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026-1302-08-000
:partmentofCommerce Q%d PRIVATE SEWAGE SYSTEM County: St. Croix Building Division A� INSPECTION REPORT Sanitary Permit No: 488099 0 c RAL INFORMATION (ATTACH TO PERMIT) ate $ Pla D �No: ,nal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 2 = TQ1QW • AAQ mit Holder's Name: City Village X Township Parcel Tax No: P.C. Collova Builders, Inc. I Richmond, Town of 62(p - /302- 0 8- oo O CST BM Elev: t Insp. BM Elev: I BM Description: Section/Town /Range /Map No: p 07.30.18. 15 1 r 6 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark � t�soA(o3 Dosing �/ Alt. BM Aeration Bldg. Sewer , 1 1. lb gZ. Ifl Holding St /Ht Inlet ' � Q I• O � t u et TANK SETBACK INFORMATION t TANK TO P/L WELL BLDu. Vent to it IntaKe ROAD Dt I Septic Dt Bottom D osing Header/Man. A eration Dist. Pipe T o mg o. Sys � , PUMP /SIPHON INFORMATION ma ra e ' s ' c l� •� M anufacturer Demancl 6t Cover , bU _ GPM I el Numuer It • i F riction oA) (S Z e Heac W 2 I F , orcemain e g n / ia. 'PTION SYSTEM Z �I ) (C. 01-11-A.7 1vvII r- - 11 MECHIJIMAU1 1. INFORMATION CHAMB IT - I S ��C- PIL DIStIlbut—I 1A Hum JA I Illu opdChly QQ Length Dia Length Pipe(s) �v Dia 2 Spacing J 3 Z x Pressure Systems Only xx Mound Or At - Grade Systems Only Bed/Trench Center Bed/Trench Edges Topsoil Yes - -I N Yes No CO ENT: (In�clu a cod d' ci:re ies, persgns present, etc.) Inspection #1: (A � Inspection #2: �7 Y� g %% Location: 961 165th Avenue New Richmond, WI 54017 (NW 1/4 SE 1/4 7 T30N R1 8W) Ninety fifth Street Site Lot 8 Par 07.30.18. 1.) Alt BM Description 2.) Bldg sewer length - amount of cover = Plan revision Required? ,i No Use other side for addition*,a,i, _-Ieoes S,g,ratnre - -- —�' SBD -6710 (R.3/97) � n 0� Safety and Buildings Division County N consur, is 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) nt of Commerc I (608) 266 -3151 State Pl I.D. Number EIerm yiication � In accord with . de, personal information you provide rxt ry purposes Law, s15 .04(1)(m) Project Address (if different than mail g ad ) App ication Informaatiion - Ple se Print All Information Block # T. CROIX COUNTY Name V '0�/ ` (J�l� • / G�+ #� Property Owner's Mailing Add � Property Ctioonni 0 ' /., y/� ' /., Section City, State Zip Code T Phone Number i � ,� ^ 2l ircl ne) N; R E 6 H. Type of Building (check all that apply) R 5 110 r 5 ' or 2 Family Dwelling - Number of Bedrooms 116 , Subdivision Name CSM Number ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use 1 ❑City ❑villag Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑Permit Renewal ❑Permit Revision El Change of ❑ List Previous Permit Number and Date Issued Permit Transfer to New / Before Expiration Plumber Owner C�Q IV. Type of POWTS System: Check all that appl ot ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil - e ❑ 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: Dqi4n Plow (gpd) Design Soil Application te(gpdsf) Dispersal Area Required sf) Di,p ;d Atea Propo (sf) System Elevation / VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing 1 Tanks Tanks I X- 11 1 ZIL4 44 ' Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber 2 VII. Responsibility Statement- I, the undersigns me responsibility for installation of the POWTS shown on the attached plans. s Name (Print) Plumber's gn a MP/MPRS Number Business Phone Number 5 7 cw(- - < Plumber's Address (S set City, State, Zi e - A) U-2i < VIII. /De art nt se Onl Approved ❑ isapproved Sanitary Permit Fee includes Groundwater 1 � 7 Iss Issuin A nt Sign S Surchazg, Fee) 7 / 11 rven Reason for Denial t P IX. Conditions of Approval/Reasons for Disapproval 3 \ J 1 SYSTEM OWNER: J 1. 8sptic tardt, effluent liker and P � d-- 4, dispersal cell must all be services / maintained n as per management plan provided by plumber, r S�Q re M 2 r All setback requirements must be maintained `�> � p , �' a +� 5 n as per applia" code / otdirarlces. 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) f I 143VtWO MST=Y8 lino -00 0n9vMq ,Anal 30"P- . t ber:F -*to ., j ,wpei Has Tla dA .S .¢j;)i ;v(►ib10 ! $ boo glc'"4w 104 as PROJECT P.C. Collova Bldrs. Inc. PLOT PLAN ADDRESS P.O. Box 489 erset Wi 4025 NW 114 SE 1/4s 7 /T 30 N/R 18 W T0%VN Ric nd CO UNTY ST. CAOIX SYSTEM ELEVATION 98.6' BEDROOM 3 CONVENTIONAL AT -GRADE )00( � V CONVENT LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of chambers none BENCHMARK V.R.P. Top o f Survey Iron ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOR E * -R. P. Same as Benchmark JUN 14 2006 C , << ST. CROIX COU NTY —� Property Line Scale = 1/4" = 10' 95th St. Well is to meet all setbacks found in Comm. 83 Area 15' below system is to remain undisturbed Pro 3 Bedroom 5% Slope House B-3 -� 9 6' Huffcutt Combo Tank 97' Tank is to be properly 98 bedded and provided with lockdown covers 98.6' with approved warning B-2 99 la Grading is to be done to divert ert B-1 run -off away from system B. M. Property Line Z•d dbZ :to 00 50 deS PLOT PLAN PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O. Box 489 Somerset Wi 54025 NW 1/4 SE 1/4S 7 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION 98.6' BEDROOM 3 CONVENTIONAL AT -GRADE XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TA NK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of chambers none IL BENCHMARK V.R.P. Top o f Survey Iron ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL H. R. P. Same as Benchmark Property Line Scale = 1/4" = 10' 95th St. N Well is to meet all setbacks found in Comm. 83 Pro 3 Bedroom House ea 5' below system 5% Slope is to re in undisturbe B -3 96' 97' Huffcutt C bo Tank 98' Tank-is to be properly bedded and provided 98,6' with lockdown covers with approved warning B-2 99 labels Grading is to be done to divert B-1 run -off away from system B. M. Property Line • O O Wisconsin Department of Commerce OIL EVALUATION REPORT Page of Division of Safety and Buildings f�,� nce with Comm 85, Wis. Adm. Code County Sf G'".0; 7(' Attach complete site plan on paper not le han 8 1/2 11 in r �— t include, but not limited to: vertical and horizontal refer ice ,on and Parcel I.D. c4 percent slope, scale or dimensions, north arrow, and I lion and distance to nearest roa . Q 5 Revie by Date Please print all info tion. AU G 2 i Personal information you provide maybe used for secondary rposes (Privacy Law, s. 15.04 (1) (m) Property Owner Lo ion ' ZONING �• 4/ o 114Sf� T 3ON R E( W Prope rs Mailing Address Lo # Block # Subd. Name or CSM# City State z ip Code Phone N ❑ City ❑ / Village T N Road / O /�+� /S� I �OpZJ (7 /J"'j�J' / o�I7.Z � /�G/s � Oi+ -��C• /.Sim .S E5N Construction Us sidential / Number of bedrooms Code derived design flow rate J?� GPD aw ❑ Replacement ❑ Public or co mmercial - Describe: - - - -- - -y - --- - — Parent material O ���T •�� Flood Plain elevation if applicable ft General Corrrrrents and recommendations: le (J `L/ S f a1<e�f p� Boring # El Boring ✓ pit Ground surface eiev. ft. Depth to limiting factor in. Soil Applilcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - 'Eff#1 'Ef#2 l0 0 3IL --- m{� LEI a Ong # ❑Boring � ./ pit Ground surface elev29 , ---- ft. Depth to limiting factor tn. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 L p 3/ �_ / Z S U 10 Z Z —Z 5 4 j �- Z �, to . , y . 7 • Effluent #1 = BOD > 30 1 220 mg1L and TSS >30 1 150 ' Effluent #2 = BOD <_ 30 mg& and 7SS < 30 mglL CST Nine (Please Putt) Si CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 540 01 ,.t 715 - 246 -4516 tt Property Owner _ Parcel ID # Page of J Boring # Cl ring ❑ it Ground surface elev. ft Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfff in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 G- 11 i e - 3 / 51 s z 1 A Z /_� y/ Z s k ti C o ❑ Boring # C] Borin [] Pit Ground surface elev. ft. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 EJ ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Soil Atiplicglion Rate ❑ Pit Horizon Depth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GPD/fF in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 • Effluent #1 = BOD > 30 1220 mglL and TSS >30 _< 150 mglL • Effluent #2 = BOD <_ 30 mg& and TSS < 30 nVL 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- 2648777. seae330 QL6M)) r / Soil Test Plot Plan Project Name P.C. Collova Bldrs. Inc. T d Address P.O. Box 489 Somerset Wi 54025 #226900 Lot 8 Subdivision 95th St. Site Date /18/05 NW 1/4 SE 1/4S 7 T 30 N /R W Township Richmond F] Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 98.6 *HRPSameasBenchmark Alternate Benchmark Top of 1/2" pipe @ 100.3' Scale is 1" = 40' 303' unless otherwise Prope lane noted 50' ❑ B -3 5% Slope 97' 60 - 100' B -1 40' � 1�B.M. 265' Property Line 120' + Safety and Buildings 10541 N RANCH ROAD commelrce.wi.�ov HAYWARD WI 54843 iscon TDD #: (608) 264 -8777 www.commerce.wi.gov /sb/ Department of Commerce www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Se c r etary March 15, 2006 CUST ID No. 226900 ATTIC• POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING, INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/15/2008 Identification Numbers Transaction ID No. 1248570 SITE• Site ID No. 710314 PC Collova Builders Inc Please refer to both identification numbers, 95TH St above, in all correspondence with the agency. Town of Richmond St Croix County NW1 /4, SE1 /4, S7, T30N, R18W Lot: 8, FOR: Description: New at grade, 3 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 1065692 Maintenance required; 450 GPD Flow rate; 36 in Soil minimum depth to limiting factor from original grade; System(s): At -grade Component Manual, SBD- 10570 -P (R.6/99), Pressure Distribution Component Manual - Version 2.0, SBD - 10706 -P (N.01 101) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes p,Q and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in Condiitu chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. R� No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, I stats. DEPAFtTMEW I ION OF The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: SEE • oWe This system is to be constructed and located in accordance with the enclosed approved plans and with th design manuals noted above. • In the event this soil absorption system malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described the At Grade Component Manual are complied Key Item(s) • The designer proposes to install an effluent filter to achieve the requirement of wastewater particle size. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the septic tank outlet filter will be required. The outlet filter shall be installed per product approval stipulations. Reminder • Insulate building sewer per COMM 82.30(1 1)(c). • The orientation of the at grade system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the at grade per At grade Component Manual. • Surface water drainage shall be diverted away from the system area. SHAUN R BIRD Page 2 3/15/2006 • Materials shall conform to the requirements of COMM 84. • Maintain well and waterline set backs per COMM 83.43(8)(1). A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation o :7tenance of the POWTS. Sincere Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Patricia L Shandorf POWTS Plan Reviewer te WiSMART code: 7633 (715) 634 -7810, Fax: (715) 634-5150, M -f 7:45 am - 4:30 pm pat.shandorf@wisconsin.gov cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 317/06 Owner:P. C. Collova Bldrs. Inc. Location:NW1 /4 SE1 /4 S 7T30 N,R18W Lot 8 95th St. Site Richmond System type: At -Grade Manuals Used: At -Grade Component Manual version 1.0 SBD 10570 -P (�.g/99) SSWMP Publication 9.6 Design of Pressure Distribution �tlat Networks for ST -SAS (01 /81) Page# 1. Cover Page 2. At -Grade Plot Plan 3. At -Grade Cross Section 4. Pipe Cross Section /Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7 -8. Maintance and Contigency plan 9 -11. Soil test Shaun Bird Signature License n m Cr226900 > 57 B ? 5 "TUP Ps" 5 I t-- #�tSTRt �Tt STASiLl ZED 00� = •�RT�ars WELL Q > 5' 1/613 F j L / - E C.E.LL O Iz Z%z AsGAC��TE a �7x.ITt Fabric { Distribution Lateral ,;, S oil Cover STABILI bserv©tion -_,,_ �,cc`' � �E ate l l 2 A �2` : > 5' Plan Viev and Cross S af4 isiGOSZre ��_gtade �Tttit: wittz a Single Absorption Area on a S1 p g Page Of Distribution Pi Re Detai! for Lateral Ifetwork AC Ce s� ' TURN - UP" (CLrtr.�out) _ PVC Force Main t - pvc Distribution Pipe P Last Hole Should Be Text To Tuitr� -uP _ P H Diamet �` � � Inch � � Ft- Inches Lateral diameter — Inch Inches Force Main Diameter Inches # of Holes /Pipe �y Invert Elevation Of Laterals ? ;e, e, Ft. Signed: License der: Date. 5£g� IC PUMP MP Ci;AMfirR CROSS SE CT C TAN SPECIf ICATIONS Tf- ATHERPRWF APPROVED SIN . GRAD jO N CTION BOX MANHOLE COV ER 4 „ �a vT_NT PIPE i ;A1i3£1 CR WIT CONDUIT �! PAAL{ICK � I`RLIM D40k, t rc INTAKE yip T dG iABE.. MIN- F1141 GRADE t8 Wag- INLET GAS' TZvHT , JOINTS VITN WATER TIGHT SEALS SS EAL ; ApQjt{jYEB PIPE ALM PALTER -- x flrt 3' OSflII APpROVED s SMIC PI?£ 3` C OFF 099 SQ3Ig SOIL pump UFE EL.EV - APPROVED K F � fl r BEDDING UNDER TAN _ COi�ICR£TE PA-1) 3 =_ SPr�2£ ICATI ON ,�- N'tltiBLR �C3SES ? DAY = �.-- -- SLpTiC / DOSE l L�C��c' C DZN� GAL AhK *'�At'iJFAC2i3 _ER: I3fl5r v�TS�HE F LLt i CA i„ FLf3L:$AC�C STIC =�� J EP T AIiK SIZES � GAL _ �/- � INCHE ---- -�""' -" I7t?SE CAPACITIE 6 ?��Tl✓� = A _ _ 2 AL- 8 2 ZiJCHES _.L - - AIA MANUf.AC�3RER= _ �� J GAL. MODEL ;TCS NUMBER: = r C' � = L� J �II�CHES —_ -- S TYPE: C 3L FpCTURF.K = J-- II = INCHES = ��- ------ pump MANN3 /' ✓/ 15.23 WAl MODEL NU!'iBER : f? / ' PER AS z'- ��t. �H t4 rI =FtI sw rcH Ty PE A L A JSCH 0,2 IRS T3ARGE RATE l__- -- PIPE �-i� -- FEET REQu _ - sod_ FE£T pUHp QFF is,IdO LJiS -!ITT VERTICAL DIFFERENCE $E- Fy7E£3I ��R- - - - ,TION FACTOR . FgI� FEET t1It'4i3 NETWORK SUPPLY PRE �� > T/ I£I g FT - �, DYMAM �C M� MI �---- �� r�£T PORCEMAIM X£�Au D i AH TER ._.. ---- J i T �. ----� c of get ? TANK: � IQ�I - - ----- INT£RNPRL DIMENSION DA' = LICERSz h`tIM$Eg - 5 IGNED _ TOTAL DYk- r:ZADXAPAC PEER miwTE �c uEN- AND DDII-JERING A HEAD CP CURVE C D L MODEL 152 5 F mODEL i 152 — 7 — Fee i Meiers I GO:. : 1 Liters Got 50 15 6n I 261 77 291 153 1 231 70 2 bo . 1 ! - J 40 231, 53 20 6, 5; 2 1 44 T 42 25 34 129 1 30 9.t L) 33 5 2 30 C, 7 85 0 - 42 O i I k Vaiv-e r� 6 4 0 fit. t1z" 41 0 �i 6 1 0 80 on GALLON'S LtTEPS 320 0 80 50 240 7/ FLOW PER VINLJTE 41 27/3 CONSULT FAC TORY FOR SPECIAL APPLICATIONS ) 7./ • Timed dosing panels available. S, are avail . able and supplied with CM Electrical alternators, for duplex system an alarm. • Variable level control switches are available for Controlling single phase systems. es are av ailable for variable Double piggyback variable level float switches level long and short cycle controls- • 771 Sealed Qwik-Box available for outdoor i See FM Over 130 °F. (54 special quotation required, 152/ Series Control Selection 1511153 MODELS 1/8 1�ph Mo(w Amos Du les I! Model 2or3 8.5 1 .4152 Y SN152 Auto 8. � simplex Included 2 or 3 � 115 1 T1 - E152 230 1 Non 4.3 1 i 2.r3 2E152 1 230 1 1 Auto 4.3 Includ 2or3 1 1 2) or 3 N1 53 116 Non 10.5 - SELECTION GUIDE -PNI53 115 1 lrziuded 2 orj A 10.5 E1 53 230 1 - 3 p iggyback variable level float switch or double pigqybaclLvXiaDle level float N o n ? 1 1 2or � 1. Single p RE153 230 1 Auto 5 3 !nrjud&a 1 2 or 3 cw;jcn. Refer io FM0477- I-& CAU-nQN 2. See FN10712 for correct model of Electrical Alternator E-PBk. Aj, installation o f con t ro ls, protection devices and wiring should be done by a qualified 3 v le control switch !0-0225 used asaconiml activator, specify duplex(3) licensed electrician. All electrical and safety codes should be followed including the most. or (4) float system recent National Electric Code (NEC) and the Occupational safety and Health Act (05M). RESERVE POWERED DESIGN For unusual Conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: p.0, BOX 1 6347 Lows e, KY 4o2. =7 vtanufacGrrersof.. SHIP TO: 3649 Carle Rur Road 21 1 Z N r I 1 1, 0 sville, KY 40211-1961 awry AM1 511yrf Louis f502) 77c�-2731 - i , 80D, , 923-PUMP hnP com I M. F,�X (502) 774 - 3524 A�l ri @ Copyright 2000 Zoeiier Co. ghts reserved. . T PLAN Page of , t S OWNER'S MANUAL & MAt�lA SYSTEM S E QL F ATIONS Septic Tank Cal3acdY al ❑ NA �l rK>`oRM.�nax tom,/ /' 14A pier , c Tank d / Septi ManufacctuTer !' Permit- Effluenf l~tIter Manufacturer Cl kA Effluent Titer Model © NA fiufnber of BednaaT's A Pump -Tank ( V36ity L`� C� ai DNA 9 -' N A Number of Comrne� Units aVda p Tank Manufacturer tom. ' L MA Estimated !)ow (average) aS1d p ump ManutachlreC /j/ Estimated x 1 --�) t/d � S � �k7 Design flow (Peak), ( Purnp aa /ft Ram t Unit e` p S Flitter D Peat Ft soil ATP' Monthly average- lnfluent/Efflue� Qua �iO mgIL C] Mechanical Aeration ID Wetland Fats, Oil & Grease (FOG) n Other. e Demand (gOD� 420 mg -j1. ❑Disinfection I3fochelnical Oxygen <I SO m 1L Manufacturer Total Suspended solids C[ SS) rsai Cel1(s) Monthly average Dispe C] in-ground ( pressur¢ed) Peed Effluent QuaCrty ❑ in -ground (grave}') O Mound Oxygen Demand (SODS) 531) mg1L At grade dlemicat Ozy9 S30 M911 ne ❑Other $io Total Suspended Solids (TSS) 51 0` cfullDOmI ❑ Qri Fecal Conform (geornetric mean) Values typcc far domest+� (non cammen r aS1ew+LU and 1111 I Y i diameter tank went ►rasteMratu Maximum Effluent Particle Size values types tor p pINTENANCE SC HEDULE Service Frequency Service Event '� p months years) (Maximum 3 yrs.) At feast once every uals One -third (K) of tank volume inspect condition of tanks) At sludge and scum 8q ntents of tank(s) 177, w C3 months yes) (Maximum 3 yrs -) Pump out When comb At least once every"> Tsai cell [} months ears) inspect dispe At least once every •��� Cl month ears) D NA Clean effluent filter At least once every s ) p NA El months Inspect pump, pump controLs & alarm At least once every ore test U m onths ❑years) DNA Flush laterals and press At feast onfle every ocr� CO3 months 0-1 year{s) ❑ tsA At least Once every ocher_ The dispersal following licenses or n one of the AAAII�tYEHIANCE INSTRUCTIONS cbor. POWTS Maintainer, Septage InspeComs of tanks and disperser °elm shall be made -t an indivldFO�s nspe any Missing sln9 p y back or broken w ins: Master Plumbe r: Master ust roil Restricted insp ection to identify on of the tank(s) m and t check for an u Servfdn9 Operator. Tank inspections must Include a visual Inspedi the effluent levels hardware, I r cracks or leaks, lur the volume of Co mbined stodge and scum of effluent on the mend surface caell(s) shall be visually Inspe a pondiJ or ponding of effluent on the g nding of effluent on the ground surface. uta authority- tlon pipes and to check for any p requ th Immediate notification of the local r� to+Y in the observes nd fume, the ground surface may indicate a fading condition a r or more of the tank vo e and scum in any tank equals for an d ( NR a cc umulation of sludge erator and disposed of in accordance with When the combined �`- entire contents of the tank shall be removed by a Septage Servicing Op 113, yyf$c;ansin Adminfstmtrve orlents, p retreat+�me c orrlponents; and any Code_ nt The sefYicing of effluent filters, mechanical or pressurized PO4'�1TS comp rfocmed hY a �t�hfied ppyy7'S Maintainer- authority vYithin 1Q days of comp[ejon of arty service vrent oftter rnatntenanae or monitoring at intervals of � � months or less shall p? A WXAce reF� Shall - be provaded to the focal regu ' resence of painting products or other S TART UP AND O PERA TION C hi gh concentrations are For new constxvc Lion, prior to use of thPD ss annd/o damage the dtsp �l cell(s). g chemkais that may impede the treatment p servicing detected hire the contents of the tank(s) removed by a Sep ta a 9 9 operator prior to use_ i Page i �rditions are frozen at the infritra�ave sut pace_ System. start up shalt not Occur when po wer is restored the excess >�uirng qes pump tanks m aborr�t n cell(s) r onelar e dose, s l ave oad�ng e cen(s) and May result in the w+�i rie dicharged to the dis,�� g p ump tank removed backup Wa stewater surface d range of effluent avoid this Zmation t1av8 ti-,e co ntents of the P g by a =ng power to the effluent pump or contact a Pfurnber or POVVTS tYfaintainer to age Servica 19 ppeyai°r Prfor.t° . assist in manually opetin9 pump c;orttmts to restore normal levels within the pump tonic e or vehi Oyer wanks and dtspetsal COS_ Do not drive or park over �r t?tflerwlse disturb or C ompact, Do not &iy � mound or at -grade soil absorption area, the area %ifhin 15 feet down slope of any from the wastewater stn�am may improve the perfr�rrrtartce and prolong ft ffie I{edudion ar eClrrltnation of the fallowing swabs; d egreasers; . of the POYYTS: antibiotics; �ba�bywiPes. dgarette butts- condoms; - aXtton sers; dental floss: diapers; disinfectants; fat: foundation dtaitl {sumF pump} water, fruit and vegetable peelings; gasu ine; grease; herbicides; meat medications on; {painting prods; pesftctdes; sanitary napkins: tampons;'and water softener brute_ soaps; - ABANOON SME_NT taken out of service tie fallowing steps shall W taken to Insure that the When the POWYS falls andfor is permanently system is properly and safely abandoned in cOmpHance wiffi ch_ Carrlrn 83.33, �( Administrat ve Code: piping to tanks and pits shall - be disconnected and &.e abandoned pipe openings sealed_ All All and Pits shall be removed and prcperty disposed of by a Septage 'Servicing Operator Th hellos of s be excavated and removed or their covers removed and the void space After pumping, all tanks and pits shall filled %ith soli, gravel or another inert solid material- CONTINGENCY PLAN repaired the folio>Sr:ng measures have been, or must be taken, to Provide a e if the POVYTS faits and Cannot be compliant replacement system p A suitable neplacerrrent�area has Keen evaluated and may be utilized for the location of a replacement sot ;a bsorption system. The replacement a from existin be and pro ptoposed tructure, lo disturban t lies co d and not llls_Fail re to be infringed upon by required setda 9 protect the replacement area will result in the need for aw soot to n effect at ttsat time t3b�sf1 a suitable 'and s it e :evaluation to replacement area- Replacement systems must cornp.y is not available due to setback arldfor soil limitations. Barring advances in POVVTS n A suitable replacement area last resort to repiax the faded POvYTS_ hn tecology a holding tank. may be ills - tailed as a fai7*1re of the POVY3 S a soil and The site has not been evaluated to identify a suitable replacement area_ Upon site evaluation must be performed to late a suitable replacemen *_area_ If no replacement area is available a �` a last resort to replace the failed POV olding tank may be installed as plac nd and ;at-grade soil absorption systems may be reconstruct- in pace following remora) of the Diomai at me nfiltratrve surface. RecansGvctions of such systems must comply with the rules in effect at that time <<WARNING>> _ ASSES SEPTIC, PUMP AND OTHER TRFAT M QT TA EAT Y CO NT AIN TA U D1=RR ANY CIRCUMSTANCES' l � GEh_ P OR SEPTIC PUM IMP OSSIBLE- 7 ENTER A ULT OR IMP DO NO DIFFIC Y BE RESULT_ RESCUE OF A PERSON FROM THE IN rERIflR flic A TANK IkrA ADDITIONAL COMMENTS po TTs INSTALLER POWTS j"NTAINE.R Name� Nam? Phone P �one SEPTAGE SERVICING OPERATOR PUMPER LO REGULATORY AiJTfiORl7Y c dame , /lrN- c ry Agency Phone ;78 Thus dom(nent was dratted by the stafts of the Green Lake, Marquetts and Waushara Corjnty 7_orring and Sanitation agencies_ This docrrtrient meets me minimum requkements of &L Comm 83.22M(b)(f)(d)&(f) acrd 83.51(1). (2) & (3). Wisconsin A ls�� Ccde Use of this doarment does not guarantee the performance of the POWTS_ CMW (1101) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C. 61 1 13 Ja. BQ i 1A4e,( S L Mailing Address J as Rt j a-d sk I Ll� 11,° . _� C %rr tease Li I Prop Address I � t1 P Y (Verification required from Pla ing Department for new construction.) t> 2-Lt— City /State � ) R ) � Li l Parcel Identification Number G 3� b No LEGAL DESCRIPTION f Property LocationN '/4 ,S '/o ,Sec. , T 36 N R_!_JW, Town of IC'�1Y1 Subdivision Lot # $. Certified Survey Map # , Volume , Page # Warranty Deed # VolumeZ.. ,Page # Z Spec hous? S U no Lot lines identifiabl% yes LJ 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 County 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 Dep ent within 30 days of the three year expiration date. rfl 4 0 n �i Uoj�o 3 / / o ff, 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 pro describ d above by virtue of warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. I U 2 8 2. 4 P 12 0 -7 c-9 -7 821 tl WALSH State Bar of Wisconsin Form 2 -2003 KATHLEEN H. REGISTER OF DEEDS DEEDS WARRANTY DEED ST. CROIX CO., WI Document Number Document Name RECEIVED FOR RECORD 06/16/2005 10:00AN WARRANTY DEED THIS DEED, made between David J. Kieckhoefer and Pamela A. Kieckhoefer, EXDPT I husband and wife REC FEE: 11.00 ( "Grantor," whether one or more), TRANS FEE: 876.00 and P. C. Collova Builders, Inc. COPY FEE: CC FEE: ( "Grantee," whether one or more). PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following Recording Area described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space Name and Return Address is needed, please attach addendum): ^ ": 7 Part of the NW '/, of the SE '/. of Section 7, Township 30 North, Range 18 West, Town of Richmond, described as follows: Lots 1,2 and 3 of Certified Survey Map recorded June 6, 2005 in Vol. 19, Page 4992, Doc. No. 796820; AND Part of the NW '/. of the SE '/4 and Part of SW '/, of the NE '/4 of Section 7, Township 30 North, Range 18 West, St. Croix County, Wisconsin described as follows: Lot 4 of Certified Survey Map recorded June 8, 2005 in Vol. 19, page 4993 026 - 1024 - 30 - 050 and 026 - 1025 - 40 - 050 Doc. No. 797062. Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights - of - way of record, if any. Dated gUOl t0 J S� ~ (SEAL) (SEAL) * *David J. Kieckhoef avn (SEAL) n'a/Y>\JC.Q, @ Q h ` (SEAL) * *Pamela A. Kieckhoefer AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF ) ) ss. COUNTY ) TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on •SE (�• ; - (If not, the above -named David J. Kie khoefg authorized by Wis. Stat. § 706.06) Kieckhoefer husband and wife *•'�•.. to me known to be a person(s) who exe t#. 'f(egQingl` THIS INSTRUMENT DRAFTED BY: ins - d�a 1 he =e N U v 1 . Attorney Kristina Oeland Hudson. WI 54016 * D %It D Y9 • v4iCA L, %C Z a Notary Public, State of W %b CJ a s I 'r . ; , Q. 4 My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIE . 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