODEL NUMBER ; ~' D ~ ~ TNCHES = ~~_GAL SWITCH TYPE: ~ RE~UiRED DISCHARGE RATE ~„ GPM PUMP ~ ALARM WIRING AS P£R ILHR 1fi.23' WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 12 FEET + MINIMUM NETWORK SUPPLY PRESSURE F£ET + ~(J -FEET FORCEMAIN X ;1•`0 FT/I00 FT. FRICTION FACTOR /~~ FEET -- TATAL DYNAMIC HEAD - .3 F£E'= INTERNAL DiMENSIQNS OF PUMP TANK: LIQLTD ~~,,,~ ~DTH...=.,.~; EmER~I `~`_ SIGNED: ~.~.~"~ ...•.~- LICENSE NUMBER: ~~d DATE; .~ +~~ 1/88 @52312@@3 1@: 19 1- . ~~- ~, 17154256864 APPtJCAT10118 SpeciiicaRy designed for ~ following uses: Noffluent systems • farms • Heavy duly sump • Water transfer • Dewaterlnq SPECIPtClItIONS Pump: EP04 Solids handtinq capebiGty. ~/: maximum. --, • Capacities; up to 55 GPM, j •~ • Total headx up to 24 feet. / • Discharge size:l'/i NPT. ' • Mechanical seal: carbon- . rarity/ceramic-stationary, BUNA-N eiastomers. • Temperature: 1tk°F (40°C) contlnuaus 140°F (60°G int~mitteat. • fasteners: 3p0 series stainless steel. • dryvvlthieolA nderr Qe to components. Pump: Et'05 • Solids handf+nq capability: ~' rraodmum • t.apaaitfees: up to BO GPM. • Total heads: up to 3i feet. • Oischefpe siza:l ~fi' NPT. • Mechar-ical seal: carbon- ~Y/camrrric-stationary, BUNA-N elastomes. • 104°F (40°C corrdnuous 140°F (PO°C) interrnittent. %~ ~ 19YE Qoube Pump, Int. • Fasteners: 30D series stainless steel. • dryw5ittroutdaninp maQe to components. fito:or; • EP04 Single ptease: 4.4 HP, 115 or 230 V, 601•it,1 a5Q kPM, built in overload with automatic reset. • EP05 Singla ph~e: 0.5 Np, 116 V, 60 Nz,1550 RPM, built in overload with automatic reset. • Power card; l0 foot standard length, l6/3 SJTQ with three prong grounding plug. pptiana120 foot length, 16/3 S,lTW with three prong flrcundinq plug (standard nn EPO3~. ~ ~t yo~- 9 e z ~ s a 0 41 Y w 2 a WEGERER SOIL TESTING PAGE 18 Goulds ~~ ~ °~ ~ Submersible Effluent Pump ~~ 3871 EP05 • Fuliysubmerped in high grade turbine oN for lubrication end efficient heat transfer. AreilabN for eutemattc end meuatel operatloa. Automatic models iaai~e Nlesbenicei Float Swllch eesembled and preset et the feotery. FiEItTURfri ^ EP04 Impeller. Thermo- plastic Semi-open design with pump out vanes for mechanical seal prot~tian. ^ EPOS Isrpeiler. Thermo- plastic eaeleeed design for improved perfom~ance. ^ Casing end Base: Rugged thermoplastic design provides superior strength and corrosion resisteitce. ^ Mofor Hoaslap: Case iron for effiaent heat transfer, strength, and durability. ^ Motor Boxer. Thermopias- tic cover rvth integral handle 'and float switch attachment paint3. ^ Rower fable: Severe duly rated oil and water resistant. ^ Beeritt{pn Upper and lower heavy duty ball bearing construction. A®ENCY LISTING ~~ gauiu S Jlsaocielioa (CSA listed mode! numbers end in "F' or "AC".j ~ ' .~ ~ so ~ ~ I ~ i ~~ ~ , i} ~~ ~ ~s 14 i i ... ,~ ~ ~w ~~~ 1 ~ 5 °a ~o s o ~ ~ o .: s a ~ c~ L ~ a E 4 e 6 ~ tip 12 re+f~ CAAACrrY vYisc.orrsinDepartmentofCommerce - SOIL EVALUATION REPORT p Page I ot~/ Division of Safety and Buildings 0 3 ~ Q7~L-rv /~IOG/fm,~/ • m aoDOroance wrm ~orrrrn u~, vvis. r-am. warx st Pl m i 8112 11 i h i -_ --- ~' S -f-. c ra ~' ze. an u x es n s nc Attach complete site plan on paper not less than inducts, but not Ilvnited to: vertical and horizon~t reference paert (BM), direction and distance to nearest road. percent slope, scale or dimensions, noRh arrow, and I Parcel LD. , Z O - 13 Q S - ~ . QlIC~ 0 ff ,Please print all f n ,._L r~/ f 1, by Date Personal infotmatiorr you provide may be used for (F'rivaoy La~i,~. 5.04 (1) (m)). ~~ ~Vj~ ~~ " ~ (/ H ~ ~~ / ~ Z Property Owner ~ ~•,. ~iC 1. ~.~~~ ~ ' :P ~Y Loca • . : Gmut. Lot N t 1/4 r\s w1/4 S~ T 2 N R (9 E (or Property Owner's Mailing Address __.~, ,'~` s`I '~ ~ # Block # Subd. Name or CSMii: ~ ~ Z.O s-~• i ~ ~ W ~ ` AO~r r' S e City State Zip Code ;.PI`rgne N _ G n~Fk;E ~ ^ Yrllage (~ Town Nearest Road . . ~Sti'Ilw«•~r t'Ytr\.. ~'So~Z ( ...~'~-Zy ~ s ><~nn ~. ®New Construction Use: ® Residential /Number ~ rdorits% Cade derived design flaw rate DSO ll0 4 O GPD ^ RepHaoement ^ Pub6c or commercial - Desabe: Parent maberiai OU fc.,JG~-S (~-~ Flood Plain elevation if applicable ~ 38 • ~ R• IGeneralcomments s s~ „1 ~,~ ~.~a o sys~ ~ ~ and rec~mmendatbns: ~ •~• e. I .e, ~ a d-,b >~ - . q g . ~ ~~~~ out ,f ~.o' ad J2 O. t{ ~ 60v~ ~ ~~ ~ p,7 -- wa~wf~~° -~ ~o~:eS ~' ~ . ~ J .. _ Boring . ~5 n a r ~ G ow ~rrt.~ rr w. ~ ~ ,,,,~ ° .~ ~ ~ u^^....--Y - Boring # II~~11 Cpl Pit Ground surface elev. 91 •1 ~ g• Depth to limiting factor f ~~ in. Soli ' n Rata Horizon Depth Dominant Redox Descx~tion Texture Structure Consistence Boundary Roots GP D/f(~ in. Munseti Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'E~1 'E~ I o- I lO 3 -- si l 2 k cs t v .~ . 5 • 8 Z 12 -2b i r y ly -- s' Z ab k mfr- c S - • 5 • ~ 3 zo-io8 r ( ~ rn5 Ds ml -' . 1 t. z ~~ # ^ Boring ® Pit Groundsurfaoeelev. 9~. ~t~ ft. D~th to limiting factor l 1 D in. ~ ~ Horizon Depth Dominant Cob Redox Desaiption Texture Structure Consistence Boundary Roots GP DIft? in. Munsell (hi. Sz. Cont (:olor Gr. Sz. Sh. ~ 'Eff#1 'Etf#2 ~ o -B to -_- - 2r~k . c s l v ~ • 5 • 8 2 S-2~ !~ ~ y ~y - s<<.1 Zrna k ~ rY->~t c:s - . 5 3 Z~-ilk ln.,~yl~., - mS Asa mi - - • -~~ I. 2 kvl`'C' ~ ~n`'/~~„~ '7 4/ ~ S~ lrY~ ~ Si s ' Effluent #1 = BOD9 > 30 _< 220 mg1L and TSS >30 < 150 mgll. ' EfliueM #2 = BODg < 30 mglt. and TSS < 30 mglL ~'T Name {Plearse Print) Sig. CST Nun~er ~~ Date Evaluation~iMuctad Tele~one Number 2!/ 3 &b'~ Sf S6rncrSef t_i~l 5yOZ~ ~ -J-O/ --15-2y~'y~g p~~, O~~ Q„y- ~~. ~ ~ Parcel ID # Page z of_ 3 . 3 Boring # U Bow ®Pit Ground surfaceelev: ~9 •~ ft. Deptn to limiting factor l~ O~_ in. Soil lication Rafie D th t Color D i Redox Description Texture Structure Consis6anoe Boundary Roots GP D/it? Horizon ep in. nan om Mansell Qu. Sz. ~ Cont Color Gr. Sz Sh: 'Eff#1 'Eff#2 I O-I 10 r3~3 - ii Zrr~b rr,-~r ~S __ l.r-~ • 8 Z it-! 10 `•I - nn 5 oS m i -'1 l - z~ <i S, ~ 7. Z `~ ~3 2~~ ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limifing factor in. ~~ iration Rate Horizon De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff p in. Mansell ~ Qu. Sz. Cont Color Gr. Sz Sh. 'Eff#1 "Eff#2 Boring # ^ Bonng • ^ Pit Ground surface elev. eft .Depth to limfing factor in. Sal ication Rate Horizon De th Dominant Color Redox Description Texture .Structure Consistence Boundary Roots GP DIfi? p in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 "Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 <_ 150 mglL " Effluent #2 =GODS < 30 mglL and, TSS _< 30 mglL 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 (R07/00) . -. z PAGE ~ OF_~ NAME 14 Y` K~-~ ~ LOT# /~ LEGAL DESCRIPTION,(~k '~atiu1'/4,SZST2~x NR KjE(or)~ SCALE: 1"= yD , BM I ELEVATION /OCR • d K BM 1 DESCRIPTION -~o ~ o~ I z ~~ P ~ c- p .' ~ e •` t BM 2 ELEVATION I ~1. o~ ~ SeG, Z BM 2 DESCRIPTION ~,~0 0~ 1 L~yc P~ P~ SYSTEM ELEVATION 9 ~ ~ 9 ~ ALTERNATE ELEVATION q s• ~ o CONTOUR ELEVATION q~.o~, 99'•Oo, /d~- a ~- pro oSe~ (td ~201•c~ ' Q~.oo 89' ~.~ •~ 0 z~' 8.~ a3 , ~ . /~6 ~~ ~, G ~ • ~a~~-~- ~~ ~~ Q'3 ~~~ Gd~~ ~ 6"~' ~TZ ~ ~~ , SIG TURE s ~,\ -C DATE ~ - ~ - G SEPTIC TANK MAINTENANCE AGP.EEMENT AND OWNERSH[P CERTIFICATION FORM OK~ncr/f3uycr ~~YY,`a-c~-~- f~d'ht ~~ ~~v~ Mailing Address ~l~' 3~ ~ a t^~S Esc ,N' a.,~/ ~- ~ ~ ~~ ~`~ nz ® i12,lJ ~.,5~ O fi,2 Property Address , ~ ~~ % /l `max =~ ~ y' ~` ~ l~'1 ~~ (Verification required from Planning Departrnent for new ~ty/s~ Parcel Idcnti~ication Number Qom' 13~~' /rt'- T.F,GAL AESCRIPTION - o ~~ v Propcxfiy Locarioa ,~0~. '~., ~ ~~., sec. ~.5' . T~_N-RAW, Town of _1_~~°~ . Subdivision s' C ~' ,U.`~'- ...~> ~ rl ~' .Lot # .,.~~. Certified Sarvey Map # .Volume _ .Page # wt~rranty Dead # ~ ~/i~~~`~ . val~a JG G :~ . Qaga # ~~~ Spot hatise (~, yes ^ no I.ot tines idcntsfiable yes ^ no S~S~„~VL MAINTf~NAi•ICE . Imiaapa use sad raamtea:aoc of your septic tystem oouId result im its pr~efaiTzsc to handle wastes. Proper aramicdance ooasistt of pmotpiag oat the septic txak every three yeas or sooner, if needed by : Ii;oeasod prtaspcr. What yon put iffio the tysGtm . exa atioet the fime~on of the septic tank as a tzeatmrszt stage is tine .rssae dL~ul sysoem. 'Ibe property avPnac agues to txthmit to St C~viz Zoning Depaz~te:nt ~: ~ foua, signed by the owars and by a ~PI~y~P~ restridcdphnmbexor:lir~atodpuarpervaifying tt>si (I) the oa-site ~watcrdisposalsystcm is is ptvpex opeatiag eoaditioa rad/oc (2) sftct inspection tnd pvmping.(if necessary), the tcpdi,e tank is less than 1/3'full of siudgc. Uwe, the madet:ig~sod hive read the above roquir~ts and agroe tp taaint:ia the private scwsge disposal system with the standards set forth. llertia, ss set by the Depsrtinoat of Commerce and the Dcgart~meat of Natural Resources; StaOe of Wiseonsas. Cctti#atioa stating that yoar eysLem has hexer maintained must be c~nplded and retained to ~e St Cmix t;ouaty Zoning Offict within 30 drys of flue threx year expitttioa date. SIG2~UlTURE OF APPLICANT G= DATE OWNER CERT[I~CA'I'ItON I (we) certify ttatemcats on this form tu+e true to the best of my (our) larowledgc. 1(we) am (an) the ownex(s) of the , by vutrue of a warranty deed cocotdcd in iegister of Deeds Office. io3 SI APPLICANT DATE •.s..a ~, iofornutioa that is rail tedmay result is the sanitary permit being revoked by the Zoning Dcpa,risncnt •••`• ` •• Ioelude rith this apptication: a tta warranty decd from the Register of Deeds ofTie:e a copy of tlu ee:rtifed survey uup if reference is trade in the warranty deed Pa1AfTS OWNER'S .MANUAL & MANAGEMENY PLAN Pei®~ ot~/ FIi.E INF TIOh Owner q-E,~ f{~(pyyl~ ~ ~Il,{Jllf Psrmht L ~ S OERION PARAMS'!"iERS Nufnb~ of i3edrooms ~ d NA Numbs' of Public Faotlity Units O NA Estimated flow (average) ~ Q'Q at/da Deslpn flow lpeskf, tEstimated x 1.!sl ~~ ~ ~lda &~ Application Rate ai/d ntz Standard influ+snt/Efffuent nuaEty Monthly average' Fats, 0!I li< t3rease tFOGi 530 mglL 8ioohemioal Oxygen 13emand tf3Ot)ai 5220 mplL DNA Total Suspended Soitds tTt3Si 5160 mg/l. Pretreated Effluent auallty Monthly average Biochemical Oxygen Demand t13ODs) s30 mglL Total Suspended Solids {TSSI 530 mg/L 0 NA Feaai Coliform tgeometric meant 5104 afull OOmI Maximum Effluent Psrtioia Size ~ to dla. 0 NA Other: ~ NA 'Values tyR~ for domestic waeteweter end septic tank effluent. SYSTIfM 8P8C11=1CAT1ON8 Septic Tank Capacity ,'~ ~ al ^ NA Septic Tank Manufacturer , 0 NA Effluent Fllter Msttufscturer ~,tz !~33 NA Effluent Filter Modal d~J' d NA Putr~p Tank Capacity Q' al i7 NA Pump Tank Manufaoturor rB.S ~Y DNA Pump Manu#acturer ,~.~u/ DNA Pump Model ~ DNA Prstreatm~t Unit Q Sand/C3ravet Fllter © Meohan~at Aeration D Disinfection C] peat Fllter O Wetland D Other: DNA Dlepersal CeiNs) D tn-Ground tgravltyl 0 At-6rsds D Drip-Line O NA D In-Around (pressurized) D Mound t7 Other: than: DNA r: DNA Other: 0 NA MAIN S SCFIIFQtJ1.E Setvlee Event ~~~ Fa1- lra;pe+ct ooaditbn of tank{a1 At least once every: 3 a e tMaxMwm 3 ysaral DNA Pump oat oontente of tankta} When combined sludge and scum equals one-third {Y~? of tank volume ^ NA Inspect dispersal Dell{s} At least onoe every: ~ ntat ~~~ (Maximum 3 yearo} O NA Ciasn effluent fiksr At least onoe every: j ~~ a) O NA inspect pump, pump oantrois 8i alarm At least once every: ..--- m~thtsl d al O NA Rush laterals and preseurs test At least onoe every: .--- D mon tai DNA ' At tenet once every: ..r 0 mon ~jts} DNA Ottwr: Q NA MA~iTENANCE INSTRUCTIONS inepeatiana of tanks and dispersal cells shall be mad. by an individual carrying one of the foitawing licences or oertiflcatlorts Master Plumber; Master Plumber fiestricted Sewer; POWT9 #napectar; POWTS Maintainer; Septage Servicing Operator. Tani inspeotlons must inatude a visual inspection of the tank(s) to identify any misstr-g or broken hardwaro, identify any oracke ar Iseks measure the volume of oombMed sludge and Baum and to check for any back up ar parading of effluent on the ground surface The dispersal cell(s) shaft be visually inspected to check Lhe effluent levels in ~e observation pipes and to cheek for any pondin~ of effluent an the ground surface. The ponding of effluent on the ground surface may Indicate a fallMg condition and requires the immediate notiftoation of the loos! rogulatary authority. When the combtned eooumulation of sludge and scum in any tank equals one-third tY~} ar more of the tank volume, the entire contents of the tank shall be romoved by a Septag• Servicing Operator and disposed of in accordance with chapter NR 113 Wieoonsin AdmittUtrstiva Coda. Ali other serv#oes, including but not limited to the servicing of effluent filters, machanicsl or praswrized Components, protreatmen units, end any servicing at intervals of S1 Z months. shall be performed by a certified POWTIii Maintainer. A sarvioe report shalt ba provided to the local regulatory authority within 10 days of completion of any service event. Page _ ~of v Si'ART UP AND OPERATlOAi For now conatruation, prior to use of the Pt}WTS check treatment Yank{sl for the presence of painting products or other chemicals that msy impede the treatment process and/or da+nage the dispersal celilsi. If high concentrations ere detected have the contents of the tenktsi removed by a septage servicing operator prior to use. System stag up shall not Occur when sail Candltions ors frozen at the infiltrative surface. DurMg power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellist in one large dose, overloading the ceittal and may result in the backup or surface discharge of effluent. 7o avoid this situation have the oontents of the pump tank removed by a Septsge Serviainp Operator prior to restoring power to lire effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels v+rithin the pump tank. Uo not drive or perk vehicles aver tanks and dispersal eelis. Do not drive or park over, or otherwise disturb or compact, the area within 18 feet down slope of any mound or at-grade sail 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 burrs; condoms; cattan swabs; degreasers; dental f#oss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; cif; pginting produote; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails andlor 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: s Ail piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of ail tanks and pits shall be removed and properly diapoaed of by a Septage Servicing Operator. • After pumping, all tanks and pits ahaii be excavated and removed or their covers removed end the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN li the POWTS fatly and cannot be repaired Lha following measures have bean, or~must be taken, to provide a code compliant replaoement system: D A suitable replacement area has been evaluated and may be utili=ed for the location of a replacement soil absorption system. The replacement area shauid be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, fat lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaktation to establish a suitable replacement arse. Replacement systems must oomply with the rules in effect at that time. D A suitable replacement area 1s net available due to setback andlor soil limitations. Barring advances in POWT£ taohnology a holding tank may be installed as a feat resent to repiaoe the failed POWTS. ~~ D sit sits e rani ^ Mound and at-grade Boil absorption systems may be reconstructed in place fallowing removal of the biomat at th+ infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNiNp> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL SASSES ANDlOR INSUFFICIENT OXYGEN. DO N01 ENTER A SEPTIC, PUMP OR OTHER TRIEATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF E PERSON FROM THE INTERIOR OF A TANK MAY Bin DitrPiCULT OR IMPOSSil3LE. AiiiDITIONAL COMMENTS ' POWT3 INSTALLER Name r`l/,~u ~,.-+ ~.i~GY~ Phone ~ ~ _ ~ _ ~ ,,;r POWTS MAINTAINER Name Phone SEPTAOE SERVICING OPERATOR {PUMPEAi LOCAL REGULATORY AUTHORITY -~- Name Name ~ ~ d 1 x ~ ~ D~~/ Phone Phone 7/5~~3 ~ ~ 6d~b ?his document was drsfud M compliance with chapter Comrr+ 83.Z2t2itbitlitdl&{fl end 83.54(1), {21 & tai, Wisconsin Adrninisirative Code. ~ Document Number .. },...~ .y. ~~,~ 16G2P~~289 648604 Y.ATHLEEM H. WALSH DOGim'°tZSde REGI5TER Of DEEDS S'i. CROIX CQ., WI RECEIVED fDR RECDRD 06-19-2001 12:45 PM WAkkANiY DEED EXEMPT N CERi CDPY FEE: CDPY FEE: TRANSfEk FEE: 9900.04 RECDkDING FEE: 14.00 PAGES: 3 ~. Raording Mca Name and Red~rn Addcest I.-a.l T.-F1z, 1r~ . ! 900 ~'~ lv c r ~.n k e Zoe. Ncw l~irl~l..bn ~ MN SS/1 Z C7Zo - 1 Ob9 ~ 70 - oo ~ Pacrrt IdtntiSntion N®bv AIM (7Z U -- l (~ h4' - DSO - cJ U p p2 n ~ 106`/ -~10 - 0ov C7 20 - 1©7D - coo - Cep 020 - /070 ~ ~v -nv~J U 2 c~ ~- ~ o '7b - z o~~ ~: "THIS PAGE IS PART OF THIS LEGAL DOCpl~'NT - DO NOT REMOVE° Zhu uaaemdoa muu be ooa4leted 6jr abm;~ ~tnr dcfe. ~e ~ rcnan addrcst and N a< rht scondn~ cloaca, ksa! daalPdan, ~ ~, ~ I~ ow ditr ~- Nrc9~~l• odw lywaatdoe cord. docrmw~t ~o ~ We of dlt twtrF4[~ Cdr ant ~ ~r PaK 4f+~ or u'°)' b~Plned we adddond pega of die PaK 7'a~ daeranerct and S2 Ot7 w du rrcv~i « 1Pucrocccin SYmau, S-.S17. 1YRDA 2/AS r: ~' QOCUMENT NO. wwnnAxmTr nnsn STATE OF W19CONBIN-FORM 8 Vl)I ~~~~~` THI[ [-AU REeERV EO FOq q[COROINO DATA THIS INDENTURE, Made bY.RICHARD N. PEARSON and JEAN M. PFARSON, husband and Wife, ............................................................... ...................................................................................................... . grantor. S.. of....St. Cro3.x ...........................................•---........Conntpp Wisconsin . hprebY conveys and warFants to_.._CARRIAGE HUMFS XXI, INC:, a :~ MLnnesota IrorporatLOn, ..................._.-....---...............-....---..........- , ..._.....- .._.._.---••--- ...................................................~ rantee WashLrigi;on ~ii(~yrr~(~~~~{{}}t ........ of ......._: .........................---_.........................----........County, 1~iYc~lflrilS ~or the sum of;: Qn~„Qollar..and-,no1100----(~1: 00)--and..other--good.,and valuable--•!~RETURN TO L,,~.~t:1 T~~It 4'on.8>•41eX~tlorl ............... ......... ......... IS1i3?r/t/.3 /~JC`c Sr I v<t l<tl(e 12e.~. ...-----• ..................•--••-- -~~ S f 2 c E the following tract of land in..._St.r....C.COi.if ............._-...............---••--•-......................, ~rl:'E •~.' ~~ I J ~(~-o „~ M/ti ................................County, ~ s'i/ t Wisconsin: .A~.l,..Q~..~41e..N_o;-(~~w~~•t--Quarter-_•jt~ry~ls;~.-and,-,(~orth•.Half (N~) of the Southwest Quarter (SWtd) of Section Twenty-Five (25), Township Twenty-Nine (29) North, Range Nineteen (I9) west, St. Croix County, Wisconsin, except Lot One of Certified Survey Map filed June 29, 1994, recorded in Volume 10, Page 2782, St. Croix County Register of Deeds, as Document No. 518444. See Attached Exhibit A Parcel Identification Number This is not homestead property • iin Witness Whereof the said grantor. S.. ha°~...... hereunto set......... their..... hand 5... and seals.... this .. ....... day of... ~aY ....................................... A. D., Y-(-_2Q01 616NED AND aEALED IN PRESENCE O[• ....................... ._..........................................................(SEAL) ...................................................................................................... ... .... .....YStrg- 7•- ........ .(SEAL) ~n gSp / ..............................................................................................(SEAL) State of MJ.n(1gSpta ,,,•„-_Was~LngtOn _. ;County. Personally came before me, this.7~:.'.~:.. day of.. ~.`..~......... A. D., iKj`C-..2.9,01 RICHARD N I~EARSON and JEAN M. PEARSON husband and wife• ••-•` the above named ..............._.._....~........................._.... .....................1...................---.........------ -- to me known to be the persons..., who executed the fore8oing instrument and acknorr7ledged the same. ...........................yry............ . THIS INSTRUMENT A>( DRAFTED 6Y ` ~.ARl~X-MOUNTAIN RichaYd J. Ga~rzel, #32864 ~-• NOTARY Notar Public, . "' ~: HQTARY PUBLIC -MINNESOTA Count ' 880 Sibley Memorial Hwy,, #114 'E"L Y ~ My comm.ExpfrasJen.si,~zoos- Yr Wts. -1736 Diy Commission (e71 ' ........................•---............ ".. (section 39.71 (i) of the V7iscomin Stamtta provides That tll irutrumenb to L< recorded skill have plainly printed or typewrittrn th<reon menti~ ~ ~< ~~~~ gfanttea, witnascs tnd notary. $<rlion 79.317 similarl7 R9uirea that the name or the person who, or govern genq whlck. dntled sutL imtmmenq shall Iti printed, typ<wrirten, stamped or written thereon in t IegiLle manner.) WARRANTY DEED STATE OF WISCONSIN wtaeoneln r.ogat Biank OOMDtrtr7 p'ORT[ No. 9 Mtiwsukee, Wle, (Jots 39511 ) .. ` ' y~~ 1G62o~~:291 EXHIBIT A Parcel Identification Numbers 020-1064-70-000 020-1064-80-000 020-1069-90-000 02o-lo~a-oo-ooo 020-100-10-ooo 020-100-20-ooo II ~ I~ w U ~ I • I w 9 j ~ \ \ ~ I ® Q~ N UI tm I I i `` ~ ~ ~ `\ ~, ~ r~~/ ' r "~ ti ~~ ~~ ~~~ ~ ~~~W,~,,~~~ ~ ~`~~"~ ~~ ~u ~l ~-~N ~