HomeMy WebLinkAbout020-1454-00-109 r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix —
Safety and BuiiUjng Division S anitary Permit No.
INSPECTION REPORT 499227 0
GENERAL INFORMATION (ATTACH TO PERMIT) 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, Town of 020- 1454 -00 -109
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No
/ Od n j M. , 1 LST 36.29.19.2924
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ��' ^5 S CAPACITY STATION BS HI FS
ELEV.
/
—
Septic ��/ b o ` 0 Benchmark 1/.4,z. /614.42- id
i I nn g J Alt. BM �� O
be G .6 J Li. s s
Aeration Bldg. Sewer , c 95. aZ
Holding SUHt Inlet /x r 5 9 y, 3 z-
St/Ht Outlet U
TANK SETBACK INFORMATION /6 ,S . / Z_
I TANK TO PiL WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Al o(a.
Septic 9d d 1j 30 7 '5 0 Dt Bottom
Dosing Header /Man. 16 ,14, 93.7(,
Dist. Pipe /� 13. -7
Aeration /6.11 1-3.7/
l Holding Bot. System /2 , O ?2 • (, -- •&,
I
Final Grade Z
PUMP /SIPHON INFORMATION `
(Manufacturer Demand St Covet kJ I y , 55 /i 6 7
GPM _
' Model tuber �______
I TDH Lift Friction Loss J tet9 TDH Ft "'
1
1Forcemain ength !Dia. IDist. to Well I
SOIL ABSORPTION SYSTEM
BED /TRENCH rah i Length/ / I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. !Liquid De
DIMENSIONS 3 Qg >r !Z I Z &�
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacture, —. ,1 4-4t-kw-k-- INFORMATION CHAMBER OR 4ti
Type ), f System: �, (� 3 I 5 I / A) / /� UNIT Model Numr, ?
DISTRIBUTION SYSTEM A /9? 0-6 Al. 44515 z:5 4--- zz 140
Header /Manifold i/ Distribution x Hole Size x Hole Spacing Vent o ! t i n e
/ Pipe(s) /o."`
Length _ Dia 4 _ Length_ _ Dia Spacing \ \ c
SOIL COVER x Pressure Systems Only xx Mound Or At - Graae Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Muict ed
Bed/Trench Center "7 I Bed /Trench Edges \ Topsoil ` _ y ,. N \Yes No
r
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / inspection #2:_ / /__
Location: 818 Mitch Circle Hudson, WI 54016 (SW 1/4 NW 1/4 36 T29N R15W) Cottonwood Ridge 2nd Add Lot 109 Parcel No: 36.29.19.2924
7 CIO (JAW
1.) Alt BM �
Description = l e-L' C bv'« — L
i
2.) Bldg sewer length = 3'7
- amount of cover = /
5
Plan revision Required? Yes No
1 201 op , , ( )
Use other side for additional information.
D Insepctcr'�Signar Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County _
20 1 W. Washington Ave., P.O. Box 7162 .5 7 C g o (x
\Sti s � n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
O �, (608) 266 -3151 4 /17 z Z-
Department of Commerce
Sanitary Permit Applicatio State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information ovi e
may be used for secondary purposes Privacy Law, s15.04(I) ) ,......e Project Address (if different than mailing address)
1. Application Information — Please Print All f m4 on KhUEED p
� � D Q � O ./y1�/1 /� 9 c ce
Property Owner's Name � v Parcel # Lot lock #
1 5 2006
2��'Z ( OCT 2 OZo 4/s $e- oo /0 9'
4 6
Property O ner's Mailing Address P Location
�� S C R RO OIX COUNTY f n 9
City, State 9 Zip Phone Number f A, ., Section f -(�
-ue .� W/ 5W/4, 7/5— Ask 777)--T / N; R E oeo i 2� 27
II. Type of Building (check all that apply)
0A S °b^^' g-el Subdivision Natne CSM Number
or 2 Family Dwelling - Number ofBedrooms /7'Ot ---pier. A._
❑ Public /Commercial - Describe Use CO t oA) w x(09 tz — AV-P
❑ State Owned - Describe Use 2 b;51- 62.01.1, (.t..) J ZZ -I 23 Gt1.4.0 40tr3 ❑City_ ❑Village ]- Township of ep f0 Al
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. Q��
yo-New System �` y ❑Replacement 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 Plumber Owner
v. eicvr
IV. Type of POWTS System: (Check all that apply) 4 .Y C; 111-ic
(■on - 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 ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information:
Desi Flow (gpd) z Design Soil Application te(gpdsf) Dispersal Area Required (sf) Dispersal Area Propos s System Elevation
VI. l ank Info Capacity in Total Number Manufacturer Prefab Site
P h Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing // /� C I
Tanks Tanks 41/24 t212. RD � oe l kA.c�.
Septic or Holding Tank ,_� / Z/60 /� -e J ` f
Aerobic Treatment Unit r r
Dosing Chamber
VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber' Name (Print) Plumber's Si•,nature M144PIta Number Business Phone Number
lo - rOOCt-d 2z - / 27 A. /
Plut ber's idress (Street, City, State, Zip Cod//
L Lfm)(12 + � e ,574// ,,,///
VI11. .ount /Department Use Only 1
Sanitary Permit F e e ( includes Groundwater Date sue. Issuin • en[ Signature •
PProved ❑ s' app .,
Surcharge Fee) Cg g ( il
` t 1/460- b 1 d 3d o (p / ��
❑ • .• er Given Reason .r Denial a r , ,
IX. Conditions of Approval /Reasons for Disapproval
SYSTEM OWNER: 2` @ Jt I / no
J 1 l c 0 - � O +a p RI J : r e 0 t I--
1. Septic tank, effluent filter and
dispersal cell must all be services / maintained a c Q.. pa.-42.0.4- h 0 le■cum.pa - Yak -
. as par management plan provided by plumber.
2. AM setback requirements must be maintained
as per applicable code / ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/03)
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1 sconsin SOIL EVALUATION REPORT e 1 of
Department of Commerce in accor• .- nce with Comm 85, Wis. Adm. Code Page
Division of Safety and Buildings O Steel's Soil Service, Inc.
Attach complete site plan on paper r not less than 8% 11 in e Oze. Plan must County
P P P ,� St. Croix
include, but not limited to: vertical and horizontal reference po ), 1 ection and
percent slope, scale or dimensions, north arrow, and location an • • i nearest road. Parcel I.D.
Please p t all ' � O / � ndi -,
R evie d By ( / D
�� ate
Personal information you provide may be sed for sewn ary�Privacy Law, s. 15.04 ( (m)). /
Property Owner Property Location / / / ��
Bast, Kemon APR 1 3 2005 _Govt. Lot na W1/4,f-W1/4, S36, T29N, R19W
Property Owner's Mailing Address ST. CROIX COUNTY Lot # Block # Subd. Name or CSM#
948 Labarge Rd. ZONING O COUNTY 109 na Cottonwood Ridge 2ND Addition
City Stat 1 City ❑ Village ❑ Town Nearest Road
Hudson 1 WI 1 54016 1 715- 386 -7775 Hudson I Cty Rd N
❑ New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement ❑ Public or commercial - Describe: na
Parent material Stream terraces and pitted 0 U- .+: a y/7 f /4, /h s Flood plain elevation, if applicable na ft.
General comments Conventional system, system elevation 92.90ft. Trenches spaced and depth to
and recommendations: code 7.00ft below grade
1 Boring # Boring
El Pit Ground surface elev. 99.90 ft. Depth to limiting factor 130 in. Soil Application Rate)
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color *Eff#1 *Eff#2
1 0 -13 10yr3/1 none sil 2msbk mfr cs 1vf .6 .8
2 13 -26 10yr4/4 none sicl 2msbk mfr gw na .4 .6
3 26-40 7.5yr4/4 none si 2msbk mfr gw na .6 1.0
4 40 -130 7.5yr4/6 none cos /ms osg ml na na .7 1.6
V_____ . /
A 36 inch silt lens is present from 3 to 60 p inches 2
2 Boring # [] Boring
❑ Pit Ground surface elev. 99.90 ft. Depth to limiting factor 130 in. Soil Application Rate)
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color *Eff#1 •Eff#2
1 0 -13 10yr3/1 none sil 2msbk mfr cs lvf .6 .8
2 13 -29 10yr4/4 none sicl 2msbk mfr cs na .4 .6
3 29 -46 10yr4/4 none scl 2msbk mfr cs na .4 .6
4 46 -77 7.5yr4/4 none sl 2msbk mfr cs na .6 1.0
5 77 -130 7.5yr4/6 none cos osg ml na na .7 1.6
A 24 inch silt lens is present from 24 to 48 inches
--- 11
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L "Effluent #2 = BOD < 30 mg /L and TSS < mg/L
CST Name (Please Print) `--- .��S ture:ture: CST Number
David J. Steel / 248956
Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number
994 200th St. Baldwin, WI 54002 4/10/2005 715 - 760 -0347
SBD -8330 (8.07/001
Property Owner Bast, Kemon Parcel ID # Pending Page 2 of
K ,
3 Boring # El Boring
A Pit Ground surface elev. 99.40 ft. Depth to limiting factor 130 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -13 10yr3/1 none 1 2msbk mfr cs 1vf .6 .8
2 13 -22 10yr4/4 none scl 2msbk mfr gw na .4 .6
3 22 - 46 7.5yr4/4 none sl 2msbk mfr gw na .6 1.0
4 46 -130 7.5yr4/6 none cos osg ml na na .7 1.6
1 - -
r A 36 inch silt lens is present from 30 to 60 inches
�l
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/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
—
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777.
SBD -8330 (8.07/00) Steers Sod Service, Inc.
'l
STEEL'S SOIL SERVICE INC. 3 of 3
David J. Steel Kernon Bast 994 200 St.
CST - POWTSM NW1 /4,SW1 /4,S36,T29N,R19W Baldwin, WI 54002
Lic. #248956 Town of Hudson, St. Croix Co. CeII (715) 760 -0347
Cottonwood Ridge 2ND Add. Fax.(715) 684 -3449
Lot,109
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use.
Legend N
1 " =40'
= Benchmark Ele. 100.00 ft
� l /� Top of 3/4" a E
Alt Benchmmark k Ele. 100.10 ft
� 7, 3 / efd�'' Top of 3/4" pvc pipe
k ❑ = Borings
Boring Elevations
B1= 99.90ft
B2 = 99.90 ft
B3 = 99.40 ft
4 B4= 0.00 ft
0
'4 p IN `
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in 10 — X
LOT 96 x - ' v 216.84' c
2.00 Acres 1043.1 pIcATED TO THE PUBLIC 8 _ JO
35 262.73' — ----
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1$ 1.4
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. / Z�� / • / 1040
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00, / LOT 110 m LOT 111
/ - - 2.03 Acres
N.B.A. = 2.0 AC 2.01 Acres
' / N.B.A. = 2.0 AC 4 10
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- 1040.7 I
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L OT 109 x
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c9.5 I 2.01 Acres 1038.7 2 �3�
I N.B.A. = 2.0 AC -. WEST 1/4 UNE OF SECTIOR36
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N . • . • LOT 108
I . ' • . 2.01 Acres
I , TTB- ` '1 - x N.B.A. = 2.0 AC X A e LOT ( a I / ' - - • 1037.1 1037.1 — — —
iik 50.00' 614- - 414.54'
-. ROAD LENGTH 196' +I , \\
DEDICATED TO THE PUBUC 5 t - N \
1 1037.1 t
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W I � p er
_ - - X 103
LOT 107
( ...
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• N.B.A. = 2.0 AC 8
�► 1 LOT 106 ���� co 110 4 q
2.02 Acres �` I 10
N.B.A. = 2.0 AC f
• U 2 7 39 P 316 '7 861CD9
• KATHLEEN H. WALSH
REGGISTER OF DEEDS
ST. CROIX CO.. WI
STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD
Document Number WARRANTY DEED 01/28/2005 03:15P?1
THIS DEED, made between Neil L. Wilcoxson and Mary Jo MARRXEMPT # DEED
Wilcoxson, husband and wife, Grantor, and Kernon J. Bast and Donalda J.
Speer -Bast, husband and wife, Grantee. REC FEE: 13.80
Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE 90
COPY FEE:
the following described real estate in St. Croix County, State of Wisconsin: CC FEE:
PAGES: 2
SEE ATTACHED EXHIBIT A •
Recording Area
Name and Return Address:
Edina Realty Title, Inc.
400 S. 2" St. — Suite 115
Exceptions to warranties: Hudson, WI 54016
Easements, restrictions and rights -of -way of record, if any. 456780
1 1— 1'— 1 -1 1
020 - 1110 -30- 000... 020-1109-55-050
Parcel Identification Number (PIN)
This is not homestead property.
Dated this 28 , •t: y of January, 2005.
r
.t A I IL� �•! , (kJ '
t1 L. Wi cox!' * Mary Jo i oxson
* t1
AUTHENTICA p UbVI C ACKNOWLEDGMENT
Signature(s) Nit i '� ; SC Cf SIn STATE OF WISCONSIN )
ST. CROIX COUNTY. ) ss.
authenticated this 28th day of January, 2005
Personally came before me this January 28, 2005 the
above named Neil L. Wilcoxson and Mary Jo Wilcoxson,
* husband and wife to me known to be the person(s) who
TITLE: MEMBER STATE BAR OF WISCONSIN execut .. .e fore • oing instrument and acknowledged the same.
(If not, f
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY *Chen : rown
Notary Public, State of Wisconsin
Peterson, Fram & Bergman — Steven H. Bruns My commission is permanent. (If not, state expiration date:
50 East Fifth Street, St. Paul, MN 55101 3/11/2007 )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
*Names of persons signing in any capacity must be typed or printed below their signature
WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000
•
U 2739P 317
EXHIBIT A
Parcel 1:
A parcel of land located in part of the SW '/4 of the NW '/4 and part of the NW '/4 of the SW '/4 of Section 36, T29N, R19W, Town of
Hudson, St. Croix County, Wisconsin; more particularly described as follows:
Beginning at the W '/4 corner of said section 36; thence N00°16' 10 "E, along the west line of the NW 1/4 of said section, 1248.49 feet to
the north line of Lot 1 of Certified Survey Map recorded in Volume 3, page 669 at the St. Croix County Register of Deeds Office;
thence N63 °02'59 "E 148.42 feet to the north line of said SW '/4 of the NW '/4; thence N89 °26'58 "E, along said north line, 1182.70 feet
to the east line of said SW '/4 of the NW '/4; thence S00 °21'37 "W, along said east line, 350.04 feet to the north line of Lot 73 of the
Plat of Cottonwood Ridge First Addition recorded at said office; thence S89 °26'58 "W, along said north line, 10.00 feet to the west line
of said plat; thence S00 °27'24 "W, along said west line, 2096.76 feet to the centerline of County Trunk Highway "N" and a point on a
1999.00 foot radius curve, concave southerly, whose central angle measures 7°10'30", whose chord bears N84 °30'41 "W and measures
250.16 feet; thence westerly, along the arc of said curve and said centerline, 250.33 feet to the point of tangency; thence
N88 °05'56 "W, along said centerline, 83.64 feet to the point of curvature of a 2700.00 foot radius curve, concave northerly; whose
central angel measures 3 °17'53 ", whose chord bears N86 °26'59.5 "W and measures 155.40 feet; thence westerly, along the arc of said
curve and said centerline, 155.42 feet; thence N04 °29'56 "E 244.01 feet to the point of curvature of a 167.00 foot radius, concave
westerly, whose central angle measures 34°24'12", whose chord bears N12 °42' 10 "W and measures 98.78 feet; thence northerly, along
the arc of said curve, 100.28 feet to the point of tangency; thence N29 °54' 16 "W 274.22 feet to the easterly extension of the north line
of Lot 1 of Certified Survey Map recorded in Volume 12, page 3456 at said office; thence N89 °' 12'45 "W, along said easterly
extension, along said north line, and along the westerly extension of said north line, 670.44 feet to the west line of the SW '/4 of said
section; thence N00 °37'50 "E, along said west line, 496.89 feet to the point of beginning.
AND
Parcel 2:
A parcel of land located in part of the SW '/4 of the SE % of Section 36, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin;
described as follows:
Beginning at the South % Corner of said Section 36; thence N00 °27'05 "E, along the north - south ' / line of said section, 1216.78 feet to
the centerline of County Trunk Highway "N"; thence S76 °47'47 "E, along said centerline, 1354.82 feet to the east line of said SW '/4 of
the SE %; thence S00 °07'02 "W along said east line, 897.02 feet to the south line of the SE %; thence S89 °33'25 "W along said south
g g
line, 1326.80 feet to the point of beginning.
Oc.t 24 06 12:33p Team Speer Bast 7153868660 p. 2
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• POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of Z
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner ( / Septic Tank Capacity / 20 gal ❑ NA
Permit # Septic Tank Manufacturer 64t-5 ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer szAerr Z ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model A- ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity ga l ❑ NA
Estimated flow (average) ' gal /day Pump Tank Manufacturer _— ❑ NA
Design flow (peak), (Estimated x 1.5) 6a gal /day Pump Manufacturer ❑ NA
Soil Application Rate r 7 gal /day /ft2 Pump Model .. - ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, 011 & 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 Cells) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L 18 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 eve ❑ month(s)
ry� � RI year(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (3/ of tank volume ❑ NA
Inspect dispersal cell(s) At (east once every: 3 CI month(s) ®year(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
r � HI year(s)
El month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: 3 H year(s)
Flush laterals and pressure test At least once every: 3 CI month(s) ❑ NA
'® year(s)
Other: ❑ month(s)
At least once every: ❑ year(s) ❑ NA
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.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
. . s,
Page Z of Z
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal 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:
❑ 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.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name R p c, 6 R. M E L S Name
Phone ` 1 S- Z 7 3° 1 4 I 1 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name 7 Cl o ix Zo r✓/�/�
Phone Phone Z`'! 3 g 4 - ce
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.
Oqt 24 06 12:33p Team Speer Bast 7153868660 p.
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•
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
•
Owner/Buyer KC Abv 'T. BASS • • •
•
•
Mailing Address 94'9 t# .6494E Aeo Nvosclt) � 5 •
•
•
Property Address 7M Ati re H ee — NvosaN .. w1SCAArsrrt) • 1 '
(verification required from planning Depamment for new construction)
•
City/State A100540 f r Parcel Identification Number Ozo- /1554 ad - / of
is.G D7.SCRIPJION
•
Property Location 54e V. 1/4, Sec. 3G T. N -R /9 W, Town of
•
Subdivision Co7T' . _ E106£ .sews/0 Qfilo47 . Lot # /D9
Certified Survey Map N , Volume , Page U
Warranty Deed g d 7 `� . p ,/ A , Volume , Page N.
Spec house ycs O no Lot lines identifiable Ai yes ❑ no
SYSTEM MAINTENANCE
improper use and maintenaneeof your septic system couid result in sic pre:nature fat:un to handle wastes. Proper ma tnrenance
consists of pumpng our the septic tank every three years or sooner, if needed by a licensed pumper What you poet into the system
can affect the function of the sepurc tank as a treatment stage in the waste disposal system.
The property owner agrees to subnut to Sr. Croix Zoning Depamnenr a csrtefiestion forthm, signed by the owner and by s
mast:, plumber. journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -sae wastewaterdisposat system
is in proper operating condition amber 12) after inspection and pumping (if necessary). the septic tank iS less that 1/3 MI of sludge.
1 /we, e - ride gned • read the above requirements and agree to maintain the private sewage disposal system with the standards
se nh. her act the Deportment of Commerce and the Department of Natural Resources. State of Wfseonsen Certefreaaoo
ssat1n &•that apt ryst has been maintained must be enmpieted And returned to the St. rroiu County Zoning Ofllee within 30
clays or three ' cxpr i dam.
1 .r4/t•
A APPLICANT DATE
� WNF...!+. F •
1 y t a statements on 1131$ farm arc true to the best of my (our) knowledge I ewe) am (are) the owncr(r) of
the prop • en • d hove •y v� ur of a warranty deed recorded in Register of Deeds Office.
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GNATU - .iii . PLICANIT DATE
•
Any information that is mis- represented may result to the sanitary permit being revoked by the Zoning Department.
-' meiotic with this appricauon: a stamped warranty deed from the Register of Deeds office
a copy of the candied survey map if reference is made in the warranty deed
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INFILTRATOR SYSTEMS, INC. ADARA
(a) The structural htegriry of each c end ST plate, w end D oaer accessary menu factwed RRANTY by InfUka (•lldts�, when "s and operated
h a leachfidd of an onsite septic system in acoodance with "fittretar's "strvcl bnoLIMITED . W Ls warran to the orighel purchaser CHOdei') ag ainst defective
materiels and workmanship for one year from the date that the septic pemdt is Issued fo the septic system con t he UNts; provided however,
that If a septis wa is not required by u st not ble law. the warrent will beg" upon the date that Installation of the septic system commences. INFILTRATOR O
t exenrise i warran rig Hold must nodly Infiltrator In wrung at its Corporate Headquarters "Old Saybrook, Corvlectbut with" fifteen (15)
days IE of the M alteged detect. Infinretor will soppy re Units for Units determked by Infiltrator to be covered by this LkNted Warranty
Infiltrator§ pab5ty spedriwlly WARRANTY exckdes AND REMD oast of removal SU and/or Installation of the Unns.
T LIITED E ES W BARAGRAPH (a) ARE IXCLUSIVE. THERE ARE NO OTHER WAARANr1ES WITH RESPECT Y'�` I
(b) R
TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES P OF MF3iCWWTABILITY OR FITNESS FOR A PARTICULAO PURPOSE, SYSTE 1 1 V
(c) This Umite Warranty chap be void N an y but of the chamber system is manufactured by anyone other than Infiltrator. The gees. i d Wanranlo does
not ext end to hcdental, consequential, specie) or indirect damages. Infiltrator snap not be liable for penanles or Y .., any i damages, ear, Q bas of Environmental Onslte Wastewater SolutlonS'"
(c) Thi tion and P raha, mbar and materiels, overhead costs, or other bases or expenses kovrred by the Holder or any third party spear,* excluded from Urtated Warranty coverage are damage to the Units due to =finery weer and tear, alteration, strident, misuse, abuse or ne of
the Units; the Units bang eub)ected to vehicle traffic or other con stlona which are rot pemfitted by the hstellatbn hetructbns; faYure to mer the 6 Business P ark Road • P.O. Box 768
mhmum ground coves set form "the „stamen katnuctbns; the placement of Improper materiels Into the system oontabkg the Units; fasure 01
the Units on the septic system due to kn siting Or r oier ewng, excessive water usage, compl r grease f the t al. or m pmper operation; or Old 77000 Saybrook, CT 06577 475
any other event not caused by Infiltrator. Lknited warranty shall be void If the Holder fails to comply with ell of the terms set forth h this Lmted
Werra a• 860 577 • FAX 860 7001
Bother h no event shah hfittretor be responsYNa fo any l ose or damag to the Holder, iha Un its, a any third party resulting from installation or SNP-
800-221-4436
meet, or from ar product tabptt dakns of Hader or arty third paty For 1188 Ubled Warran t o apply, the Units must b.e "stalled in aa:o rdance
With all site conditions required by state and bcai codas eN other ap laws; and InNtra hstatatlon hatructlora
(d) No representative of Infiltrator has the authority to charge or extend this Limited Warranty. No warranty apples to any party other than the origl-
nal Holder.
The above represen the Standard Units Lkrrited Warranty oneed by kNYtrato A Ymned number of states and counties have dinerent warra requ
ma nta. My purchase Units ehoutd contact Intrator's t
fi Corporae Headquarters h Oki Saybrook, Conen,•Iicut, prig to such purch to obtain a
copy of the ap ppceble warranty, and should care mad that warranty prior to the purchase of Unns.
U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 ,
Canadian Patents: 1,329,959; 2,004,564 Other patents pending. '
∎o
Infi ltrator, Equalizer and SldeWinder are registered trademarks of Inflttrator S Inc. Infilt is a registered Vademark in France. Inf Systems Inc.
is a registered trademark In Mexico. Contour, Con tour Swivel Connection, Mic roLeaching, PoyTuff, SnapLock, ChamberSpacer, PasiLock, QuickCut, QuickPlay RECYCLED PAPER
and Quick4 are trademarks of Infiltrator Systems Inc. ® 2003 Infiltrator Systems Inc. Printed In U.S.A. 0011203HP -0