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HomeMy WebLinkAbout026-1121-22-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 420335 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: Halle Builders Inc. I Richmond Township 026- 1121 -22 -000 CST BM Elev: Insp. BM Elev: IBM Description: C ` I job •e> s F (Ca- e a*-() — TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark •� D I Dosing Alt. BM V. I �J Aeration Bldg. Sewer Holding St/Ht Inlet TAN ETBACK INFORMATION St/Ht Outlet J TANR TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic X Dt Bottom Dosing Header /Man. Aeration Dist. Pim Holding Bot. System t L �- Final Grade PUMP /SIPHON INFORMATION r �,Q Manufacturer Demand St over �.O •S t Model NANer TDH Lif Friction Loss System Head TDH Ft F cemain Length D a. ell SOIL ABSORPTION SYSTEM /TRENC Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DI S / (3 SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING M r INFORMATION CHAMBER OR Type Of S UNIT Model Number: 5 3' 1 2. $ . . DISTRIBUTj9N SYSTEM - p14. u 1Z,1� }ti So. r L Header/Manif Distribution x H ze x ing Vent to Air Intake A Pipe(s) �f { length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil �,/� [, Yes L_§] No [] Yes [� No COMMENTS' I clu ec od�isc�repe�es er ons pr sent, a c.) r In�pectiorz #1: � L/U Z Inspection #2: --- ;- ---, -- h a. // e� Loc ion: 1715 1 7th St ee Hudson, WI 54016 (SW 1/4 S 1/4 5 T30N R1 8W) Partridge Run Lot 22 Parcel No: 05.3 18.737 1. Alt BM Description= ata, W `_ 2.) Bldg sewer length = � Z Z s S u 3 � amount of cover = g 4r, aAA- �`� Plan revision Required? :, Yes No Use other side for additional mforma ' n. natur epc Date In SBD -6710 (R.3/97) stor's ige Cert. No. s) 0 wAW O's �� /omJoz *islconsin Safety and Buildings Division Cry 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 Site Address D artment of Commerce l b -, e Sanitary Permit Application Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you Provide r ❑ Check if Revision may be used for secondary purposes Pr ivacy Law, sl5. 1 m I. Application Information - Please Print All Information State Plan I.D. Number A roperty is Name — . Parcel Number oar 41 - Property Owner' Mailing Address Property Location p 7p W F,v O ���2 kI %SC 54; SJ T J� N. R �O 9' City, State Zip C e Phone Number Lot I�u1rt{aCr Block Number , C' F e Su 'visi n N e CSM Number II. Type of Building (check all that apply) ❑City ❑ 1 or 2 Family Dwelling - Number of Bedrooms 3 2 -a'e -J Dvillage ❑ Public/Commercial - Describe Use i ❑Township ❑ State Owned 3 /tpiie "' -a 0 3 - 7 W ! v Nearest Road 1 Q 3' X 8 i l l 3 clal`!' '4d AD 7 - ' 01' M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A w 2 ❑ Replacement System 3 ❑ Replacement of 6 10 Addition to For County use stem Tank Only E ' stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued of Permit: (Check all that apply)(numbering scheme is for internal use)'� �.S s — on - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 3 � I '� 45 11 At-Grade 46 11 Aerobic Treatment Unit 49 ❑ Recirculating 30 11 Other ' .3 7 V. Diss1we rsai/1Yeatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate on Final Grade / Required Propo Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic ` Gallons Gallons of Tanks Concrete Constructed Glass New I ExisdnY 4-1a Ll Tanks Tanks � 7' / Lsq# Holding Tank )60c /t?a V Dosing Chamber C ot, ('00 VII. Responsibility Statement - I, the undersigned, assume responsibility for ' the POWTS shown on the attached plans. Plumber's Name (Print) Pl 's Signs _ r Business Phone Number Plumber's Address (Street, City, State, Zip Code) 3'2 Z y � s 7- 1"/J '5 Cozen /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Da Issued Is ' ent Signs Stamps) Sure a Fee) Gz.. ❑ Owner Given Initial Adverse Determination IX. Conditions f Approval/Reasons Proval _ � BZ � ��',���� � ��� nom.✓ �� � ►�Ji�/7s �� �a�., r � ol Attach plans (to the Coui# onl ) rorffie rystem a paper ae ess than SM � in&es 16 size SBD-63 8 OS/ 1 3 ,.���,rn✓ �� ;?sue ����, >�'' �-� Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 Pw isconsin Madison. WI 53707 - 7162 Site Address y� , Department of Commerce Sanitary Permit Application ganitat Permit Number in accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑Check if Revision ma be used for Privacy Law, s15. 04(%m m I. Application Information - Please Print All Information State Plan I.D. Number P 111 3 i s Name __._ � Parcel Number ty Owner• Mailing Address Property Location � O 9 2 �� 2 G " 7 p c; G✓ SfS� Sf: S� T ,�C) N. R �0 may. State Zip C e Lftonwe Number Lot i t Block Number ST. Gi" 1J. "; ZG!CE Su 'visi n N CSM Number II. Type of Building (check all that apply) ❑City ❑ 1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ❑Township ❑ Stue Owned #9 3 'X 7W / v Nearest Road f Q 3'x S l y 13 C AV-- " /67 -,00, M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A w 2 ❑ Replacement System 3 ❑Replacement of 6 ❑ Addition to For Cony use stem Tank Only stem B. ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. of Permit: (Check all that apply)(numbering scheme is for interval ufte) JA r.S 4a�J�ATOn - Pressurized In -Ground 2111 Mound 47 11 Sand Filter 50 11 Constructed Wedand' y� 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 C1 Single Pass 51 ❑ Drip Line 3/. / / 45 ❑ At -Grade 46 11 Aerobic Treatment Unit 49 11 Recircalatmg 30 ❑ Other ` .� V. tment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate n Final Grade / Required Pro Rate( Gals. /Days/Sq.Fk) (Min./Inch) o�•�j`. O ./ IIcevaflon q p9rd So�Sd / /�'s / - VI. Tank Info Capacity in Total Numbe r Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New > w Tacks Tanks or Holing Tank j W V - /coo VII. Respo nsibility Statement - 1, the undersigned, assuzoe responsibility for the POWTS shown on the attached plans. Plumber's Name (Print) Si r Business Phone Number 's gns '7 /f%�i� Ce j ,/V // Plumber's Address (Street, City, Stan, zip e) 3 Z 4/a i s M -ee la /-1 S'Sioo / County ent Use Onl Sanitary Permit Fee (includes Groundwater Da Issued ent Sign Stamps) Approved ❑Disapproved ❑ Owner Given Initial Adverse �- �/ ' d .1S: °i ' v Determination _ IX. Con pf Approval/Reasons for Disa proval Attach � (to me Co for s�atem yn ttun 1 arse SBD-63 8 051 1 �3 w q.7-1 _� I i - - Z -- - - - - - - -- - - _ i I _ _ t 13 I i I Z '0�Qd_ - I • 1� -- ,a I I ` - 1 - -- ; 1 : ALL - I I � t t� I : \ - � Y i i 7 A' Gc Qv I i i 13,a' ' I Z i 9/ 1 i _ I , 1 I f � I i �I i I i C 1 7 � IL 44 Dp cjO I i 0 0 '�rp.a 912' 9� ',� -, r fi j � i � - �� � �.� � �i �, � i { � i � j ; � ,_ - - -� I i � _ _ � � _ � _ � r �- - ���- - - � -� - �� -� -� - i i I � I i � _ __ � �' ! � I __ I _ � _ I� _ _ i I I I � �� i - �� '� � � I � _ i _ -' I I � i s � i l- - i _ _ i � __ i I ii I - i —j _� � ! I � � - - � �, � _ ', _ � �', �� - - - — -. _ _ - _ _ � -. �I� - � � - - � - - � __ _. _ i I j i ± � r I i i � �� i ! _' i i � i i � F I l f t i � _ E_ .__ - -- � t i � � - � t � ', _ � � I ��� � -� _ _-1 _. I _� � ! � C_ ' I i r ' II 1 �� 1 � _� i � � �- r � ', ' it ii I ' ' _ � I � ' ' ! � I I j i _ ___ ,_ _ — , -- - } — j j � � r _ _— - I � � i � i i _ I _' ' _ _ -_ � - -� __, � � - - - i _ _ I � �' � _ I �— _ ._— , r-- -- I �,, � � __ i _ _ i � - � � — + I II� -- � - - - -� -- � � � ff � i i ', � � � I � L _ , �� � , -- G -� -- � - - i � � � i i � _ '� � � � � _ _ _' ,- _ � - � - -- � __� i _ � -� i �r-- �� i � ! � j i I j i �, i �__ �� _ 1__ , - _ - - -� _— __ — � � , i l � _ � I .- � j ' � i i t � i � � � � i � ... � � i r i ., '; I � I _. ' �� _ � � � ' � '� L_ - �' � _ __ I - ' _ _ _ i, t � � ' I i �� I _ _ I ' I i I ,, I � — � — -- � �� r � I _ � � -_ i _ 1. i I � i i '� r f I I '� �� I� L 1 � I I . Wisconsin Department of Commerce SOIL EVALUATION REPORT Page J— of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S�, l—. 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. () a �— M I cam' i — a Please print all information.l�� 3 �3 ��. ed by Date Personal information you provide may be used )ry' -� {ttiay Law, . 15.04 (1) (m)).� d Property Owner roperty Location li e " 1!j 2 900Z A ovt. Lot 114SC 1/4 S E) T N R E (o W Property Owner's Mailing Address `` t # Block # Subd. Name or CSM# 41 aj4, QT 1, Par+ e City State Zip Code Phonedtrrpk:f "' City [] Village RTown Nearest Road v v ew VA 6 0 4 .. L7 r ( 15 )ASK a 62 1 .d r R MSr.� � MY2� {�4'� V �� ✓� I 54 New Construction Use: K Residential / Number of bedrooms 3 Code derived design flow rate Y50 GPD ❑ Replacement —� ❑ Public or commercial - Describe: Parent material i �6,ff W4 5 t, '-,I '. )!C Flood Plain elevation if applicable ft. General comments j !5 L) 55-e S� 3 - '-A 75 ' - rQEkkt 5 Fe e - r a_,e-G, 5 '} t. • and recommendations: ' T, I 09-0a") l�s:..s rn�k, 5 4e-1: T,3 7,?D'� TAIv 9. M Boring # ❑ .Boring Td y (� �' Pit Ground surface elev. ft. Depth to limiting factor 7 D 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 a 1,s y y ��_ z s , s -9 23 3 is- s V yIb _�., ..w -T St- 3 FS a a� �� . ® Boring # ❑ Boring 4- s -� Q- �(�•� Pit Ground surface elev. 39 ,7 (o 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 4 104P,-!1A L IF69 CAS G F , 4 . b gAt 1 0 '1 .._ ...�.... L FPS- 8 s � AV 3 0 �l� �1�1 �.w.� .. ,. L, FS K Skr C W y 4 1(, f,I s , ems .� . -- 311 v. * Effluent #1 = BOD > 36 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L � ST Name (Please Print) Signat ke P CST Number Ck T sfod UM Address Date Evaluation Conducted Telephone Number SBD -8330 (R07 /00) Property Owner 14a t Le Qut I d C'f .a Parcel ID # Page � of F3-1 Boring # E] Boring X Pit Ground surface elev. Y3 ft. Depth to limiting factor 13 Q in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2 I F&9 ds QS a F . q . 6 a 6 -! )0 IR 3 1LI - ----- L. ) F Pc- ds Cw y 6 3 11 - 1 6 i) A ,5 14 aPS6K ash cW F 14 Iq aF56K , s n -- ---- .5 .� y Iq SL Fq] Bodng # ❑ Boring Pit Ground surface elev. 95-9 ft. Depth to limiting factor I / D in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -10 10 VR : L aF69 as ;� r:� S .S a 10 -3a s y k `'ICI SL, a�-sL),K 3s c�a I F 15 .9 1,5 qR qli - � - S L a Fsr� as 3 ea•.� Q;hs �oc�ce 54r% SL Y.2A— ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz 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 (R.07 /00) 1,44 1) 1 ios -Zrve_ Rt sup /y� SE'1�I Sec.. S� T 3qU, R 1g fah vi 14 L ID , .03 0.Grt St'iM a�o�l 1'7 °r 1 o ' r O 8m ► -r. Ps ' M $ttGl "ce eos_,_s 5 har - r�.�����t..y o V r o D d a a 1° 1 143. •\ s a al'1r1) )00.00 S nn 63 5S-Y3' 93 .76 BY 9s,ga' Th G 03/12/2002 09.50 6087859330 5At'LI Y RNO ML • Page Of - -- S£P` TC `SAN F' PUMP C CROSS gECTION AND SPECIFICATIONS WEATHERPROOF T '4 a13: c ;�^ _nat$ in, JUNCTION BOX APPROVED WIT OI�DUTT MANHOLE COVER W! ?ADLt3CK WARNING .1,ABZL FINISkjED GRADE „ MIN,. I 0 1K IN. • �1� I NLE T GAS- ► WATER TIGHT SEALS 77 T701i � 1 � APPROVED A SEAL • t ; joTNTS WITH E ALM AiPPROVE PAP APPROVED Z - B t 3 ONTO SOLID S.OIL PIPE 3 SOLID �.-- ��- �-- �-."�.` C ! 4 #�� R EX"�T. ONTO ,. OFF SOI� pump pFr ELEV . FT. PERMTTTED ON L! D IF TANK MANUFACTURER _ HAS APPROVAL B dd rc7. n 0��"d =e w fih prQduot appr , ��a nde C mna 84-10 CoVCRSTE PAD SPECIFICATIONS c / JO DAY- SEPTT _ �tiJMBER DOSES PER TA14K 9ANUFACTURER . ' O CAL. Dosr VOLUME INCLUDING _ `�l1NKS' SEPTC DO--_. GA FI,QWSACK. M Z Z GAL. DOS a CAPACI A 3 xxcx� .3 ALARM MAMJFACTURER: 30 CA MQDEL MJMBER : .�.— B 2 INCKES w SWITCH TYPE: C z ,/3 INCHES ZZ GA PUMP MANUFACTURER= 8 GA MODEL NUMBER ' D c ' INCHES swTTCH TYPE. RE U IRED p j SCRhRG E RATE _ _� GPM PUMP t ALARM WIRING AS PER xLHR F �44r, � i mpk fix M FEET VMf TSCAL DIFFERENCE BETWFF'N PUMP OFF AND DISTRIBUTION 'PIPE FEET MI t rM NETWORK SUPPLY PRESSURE - FEET rORCEMA.IN X k r — FTI�,Op F TOTAL T DY'NA M IC A HF.A•D ; • L`ET WIDTH > i N'�ERNAL nIMP s T a NS OF PUMP TANK LlgGTDH 9— — l D FEB-29 -00 THE 03: PM JH LARSON 1� "il'r .36 C' 3 748 F. 03 1q1Ei /h0 CAPACITY CURVE ' MODEL "W" -• ; , j r - I t? r ` � o • 1 to U. tC ,�:�✓� tiTt:l fig PLOW 0 PLOW PER MINUTE r tot�� c +wneuTa� t , e � i'LtrfkT AIeCCf Wi.f Ea WA � t:Araarrr + L ,} I•�noo UMttJ1rM1M � /s[P 149tTt�s GAL! LTlItf3 I � � 4 S t,e2 r9 3 1D 105 tt 231 t 6 A rt 4a 03 20 910 jj I . .. .. " . . )o� UK, In: C; CONSULT FACTORY FOR SPECIAL APPLICATIONS • fiewical altema wsr for duel 91( systems, are available and • Var,abM' Icevel float rs ;arc -wa lable for conlroMng single suW30d with an alarm. and Three ohase syst •• • Mechon(cel eltternetora, for OtlpCex sy�s iems, am a valtable with • Double piggyback w : nv levt;t floe: 8witcltas errs rtvAllable or WkhoUt stlarml sWllCltes. for variable Wei 4.)n ; c: It Controis ON GUIU1. t integral Poe,oia=ntpe' r '!•iA!4aI noetiernslresntrotrogll ►raid 11 s - mode 1!�h /elslht 3 l YI, M .P . _ 2 Sn, !e + p Wu% v ariably? t .•at Wtch or drift t vmMls kWei ..�.�_...., Y P D Y P QAY� , t 1 tt _ t►oRt twltr.n Rerp fc FMr a LniV CM s% __ P ex J N• #chuMce; uttemam: 1: pp7$ AN fill �. O S 1 1 See FM071l 'c.• Wrt I r.n.:. c ::inc r 64 ACM r•atur. G•Pok. 1L'f__.r. .li,�, �__ 9a,r4 �, s GanVur ew7lrn •r: 0225 c. c•ntrc• a�terot,�r, >tiner!♦ry daltrtex (3) Cr {I) J _ AeRa a;7 ­ 12" s T _ _. ftastaysrem of Four (4) r .+ l'sA, p - , -5, 6ale/tig1( 1nection or whpd -In Non 4 .1 2 or 2 as T^ 3 or 4 s 5 elmptelr or duplaK ope rwic ^ X 1 2 T iwe) i T} rule •pOK inr r.a•,. : rJnnp }Irpn or tptic:e i:AUr,cn fain - rdi( tenon Iwl arowoanCa- *mwnilaner. FM0514,Pgoilseat A!I Inetslbur, +. „1 c a•r;tet and WI: ny Should be llnot b f I quotilitd VtfehMlev+t8wh hN,ITW4'7;Elnfttt Alto iw1or,PlA M.Meedenice! Also mas±r,FM0/o6.8wv;W Ilceneed.rnoern;r+ nlrer•rtr yc00ett le.;dbetmtowedlnctutil" the "Knat swMp Istint. FMUV. and "OW ftte, IlA ,ei!ru Pump 0MIMIRIeansynlws>'AM2 rocehtM4iMne'.F,r,rr.�(Irtr , s, neQcc :pN,�121 2e10Y806 HP#I11i AdfOSNA) RESERVE POWERED DESIGN For Unusual con a reserve safety factor ?s engineered incv ti-,e rir •: . of every /(etlet pump. _ �1 _. _ • MAIL T& PI) nox •f: e; Ik ? A 31 1) 't 111 R i Nlf fD , 7{N9Ce Hr,n Rum s .: /�,U/41A� L �. (so ?� 11B• ?l31 • r ra;rl y2a•rc.;I.r. f.��ei.1i,. S+vcr' �,y.� PNl1S?;11r1 Jt;.-c • : ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Pfa. Ut 1�� F i-h t^ - Mailing Address [ l 3 I�ew h _� W 1 5 `t y t ^7 Property Address (Verification required from Planning Department for new construction) s City/State N E ( � E 16 r� l y 1 Parcel Identification Number � -' / C l — lo © © O LEGAL DESCRIPTION Proper Location '/., '/4, Sec-. . T _N -F 7_ , Town of P Subdivision �� �, -;�c. e �wh , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # &03(03 , Volume Page # 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 three 77 T da e SIGNATURE OF 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 property des 'be ve, e of a warranty deed recorded in Register of Deeds Office. 4K v /" f L U -�- SIGNATURE OF APPLICANT DATE * ** * ** 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity GdQ a l ❑ NA Permit # � Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer [3 NA DESIGN PARAMETERS ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model -o(_ Number of Public Facility Units ❑ NA Pump Tank Capacity 00 al ❑ NA Estimated flaw (average) 3401 al /da Pump Tank Manufact ❑ NA urer Design flow (peak), (Estimated x 1.5} ys�� al /da Pump Manufacturer ❑ NA Soil Application Rate gal /day /ft Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA 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 /1OOmi ❑ Drip -Line ❑ Other: Other: [3 NA Maximum Effluent Particle Size Y in dia. [I NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * values typical for domestic wastewat r and se / tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) Maximum 3 years ❑ NA Inspect condition of tank(s) At least once every: 5 I"rear(s) Pump out contents of tank s) When combined sludge and scum equals one -third (Y o volume ❑ NA ❑ th(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) aD At least once every: years) ❑ m h(s) ❑ NA Clean effl t �e r>GVYin ' )M At least once every: earls} ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) ❑ mo t once every: Y nth(s) ❑ NA Other: At leas ❑ earls) Other: ❑ NA MAINTENANCE INSTRUCTIONS OV o47 &a S e0 P'v- 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 a indicate a faili effluent on the round surface m ay 9 condition and requires the of affluent on the ground surface. The ponding of eff g 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 (4101) x • Page of STAWr UP AND OPERATION of the POWTS check treatment tank(s) for the presence of painting products or other chemicals For now construction, prior to use 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 lo cation 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 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 INE12MR POWTS MAINTAINER Name Nam Phone on e - �� 6 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name �57, !, y Phone Phone /� : 3 — 76� This document was drafted in compliance with chapter Comm 83.22(21(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. I yn 1452PAuM 609363 KATHLEEN H. WALSH DOCUMENT NO. State Bar of Wisconsin Form 2 -1982 REGISTER OF DEEDS ST. CROIX CO., WI WARRANTY DEED RECEIVED FOR RECORD O8-27 -1999 9:15 AN WAR EXEMPTT1 DEED 15 Wesley W. Halle and Linda R. Halle, husband and wife, convey CERT COY FEE COPT FEE: and warrant to Halle Builders, Inc., a Wisconsin corporation, the TRANSFER FEE: following described real estate in St. Croix County, Wisconsin: RECORDING FEE: 10.00 PAGES: 1 Halle Builders, Inc. 1113 Highway 64 New Richmond, WI 54017 Parcel No. 026-1019-10-000 The Southwest Quarter of the Southeast Quarter (SW1 /4 of SE1 /4) of Section Five (5), Township Thirty (30) No a een (18) West, EXCEPT Volume 728, page 136 as Document No. 407700, now known Lots 1 — 26, PI of Partridge Run, in the Town of Richmond. This is not ste roperty. Exception to warranties: municipal and zoning ordinances, easements and restrictions of record. Dated this day of August, 1999. /. r � We ey W. le Linda R. Halle ACKNOWLEDGMENT STATE OF WISCONSIN ) ) ss. ST. CROIX COUNTY ) Personally came before me this- day of THIS DOCUMENT DRAFTED BY: August, 1999, the above -named Wesley W. Halle and ON L. HA ' da R. Halle to me known to be the persons who Judith A. Remington �� Bx ted the foregoing instrument and acknowledge REMINGTON LAW OFFICES S the s e. P.O. Box 177 , K Q - VARI New Richmond, WI 54017 ' • — (715) 246 - 3422 �c PVa�1G Publiq Stat f Wisconsin Commiss xpires: 9T fi 0 F W�SG J N vi E2 �N A C 28 v .... v1 1.0 o ? cn d es• 56.66 ' 139.51 S00 "E 966.95' 223.00' 385.69' 173.07' 168.00 98.72 o > =f 68.90 0 o 0 Io � ro Z (11 Z -�G�/' I VV ui �O OD cc co 0 1.8 rn CA > - 00'59 � o _a N w o cry o r*i (n n 41 w n� ..�Z.1.4.90N In o '� �++ P m m rn C M N N m (n r*i (n > rn N > •�• ... � ............... N ..........�..... N O N U W N . i .. O ...., r . O... n.. .`._. O .,..�.N.......... O NO OI ( 1- --, 0o I I I j j o i I I I SOO'04'29 "E 1297.20' w -- - 107TH STREET - - - - w N00'04'29 "W 1297.10' w i I o I I I t o i C i OD I I co co �► . I � {► I I w ....`.. n a► L �+o 0 o .............. 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