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020-1395-66-000
i n v m O ~ _ ~ y _ N ~ ~ ~~c N N ~ ~ O y ~ ~ ~- 7 7 W ~ I ~ I v m u> Z D ~ m ~ D W ~ a c ~ O r. ~ ` m I I y o ~ ~~ ~ ~~ c 3 I o ~ m ~ I ~ m < N a ni 3 i Z o_ I O ~ o' ~ ~ ~ N C W I °- fD ~ Z 3 ~ N =i I ~ w o' I I 1 I I Soy~D N• N ~ ~ ~ Q ~ ooga`D,no ~ ~ 7 ~p y ~ yoo~.~ y ~ ° `D s o;3 =ti N N m 3o.o ~ ~ (~ ~p y 4=y <_.c 0 3 ~ ~ -w _.dy y ~ In p (D a ~m,y»~v° a~~3~° a' ~o~ m.oa~v ' rn wo ~~x ~o . ~ a CD m o °- fD ' ~ O O O ~- n to O °c °.: ~ :. ~ ~ W ', ~ ~ m ~ 3 O ~ ~ ~1 O ~ O ~ j O 3 O I ~ c 2 ii " n. ~ a I, cwt A_ ~ ~ ~ ° ~ ~o - ~ ~ ~ a 0 ~~~~. ~ v o ~ rn ~ p1' W y re y 3°-' co .. ~ '~ o ~ ~ ~ o m ~ a m y A y C C f7 N A p. w ~ ~ `° Q O fD ~ u, a W ~ a 3 °o ~! Z f A G C 7 a 3 ~ o 3 ~ 3 ~ ~a d ~ m ~ ~I C ~ N N N O O ~_ ~ ~ f.J CO O ~ N ~ O 7 ~ W y O O ? o 'D N o c 3 'Y ~ .. ~~ n 2 A ~ ~ -~ ~ e~ A ~ 7 ~ ~ ~ z ~. ~ ~ ~ d ?:. ', 0 '! C fix' C 1• O ~~ v V h A A 0 0 A d 0'Q O~ f0 ti Safety and Buiidings llivi~ion ~ County ~, .~ r 2Cti1 W. Washington Ave., F.O. Sox 71ti2 ~_` ~~d ' ~OnS~n I Madison, WI S37Q7 -'7162 Sanitir Permit Number (to be fll in by CQ.). ~~ s ~ cases 2s6-~ 1 s 1 I De artment of Commerce ~ ) S3 Sanitary Permit Application s~~ Pian 1.D. Tiumber In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ~ /"t ~ may be used for secondary purposes Privacy Law, siSA4(13im) Project Address (if different than mail;ng address) I. Appllcatioa Intorasation - l~ ~~e'~ar~e>^ Property Owner's Na me ~ Parcel ~ Stock tr ~ M,~'~' ~- ~ 2Oi1~ CG' Property Owner's M elling Address Praperry Location ~(~.~ ~`L~~' ,~ 6a- e !~~ ZC KING c~F f c _ I i~~.L y~,S~C/ ',i,Section ~~' Z~`,t City, Staa Zip Code one Number I~ ~ il. Type of 8uildinS (check ali that apply) /~ T ~ N; R, f,~„E ot~y/ ~1 or 2 Pamily Awelling -Number of Bedrooms ~Q/~ ~,L rc~( Subdivision Name CSM Number ` ^ PubliclCommercial -Describe Use ..__. G r ~ 'rllS ^ State Owned -Describe Use Dt.S~C~2,C~S ~ Q ~ 1.s~~'2~i3sa ^City~L-]ViUage~1'ownship of c~so-r/ III. Typ~e-ot Permit: (Check only one box on line A, Complete line B if applicable) A' rd..kvew System ^ Replacement System g p y g y ^ Trearment/Hoid;n Tank Re laratttent Onl ^ Other Modification to Existin S stem B. ^ Permit Renewal Permit RlYision ^ Change of ^ Permit Transfer to Now ~ List Previous Permit Number and Date Issued Before Expiration __~. Plumber Owner ~ ~..~3~~ ~ ~ S-- Q IV. Type of POWTS System: {Check all that apply) I Non -Prauuriaed In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < ?r1 in. of suitable soil ^ At~,rade ^ Single Pass Sand Pilfer ^ Constructed Wetland ^ Pressurized Yn-Ground ^ Holding Tatvc Peat Filter ^ Aerobic Treatment Unit ^ Recirculatintt Sand Filter ^ Recirculatin S nthetic Media Pilfer hin C}yamber ^.' Dri Luie ^ Gravel-teas Pi Other ( sin V. Dls rsaUTreatment Area Information: ~/ ~PJLo Dcsiga Piow {gpd) Design Soil Application Ratc(gpds~/ Dispersal Area Required (sf) Die sal Area Proposed (at) Sysutn Elevation VI. Tank into Capacity in Total Number MarnJfacturer Prefab Site Steel '~ Piber Plastic Gallons Gallons of Unite /~ , ( Concrete Consttucted ~ Glass Now Exisdrtg j vt//~~,t(~V ~-//~l ~/lAr/ 1 ~~ . Tnn4e Tenrc I 0[ VII. Res tuibility Statement- Y, the flmder ed, assume res otssibWty for iz allation of the PbWTS shown on the attached ' Plumber's Na the (Print) Plumber's Si gnatur P MP12S Number ~ Business Phone Number Plumber's A6dre to (Street. City, State, Zip Coda) , I . oust /De sstment use Onl ~ pprov4d ^ Disapproved Sanitary Permit Fee (includes Groundwater A~ slued Is ng ent Signature { ' mps)~ ' Surcharge l;ee) ~/ () ~ y ^ Owner Given Reason for Daniel ~` ~ ~ ~ 1X. Conditions o[ ApprovaUReasons for Disapproval -,~o~~d s _ ,~~ ~ ~ , SyS-~ s~~~~ b-~.l~.:O/m ~' ~; 7' ~~,~1~J ate. Atlaei< eotupeste tlu Cotspty oaly) for the system en paper sot test t5ate 61/i x 11 ipeLes is ales J SBD-4398 (R. 01/03) FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 04 2004 09:07AM P3 zU~.s~ 4'J ~co~'z.. ! ~ alDi ~/7~ ~f~~' ~48~ ~ ,B~n~ ~/i~yc /~.Z 8~ -T- ~~ r lg ~. 3 ~-~~- s~u~s ~G C~'l ~~'~, -~ s~ ~d B~ ~ ~Ga~~ I s °~~~ ~~~ ~.d~~ loe~ ~~ ~ e~~~~~~ ~ ~))~~w ~ W~ y~ ~~ ~. ~ ~ ~~ ~ u~ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GEN~RAI~ INFORMATION (ATTACH TO PERMIT) Personal infon.iation you provide may be used for sewndary 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 ~ / a S U Dosing w / ~~d ~<~r Aeration Q_`' L,. _~ .~ ~T/wr~[ ~Qu~S Holding TANK SETBACK INFORMATION TANK TO P/L/A S[TLC~7 h WELL BLDG. Vent to Air Intake ROAD Septic ,~ i \ 1 J S~ i Dosing Aeration --- ----~ Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift ion Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well ELEVATION DATA councy: St. Croix Sanitary Permit No: 453068 0 State Plan ID No. ~ Parcel Tax No: 020-1395-66-000 Section/Town/Range/Map No: 25.29.19.2460 STATION BS HI FS ELEV. Benchmark /~ ~ // O ~ ~` Alt. BM Bldg. Sewer 3d3~- ~¢- ro' 2,~ /O~'~Z SUHt Inlet 3 . ~ ~ ~- t/ t Outlet /off. Dt Inlet Dt Bottom ~ Header/ n. ASS ~ a [' 7 _ S ~ OZ . 2 Dist. Pipe L ~ ~ %~ Bot. System / 1 ~ , 2 .7 Final Gra e ~I BZ- 5 ' so pos. St Cover ~. ~~ S -. ~ /~~• Z SOIL ABSORPTION SYSTEM ,T ~-, BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ C/~/ ~ OODD SETBACK SYSTEM TO P/LS BLDG WELL LAKE/STREAM LEACHING an urer: INFORMATION CHAMBER OR Q~ T e Of System: Q ~Y r Model Number: ~ /'~ n DI~RIBUTION SYSTEM ~Q~ ~ ~ ~.~ if Header/Manifol ~~ Length~Dia Distribution Pipe(s) ~ t Length~_ Dia ~~ Spacira x Hole Size /~ x Hole Spacing ~- Vent to Air Inta G-~'lIL/ ~v~' ~ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over / Bed/Trench Center ~ ~ Depth Over e Trench Edges xx Depth of Topsoil xx Seeded/Sodded xx Mulched , Yes No Yes No COMMENTS: (Include c iscrepencies, persons present, etc.) Inspection #1: S /~~ Inspection #2: / / Location: 815 Highlander Trail Hudson, WI 54016 (NW 1/4 SW 1/4 25 T29N R19W) Scen/ic Hillss Lo~t~6~6 ,, ~~~( Parcel No: 25.29.19.2460 1.) Alt BM Description = ~~ ~ ~ ~c~ G~ 2~~1~~`-'M"° - ~,~/ ~ , 2.) Bldg sewer length = `S . ~y,( , fj~y,-~ ~° SO' [~~1 ~G~2 a~y~ - (/1~' - amount of cover = i~ ~(~ ~D ,51~0~'~-~ ~ 9~U Yr~LC.ar~ ~ (~f/L~K ~~,L~.,/~yLO~ ~s`~ O °jo ~.2R-~ O. - - -_ -- Plan revision Re uired . Yes No /~ i / / Use other side for additional information. Dale ~C~InsYe~pctor's ignatur Cert. N . SBD-6710 (R.3/97) i D_ _ ~f L~j~L, (/ r~ ~ ~ ~i „n _ L __ FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 Sat'e-y And Buildings l7t~i~iun 2C1 W. WASbittBWle Ave.. P.O. 9oX 71lr2 Mrdiaot-, W1 x:1707 ~ 7162 May. 04 2004 O9:O7AM P2 wnry -~ ~~~yv -'~ niary Pertttit Ntuttber (m hs filled l7 Dy Co.) ~ Ds artment of commerce I (~~) 1t+ti-31.51 Sanitary Per~ait Application ~'"` t~ f~b''~"'°~`r in accord with Comte 93.11 Wis. Adm. Cods, p.nopsl ilitbrtbstion you provide lstay be wed for saeandery putposa Ptivscy Lw, sI3.b4(1XtN - Praeet Address (if difGtrria: then n-aAiat eddross) I. App{lortlou Itdarmotlan - Maare plat All Ilydbrtesatlop ~- ~l S ~' ~~~.1e/ s. roperty t)Wn4's N: me __. Parcel ~ Lot ~ 8lvrl< k i ,B cc i Propergr Owttm's >K ellllup Address Rgpetay Laeatloa I 9'Y~' L _~~, ~o'~ t s +~ oo s ~ ~ Cit 4tese Z C ~, , ec n , '"'"-- "" -"~'- y, od. lp Plwoe Nuptber ~ ~~ ~/ ~ S~Q~G (cilct0y91a Il Ty e of 8 udl h k ( l ~~ rt~N; R,~L „8o . p u c ee nt; V eltet aOply) i ~1 ur 2 FaetUy AWSlling -Number of Bodropna _ ~ '.kt6divbiora Name C5M Ntmtber l ^ PebliclCommarcjal -Describe Us. r ' ~~~a/.S f ^ 5tstt Owned - Describe Usa~ i ~ ^City~^Vlllw~t~l'ownsNip of III. ape aP 14artrslt: (Cbrelt only one 6wt on )doe A, Cotnplte line B ft• appikable) I A' ~e,v Syswu: ~ ^ Replscemeru Syrtem ^ 'C'resoner-t/Hoid:n~ Tank Replacemeurt Only C~ otlta btedNication to Fulsting Syygm g• ^ Psrrtrit Itenewal Permit Rpvuinn ^ C)m4ge o! iJ Pttmit 7Ysmfer to Now i List PYeYieW 'Number end Date IaaueQ i 8efare P.ttpltetit)e Plttmber Owtar ' ~ ~ 1 ~ l`V. Type of POWTS System: (Ch4ak all that ap ply) I ~ Non -PressurLlsrd CtrOround ^ Naund ? yt In, of sui~ble cult ^ Noued a 2s in. of sugsWa soft t~ AeGrtldlr ^ 9igole Pau Sand Filter I ^ troatgtitcssd Wetland ^ !'rsss4rlmd Inlltcx~na ^ Holding Park ^ Peat t=iltbr Q Aerobic : reanftent Uric ^ jGpirGUltatltr~ Band F~:Rer ^ RsvirCUL ' ~ pfhetu Madla piltae Leachi Chsmbst ^ Dri Lino ^ tiiravst-loos (Pi ^ Otltsr i I ~. naLTtaatmant Aeon ra[oetatttloq: _ DetiW plow (®d) AwiW- Soll Application Iilste(~fl Dlrp+rasl Arse Required (sf) Dispsrsai Aron Ptvpased (sfl $yemm n ` . ~Q__ ~ ~ ~_~ r.~; ~ ~ ,mac- ~ - CD 1 t~t+aAWts I of L•nia septa: or nototn{ Tagk _ _ _ __ Con~creta 1 Corrsrrur~e+d VII. Iles W Statement- I. ehe sssuros rapotratlbWt fur ail~tiorr oP ebe Pt)'W1'19 s4owts on sliu axtachei ~ PArmSrr's Ne nrs inq Plumber's Si i~d M Nusltber I Buairwa PAone Ntueeer Ptun~ s ~am~. as ( ~Ct ~ ware. °' I S- ~ rr z>//p cad.> ~ E s~'- ~c ®~'® ~' I . Cotmt opt Use Opl ^ Approrpd Q Disepprevsd ertitsry hermit Fee (Includes GroYttdwatef Dak 1ss'ued lsautrtj Agent SijiuAtrc iNo $iampa) ~ Ci Owner ptvan Raeoo tar Det-ial SurcharSs Faa) D . Cotedldntta or ApPro for Dist~t~mal ~_. -..--.-~~_~.,.-- ~c ~ U~~ I ~JV I '~~ ~t-+er• ti tevMy ee69 ror th. systr, w ~tsr ast Iss rMaa •ws * t1; taeJSr sta. -~ 4Ri)1zOJQ ~>D n, mom. ' ~,, FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 04 2004 09:06AM P1 Sfh~//!IIl~N PlYlatfib/1!~ 1070 SCOTT RD HUDSON WI 54018 Pone 8 Fex (715) 396-3121 DATE : ~~~® FAX ~ T0; ~d~ ~,~' NO.OFPAC+SS; ., 3 RS: ~G7~ /~ I - SP9CIAL INSTRUCTIONS; FROM: * ~. Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in arcnrdanrp with Cnmm R5 Wis Adm. Code 1426 Page 1 of 4 Steel's Soil Service Inc. County Attach complete site plan on paper not less than 8'/Z x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. . . Pendin ~ g Please Tint all i~ ~nfor-nation. „..._ al information rovid 15 04 (1) (m)) P o (3 i s b r c viewe y ti Da~-~ ~l ~ . erson y u p e m y e use ~r va . . y , L. , C~~In• ~/ l Property Owner Property Location ,.~ Bay Pointe Development, Inc ;;, . ,- Govt. Lot na NW 1/4 SW 1/4 S ': T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name . C$M# 757 Packer Dr. na City Sate Zit~~~~P~o~ d ber ~L~ City J Village ~ Town Nearest Road Hudson ~ WI 54016 ~~-~''f"~ Highlander Trail New Construction Use: 1/ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement J Public or commercial -Describe: Parent material outWash Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 98.85ft. Trenches spaced and depth to code 6.OOft below grade. System could be shallower if extreme east side is used. Boring # ~ Boring ~J Pit Ground Surface elev. 104.25 ft. Depth to limiting factor 115 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-20 10yr3/2 none sl 2msbk mfr gw 1f ..6 1.0 2 20-41 10yr4/4 none sl 2msbk mfr gw na .6 1.0 3 41-62 7.5yr4/4 none scl 2msbk mfr gw na .4 .6 4 62-115 7.5yr4/6 none Is osg mvfr na na .7 1.6 ~° ~ ~ ~ 0 r/ / ~ ~-g / I r ~ s ~ ~ . ~ ~ s"~ ~ 9p, -~~ 2 -. Boring # ~ Boring Pit Ground Surface elev. 104.25 ft. Depth to limiting factor 115 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftZ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/1 none I 2msbk mfr gw 2c ..6 .8 2 8-23 10yr4/4 none sl 2msbk mfr gw 1f .6 1.0 3 23-42 7.5yr4/4 none Is osg mvfr cs na .7 1.6 4 42-115 7.5yr4/6 none ms osg mt na na .7 1.6 * Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS <30 mglL CST Name (Please Print) --3ignature: CST Number David J. Steel ~ / 248956 Address Steel's Soil Service Inc. Date Evaluation Conducted Telephone Number 1564 CR GG. New Richmond. WI 54017 4/30/2004 715-246-5085 Property Owner Bay Pointe Development, Inc Parcel ID # Pending Page 2 of 4 Boring # Boring 1~ Pit Ground Surface elev. 99.25 ft. Depth to limiting factor 115 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/1 none I 2msbk mfr cs 1f ..6 .8 2 10-27 10yr4/4 sl 2msbk mfr cs na .6 1.0 3 27-45 7.5yr4/4 none Is osg mvfr cs na .7 1.6 4 45-115 7.5yr4/6 none ms osg ml na na .7 1.6 ^ Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effuent #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. Page 3 of 3 David J. Steel CST-POWYS Lic. #248956 STEEL'S SOIL SERVICE INC. Bay Pointe Development, Inc NW 1/4,SW 114,S25,T29N,R19W Town of Hudson, St. Croix Co. Scenic Hills Lot, 66 1564 Cty Rd GG New Richmond,WI 54017 Bus.(715} 246-6200 Fax (715) 246-9372 Legend 1"=40' • =Benchmark Ele. 100.00ft Top of 3/4" PVC Pipe ~.Bh~no~''~1~r • =Alt Benchmark Ele. 102.85ft Top of 3/4" PVC Pipe ~ =Borings Boring Elevations Bl = 104.25ft B2 = lOtl:25ft B3 = 99.25ft B4 = OO.OOft ~~~ v`' ~q. Pr ~ ~ ~~ j/ 1~Oi~4 ~t ~ r--~ ~ ~" ~~ i r ~~ I " X ' i~~ ~ X? t j ~ i 1 5.4 ;f 06.9 i~ '~ '••'r 1 Od3.7 ~ ` `~' { 8.0 i i ~; }~~ / ; ~ 1 C~ 34.? ~ ` ~ t ~ _..__~ , 1 ~ ~ ~~ ~ ~ ~~ ~ ~ ,, ~ ~ t~ ,. ~ ~ ~~ ~ _. _._- _ ~, f %. ~ ti _. ~ ~i i , .- 1 ~ f t ! • ~ ~ ..~ _ _ ~ - ~ ~ ~ _ ~. O ., .~ :a~ ~ '~~ -~ ~ ~ "" ~ ~ -3 ~~ { ~ `-l'f~~ ---' _- ~ ~\\ 1. ~ ~ --- ,, __ __ -3~, ~, x :; -- ~~, l G2~.1 ~ . _- _ ~ ~~~ :° ..-~ ---~ _ __..r i _.. _ _ __ . .. _ ~~. ~- , z i ----------- ------ ~~ - ~, ~~ --- ~ 1~~ ~ 4.81 ,,~ ~_ ~ __ r ttl w,~ l ~~l ~~j.~7 ~ 0 ` . i •~/! ,.. ... _- -: ~ -- ~ ~, 1023 ~+" .,r -, ,cu _ ~ ~-+ __ - ,~. _ ,. _ _ _.- ; ^-.~ `-- ., i ,._. _ ~ / ~~ ~ ~JI 1 _ .~ 'y ,.J - - "~ ~__--- / ~ ~j i t __.. ~ ~ V ~ ~ j ~ ~ f ( ~ i ~ \ X ~~ r ~~-~ .. t ~ ~--- ___ \~ - `~-~~.1021. t f `~ ; r% _ !~'~ j~~. ~~ '.~~ ' 0205$ i r ~ _ , r ' r ~, Y - r f ~ - ~ t,r4.. , x~_.._..._..._.~ , .....n--_..-~„>r ~ -, a ,.;...,, _ _ ._ r - , .. R ~ t+j~~ r,~ r l ~ - r ~~ -~~, t ' -` j.:S, .~. 7- i ~ / v ~. ,~ ?j ;' j ,`~ 444' ~,, .~ ,, ~, ~~r .~- ~!'1 .. ~-~ "..r ~ S._] ~ ~ ~ ~' ~~a~s~cd~~X' s'~.t~'ti. ~ ll~•:... (r r :~'d~ ". ~Kt,r (i\'~i ~~-j •~+r' ` Safety and Buildings Division County ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~ Q,,,~ «cons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to filled in by Co.) Department of Commerce °~•~ ~~°~-, ~.~ O~p Sanitary Permit Ap lication ~~ ~ state Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, perso info ~t(pn ~~u,prov de ~ may be used for secondary purposes Privacy aw, s % 1)(~n)4 ! ~ ~ Q ~ Project Address (if different than mailing address) I. Application Information -Please Print All Informatio S~ r ,;~ , ,; 7n ~ ~ ~ ~ ,~ r I~ t ~~S (~~ ~~ Property Owner's Na me azcel # Lot # ti~ ~~. ~ ~' 66' Prope r ty Owner's M ailing Address Property ation ? %~ ~~ ~ ~ G ~~ ~~ 'ti~~ 'k u S City, State Zip Code Phone tuber , on ec S ~ 3- G f` (circle o l` ~ II T f B il ' E o T ~ N; R . ype o u ding (check all that appl / I -~ ` 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name CSM Ntunber ^ Public/Commercial -Describe Use ~r ,_j ~ ~ i ~~. ~ j~-S ^ State Owned -Describe Use Dr ^City Villag ,~To nship of t ~ 4 ti . t. III. Type of Permit: (Check only one box on lin A. ompl a line B if app ab a p20 - g - (Q - . 2 A' ~ New S stem y ^ Replacement System ^ Tr nUHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Ch ge ^ Permit Transfer to New List revi s Permit umb~yand D sued Before Expiration Plu r Owner S IV. Type of POWTS System: (Check all that apply Non -Pressurized In-Ground ^ Mound > 24 in. of uitable soil ^ ound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground Holding Tank ^ at Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leachin Chamber Dip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Information: S'T''cf .~; /~ ~~ ~ -y 2 3 K Design Flow (gpd) Design Soil Application Rat gpdsf) Di rsal Area Require (sf) Dispersal Area Proposed (sf) System Elevation T ~' s- 7 9~- ~o VI. Tank Info Capacity in T tal Number Manufactu r Prefab Site Steel Fiber Plastic Gallons G Ions of Units .~ n \ Concrete Constructed Glass New Existing _ W l->v p~ ~ . ~~ Tanks Tanks ~ J Septic or Holding Tank , , .?G~l~ _ ~ i l Aerobic Treatment Unit Dosing Chamber ,/ /~~a VII. Responsibility Statement- I, the undersigned, assume responsibility for ' allation of the OWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature MP PRS Number Business Phone Number ~~ ~ SG ~ ->, r..~ " ------ ~~ 7 YC~ ~~S 3~~--3f Plumber 's Addre s s (Street, City, State, Zip Code) ) ~~r // c ~J /~// VIII. Count /De artment Use Onl ~, Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Surcharge Fee} - Date Issued Is uin gent Signature (No Stamps) ^ Owner Given Reason for Denial 25D ~ 1X. Conditions prov al Q9.~ta~~~ 'n" ~-~ ~ ~ S ~~ 3) S~S~n~. .a . SYSTEM OWNER: 7 Septic tank, effluent filter and ~ ec~.~ $2 l t1taT~ S t ~ 6u~a' dispersal cell must all be serviced /maintained ,~\ ~~ as per management plan provided by plumber. `~ ~~ p • ~~42 Ssi~S . U 2. All setback requirements must be maintained as per applicable code/ordinances. SBD-6398 (R. 01/03) arracn compte[e plans (to the County only) for the system on paper hot less than 81/Z x 11 inches in size L ~~ ,-S ~- ^~ ,- 1-~ .~ ,. V ~~ i~ D e /` .. ~~ ~~ s. o ~~ °~ ~3 ~N s ~ .~ ~~ ~N ,~ ~ ~~ ~~ ~ ~ 3 d ~' 1 ~ a `rte Cn~ ~1 ~1 e i ~~ ~ ~, ~ `, P 1 N ~ o ~~ h d k M ~ ~O ~\ -~'' Q Oo t? G_ ~~ t t N J - ~ ~ ., °. J ~~ 1~ _~ t ^ V ~ ~~ M° ~a \ ~' a V~fsoansin Departrnerit of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings page I of ~ m aoooraance wim wmm ~, vvis. rwm. was ~ 5 f c r ' t l m i ae o ~ . Attach complete site plan on paper not lei than 8112 us an . P x 11 iridies n s indude, but not lambed to: vertical and horizontal percent slope, scale or dimensions, north arrow, and daedion and p ' nearest road. Parcel I.D.. , Q Z d - / 3 9 S = ~O - ~~ Please prl~tt all / n. Date . . Personal iMormation you provide may be used far ~ purpo:~,~ y Law• s.15:f (1) (m)). ' ~ p ~l 3 Property Ouvrter r> ; ; `' ~ ,~U P Location - ~ ~ . ji ~ Govtt ~(jw 1/4 ~ 114 S Z ~ T 2 9 N R /~J E (or~D Property OMaters Mai~g Address i } ', Sr ~ ~ . t. Lot ~ ~ T Biotic # N~ or CSMIf Subs ~ S City State Zip Code rCE . > dY ^ Vfllage (~ Town Nearest Road _ _ ~STi Ilwa.~-cr -11v~.. fSo~Z ( b~''~} . .. ail ~-,,.~~1J`:y' ` ,- ,~, eZc~ ® New Construdion Use: ® Residential / Number of bedrooms • 3 _ `1~ Code derived deaign flow raEe ~.SO ~~ O O GPD ^ Replaoernent ^ Public or commerdal -. Des~xibe: Parent material CCU ~-c~J0.8 (~ Fbod Plain elevation if app~ble tiles ft General comments S ~ 6l. ~ .. ~ ~ L'~- 6~- ~`'f? ~~~'' Z' s~~ c;-~ rvl e.l c~a ~b n - ~3• and recommendation • -~"- _ ~! Z- z 6~ !~ a~' 9 Z• ~ ~ b ,~J s ~ z,~ - wn.Q.'r•Q k., ~ ._ _, _ ~~ # (O~! gating ~ G~-~-f.~~C. (~tJ-Yt:~d?itJ}/./ 7°.Je-ems ira a lam. --~P-~ ~sp~.f.Cirt i:pi Pit Ground surface elev. 7 ~ v ft Depth to limiting factor i 2 O in. //// Sal ' n Rate Horizon Depth Daninant Co Redox Descr~tibn Texture Strudure Consistence Boundary Roots GP D/fF . in. Mansell (hi. Sz. Coat Cobr Gr. Sz. Sh. 'Eff#'1 'E1f#2 Z ~-Zy fly -- SiLI 2 sbk m~~ cs - 5 3 2 -yg I i'~~Cv .2 `2~C~ SL 3mSbk m~ c_s - 5 , ci `-~ ~"I yI~ "-. m`~ ~S~ m~ - .-1 I.2 by . 92~ ~'' '.~-~. 9z ~~~ f'O~ > Z' b . Z r,qZ~ d~ ~~ 2 ®Pit Ground surface elev. 9•G • Q' 0 it. Depth to limiting factor I LB in. ~ ~ a~~# ° ~~ Horizon Depth Dominant Cobr Redox Description Texture Structure Considence Boundary Roots GPD/li? in. Mansell tau. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 -.i-z lc~ 3) - -Sit L bk. mks cs Ivy . 5 . ~ ~ iZ- ~b I ~ 5 y ~Ir.l 2 sbk ~ mfr c s _ , 5 ~ 3 3~~-~ ~~ Sly C2P ~,5 r ~-1I~ SL 3msbk m(~; cS - ; 5 t ~-~ 5 I 10 r LI ~w m S ~ m I ~ - , -i I. Z 2•`~ c/ Q ~ _ • .S ' Effluent #1 = ~ > 30 < 220 mall and TSS >30 < 1 50 mo/L ' Effluent #2 = BOD< < 30 mglL and TSS < 30 mglL CST Name (Please Prart) Signature ~~ CST Nu~er ~~ Vyt ~ ~n ,cJ vVtoc_.k e. r"` ~-~~ Q Z5' 3 3 0 4 Address Date Evaluation Conduced Telephone Number 3 Property Owner Q.r ~~ ~ ParcellD # Page z ~^ 3 3 Boring # ^ Bow ®Pit Ground surface elev. 99 U ~ ft Depth to limiting iactor I 1 ~o in. Soil lication Rate H ri th D Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff zon o ep in. Mansell Qu. Sz. Cont Color Gr. Sz Sh: "Eff#1 'Eff#2 1 6--20 1 ~ 31~ ~ SCI Zm~bk mfr- e-S ~ v~ . ~ 2- 20 -3 5 l~ ~, cl Z m5bk r,-~ ~'r c 5 _ : `_~ 3 31~-~{(~ l ~ 5 C2~ `~•5 ~:~I ~C~' ~ 3msbk ';~-,~', ~ 5 - . `7~ ~ `f. ~, ~r7, ~f3. ~~ ~ rh' ~ ~ s h^-o ,. ~, ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth m limiting factor in. ~~ ~~ ~~ Horizon th De Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP DHi? p in. Mansell ~ Qu. Sz. Cont Cobr Gr. Sz Sh. 'Eff#1 "Eff#2 Bonng # ^ Borrng _ . ^ Pit Ground surface elev. R .Depth to limiting factor in. Sal luatbn Rate Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GPD/fl? in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff~2 i ' Effluent #1 =-BODE > 30 < 220 mg/L and TSS >30 _< 150 mgll. ' Effluent #2 = GODS < 30 mglL 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 (R07/00) r PAGE ~ OF~_ NAME -4 Y` K -e- ~ ~ LOT# Co~ LEGAL DESCRIPTION Nw ~/<~/e S L5i' Z g N R 1 RE (or) SCALE: 1"= yU BM I ELEVATION l00 • ~ BM 1 DESCRIlTION ~R a ~ (~ 4 ~ ~i ~ O,'a BM 2 ELEVATION q ~. y 5 Sec • z s BM 2 DESCRIPTION~c, pT ~ 1 ~ "o~__r c ~p , p -e x I SYSTEM ELEVATION R'3. S'O ~ _ 1 ALTERNATE ELEVATION ~ Z • Z d C NTOUR ELEVATION ~ cx~ y q o O 9 ~ 9 SS .0 q o K ~pT ~~ ~~ Q~ ~•I-,~~. ra ~ o ~ / ~ L °~~~ V Ql, t ~b . l , 1 C-0T ~ ~ ~ -J r~ J ~ ~ ~,~~ ~ '~~'~~ ~~ a `, Q~ JJ 1 ~~ . ,tea ~ (° ~~.~~~`~ Q~ ~ .~ ~ ~~ ~ ,, ~ ~ ~ ',L ~/ ,. SIGNATURE ~• ~~.~ +' ,~1 2~'' J 5" ~~' ~Z ~~,~;i(r1 " . a ~.~ ~ /-a a f ~ ~ ~ .._.- "" / ~. H,w ~,,• 1027.25.6 1b2a.a x 6 0 a-~ J r 0 x 1026.1 " 1023 f ~~1 I ~ a~ l• ~ *~ _ ~-I ~~ ~ X10 .7 i 10 1.5 104, l 44 ' ~~ff i ;g~c~ . ~•J 4 ~ z,7 C1. 991.9 98 99 ~~~ X 98 ~ _ ., ~x .Y ~ oi3.2 / V o ~~~~ ~ L {y y ~.. , 4" CI '1'r'Ni PI'pE Y?" fi:IN . ABJti £, GRAD£ 3 FRESH ~AIRM-OQJR i W+~ti;~OW OR iN3'AKE ~RAI` E 4~~ CT RI5ER ---..~~ ~~ X •l' 4il- i ~ / ~ ~ /" ~ n......~,~~~ , +~£At'i?ER~~04~ Jt;NC y IO:r' ECX WI ;'H C!~NDL't? 4\• I `',' ~ WA ~t~ T n" `T ~ ~ ti s • I~rf,. SEALS GRS~ ~ ' ' ;~QRO ~ n A ~xGHT ~ `: ~ ~ VE3 {..,~ ~ EAL ~OII. ~ ~ ~~D ~ .~ s~°'tIC !DOSE 3" APFRv~'ED ~EDDNG J~1DER TA.~TK ..~.,,~~'EC~~„F, CAT2C~~ 5~.. '~'~~. s....~~s : s~~~i c ram SAT + M . DOSE a~ Gp.~,. `gLAA!~! MA~1i1FACTURER: Mo~~L NUMBER : ' SWITCH TYPL: '~.,.; ~' MAN{,~F"ACT'JRER ; MOREL NUMBER : ._._.. A~ ~----~~ Sw2TCH TYPE: ~ ~ `~/JIAPROVE? ~ALM JOIN'S iiitN ~'P~YEO P iP~ SON f ~ 3' ONTO so~to. sozL ~Fi ~ ~ '~« 1lSSElt EXIT P£RM~iTED CNw~ ' ~ ?F TANK ~~ MANUFACTURER MAC APPROVRL CONCRETE PAD ~~~~~R L~~~s ~~R ~A~; ~,..~./ DOS£ vC;,tJ;~£ ZkG:.UDTIaG cAI~Ri Z «2 E-5: q s I.~vCMIS s ~..~ .~..~,,.^ SAL. 8 ~ ,,,., ~ T YC HL S •~MGA i . C ~ ,~„ INCHES ~ 1.F~._._.3A :,. ~~~ iR~A DISC D .~G,,. ~:tCHES s -~.~.wAL. ~` ry HARGE R,AT ,.~. GP: PUMP t A;.AR~ ~rRING ~ ~1t./ w~~1rMAL iJ~.d i f~1~dY11L BNr 1~' ~~ • ~ ii/~il ~~~t~ t~1'Ilb ~"YNSMUM NETWORK SUPpI~Y PICESSURgBr ~' •RND ~i STP? SU i Y ON PIPE , _~Q,,,..,,, FEE'* F ORC~AIN X . ~ ~ ~ 1~7 FEE:' r I'd F2/1~C £:. F'R:~T:t~~~ FACTOR F£~T' ~""ERhigL DIME:~'SIChg CF FL'!y? :h?JK: ~£'~~1. -~...._ , gE:.: ' ~ r +~ PPR O'J c,D ~iMY~QL(r VV~y W ~ PADLOCK ~ WARM fuG r„ggE; ......~," M~,~,', ~. w~C~~~ 5'Y~I~. ''E~~; Its "brae a9 Subm®relbfe `~ ~" Ei~uent p~m~ ~~ X571 -~ na~a ~~1 ~;~ ~"~~"~`` ~~~Q~r. r~~~f 1 . ~~ ~Mt >IIAII •~~ b ~~ .'~ wt b d0 OpM, •T ty~ ~1oi111~ . yr~w~~. ,~,t~' NRf, ~ t - ---•~..,~a, ;~ ~ l^~If{L Q 1lrp p~ Nn~, i~p ~i~ea+lr~ ~oo,~,~ ~~ !. ~ to ~ t 0~~1 H? ~ ~'..., N~ f 66G 1~V, 0~I~ ~ ~M ~. ~~ ~~ ~e~a: ~a inoc ~ ~Unplh,ld~ SJTQ aua ~l ~o ~ ~ ~ ~ SJrW wlt~ lied ~n goo al~c Mf1lPI~ . w~. t C .~ ~~~ ~~ ~INMIMt ~ ~6 ~ Rs~nult . Flea MNlrfi AIM q+MO{ Of yN ~~ IA! FAA pally Olt ~ bt • ~ - -- -- a fi~ ~ pr01~/ ~~! 1~ ~~~ Garrrorr ~~r11~1~ r. ~t p,,,. .OOlnt~, «~~ ~~ +1~d ~ ~~ ~YdI~A+ea ~ ~~ ~uoraL ~ ~y ~ ~~~~~ 4 ~... • ~~ The Standard Infiltrator' Chamber The Standard Infiltrator Chamber T L >~ ~~ ..-• sze(WxLxH>! .......:.......34'x75rx12" (85 cm x 191 errs x 3j~cm). Storage Capacity. ........:....77.5 gal (293 L) Weight..... .....' :... .....::....26 Ibs (t 1:8 kg) I ~. ~• ~ I I Louvered Sidewall Height .. ..6' (15 cm), , UIFILTR_ATOR SYSTEMS ING STANDARD LIMITED WARRANTY MIHLTRATOR SY57EM5. MC. (Mtr,b~ STANDARD LI+tTEO WARRANTY FOR SEPTIC PRODUCTS iel Theffiuw„I wgty a rtdt oteember atd and plra ew.re~d bbyy tilfa,e« kasetieely trmae b as "UMs7. ~+ssrNm end apw,red h a YactlMld d an atesfe ~syawtt n eeoerdatcs wtlt ttatrabrs Mtearlan MtnrJiotw. b wmwaed b me arlgsW puMtner rHok+~ r• M aairlefs aM tto,la,r,sltip br one p) yar tom me db upon eNtidt a septik penes k Lseed br the sepde system wrat+5 howawr, me t a septic parmlt is r,a tsq~iad tr we sptle yisw^ M +aak'+tk Net the «. rf) year wrr,ory vetiod wi Depot w~ me etas met intaledan d ate septlc ttysoem atrtttttattns. h ceder b eemiee wetrrty tigtn. Holder tnex nay tditrata h v,MYtg at ~ cap«ets hndgttrurs n old syormh, C«etecacut wait Mrs Od) den a me aNgad area. traat« vt~ simply teplsnnwa Ibis br mosa ttis deteniwd M t+iwr« b W aWgha rd caeca by tltls layered Wrrray. l,atramrY ieeuy sprdeuy ~luaess me cost a rmwtl aMlat eauYOm a d,e units. t4 TtIE IIfAITED WARRANTY AND REhED1E5 W SUBW WAGW Wl1 ttl ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNn'S. NCLUdNG NO tJPLED WARRANTES OF MERCWINTABIUTV OR FITNESS FOR A PARTICULAR PURPOSE. p TM Unird Waaaay does rot atnetd b Ytadatael aaraquetttld. sprdel « Y,dkeu detrwges. IdAar« shay not lts 4ab far p^trsas « equaeted demo ag; YcYMig loss d and pMas, re« aM neeswNlt. awahrd rnrs « ems losses « attpetxs stnarod by me Holder « airy thnf ~P~Y a,eieded M LMaO WRaay easaps k drnage b lhs IMis due to ardney was and tee. Nestles accNee. mWae. eh~e « a dw IAtAS, me fAis ltaYtp rayeaed b waiia seise «amr aadtdae whld, w na praised M ms MrNwlatt Mbealotts; tarn b nnYt- taet ms nVrtlnem goad caws sr lam h ar Mutatbtt ttstteabrts: me pWarstwa a htprapw neelMYs sao me system caa.Yity rr Urets: tetra date UNts «me sepdc sylen due b Ytpdper atlg, Ytp~pw bhp, waassM watr usalp, htpraper geese dfspossl «tmopw aperebn «ary easy aweY na ousel by hptatar. TNs littaa MMrq ehi Oe valdrma Holder Ntt b aotnply eM N d me sesta ar IeM 66 tNS lYtiM Wrrrry. iulltat h mawra rrl tr>ttrala b taapotta6Y for any bas a drnapa b b 11o1dR ma Ultts. «ry tlid piny sasillitg tam YWNrbt «!i¢mwt «tom any prodrt Yhaty aabr d lloldr or aid F« tlis flatted Wwrray b me ads eons tta 4etiad h aoaMwtoe wM N aM a«tAlae uquYad M arofs and bal coda. N amr apple- e61a Yws aM YitrMat YnlMetlat~ - irtuybns. q No tnpnwaane. d tmlor nn ar .atotty b drips ws ut+w wtaway Yt any mr.tw wlesswwr. « w rrro ws antes Wmray. ~ wanteati b can way ashy atte ar ati~iar Hdar. The ataa teprasars Uw stetdwa IMLd Wtaway aired by ttllaaeor. A stied nrtthr d rates and oou,in Area dMtwt Igtiar,tras. wanaay uatay'renrty Pda ~~ Cannecda,. prior b strdt ptrdtsss, b ohsdn a Dopy d me ~ . • ~ SYSTEMS I NC Envinxlmental Onsite Wastewater Solutions'" 6 Business Park Road • P.O. Box 768 Old Saybrook, CT 06475 860-577-7000 • FAX 860-577-7001 1-800-221-4436 www.infiltratorsystems.com baaala Sysettw don rot raartnrrd Mtaartp orrta tyireseu tndr paw,nra. QYadwa Illlnl Oa MtNW aaaNnp b niRaataaarl<Mttealorw. fate b MIN aooerdnp b erWel,cerarY YsuuWOrts a~a wi0 wrrray. hlkna Syslrsr raoettattwtds aw sofa d ttrpdr: Ytllt Mrs aM letatdry Rrn cash N atNS tlepdc systras. Syswn itlttp k daWnitd lty gseatwsmeagrrww. ~' for technical assistance, i~tistailation tinstructions or customer servlce, call infiltrator Systems ~at 1-800-221~4~6• 1' Overlap at Latching Mechanism U.B. Pa4ents: a.759.861; 5.017.041; 5,156.488; 5,336,017; 5.401,118; 5,401.459; 5.511,903; 5.718,183; 5,588,778: 5.839.844 Canadmn Ptttertb: 1,328.959; 2,004.584 Olher petxtb pendatp• klBMrebt. Equdizer and SidaNrrtder ero tapitlerod tadenlslkt d klRltrslor Sysbme Inc. Irfiltredor fa a llQl6klad tredetltetk in katce. Mdltrabr Syabnla Inc. M a repkterad haderltsflt In t4aldoo. Ganbur. Mlitxd:ssehirfp. PdyTtAl, BroPLQdt. ChenrberSpeoat PasLodc. QuidtCul 75' J Effective Length POWTS QWNER`S MANUA! & MANAQEMENT PLAN p•$Q w._ cf OS1igN i'ARI1MgTdRB Number of Bedrooms ~ d NA Number Of t~tiibiic FacUity Unite NA >Aetin~ated flowv laverape# ~ N/da Deaipn flow ipsak}, (Eatimatad x 1.5} li G~ D alld Soil AOtlon Rate ~ • ~ at/da ltti Standant Infk»rttlEffluent Duality Monthly average' Fab, Oil A Grew {FOG# s30 mil/L 6ioohsrnbal Oxygen Demand {BOD~,1 s2~o nKi/L O NA Tatd Suspended SoNda {T881 sf 8O mglL Pretreated Etf{uent Guagty Monthly avera>Za Biochsmklal Oxygen Demand i800s# s30 mq/t. Totst Suspended SOlida {TSSi S30 rr-gli. Q NA feosi Coiitorm {peonnstrio moan} stO• cfult04rnf Maximum Effkaent Partiole Size yi In die. O NA , • DNA 'Values typieat for dornesRic waateweter ar+d septic tank effluent. SYST~rI (I~ci~~c~- 9eptio Tank Capacity ,? d si L~ NA Septlc Tank Manufacturer ~ Q NA Effluent Filter Manutscturss ' ~ r¢ I~3 NA Effkwtt F11ter Modei ~/~' d NA Pump Tsnk Capacity sl O NA Pump 1'snk Manutaoquer / do DNA Pump Manufsoturer ~y,.,u / ^ NA Pump Model ~ p DNA PtetrNtment Unh 0 Sand/C4ravel Filter O Meottar-icaa Aeration O Weirtfeation Gl Peat FUter D Wetland O Other: Diapefsal Cells} t •Qround tprsvity} At-Ciradr D Drip-Line O NA D In-Ground tprssaurized} ©Mound O Other: that: ~A Other: MJ~uiwr a •c~wu~ ienlro. >ii rvia !<req~Jenoy Inspect oonditlon of rankle) At least once every: 3 e t#Aas~m S years? O NA Pump out oonteftta of tankts} When comblr~ed etudes and scorn squaie errs-third ~yy# of tank volume ©NA inapet:t dispersal oeit(s1 At least ones every; tr~ort ~ ai (pAswdntum ~ yeanl O NA Clean affluent filter At iasat ones every: . ~ aerie ei DNA Inspect pump, pump Controls 6~ alarrte At feast once every: ..~- D nteftM s O NA Fhish labrab and Jyrsteure :set Other: her: At asset once every: .-- At feast anae every: ,_._. O ~ ai O mo11 si si ©NA DNA O NA MAMtY~IANC~e NYUlTRt1CTlON(3 - lnspeotions of tanks end dispersal calla shall be made by an indfvldual osrryinq errs of the folbwinp ucsnsas or oertifioatlons: Neater Plur,+ber; Master PlumiDer Rearicted Sewer; PC}WTS Inspector; POVV'f8 Mabtalnar; Septaps Servicing Operator. Tank atspectiorts n+ust lnolude a viauai ~spectbn of the tanktal to Identify any rniastng or broken hardware, klentHy any pecks or leaks, measure the volume of oombined sludge and scum and to check for any bask up or pending of effluent on the Around surface. The diepereeJ aellte} shat( Fee vlauaiiy inepeoted to check the effluent laveia in the abeervatkM pipes and to cfieok for any pondinQ of effluent on rite ground surface. Ths pondhp of effluent on the ground surfaos may indicate a fai(Mip oandltion end requlrea the immediate notlficatton of the boll rsauiatory auMorlty. When the combined accun+ulation of eludes end scum in any tank Wwla ens-third (>S# or mow of the tsnk volume, the entire contents of the tank shsN be removed by a Saptage Servicing Operator and diapoaed of in acoordanca with chapter NR 113, Wisaanein Adminietratiw Corte, ~AJi other earvtoea, Inoludin~p but not limited to the aervJcJr~g of effluent filters, machanica! or preaturiied Components, pretreatment unite. and any servioinq at interoa~ of S12 menthe, shall be rtormed pa by a Certifgd POWTS Malntdner. A ssrvios report shall bs provided to the focal regulatory authority within tO days of completbn of any sarvlo• avant. START t1P AND OPEAA710N Page ct ' For new construction, prior to use of the POWTS check trsetrnent tan~ecs) for the prRaence of painting products ar'other charr,iGei that may impede the treatment process and/or demapq the dispersal cglilsl. If h'sgh_conc®ntrationa are detected `,have the content of the tenk(sl removed by a ssptag• servicing operator prbr to ues. - ~w System star up shall not occur when eoii conditions are frozen at the intiitrative surface. During power outages pump tank: may fill above normal hlghwater levels. When power is restored the excess wastewater will b. disaharped to the dispersal cell(s) in one large done, overloadlnp the celllal and may result. in trio backup or surface discharge o Effluent. To avoid this situation have the aontants of the Rump tank removed by a geutege Servi~9 Operator prior to -estarin4 power to the effluent pump of contact a Plumber or POWXB Maintainer to assist in manually operating the pump controls tc restore normal levels within the pump tank. Do not 4rive ar park vehicles aver tanks and dispersal Delis. Do not drive cr park over, or otherwise disturb ar compact, the area within f $ feet down slope of any mound or at-grade Bail absorption area. ~ - liaduoiion Or elimination of the }oflowirt$ from the wastewater arresrrl may improve the performance and praiang the fife of the P4WTS: antibiotics; baby wipes; cigarette butts; condama; cotton swabs; degreaser9; dents( floes; diapers; disinfectants; fat; foundation drain {sump pump{ water; fruit and v®getabls peelings; gasoline; grease; herbicides; mast scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; end water softener brine. ABaf~IOONMIENT When the P01NTS fails and/or is permanently taken out of service the following s:epa shalt be taken to insure that the avatem is property and safely abandoned to compliance with chapter Comm 83.33, Wi:eonaln Administrative Code; • AN piping to tanks end pha ahe[I be dlacannacted and the abandoned pips openings sealed. e The contents of all tanks and pits shelf be removed and properly disposed of by a Septage Servicing Qperator. e Attar pumping, aN tanks ar+d pits shell be excavated and removed or their covers removed and the void space fi;ied with sail, gravel or another inert solid material, CONTINt3BIVCY PLAN s if qte POWT$ fails and cannot be repaired the following measures have bean, or must be taken, to provide a code compliant replacement syet~rtt; A tuitabte replacement area has been evaluated end may be utilized for the location of a replacement soil absorption r ~//A system, he replacement area should ba protected from dtsturbsncs and compaction and should not be infringed upon by required setbacks tram existing said proposed structure, lot lines and wells. Failure to protect the replacement area well result In the need for a new soli and sits evaluation to establish a suitable replacement arse. Replacement systems must comply with the rules in effect sit that time. C1 A suitable replacement arse la not available due to aetbaek andlor soil limitations. Barring advances in POWTS tschno[ogy a holding tank may be installed as a last resort to replace the fs)led Pr)WTS. 0 D Mourtd and at-yraQs eoii absorption systems may be reconstructed in piece following removal of the bioma# at the inTilirttivs surface. Reconstructions of such systems must comply with the rules in effect et that time. c <YIIARNINIp> > SEPTIC, RUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL QA8$ES ANi?!OR [N8UFF[CIEIVT OXYGEN. DO NOT !`LATER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CiRCUMSTA~ICES. OEATH MAY RESUIT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE WFRiGCi1.T OR iMPOSaIRLE. ADDITIONAL, COMMENTS POWTS INSTALLER Name ~~rrr~'~ ~•~-~ ~' s~ ~ Phone 7 l •» ~ ? _ ~, ~ POWTB MAINTAINER Nsms Phone t+EPTAAE IERV CINO PERATOR 1PtJMP RI tOCAI REQIa TORY AUTHORITY Name Name ~-, ( ~~"~ ~~ ~~. Phone Phtme ~-{.S 3~ . ~~~ This dooun~ent was drafted in oompiience with chapter Comm 83.ZZl~itbittltdl&tf) end 83.6411), 12) 8 l3), Wlaconsin Adrntrtistrative Code. ~ROrh~"~,R. ^F 7S1'~d!c ~ ~,Ph9 F~rNP ~.~F~Tv uUnS0~~1s 4 -~C. 2''_~ e2:~~_. ~i ~ ~~ v ~:~i~ -~ i~ ~ ~ 3~6 0902 Mdr. ST CR~~X COUNTY SEPTIC TA:'~K ~SAINTENANGE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerl8uyer e~rrt w„s Maiiiztg Address • ~ i G+~ •1~j- Praperiy Address 1-- ~ 6 ~ ~f $ ~~; l (Verilicatica required $oza Planniae Depa:3rneat far City/State ~ ld~,tsr,,~,,,,,,,,,~_ Parcel Id,entiffcation i`Ttttftbor Preperty Lxatiolz ~, %._ ~~ '/,, Sec, ~~ . 'l'~,N•R.~„~, Town of „_~~~ Subdivisica ~C.~-c.~ ~~ ___r_,__.. , I.ot # • ~_• Cert~od purvey MAp # .Volume ,Page # 'VCarranty Doed # c~ ~,~•_. ,i~, Volume o15c~ , Paga # 5~,~,_.. Spec hour ~ yea ^ na Lot linen idea:in`abte~ yes. C~ na 4yS ~.MAiNTENw_N ~' Iosp~[operusc sad taainceaaareaf your septic system could rerui; is fts ,p[G~at~:te faiivrc co lsaad:e wastsa. Proper maiatenca:~e consists cf pumping nut the septic taflk every three yeah ar •aoncr, if needed by a licensed pntnpet. What you put into the systct~ cs~s atI'eot tl+e llmcctiaa of she septic teak ar a nzeuaeai ~c in elte waste d3aP~ ~~+- Tse property ovrmor agrees to sabaaSi to $t. G~aix ZoQaag D®partmeat a certiticatiea form, tigaed by the owner apd by a xaasser pluretb~r, jovssaymsagusnber, restaatedgiuxabar or a lieeasnd pampas ~*rifyis~q txat {!)the as-site wastewatercUoposel aysteia is is propor operatsag raridition andlar (~) atser fnapect3aa usd, pumping (9f necesasry~, rho septic tHa1c is leas than i{3 fu13. of s?udEe, Ilwe, sho tsadors' d have read ~ abavo saquiresat~u sad agroo to tttaiahin t4se prsvste sowage disposal sl~stern wish the atarda:ds set forth, t by- rho 1Jopartatcat of Commerce sad the Depastirnent of I'SKetusl Resotl~es, State af'~liscar~ia, Certification sca ' t syS s bees msintaiaed multi bt eampleted aasd returned to tb$ St. Croix County Zoaiag Office within 3 a s oi' o e alo dab SI ATVRb F DATE oa this form art trvo to 'thc best of my (csu) lcaawladge, I (we)' am (aro) the owrtr(s) of a wateaaty deed recorded :n Register o! Dee4s Otlice. SIGN ' IC~l1"I' DATL• ••" ~, i~armatiou thst is snis•reprasented stay :stall is the sazitar;- ger~ti~ botttg revckad by the Zeni~g Departmca:.:'" • "'* •• Include wlth thta sppifs:atian: a susaped aa~sary dssd hors tlz.v Register of Descis affiGQ a copy of the certified survey reap if =diranca is made in the watzattry deed U; 2526P 15y 756538 KATHLEEN H. YALSH REGISTER OF DEEDS ST. CROIX CO., MI N ti °, ~~e'sbS M.vz AO'Lgb r ti ~ ~ ~ a ~--~~ cn ~ ~ ~ ~ ~~~ p~ n pU r cn U ~ ~ rn~ ~ ~ ~ ~p ~ ~~ CON ~1.~ / ~~ ~ r N s1~o1"1'p3 ~ 5~ 1Z262g0 2 ~ 1 ~~ `` / ~~ W o~ ~ ~ ~~ _~ Q ~ ~ iW ~ ~~ l rn~i ~ ~ ~^ g U °D ~ \ Z ~"~ T- a ~ o~ N $ ri I ~ W ~ ~Q ~ ~~ ~~ I ~ ~•. ~S9'4LL 3.8S~9loLOS ~ ~ ~ - - - - - - ~ \ say ~ ~ ' . . \ \ ~~ ~S9'4LL M.8S~9LolON \ eLJ ~ ~~ ............~~...~ ...~~.w=w .............. ..... .. , > ~~.