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Safety and Buildings Division County_
_ 201 W. Washington Ave., P.O. Box 7162 r , (%L,i- -L.I(, \*. seonstn Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 6 /36 3
Sanitary Permit Applicatio l State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information 1 pro
may be used for secondary purposes Privacy Law, s15.04( t - _ .- ti Project Address (if different than mailing address)
RECEp, W F �
L Application Information — Please Print All Information ` 3 / `t
Property Owner's Name / t , 1 . : 1 1(1 k Parrceel # Lot # .To Block #
t
i
A. VIM r�Ia v � • 76
Propee Owner s ailing Address ! CROIX 99 ' i Property Location
/ ! [� ,_ ZONING OFFICE 5E 36
Cit State �l Zip Code Phone Number �'• �" -' �' • Section
T 5-4-101 /_ �j Eo e)
(�/� / �. 1— CO T t / N; R / /E o
II. Type of Building (check all that apply)
Li
A l or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number
❑ Public/Commercial - Describe Use Pei l' AM,.
❑ State Owned - Describe Use ❑City_❑Villagy KTo ship of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. KNew System ❑ Replacement System g p Y Existing Y
❑ Treatment/Holding Tank Replacement Only 0 Modification to Existin System
B. ❑ Permit Renewal ,Permit Revision ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner L/76 Y2 '7-1/- 6 3
IV. Type of POWTS System: (Check all that apply) ) '- /00
1 Non - Pressurized In- 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 ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter L7 ,eaching Chamber ❑ Drip Line } vel -less Pipe ❑ Other (explain) ,
V. Dispersal/Treatment Area Information: '1 ei [%
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation /
G � , 4' X500 /$ - g 3 '79,5"/
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks ' J
Septic or Holding Task / )�l1070C 1a ( / (/ ' ' ' -_ `
Aerobic Treatment Unit W
Dosing Chamber e ',_ pbo / 1'
VII. Responsibility Statement I, the undersigned, assume responsibility for' stallation of the POWTS shown on the attached plans.
Plumber' Name (Print) Plum is Sign ure MP PRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip )
// k ,**v G� s
VIII. . l unty /Department Use Only _
le Approved ❑ Disapproved Sanitary Permit Fee (ii eludes Groundwater Date Issued Issue gnat re ps)
Surcharge Fee / '
0 Owner Given Reason for Denial g ) 6 ���0 0 /G/� / � L
IX. Conditions of Approval /Reasons for Disapproval derv__ / ,
S -i o"' u. � a aiLe-k K , 7 L9. 01 ,( 1 L s-4,k
i sa ,104t,t-4..6( a,1
Attach complete plans (to the County only) for the system on paper not leas than 81R x 11 inches in size
SBD -6398 (R. 01/03)
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COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS
PER COMM 84.25 CODE CHANGES 2/1/2004
Access Opening, not top of cover, Access Opening, not top of cover,
mud extend to a point no greater must extend at least
than 6" Below Finished Grade 4" Above Finished Grade . 1 , I , f _ i.
Cover with WEA11 -1 ' +
' ' + V f&rr 0 TB
Locking Device N , biJ 84z 1 (.1W/we , a
(typical I , Finished Grade lZ .M/i/tit ark?
....•.
„EWER- Min. 23"
> 3b P r >.4zl� 1 ,1 cess Opening
i j ] /1
1/`ISU M in. 23" Acce Opening a L. PI i 2 pyG 771/eccf:ANU S 'e
t' Oul Effluent Filter _ 4 w / f "'P Union R PC Pr,
A
Inlet Baffle ■ 9 : AAR" 0A/re ..501-/z) So/c-
s i
r
e
•0'
Rump
r.
3 "s 0e ra.ve. l heddin under -an k &u/llh iehfer 2' bluer eI S
T wo Compar ment Septic/ Tank (. key we j on 0v/sae/wetly
SPECIFICATIONS
TANK MFR: DOSES PER DAY: .4
TANK SIZE: SEPTIC c2 00 GAL. DOSE VOLUME: / 2;15 ,5 GAL.
DOSE JB2 GAL. (INCLUDES FLOWBACK & <20% OF DWF)
ALARM MFR: 4. CAPACITIES: A = taaNCHES = t 'f (o
MODEL # DAll
Switch type: 11A-A-1/ B = 2 = q R. GAL.
PUMP MFR: G' i 1 C = S VNCHES = /SS, 5GAL.
MODEL #: t 'o5 !'
SWITCH TYPE: D = 7 INCHES = 105 GAL.
I
REQUIRED DISCHARGE RATE 075 GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e)
VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) = `I - FT.
MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) = —
,235' FT. OF FORCEMAIN x i /D FT. /100 FT. FRICTION FACTOR = + 0? (.5 FT.
TOTAL DYNAMIC HEAD (TDH) = //, 8S FT.
INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH 3B `(
MP/MPRS SIGNATURE: /fm, _ LICENSE NUMBER: .3 R0 3$
0
GOULDS PUMPS
Submersible
11111/, Effluent Pump
,./ '4 = `''i MODEL 3871
� E
..
, , r --
1
w. Series
APPLICATIONS • Fully submerged in high • EPO5 Impeller: Thermoplas- • Bearings: Upper and lower
Specifically designed for the grade turbine oil for tic enclosed design for heavy duty ball bearing
following uses: lubrication and efficient improved performance.
heat transfer. construction.
• Effluent systems • Casing and Base: Rugged
• Homes Available for automatic and thermoplastic design provides AGENCY LISTING
• Farms manual operation. Auto superior strength and corrosion
• Heavy duty sump matic models include resistance. S P , Canadian Standards Association File # 9
• Water transfer Mechanical Float Switch • Motor Housing: Cast iron u s is 50
• Dewatering assembled and preset at the for efficient heat transfer, 9001 Registered.
Goulds Pumps is ISO
factory. strength, and durability.
SPECIFICATIONS
• Motor Cover: Thermoplastic
• Solids handling capability: FEATURES cover with integral handle and
' / <" maximum. • EPO4 Impeller: Thermo Las- float switch attachment points. • p
• Capacities: up to 60 GPM. tic semi -open design with Power Cable: Severe duty
• Total heads: up to 31 feet. pump out vanes for mechanical rated oil and water,resistant,
• Discharge size: 1 NPT, seal protection.
• Mechanical seal: carbon-
rotary/ceramic-stationary,
BUNA -N elastomers.
• Temperature:
104°F (40°C) continuous
1 40°F (60°C) intermittent. METERS FEET
• Fasteners: 300 series 10 -
stainless steel. _____i___
• Capable of running 9 30
dry without damage to —' -4-5 GPM —
components.
25 8 -
o _2.5Fr
z
Motor: W
x ,
• EPO4 Single phase: 0.4 HP, 6 - 20
N
11411.111111.1111.1111111 '
115 or 230 V, 60 Hz, 1550 a ® �-
RPM, built in overload with >- 2 5 -
automatic reset. 0 15
• EP05 Single phase: 0.5 HP, 4
115 V or 230V, 60 Hz, 1550 °
Milik■ s
RPM, built in overload with 3 - 10
au tomatic reset.
2 - EPO4,
• Power cord: 10 foot 5 WI ' standard length, 16/3 1 , ________I SJTW with three prong i 9 V / I
grounding plug. Optional 20 O ` 0 j
foot length, 16/3 SJTW with 10 20 30 40
three prong grounding plug 50 GPM
(standard on EP05). O z a s 8
10 12 m /h
CAPACITY
Goulds Pumps
® 2003 Goulds Pumps ' lijS
Effective July, 2003
83871 ITT Industries
,.;?,
Wir :cousin Qepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety anieuilding Division
INSPECTION REPORT Sanitary Permit No.
" (ATTACH TO PERMIT) 430329 0
GENERAL INFORMATION State Plan ID No: �
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 Parcel Tax No
Bast, Kernon Hudson Township h
CST BM Elev: .9'1 f / _ Insp. BM Elev: BM Descript ection/Town /R a /Map No.
No !! 974 - -e t� CM-Zr !� 36.29.19. s TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. +
Septic / / / a j Benchmark 2- 3 ' o Z„� . /9- ! L
V
Alt. BM
Dosing .. (A y 4),
0_4d 4.160 gi kr ear / v- 7 S GJ / 57
Aeration Bldg. Sewer ...-- -------_______ } --.....______ // & g6. s7
Holding--- ------,
SUHtlnlet 3b7y „4° 4— // OI✓ 90.31
St/Ht Outlet _ --,
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet i----
:::: Bottom ` , �� I% nQ + Header /Man. 14,74'
Aeration 1 /� - Dist. Biter” t
019 Get e✓ G • (.9C 5 • (Of
Holding ' Bot. stem
PUMP /SIPHON INFORMATION Final Grade 5
Manufacturer Demand St Cover —
GPM ----- 3 Y\' S-e - � 6 W /6 3
Model Number Pa S 3C / r / a
TDH Lift Friction Los 1SYstejadTDy Ft
1 +) (/ • f— l (./ • I
Forcemain Leth c Dia. , st. to Well
SOIL ABSORPTION SYSTEM 04-13-i- 13 4- (O - - ( 1 ay , Ata. 2 —
BED /TRENCH Width / Length / No. Of Trencs PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 / -_2 . � �-
SETBACK SYSTEM TO �t OO P /Lvj BLDG WELL LAKE /STREAM EACHING Manufa • v v - /
INFORMATION Typ- of System: I rr CHAMBER OR ......54_,_ L.
• V ,l. ` ' ZO` ` U NIT M o el umber:
DISTRIBUTION SYSTEM i "A' ` A: s
He aderlM� older ` �oi v Distribution '/ , x o e Size x Hole Spacing Vent t
� 1 Pipe(s) 7 /
Length Dia Length Dia f Spacing t!/ -�� c 5 b
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 q 44, Bed/Trench Edges Topsoil
_ 1 Yes f No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 9 ,z@ 0 Inspection #2: / /
Location: 663 Mary Jo Court Hudson, WI 54016 (SE 1/4 NW 1/4 36 T29N R19 W) Cottonwood Ridge 1 t Ad Lot 76 Parcel No: 36.29.19.
1.) Alt BM Description = (GtN.. WAG( lenk, z. d4af,,,' / -
2.) Bldg sewer length = 0,i-i wQQe '/ / du -e-
, , -
�°
amount of cover = a l' �- Add !� f/1,(i`� CAL ` due
> 3 (fie✓ k� �►-a -�i�tsu� e
J o �� O � /,
Plan revision Required? I Yes n No I I c
Use other side for additions nformation.
I / // 4{`l""/
Date Insepctor's Signs re Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County
\' 201 W. Washington Ave., P.O. Box 7082 57 .- Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 261-6546 L/ 3 32?
Sanitary Permit Application State "P lan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s 15.04(1 xm) Ppoject Address (if different than mailing address)
I. Application Information - Please Print All Inform R LT ( �-��^pV f : f ✓/ 2
Property Owner's Name . Parcel # .. Lot� #
/ ' � 200. i 76
Property Owner's Mailing Address t Property Location
p
9VA -- i 4 ;:± j /1
��'' 1 Section /
3
City, State Zip Code Phone Number V
i C - `� 0 / " tIP e- e a �J c ircle
Type of Building (check all that apply) a 1 ` N; R
0.o • ' S,... , AAA i
M
1 or 2 Family Dwelling - Number of Bedrooms ♦ _ I Subdivisio ame CSM /- n
�
❑ Public/Comniercial - Describe Use
❑ State Owned - Describe Use tall [ltr ®r. 4 t '. f� ❑City ❑Villa �To ship of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) l��L
A.
likNew System ys 0 Replacetnent System ❑ Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plunider Owner
.
IV. T .e of POWTS S stem: Check all that a , .1 is 0 ♦ �ferIP' C"� . ' / ;
I t Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At- ❑ ngle 'ass Stt Filter U
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (expl
V. DispersallTreatment Area Information: L5 d.
Design Flow (gpd) Design Soil Apolication Rat gpdsf) Dispersal Required ir.cnt Area Prnn. M /cft 1 System Elevation
Dn
• tf /t red (sf) an (525.1 1# i 95 0.70
VI. Tank Info Caps Win Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank / ____ //2 5 - 0 , k /�/'
Aerobic Treatment Unit ' ` \`
Dosing Chamber
VII. Responsibility Statement I, the undersigned, assume res onsi ility for i tallation of the POWTS shown on the attached plans.
P1� '/ ` sh ( int) oPlumbb Si •• azure a PRS Number Business Phone Number
Plumber's Address (Street, Ci , State, Zip e) /'
it-A7 . County/Department Use Only
Sanitary (includes Groundwater Issued I sui Agent Signature Stamps)
Approved ❑ Disapproved ry Permit Fee ( �°
Surcharge Fee)
❑ Owner Given Reason for Denial 25'x_ *.ii, Z® vtA.,.
IX. Conditions of ApprovaUReasons for Disapproval a te, ,,,_� 1, e
SYSTEM OWNER: 3 ; '" -'"�� "� ,
1 Septic tank, effluent filter and Vet t •• Q,ut4t __ t ic l
dispersal cell must all be serviced / maintained tt •
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attach compkte plans (to the County only) for the system on paper not less than 81/2 a 11 Inches G size
SBD -6398 (R. 08/02)
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Wsaonsin Department of Commerce SOIL EVALUATION REPORT P of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County $ T CR 0 / A-
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.O. 5-et, /3G /t cv 4-
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all t'#tIED Reviewed by Date
Personal Information you provide may be use for secondary purposes (Privacy taw, i . 15.04 (1) (m)).
Property Owner J AN 0 9 2003 property Location WE. op SW ar.l•di-
/VE / W /�eOX Soli Govt. lot .S� 1/4Af 0 1/4 S 31 r 29 N R /9 ' a (or) W
Property Owner's Matlirg Address ST. C RO I X COUNTY -ot # Block # Sobd. Name or CSM# .) tII /AJ(r_ PGA-7---
g/ le Cry. /ivy• , / ZONING OFFICE 7 '1 c i p J /
(�[. y State �< ?off D'li�' �5
Zip Code Phone Number ❑ City Village 10 Town Nearest Kited
,gop5oA' Wv /. Syo/(e � ( 75 .) 3r(• , 'pSa A) . rn < N
( -New Construction Use: (XI Residential / Number of bedrooms 3-y Code derived design flow rate '5 "' CP O GPD
❑ Replacement ❑ Public or commerdal - Describe: _ _ - / -_ ~— -
Parent material /0k-55 O OP'"' S4,,v1 y DU *— Flood Plain elevation if applicable N / R.
General comments
and recommendations: ' 7 T f} 50/7 - 4/, j /E 7/e //is /P owl
c
CO,t9 (,, r/own 4_ A a Go. Ts . (i3 /o A pros ' c &a
. s f , A , 3 • I / # O Boris o q
Boring ® Pit Ground surface elev. f �' S ft. Depth to limiting factor ! in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIIW
in. Munsel Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 •Eff#2
/ o-I z /o0 / Y L /fsh/C 4/07W Gw 2f- • y •
v a • V- /00 /q 5/L /fshe 4+1-6e c& /f . Z • 3
3 2-2 • y . 5 . ----- SL- z fsh, 'W C / rte. A. 7
9' V •90 / '4V// — .4, / f fX' 1 s --- 4W-s- 9 l. ,
❑ Boring C C P C�' Z l a ' xing# Ed Pit Ground surface elev. / 9. Z ft. Depth to limiting fador > f� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/IF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eft#1 •ER#2
a •C /ote3 L. /15,6 ihf/e w 3 f • ' 6
z '29 7.$)R Wqf — sL 27 b ' /1117 ' C5 . s . 9
3 2'• 7.5 , — LS / 1 c — . -- 7 / 2_
1/
f
• Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mglL • Effluent #2 =BOO. < 30 mg1L and TSS < 30 mg!L •
CST Name
i ?o /3E� Zl /heel c1 7— S ignature 21c."1-7 Number S
Address Date Evaluation Conducted Telephone Number
Uibricht & Associates �JLG ./7" .3-079.2— 7 /„S • 3 26- k/83
055 O'Neil Rd.
Hudson, Wis. 54018 .x- P/ /J
Ni of S Da b • / /0?• �D • d15 :9
• Se opV ) 490 //oy. (9•oaz0 .
•
L ,
.
K, T- /3 "T' .
t3� 7L /2
0 20'//o f• g.
Property owner Neil 1/,/c 4 K . SON O).O • /l b y • D • � 2.
Parcel ID # Page of
1 3 Ong# ,_D Bog
I
PSI—Pit Ground surface elev. / / ' ft. Depth to limiting factor �� in.
Sou Application Rate
Horizon Depth I Dominant Color Redox Desaiption Texture Structure Consistence Boundary Roots GPDIW
M. Munseu Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft #1 'Eff#2
/ 0 7/ /6 _3/Y 1 /15*- r► ,,, t f e co p - , y •
2 J/ • /6 �� y — 5/1 ifsh,- ,4, -fie cw / ,c . _ . 3
3 ,20 3R 7•5 5L- 2 She nmaf c . — • 5 •
_ 4 --
Boring #
0 Boring .
I I ❑ pit Ground surface elev. ft. Depth to limiting factor in.
Sou Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
M. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 Ei � # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sou Application Rate
Horizon Depth Dominant Color Redox Description. Texture Stricture Consistence Boundary Roots GPD/ff
In. Munsell Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
t
L I Boring# ° 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 GPD/ff
In. Munseu _ Qu. Sz. Cont. Color _ Gr. Sz. Sh. 'Eff#1 'Eff#2
• Effluent #1 = BO; > 30 < 220 mgt. and TSS >30 < 150 mgll. • Effluent #2 it BOO. < 30 rrgA. 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.
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For issuance of permits and designing
8 0
Contact: Ulbricht & Associates
" �_ Registered private wastewater consultant and plumbers
655 O'Neil Road
Hudson, WI 54016
715- 386 -8185 or 715-772-3442
l ,
• POWTS OWNER'S MANUAL & MANAGEMENT PLAN SYSTEM SPECIFICATIONS Page of 2
FILE INFORMATION
Owner }l � g Septic Tank Capacity /cZC 2 ga l ❑ NA
Permit # '430 21 Septic Tank Manufacturer �� ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer r 0 NA
Number of Bedrooms ti ❑ NA Effluent Filter Model / /a0 ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity ga l l .NA
Estimated flow (average) 960 gal /day Pump Tank Manufacturer I bNA
Design flow (peak), (Estimated x 1.5) OD gal /day Pump Manufacturer I*NA
Soil Application Rate 0. 1 gal /day /ft2 Pump Model 11NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ANA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ,In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y8 in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 02 N' year(s) (s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ti AT yearls) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s) month(s) ❑ NA
' ❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) ❑ NA
At least once every: ❑ year(s)
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 tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
local regulatory authority within 10 days service report shall be provided to the oca ato au Y
P
P 9 ry nY s of completion of any service event.
Page 2 of y
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) fur the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). 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 cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits 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 and cannot be repaired the following measures have been, or, must be taken, to provide a code compliant
replacement system:
l it A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot 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.
111A .. •... • -.
alua ' • • a o • Ong tank
b e a. e . ' PR D441/3 rrEz. rote- Wed NST Li O
❑ 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 POWTS MAINTAINER
Name Name
Phone Phone
` 7is � ��� ��9yS
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ST. Cie() t y (ovithy 24AI/4A
Phone Phone — 7 /S"— 3'(_ <A
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ieere/ /i's✓ 4 ,1 5.W5'7" —
Mailing Address 9 : 4/02 eaG` ,,Q. ,4!/�'.sew✓ y,/,l 6
Property Address - 3 AtALI_ __
(Verification required from PI: Dv. artment for new construction)
City /State ii/vos'ex/ `z-r Parcel Identification Number
LEGAL DESCRIPTION
Property Location r /4, %, Sec. 3 ( T N N -R) W, Town of .
Subdivision eo7 e 'e'•'e , Lot # .
Certified Survey Map # , Volume , Page #
Warranty Deed # 404 gego , Volume �i3r , Page # 3t .
Spec house ❑ yes ( no Lot lines identifiable yes ❑ no
} SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
Z /D
3
I NA F APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the prope • described above, virtue of a warranty deed recorded in Register of Deeds Office.
gaZeL.
ATURE • ' ' LICANT ATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
• J 2 1 3 5 P 3 5 5 7gi $$eGO
WARRANTY DEED KATHLEEN H. MIALSH
REGISTER OF DEEDS
ST. CROIX CO., MI
Neil L. Wilcoxson and Mary J. Wilcoxson, a /k/a
RECEIVED FOR RECORD
Mary Jo. Wilcoxson, husband and wife, conveys 02/07/2003 02:00PN
and warrants to Kernon J. Bast the following EXERT 4
described real estate in St. Croix County, State of
Wisconsin: REC FEE: 11.00
TRANS FEE: 2880.80
COPY FEE:
CERT COPY FEE:
PAGES: 1
Exception to warranties: all easements and restrictions of record.
This is not homestead property.
Parcel Identification Number(s): 20- 1109 -40 -000; 20- 11 -9 -20 -000; 20-
1109 -10 -000; and 20- 11 -90 -55 -000
Name and t �� 1. i0:
A parcel of land located in part of the Southeast '/ of the E Malty Title
Northwest 1/4 , part of the Southwest 1/4 of the Northwest 400 South 2nd Street
1/4 , part of the Northeast' /. of the Southwest1/4, and part Suite #115
of the Northwest 1 /4 of the Southwest' /., all in Section 36, 1"t j son, WI 54016
Township 29 North, Range 19 West, Town of Hudson, St. ,9
Croix County, Wisconsin described as follows:
Commencing at the South ' /4 corner of said Section 36; thence North 00 degrees 10 minutes, 01 seconds West
along the north-south 1/4 line, 1634.77 feet to the Northeast corner of a parcel of land described in Volume 526,
page 259 at the St. Croix County Register of Deeds Office, being the point of beginning; thence continuing
North 00 degrees, 10 minutes, 01 seconds West along said North - South '/. line, 1977.22 feet to the South line of
the North 350 feet of said Southeast % of the Northwest 1/4; thence South 88 degrees, 49 minutes, 51 seconds
West, along said South line and the Westerly extension of said line, 1324.14 feet; thence South 00 degrees, 09
minutes, 43 seconds East 2,096.73 feet to the centerline of County Trunk Highway "N" being a point on
1,999.00 foot radius curve, concave southerly, whose central angle measures 03 degrees, 00 minutes, 19
seconds, whose chord bears South 80 degrees, 02 minutes, 21.5 seconds East and measures 104.84 feet; thence
Easterly, along the arc of said curve and centerline, 104.85 feet to the point of tangency; thence South 78
degrees, 32 minutes, 12 seconds East along said centerline, 712.54 feet to the West line of said parcel described
in Volume 526, Page 259, thence North 00 degrees, 10 minutes, 01 seconds West along said West line 304.75
feet to the North line of said parcel; thence North 89 degrees, 49 minutes, 59 seconds East along said North line
523.00 feet to the point of beginning, all in Section 36, Township 29 North, Range 19 West, St. Croix County,
Wisconsin.
tit'
Dated this ��� day of _kJ -r0_ , 2003.
vig„,/..,
1 L. ilcoxson Mary J. W o n
ACKNOWLEDGMENT STATE OF WISCONSIN ) OF ST. CROIX ) , - t�- / r'Q Y Pt1494
•
Personally came before me this day of J 97 fo 2003, the above ' - med Neil L. Wilcorion. d Mary .
Wilcoxson to me known to be the persons who executed th oing instrum - 0 acknowledge the fine
' � ON r
Nota Public _ /n _�j
My commission expires: b 1 1 lh. # *-
C
This instrument drafted by Robert F. Wall. WilcoxsontoBastWD03 -1 �h t, O�W;Sfcc% a�
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