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HomeMy WebLinkAbout026-1149-00-011 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division 0 INSPECTION REPORT Sanitary Permit No: 479489 '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: Figueroa, Leonel & Na cy Richmond, Town of 026- 1149 -00 -011 CST BM Elev: Insp. BM Elev: BM Description: nn Section/Town /Range/Map No: �°l O I c7 3 C. 15.30.18.1116 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Z P4- / z S Benchmark B , 3 7. ) `06 f 1 Desing Alt. BM • 3�1 CA /0 3 Aeration Bldg. Sewer Holding St/Ht Inlet 5. Ft`( /00 . 2. TANK SETBACK INFORMATION St/Ht Outlet 6• z 7F $.3 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic S �/) 15 / 15 / Dt Bottom Dosing ht' Header /Man. 7.9 9$ , / Aeration Dist. Pipe - 7.47 9 4'•3 q7.$ Holding Bot. System �,ZS �� • �5 6 I� PUMP /SIPHON INFORMATION Final Grade 5 ZS led, TS Manufacturer Demand St Cover �, �� ,3, � �D3 Model Nu ber 7 • / 0 r 1 `7 TDH Lift Friction Loss em Head Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT DIMENSIONS No. Of Pigs Inside Dia. Liquid Depth DIMENSIONS 3 1 $ d� - Z. T r� \� SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHA Type 9f System: /t 2 �/ -5 / i A4— I Z3 , U OR Model Number. DISTRIBUTION SYSTEM (Je6l NS = Z - 3 a- ZZ lob aa,�.`_ Header /Manifold Distribution x Hole Size x Hole Spacing Vent to it I?ke Pipe(s) \ Length Dia T 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 q / 5 Bedrrrench Edges Topsoil \ Yes is J No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 1521 127th Street New Richmond, WI 54017 (SE 1/4 SE 1/4 15 T30N R1 8W) / Cherry Knolls Lot 11 Parcel No: 15.30.18.1116 1.) Alt BM Description= Ca uk",_ 2.) Bldg sewer length = Z I / E�e,.� pJ\, �'1 e n ` �— v�na.�- S e • \ �-c S� - amount of cover Plan revision Required? 1 1 Yes c 6 Use other side for additional information. Date Insepctor's natur Cert. No. SBD -6710 (R.3/97) i AD Safety and $uilgings C Division - - -- - -- - - __ - ` 201,W. WaehinSlon Ave., P.O. Box 7162 con si Madison, WI - 7162 ` Saninry Permit Number (to be filled in by Co ) D epartment of Com tner � '1" 26 -315 IR Sanitary Permit A c � - -- -- - - _- - - ppl� atio state Pean I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informativ I may be used !or secondary m) Grovtrk i y purposes p r i vacy Law, $15.0A{ 9(tn) `' Proj t Address (if different than mailing aJdrrs,j t! ) I. Applica_ tion Information - Please Prlut Alt tnform>:tiun ' �rrperry - f• Owner's Na Nd me _._ _ III Parcel # _ Lot X Block # 4 4 era lt! I Property Owner's M ailing Address Property Location j S City, tate j T zlp Cod,: / phone Number � 4 4,Scction p circle II. Type of Building (check all that apply) T - •3 d N; R B ow i K-or 2 Family Dwelling - Number of Bedrooms s Subdivision Name CSM Number Public/ Commercial - Describe use ! / i State Owned -- Describe 1)se - ! ^7 -- --- ------ - - - - -- _ _ ! CCity Dvillagt Jowtaship - r III. T�.—. of Pe __ ..— -- ype rmit- (Check only one box on line A. Comple tine B if applicable) - �14� L7 rr .A " Vew System i Replacement System ❑ Treatment/Holding Tank Replacement 011 ❑ Other Modification to Existing System B LL I Permit �Renewal I I- Permit Revision � i ] Chang!! of ❑ Permit Transfer to New wist Previous Permit Number and Date Issued T.- f ore Expiration Plumber I � Owner C IV " of POIVTS System: Che ck all that appl 2 �y�Non - Pressurized In-Ground - -- ' Mound > 24 in. of sunra6ie. soil !`� Mound C 24 in. of suitat)le soil ❑ At -Grade U Single Pass Sarni Filter ! Constructed Wetland Pressurized In- Ground C Holding Tank IJ Peat Filter ❑ Aerobic Treatment Unit U Recirculating Sand Filter I Recirculating Synthed Media F ilter Drip Line Gravel -less Pipe Ii Other (explain) rsa real rea esign Flow gpd) Design Soil Application Rate(g so TD�ispersal Area Required (sl Dispersal Area Proposed st) S to a ton r - vI Tank Info - _ C:ajuelty in , Total vun:ber �. - *- -- 1 .— I Manut'acturer Pr Site fiber Plastic Gallons Gallons of !units Concrete Constructed Glass i � IYrK — TExistin i i I arks ;Tanks I 5epuc or Holding Tank Aerobic Treatment Unit --' - --t - - - - - -- + I j Gusirg Chamber ", -- - -- � I VI I. R ess ri si bi lity Statem t, the uad e_rsigne d, sp y f lu• as r eoinibilit allatiou of the POWTS shown on the attached plate. j Pturnber's Na me (Print) — Fhrrtttx Si gna t w_ !MFRS Number I3u4inrss Phone Number i Plumbers Addrt $s (Street, City, State, Zip Code) - - �-- C--m VIIi. County/Department U Only Approved D isapproved Sanitary permit Fee (i Ludes Groundwater Date Issued Issuin "anir (No Stamps) } p gent Sin Surcharge Fee) + ] W aeon for Dental c_ 7� LX. Conditions of rev _-- - - - - -- _ - _ _ -- _ -- SYSTEM ° - 1 Septic tank, effluent filter and ` �Q d. S dispersal cell must all be serviced / maintained all per management plan provided by plumber. ! 2. All setback requirements must be maintained as per applicable code /ordinances. S t1..& -- �.. ' " - Attaelr complete pions (to the Cauatr only) for the system oa pa no than t, l: J O` / 2 9 M 4 r ?ad/�Qd�TP� a / COP .4 1�dl�Cl rr I lee 4 V V i ? od/�6d S�� T` r P 1Nisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 5 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. Please print all information. sewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location S4 J ( e �^ Govt. Lot s 1/4 1/4 S J T N R /� E (or)�1(� Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# y G lot G- knoIrS City State Zip Code Phone Number ❑ City Village [ Town Nearest Road c W f_ w ( 7/,57 ) - 31e c I C 6- Q� New Construction use: Residential / Number of bedrooms 3 r Code derived design flow rate `+�.5 �O /�o O O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicab ft. General comments Ct'c v • �/ S 0 O and recommendations: c v . 9S. O g MAR 1 3 ?_002 Boring � ZON OFF ICE 17 1 Boring # 9 ®pit Ground surface elev. q - ft. epth to limiting factor ��� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture ruc ure Consis oundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 6--1 16 31 3 SL 2nn3 Z r $ (0 / (o SL ?m5b m�'r c.5 .5 . 9 i F I Boring # ❑ Boring. ® Pit Ground surface elev. 9 sd ft. Depth to limiting facto in. Soil Application Rate j HorizonDepth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ID m3 0 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number ,re -e 0- 330? A ddress Date Evaluation Conducted Telephone Number 0 �P -� SBD -8330 (R07 /00) Property Owner !� e rr� �~� Parcel ID # Page Z of Boring # F E] Boring Pit Ground surface elev. q9 ov ft. Depth to limiting factor l�� 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 I -1 16 V r313 51 - 2 cs I v . 5 , 2 -q5 (v — SL 2 rn s wCr 3 5-W 10y r q Ito mS m ❑ 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 F1 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 /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) L Property Owner rr1 "" Parcel ID # 2 Page of 1-31 Boring # E] Boring pit Ground surface elev. , od ft. Depth to limiting factor —L 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 I 6 - 140 16 14r313 51 — 2 C- 1 v .51 4 it) r Li /cry m5 9 S� k�.vo C) F-1 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ❑ Boring # ❑ Boring El 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 /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) s - ' r• . !! PAGE _ OF� t� NAM �R r `��� LO T# LEGAL DESCRIPTION k;E t4 S S /r r ,f SCALE: I"= BM I ELEVATION 406 BM I DESCRIPTION Q p.—�' P� BM 2 ELEVATION `� �/. (n d BM 2 DESCRIPTION SYSTEM ELEVATION ALTERNATE ELEVATION 9S. o CONTOUR ELEVATION i G g gjo o ) j Cl &A Z � Z 1 1 i / f _ J h aQ SIGNATURE DATE SEP TAN E PIMP CHAMBER CROSS SECTION AND SPECTFICATIO SEPTIC . A. K ---- -� a WEATHERPROOF 4'! CI VENT PIPE 12" MIN. ABOVE GARDE £ JUNCTION BOX APPROVED ? 25' FROM DOOR, WINDOW OR WITH CONDUIT MANHOLE COVER FRE AIR INTAKE W! PADLOCK & WARNING LABEL FINISHED GRADE 4" Cl RISER _._.�._,_.. 4 " MIN . 18 IN. 6" MAX. 'I NLET ( �� WATER TIGHT SEALS GAS- TIGHT � \APPROVEQ A SEAL ' JOINTS WITH ...#._. f ALM APPROVED PIPE PPROVED B ' ON 3' ONTO »Ta 54tio � � SOLID SAIL ' � C : h* RISER EXIT ;OIL PUMP OFF ELEV . FT. _i_ OFF' PERMITTED ONLY D IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD — SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: NUMBER DOSES PER DAY: ---- TANK SIZES SEPTIC 1 `�.Q GAL, DOSD VOLUME INCLUDING DOSE GAL. FLOWBACK:9 GAL. ALARM MANUFACTURER: l&%)PIca 1 CAPACITIES: A = � INCHES a ( 4ba - GAL. MODEL NUMBER: b t_V SWITCH TYPE: i"��.c _ B Z INCHES = - GAL. PUMP MANUFACTURER: C - INCHES = IpS GAL. MODEL NUMBER: 'Pa SWITCH TYPE. e�_ D = INCHES = REQUIRED DISChARGE RATE t4 0 GPM PUMP & ALARM WIRING AS PER ITHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE )a- FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . . . _-___2.5 FEET + �_� FEET FORCEMAIN X Z.6OFT/100 FT. FRICTION FACTOR FEET TOTAL DYNAMIC HEAD = FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH .1- ; WIDTH DIAMETER LIQUID DTrrH �36 " &,4L pout l r LICENSE NUMBER; � y1, l DATE: � /ss [qGOULDS PUMPS Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS + FO submerged in high M EPOS Impeller. Thermopias- IN Beatings: Upper and lower Specifically designed for the g►a� turbine oil f or tic enclosed design for heavy duty ball bearing following uses; lubrication and efficient improved performance. construction. heat transfer. • Effluent systems W Carving and Base: Rugged • Homes Available for a utom4tic and th4otlop14stic design provides AGENCY LISTING manual Operation, A►IGP- • Farms superior strength and corrosion �' ranarlin Standards Assodation • Water trans su mp transfer � �j is Switch l0 Motor Housing: Cast iron (C5A listed model numbers end • Dewatering assembled and pr' 4t dt the br Odent heat transfer, in "F" or "C'.) Wary. *er*h, and durability, SPECIFICATIONS #. M4l01' Cover. Thermoplastit Gout& Pumps is ISO 900E Registerod. Solids handling capability: FEATURES cover with integral handle and g �: float swltich-attachment points, 3 14" maximum. ■ EPO4 Impeller: Thermoplas• ■ Po wwr Cable: were duty • Capacities: up to 60 GPM. tic Semi -open design with rated oil and water resistant. • Total heads: up to 3 feet. pump out vanes for mechanical • Discharge size: t'1:" NPT, seal protection. • Mechanical seal: carbon - rotarylceramic-stationaty, BUNA -N elastomers. Temperature: 104OF (40 continuous 140°F (60°C) internuttent. + METERS FEET • Fasteners: 300 series stainless steel. �---- ..�..,,; y 30 .�+�. • Capable of running J dry without damage to a is rY components. -- ---__ . Motor: i ' • EPO4 Single phase: 0.4 HP, u E zo 115 or 230 V, 60 Hz, 1550 i— RPM, built in overload with 5 automatic reset, a 4F £P05 • EP05 Single phase: 0.5 HP, n + ; 115 V, 60 Hz, 1550 RPM, 3 1071 built in overload with i:POa . automatic reset. z \ •Power cord: 10 foot I 5 standard length, 16/3 SJTOW with three prong grounding plug. Optional 20 c' % 1 20 30 40 50 GPM foot length, 1613 STIW with three prong grounding plug —�--�- ~--- (standard on on EPL5). 0 2 4 6 8 10 1 2 m =!h cAP,nerry Goulds Pumps er 2000 Goulds Pumps ITT Industries Effective February, 2000 03871 - uic4 STANDARD CHAMBER Quii Standard Chamber 48" (EFFECTIVE LENGTH) rT i 12" 8 • 34"--------- SIDE VIEW SECTION VIEW MultiPort End Cap R cl— r I 1'2 16- I r � - - -- - -- — 34• SIDE VIEW TOP VIEW FRONT VIEW ,2 Ot "M ,00 -000�,N6ih1n8uPSpecificatio WIR Re (W LX H) 34* x 16"X 12" Effective Length 48" Invert Height Wor 1.25" Invert Height 8" IN F !UffATOR�Y NTY T ire sirLAUTUoV ritcgrily in aQ oti plate, wF. arKi oirorai li� sys l'f M8hL4�TUrrlii an orlsi rie sop k rn ui(dance with Infili ovajotars is warranted X rl r ud of 't` na i provided, wrt1wer i d .1.a -als and —rko-ri to, olal year Irm the dale Itial lire snitio i r , Ps% fa ,ed , %e � 1 0 1 ic provided, hwirrr, that if 4 septic Permit s not mQu.ed by awl"u1i the warmly Psi will beak, iii ilio ziase TAtGfflo--� exor 1cise it of Ore d'iegedrizi ini will sui nj)jai Unrl� Im U!"i CWw"Intid 0, Willi to be cn,"Od by li LirliteclWar,only H "i 3 aw iy I —,fioally 0 l"oes the om of rev l—j ally /;p ini of 'ne L), ill, ii FHF�IMITFL LXCi 1 Ai NO Of HER WARRANTIES Wf7H HESPECir 0. TO [ tIEL;Nif,3,]N,;LtiDit4c.iPj()JMPJIE',;WARRANTIF�',OfK4E:,-I('HANTAB&ITY 1 11 Nk U�.;rt)l AfA!IFQULAPPLJRPO'.E. SYSTEMS INC It 51 olrec, Wao,'.:rdy 5hal I,@ void) if any i of tlxl Cnambel SYsjerjj S qaCuldlAwed Zq ;., other IhW 11111i the i Warranty - I xt tl !0 K, de. tai, i;rnl,ocilrmlral specie ur iIL11rK;t tin ay <.. Ink l alo..;hak n« to ilt)c t« pal?allle;: « kpuidak;cl damages, iru;kldirig to does ss o Environmental onsite Wastewater Soluflone Plottuclion and i late, and materials, overnead costs, or 0Ir0r:ussns oi &xPensois Incurred by the Holder or any third ow "Amilli -0i'dod i— t i VAI—lv Coverage are dai [c) title i. du tc 0 fdrierY WeAl' any 10jr-lilbratloo,acconol, �su�. atime Or ni e. Uiss, too U nits ') he 6 Business Park Road • P.O. Box 768 i SuLfedM lo YehLie naffic or oll oon6l,ons %ncn we'101 rx,,milrrod by Itre rristallaIM Mll-tol 1, fa hie loolain. 1 th 1 min ,rnorn qoLnU Coven' W, forth in Ii installation instructions: Ina MCA MPAt 0 imp l r,alensls into the system izntai,ni thoi li or the Units or Idle $wic syston' We to not i or vywironar, IWOnO etc , rr, water ni improper grease uie;posal any ow., —M nQ( caused tyY rifilk , Or alli operation, a, Old Saybrook, CT 06475 Wri"a'lly. ai This limiteoWarrantirti t,,evj1dJ1naHoIIar Ni set lorli this Limited 860-577-7000 • FAX 860-577-71001 fuftl,or. in - eve. 1 51).11 "" , o, tor e, li if: eeViOnsiba tw any loss or damoge to i Holder the Ords, ofany trrd W 1— -14"it", or hi rriml, a, Von) -- i hatAily cl—is of Huidur or any third parly For this L—led i to p Vie Go,N ; b-nilWiled in w. 800-221-4436 with all tae. cNIC11 (sqdracl tysta(eandl local eodea: at L:hw applicai end lrlipratot'it jilstai insl No wirrvity applies to wry Wdy UI)o Wjn the ori at H.Ii ThX- at-cwe rei tho $lanlimc i Wlarar!V ofti oy Ini A ivii:iod 1,11 14 ;,ale!; and co, J s lu. dqjaoj wananty m i copy of the ai:)i wai and stiokjldl carefully read that warranty prior lo, the of dnij:. US i 4.75 Cani Patents: 1,320.959, 2,004,564 Other patents pending Infillrator, i and SideoWinder are regri tradenn. , Ii of silli Infili is a lojsteleo uademark in Fronce. Infittra,or Systierns Inc is a 'N.islie'ed tranemark !it Me)( CMt0i CONOU Smni Connection, Mic oLeaclNny, FotyTui SnapLock, CharriL*rSpacer, norm -ock, QLAcki Mici RECYCLED PAPER ❑nd 0,)1C.k4 are tiadfi of SySteMS Inc. 0 2W Infli sVat6ros Inc. Pi in U.S A. POWTS OWNER'$ MANUAL & MANAGEMENT PLAN Page of flt,E IWAAA IIAAI'1GN ._ Owner :�7 7%R0 Permit k Capacity ,2 gal D NA k Manufacturer p NA I IQN RAR/1M pg ter Mwnufacturer [Deelp umber of Bedrooms �' e Q NA Q NA ter Model �d d NA umber of Public Faoikty Units, A NA Capacity al 0 NA timated flow laveraoe) - did M anufacturer J i 0 NA s � flow (peak), lEetknoted x 1.S) 0 sl Pump Ma ufaoturer ,,. u / t7 NA il Application fiats g d Pump Modal 0 NA Standard Mflue(nt/Effiuent Guilty Monthly avetalpili Prrtreatfrnent L%ft Fats, Oil A Qrease IFOG) 930 MOIL 0 NA � Q 3end/t3rswl Flits D Pest Filter fttoohem" Oxygen Demand 1900,) 5220 MOIL O NA 0 MsohMIcal Aeration O Wetland Total Suspended SOlida iTSS) 9150 mg /L 0 ft infection 0 Other: Pretreated Effluent Quadky Monthly average DWPWW CoNs) 0 NA 8iachsmlaal Cx YOon Demand (E40 930 MOIL, a In -around (Gravity) D In- Ground (preaaurized) Total Suspended Solids (TSS) 930 MOIL Q NA Q At -Grade D Mound Fecal Coliform {Geometric maen) tt0i afu /i00M1 Q Drip-Line 0 Other: Maximum Effluent Particle Sate i in die. 19 NA 0 NA Q NA 0 NA "Vsiuss typical for donnsa* wastewater and septic tank effluent. Other: Cl NA MAINIRM iCNEOilLE i9errise Event •avow Frequenoy lftPm 00WItiorn of tank(:) At least once every ti ; a tuadmum 3 year) 0 NA Pump Out contents of tsnkle) When combined sludge and scum equals oWV*d IK) of tank volume 0 NA lri spact disperul Wile) At least onc every; M0011) (MaxUn m 3 Yews) 0 NA Clean effluent faker At lsa4t gnge very: s) a 0 MA inspect pump, pump controls A alarm At least once every: .-- 0 s ( e 0 NA Flush laterals and preesure test At ,least once every: 0 anon h a 0 NA Other: Q n NA morn; (s) w, At least orms ov : Other: O NA MANOVIANCE WSTRUCTIOM Inspections of tanks and dlepersa. Celle shall be made by an individual carrying one of the following Uoenses or aenificatlons. Master Plumber; Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer; Septage Servicing Operator. Tank inapectlona must include a visual Inspection of the tankit) to identify any missing or broken hardware Identify any cracks or leaks, measure the volume of combined sludge and strum and to check for any back up or ponding of effluent on the ground surface. The dispersal ce ll(:) theli be visually inspected to check the sfflvent levels In the observation pipes and to check for any ponding ®f effkWt on the ground surface. The ponding of effluent on the ground W300 may indicate a failing condition and requires the immediate notiflostlait of the bcai regulatory authority. When the combined accumulation of sludge and sour» In any tank eq„els one-third tY3) or more at the tank volume, the entire content of the tank shell be removed by a Septege Servickv Operator and disposed of in accordance with chapter NR 1 19, Wisconsin Administrative Code, All other services, including but not limited to the servicing of offluant filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shell be perfOrned by a certified POINTS Maintainer. A service report shall be provided to the local regulatory authority within 10 day of completion of any service event. page --- Of t tanklol for tt'e p resence Of painting WOdYCts Or otter c"Micais y ae {its? • if high �oentratlons sre detected have the concert a START UP AND OP19RA"�tON $4 Mc For new construetion, POOP to ua o c4 the ndWT$ cage` a disp , e t>Zb treatment process a n d/or d a � prlt�r tp use• 11l be that may impede ry }cing op su rf ace. W &titeWgtBi W o f the tsnkts) femoved by a septage se t t infiltr ivs W the e,ce,s i fs r estored cr BU��d da to resto rge Of m start up shall not occur when ma f ill co nditions ni lira he i sch Syste f K 1 hvwatOr l evels. When po w er it in the ackup ri pump or ing During power outag$s pump tanks ma y ma y fill above norrnel hie the 0010) and may to$ b pperat the or p discharged to the dispersal cents) in one large dolls, OverlOoi a S,ptage SefviwnQ controls to um or contact a Plumber or POWTS MpintaMer to assist in manually operating effluent. To avoid this sltuation have the contents Of trio ROMP tank removed to the effluent p p restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal calls [)a not dri 9 or park over, or otherwise disturb or campaet, th area within 15 feet down slope of any mound or at-grade }oil absorp $ tht Reduction or elimination of the following from the wlkstAwptor st rgem may improve the ill dental rhoe; diapers! dial ectantsf fat P OWTS; antibiotics; baby wipes; cigarette butts; condoms; cotton awsbs; degreae foundation drain (sump pump) water fruit and vOget#►pie 0ee1in9l; gtaoli grease, herbicides; meet &craps; medications; Oil painting products; pesticides sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POINTS fails anWor is permanently taken out of service the following steps shall be taken to Insure that the system + properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: e All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. a After pumping, off tanks and pits shall be excavated and removed of their covers removed and the void space filed wits soil, gravel or another inert so'id material, CONTINGENCY PLAN If the POWTS fails and cannot be repaired tho 11ollOWIng measures have been, or must be taken, to provide a code complian repfacoment system: M A suitable replacement area has bean evaluated slid may be utilized for the location of a replacement soil absorptio, system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b required setbacks from existing and proposed structure, lot fines and wells. Failure to protect the replacement area wi result in the need for a now soil and site evaluation to establish a suitable replacement area, Replacement systems mus comply with the rules in effect at that time. 0 A suitable replacement area is not avalleble due to setback and /or soil Nmttations. Barring advances in POWT technology a holding tank may be installed as a last report to replace the failed POWTS. AIIA 13 T sit sit e tan © Mound and at-grade soil absorption systems may 09 reconstructed in place following removal of the biomst at Th infiltrative surface. Reconstruction* of such Systems must comply with the rules in effect at that time. « WARNING » AND/OR INSUFFICIENT OXYGEN. DO NO SEPTIC, PUMP ANC! OTHER TREATMENT TANKS MAY CONTAIN LjTNAL GASSES AN ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDOR ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF PERSON FROM THE INTEMOR OF A TANK MAY BE DIFFICULT OR (MPOS11111LE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name - -- Phone 7 L Ph SEPTA ! SERVICING OPERATOR !PUMPER) LOCAL REGULATORY AUTHORITY Name Name �j j .. C I)C C "-AYr)' /tJ Phone phase This docuinsrn was drafted In comptiarsce with chapter Comm 83.72(3)(b)0)(dIh(f1 aria 83.$411). (Z) 6 (31, Wisconsin Administrative Cade. ST CROIX COUNTY SE -PT1C - TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address �111e, Property Address (Verificatio quired from Planning Department for new construction) City /State K Ls). 1C av/v�d Parcel Idcntification Number y_ z/,. - 1149 to- 0 116 / 0 LEGAL DESCRIPTION Property Location ! /,,5L_ - /,, Sec. IS , T�3O N -RdLW, Town of 1 '� Subdivision Certified Survey Survey Nlap # , Volume , Page # Warranty Deed # �d�� � `l , Volume 1 , Page 11 Spec house ❑ yes Ono 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 syster 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 waste%vaterdisposal 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/w•e, the undersigned lravc 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 the three year expiration date. SIGNA F APPLICANT DATI: OWNER CERTIFICATION I (we) certify that all statements on this form arc true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGN F 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 U. 2 8 5 7 P 2 19 8x2244 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., WI RECEIVED FOR RECORD Document Number Document Name 08/03/2005 03:00PK WARRANTY DEED EXEMPT # THIS DEED, made between Steven J. Derrick and Margaret M. Derrick, husband and wife REC FEE: 11.00 TRANS FEE: 179.70 ( "Grantor," whether one or more), COPY FEE: and Leone] Figueroa and Nancy Figueroa, husband and wife CC FEE: PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Estmeln & Oglend W interests, in St. Croix County, State of Wisconsin ( "Property") (if more space ed, please attach addendum): 304 LoCust Stfed 1 G J �( Q Lot 11 C herry Knoll's. St Croix County, Wisconsin. Hudson, WI 54016 026- 1149 -00 -011 Parcel Identification Number (PIN) This is not homestead property. (is) (is not Exceptions to warranties: Easements, restrictions and rights -of -way f record, i y. Dated (SEAL) (SEAL) * * tev . Derri (SEAL) IV SEAL) * *M rgar M. Derrick By: Steven J. Derrick, Attorney -in -Fact AUTHENTICATION ACKNOWLEDGMENT Signature(s) Steven J. Derrick and Margaret M. Derrick by; Steven J. Derrick, Attorney -in -Fact STATE OF ) ) ss. authenticated�n 7 COUNTY ) G Z, 1 Personally came before me on * Kristina Oeland I the above -named TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Notary Public, State of Attorney Kristina Ogland My Commission (is permanent) (expires: ) Hudson. WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. 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