HomeMy WebLinkAbout026-1294-05-000 n Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
jfety and Building Division
INSPECTION REPORT Sanitary Permit No:
515032 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:
Smith, Gerald Richmond, Town of 026 - 1294 -05 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/D•0- S� — f�1'Tl'i l 28.30.18.1487
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ' Benchmprk
Skc.� F' ►+..- ,s i�o o s'Z� iosZ X00.
.Dosing / Alt.
Aeration Bldg. Sew
9
Holding __ __
St/Ht Inlet �
hs�a. z
St /Ht Outlet /
TANK SETBACK INFORMATION SGq 5 /OS a G 76--
�B 7�
TANK TO P /L,- WELL BLDG. Vent to Air Intake ROAD Dt Inlet F/;7— 27
Septic � G D f � 75 / Z 3 r A Dt Bottom e�
Dosing o / /V Header /Man.
:V, /
11
Aeration Dist. Pipe a
Holding Bot. System
/ Final Grade t G_!� ��. �
PUMP /SIPHON INFORMATION �j (�v ( 4_4 9-0 . f
Manufacturer Demand St Cover r�
P M 3 .46
Model Number t h 3 50
TDH Lift Friction Loss System Head TDH Ft (4� jv
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM (? %/la
BED /TRENCH Width jr Length r No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 7D . `l
SETBACK SYSTEM TO / P/L ! BLDG — WELL LAKE /STREA LEACHIN Manufact
INFORMATION CHAMBER R
Ty tl I f System: r / Model umber:
DI UTION SYSTEM
nt to Air Intake
Bader/ nifold Distribution U3 / h x Hole Size x Hole Spacing Ve
Pipe(s)
Length U Dia Length Dia Spacing �'
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Oven, Depth Over xx Depth of xx Seeded /Sodded Mulched
ed /Tren
Bch Center j V— Bed/Trench Edges I--- Topsail xx Yes No E] Yes E] No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: Z / 17- os" Inspection #2: /
Location: 1309 116th Street New Richmond, WI 54017 (SW 1/4 SE 1/4 28 T30N R18W) Richmond Acres Lot 5 �Parcel No: 28.30.18.1 8e
1.) Alt BM Description ! /W_Jxehlb
2.) Bldg sewer length= Z5
- amount of cover = GZ �J 0
Z C old cam.
Plan revision Required? El Yes to
Use other side for additional information. I_'J / i,
—�_- -- —
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
commerce.wi.gov Safety and Buildings Division County
201 W. Washington A *7. ox 7162 J �. a / X
i sco n s i n Madison, WI Sanitary Permit Number (to be filled in by Co.)
Department of Commerce . j :515 O3
Sanitary Permit Application State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental AA
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Protect Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
p urposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats.
I. Application Informat' - Please PrinjWll Inforinft
Property Owner's Name , IA/y I f, l / R E C E 1 V E P� cel # ��� y 05 -,ow-M-06io
Property Owner's Mailing Address O 2 o�p Property Location
' G O ) q 6 fl1 a V e DEC L UU Govt. Lot I /T O
City, State Zip Code Pw5ficaa6366rC u , , L
s`J k, /� ZONING OFFICE Sw / <, SE /<, Section
C/ �� V Fti l I N, 3 S (circle one)
1 T N; R /8 EorW
11. Type of Building (check all that apply) o% o o Lot
p
�1 or 2 Family Dwelling - Number of Bedrooms -3 n Subdivision Name WO /73/7
Bloc Q� () ! 7r7jA UlP�Gf_S
❑ Public /Commercial - Describe Use �3SQ -�( �+ ❑ City of
El State Owned - Describe Use p �
CSM Number El Village of
Z IJ,��- C�.�15 / -7 & Town of C.4"P
wL
III. Type of Permit: (Check on6 one box on line A. Complete line B if applicable)
A. New System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
��
B. El Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that appl
Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain)
V. Dispersal/Treat ent Area Information: a - C £ H 5 3 q - f, I G y �' - y t0 n S
Design Flow (gpd) Design Soil Application Rate( dsf) Dispersal Area Requ Dispersal Ar* P poses System Elevation
S� - �] y3 U � t ' L Z,
VI. Tank Info Capacity in Total # of Manufacturer /
Gallons Gallons Units /�j a 2 to
New Tanks Existing Tanks / Q
U
/
w / ( (�F �� FI a
eptic or Holding Tank / V Q i 1 / �j : vJ �g' S V
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS sho the attached plans.
P tuber's Name (Print) Plumber's Signature M /MP S Number Business Phone Number
CSC ke / / � 1 �w1��tis 2- Ld7L y 2- l
umber' Address (Street, City, State, Zip Code)
Z�S /So -iL u r
VIII. Coun /De artment Use Onl
Per Fee Date Is ed E Issui gent Sig
Approved ��, ve $ ,� • M �Z
uen R eason fo enial
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM i�
SYSTEM OWNER: 3 e►� k 5i
1. Septic tank, eMUL'nt filter and I
dispersal cell must all be servlces / maintained 5 4 .
as per management plan provided by plumber.
2. All setback requirements must: be maintained
code I
an Per Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD -6398 (R. 01/07) Valid thru 01/09
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Wisconsin Department of Commerce VALUATION REPORT Page __— of
Division of Safety and Buildings
an Comm 85, Wis. Adm. Code
County S't' C V �
Attach complete site plan on paper not le than 8 1/2 x 1 inch ►►��ee
include, but not limited to: vertical and horizontal referen point C m Parcel I.D.
percent slope, scale or dimensions, north arrow, and to ion and distance to nearest road.
Please print all Informs on. AUG "' ;a 2005 R ew Date
z � D�
Personal information you provide may be used for secondary pui poses (Privacy Law, s. 15.04 (1) (m)).
Property Owner ST. CROI (WUpcatio
Ge rol d, 1 C m ,r -tk ZONIN I 1/4 51•.. 1/4 S p q T30 N R E (or
Property Owner's Mailing Add re Lot # Block # Subd. Name or CSM#
1 /1100 1 e• N W a"t' o f 'rc h m c rc
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
I F-1)( R IR PIN, 3 p ( ) - $ ► i C.IN M a P4
(a New Construction Use: Z Residential / Number of bedrooms Code derived design flow rate — S 0 _— GPD
❑ Replacement ❑ Public or commercial - Describe: --
Parent material Q *.. ' — Flood Plain elevation if applicable
General comments =' 5"5 3'� - '� r Lr` �..�� S C.7 '*3 F0 C e e— e_. g . A{ ;.
and recommendations: F
P , v ►CNo dvl.�
S: -F� { • T ' 94 .2, 1 ` S ;-�� a.: �;� � � rig � +art : s iV@
T.
❑ Boring 'rAo Q L 0 T
Boring # 'S 4 ft. Depth to limiting factor J 0 in.
pit Ground surface elev. ! P g — Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
a 10 R Y - 1 L_ /� V L_ v- A W �
1::k -22 1S YlVAP V' JAA
3 %- - 7, 5 YQy)
iq 3 7 S YRS ----- o- s L_ J.
77 1
Boring #
® Pit Ground surface elev. ! 7 a , ft. Depth to limiting factor 0 in.
Soil ADPlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAF
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I 'Eff#1 'Eff#2
- CJ 3 l L Old
a I LI 1 7 . S
3 al-3t, Ye, L t= b V11Fr c4,01 vF 1
-r� �. s S a _ w, L_ — – J. Ln
Effluent #1 = BOD > 30 < 220 mg/L and T S >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS -< 30 mg/L
T Name (Please P ignature CST Number J
CL.r �-- T
A � s � - Evaluation Conducted Telephone Number
���� 7-a -os - 7 aye :35s8
Property Owner Gera' 5 m Ak Parcel ID # _ Page _ of
F,-31 Boring # ❑ Boring (�
P5 Pit Ground surface elev. _! �,�3 ft. Depth to limiting factor � _ in.
Soil licafion 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
b- I
P, 3 /2 L. o7ir•53K V a .�; ' 's
I d- o-f AV F P L tw f f C ,- .9 , to
rm rA� ; c, t,� .7
S -5a 7.5'f R yIb L I o - S rN L_
-t h _ ` X
!91 Cz C2
Boring # ❑Boring -- —
❑ pit Ground surface elev. _ ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring # ❑ Boring
F _
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/ff
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.60))
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Property Owner Gera S in Ak Parcel ID # Page _ of
1.31 Boring # ❑ Boring '1
a
�' Pit Ground surface elev. _ - I ft. Depth to limiting factor I S in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
I d- 16 1 D — L F V L f ka
-Sa 7a.5'fAYil L I 0-5r, YNN L
El Boring # Boring 1 � S ( x �ev1 &t
❑ Pit Ground surface elev. ft. Depth to IimiGng 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
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
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD, > 30 5 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD, 5 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.
580.6330 (6:6130)
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MDAOTs
(A COUNTY PLAT)
Located in port of the Southeast Ouarter of the Southwest Quarter, port of the Northeast Oucrter of the Southwest Quarter, port of the
Northwest Ouorfer of the Southeast Quarter and port of the Southwest Quarter of the Southeast Quorer all ir, Section 28, Township 30
North, Ponge 18 West, Town of Pichmond, St Croix County, Wisconsin.
(SEE SHEET 1)
24 25 ---26 274 m -6- - 28,-.' II 31 m I
-' '98&9 U 1
- -' ar OfRi
MOWN
S>5 SWCT w 70 NBIII'O w I ; I 'Q...L.,.....
9628 -- 9630 - I p' �. '. a 'VIM
964.3 201 ydT . op ________ - n` I S893r7CA 519.87 I -
m
w�" QW-lC SIC FAflWF
elp.9'40.0s' ` -' - `� I - fie BE eve Wait
10135' Iiro.. -�- - �G 1 s.7p' / '\N MM , .- N794b55E- . NB14P'S9'W�wr .7�107�7 -
m - ° V 589
2.18 acres BI , =, ^^a/gL�.,�UBm' �0
�s azlEt
- -' v 8 u $ s696 95,137 sq. !t. x r No. 7 ' I N ISWN'`�1
e95a2r F�
38 37 36 20 020' S146W ,� �
i 71N1e
1.86 acres 1.81 acres J o
211 acres 10 acres
201 acres 80,901 sq. ft 78,767 sq. ft / O` e l 2
91,883 sq, ft. E e 91,514 sq, It.
u
87,401 sq
. ft.
QQ
39 g
u I' .......... ...........,... ,..... ........., " 1.90 am M1 w
248 ones. ; ft
659 s ft. " c" 2 4XV
N 07,866 sq. IL 4.62 acres 82,75) s ( I 70,p . 9 '
/ h
p L.B.O. 955.0 i
N u
N - ZA a cr e s
F 9 t
22 22,.......
1 .. �4 e a
o� 4 945'18' ` `'r i 4 ` "•-ks l l j \ 9 7. 4 80 s q. f. c
8
9511 , ml.el. I r1N s m`p0' - •r" �s ?r \ I I J
854518 E 39128: NA
I N�lS 5
IPIt AAeY N 8945 B' E196.5 w p e a Ggb: ' Bp6Df 1' 2rllC Q ' ' 4 33, -
aQ rn \ & tl l - NB9w2rE st4�
W AGE fit' Bear %' \' _ ' 1
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got eBY 1 7
8 H.W.T. - 939.8 /k� / 1 - - R 9 or ~ 1
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93201 _/ oQ # 272 W Z.I ml � 117 acres c \n
HWE. =9350 I : c o I I �, o 94,407 sq. ft. c N S
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42 1.97 acres 45 W g
85,956 s ft. 1.79 acres w 1.96 acres ,I
E 1.81 acres 1.74 acres o q S 85176 sq. '. L94 acres
g
0 41 19,816 sq, R. , w 7L876 sq. k.
a. 2.97 acres � 75,741 sq. ��a 1 � 1 84,691 sq, ft.
129,219 so.. ft 276 acres
68.0 955.0 110,151 sq. ft. srr w,we
C L.B.O. 955.0 r z
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L o --------- --------- -------- 6AD9 NB9iDY E M, m m N89SD'Y;'E /7560 O ,
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+U, zoo.w' IW.@J' Isaac' 96' Itis ,,
600.OD' LZ
0 9693 prEAST) LOT i_ 9681 N 1.96 ones °) m 1229 ones a C
5a'FOwwwN ' o SWIRL' 1 & w 82,228 s . ff.
w L„ URIfY AfAP „ , 1 . u � 9
u' i -- - - -- 85,398 sq. ft. /
f - -- - - -- ° ° �c'� Pc -- / u
•VIA _
9685 / I 9679
2 ri4 /
:a7.6t w2Br LEGEND , Sd 9WSa'E
SB9'49'16'W 1 406.43' A nas'A'trt 4so.76' U I 4'�.� I� I
I V Section Comer 4onument of Recad Z � i h 4
fgNes79'u7laSn7 8 `^ I II I
a Found t" Iron Pipe � , (�
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0 Set 1 -I/4" x IB' Iron Reber �+ 4 221 acres
(weighing 4.303 Ibs. per Their foot. AV' 0 1.85 acres A,
o Po 96,598 sq. ft. Y
CERTIFIES tJRVE'( High Water El
100 -Y
IAAP
Poe other lo Ong 1.13 Ib comers marked w N a I'z18 'ran 80, 415 sq. ft.: 1, : .. s per Inear fact.) I / 2 Buid LT LLI ing Setback Lane ne ,
9655 VL(_ 20 Po 5068 � (100 from Right of way a as noted)
SI [
- Proposed Driveway LKOI 1 t
_ �/ TIVSY E R
. LB.O. NlowoGe Elevation of N899atrE 75a9s' 1` / 70202' 589'49'19 "W 224.00' witi08 Ak4w
Lowest Building Openng j �' 1 p;l m (R=A'eR76JO111 r411Aj111 ry�y
NOTES: HINE. e 111 8 49 I _ I l a
4 0, ^
ELEVATIONS ARE USGS III 1968 BASED ON GP5 OBSERVARONS O b 1, _ o e L
854.1 encmaap of on Reber a Pipe o 1.80 acres
�NBNGS ARE REFERENCED 7011& SOUTH UK OF THE Bhk - T o JT 3f 3 °m IVI
souTHUST 1/4 OF SECTION 26 WHICH Is ASSUMED m BEAR - - - 18,114 sq. ft. u u: CERTIFIED sups EY
2' Mity Easement along roadways $ m 0 -____ - - - - -- VV
w u i.1 acre c
56999. ., 2Q $ 1
s
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D PARCELS SHOWN CN THIS REG ARE NS (LE. TO S7A1E, COUNTY R= Recorded as - . ,,,.,_L B G... AW�.g4 o� a ...16 t30 S . ft ......_.. o m -- I - 4 -----
A n N NN9NUU { ,��' 4a' �. uo 9 N
AND 10VR75HI7 L R ULES p190 AEGULA IONS (LE. WEIU DS, A'M� ,
LOT 512E. ACCESS i0 PARCEL, ETC.). BEFORE PURCHASNG Ot )MOTH ALL OTHER LOT CORNERS HARKED VdTH A 1' z 18' � � �y � °'� N sou6tost Cannot at
ANY PARCEL C047ACT THE ST. CR @N COUNTY 2UNN'G OFFICE AND THE " 8 f
IRON PIPE (W17GHING 1.13 LBS. PER 11NEAR FOOT) !+ a MW.E =960.0 4 p Rcfion 18-30 -18
APPROPRIATE 100 BOAAO FOR ADNCE, o I �° I 8 9615 found Atummum dwke
ONfSSO1NERMSE5HOWN. w Sw06' us_or I ( gFa Neww
NO OWNER OR RESIDENT SHALL 00 ANYTHING W99,01 WddD INIERFERE 961.7 J - - t
WTH OR CHANCE THE OPERATION OF IRIS APPRCVEU CCNPREIENSIVE WATER tn6r- - .66od County Movement) - - _ M ft7SD48
DRAINAGE AND SOT' M90N PLAN FOR THIS PUT. THIS INCLUDES BUT I$ N9919'19'E ' �771.IC' Pr4aed b
i
NOT UNITED 70 BUILDING UPON, OBSTRUCTING, ALTERING. Flit1NC, EXCAVATING G _ _ _ - q - , % �,.
OR PLANING IN ANY ORAMAGE EASEMENTS, WATER DRAINAGE DITCHES, 5847919 "W n, ��A� 589'4999 "W G 751.08' a 589'49'19'W
WATER RUNWAYS, WATER CN NEA1S, BERMS OR GRASS SETTINGS. _ _ - 7532.04' /
i Phone No iTS; 246 - 43:D
,m o Ica -- N89'4999'E
SarfM1 2616.10' -- Fax No (715) 2A6 -1930
Cuater Cana o,
UN D saute ne of me SE I/4 He . box 325
GRAPHIC SCALE SectianlB -JO -18 __ - - - - __ - - - N
_ aRichmad,IM54017
SCALE N FEEL I ncA . Ica Net Estobrahed front, yes SHEET 2 OF 3
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner 0C L'r1, ,' ^, A p,iy,., r'5 Septic Tank Capacity /000 a l ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer IK,5 t /Q ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model /j�'� t / 0 ❑ NA
Number of Public Facility Units ErlTA Pump Tank Capacity (00O g al ❑ NA
Estimated flow (average) ' Y J'_ b al /day Pump Tank Manufacturer S Jf �,..+ ❑ NA
Design flow (peak), (Estimated x 1.5) 37 3 gal /day Pump Manufacturer 0 µ td5 ❑ NA
Soil Application Rate � gal /day /ft
z Pump Model rR o S' ❑ 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 121"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 C3-fd9C AirAt -Grade ❑ Mound
Fecal Coliform (geometric mean) 510° cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. p�IqA Other: ❑ NA
Other: 5'NA Other: ❑ NA
*'Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 0 year( 1(s) (Maximum 3 years) El NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Clean effluent filter At least once every: - 11 NA
❑ year(s)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: + 49-year(s)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: Z -B- years)
Other: At least once every: ❑ month(s) 13 NA
❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provid to the local regulatory authority within 10 days of completion of any service event.
'�-"'- GMW (4/01)
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START UP AND OPERATION Page of
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 tails 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 �u ' ti -�-� C Name / s f
Phone `{7 L _ L Lf L j Phone Y 7 Z- L Z 1
SEPTAGE SERVMING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name A .5 Name
Phone Phone 716 — g'� Al
This document was drafted in compliance with chapter Comm 83.2212)(b)(1)(d) &If) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
A
• s
START UP AND OPERATION Page of `
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 rtiw ti S t� C Name s
Phone �(-7 L_ Z L/ Z 1 Phone Y 7 Z - L.y Z 1
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name A s K Name �.
Phone Phone 7/S - .,
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(41 &0) and 83 540), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CER CATION FORM
OwnerBuyer i C , -t- V'CL �5 Mailing Address / / / G e / 9 D - v /�- , w , /J ' �. r c , �n ,3,T 3 3 0
Property Address O /1 (0 4A
(Verification required from Planning Department for new construction)
City /State v' e 41►i eA � Parcel Identification Number OZ L - /a 83 - /L ' °
,
LEGAL DESCRIPTION
Property
Locatio 5 v--' '/4, 5 �� ' /., Sec. Z- T _Ly_ -R �8 W, Town of � h •�, v^-
o
Subdivision ?1 o 1`� c h �-. J Q c L E S • Lot # S
Certified Survey Map # . Volume . Page #
Warranty Deed # ��O � �, Volume Z Page # _
Spec house ❑ yes 0 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
masw plumber, journeyman plumber, restricted plumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin - Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
i2. / /08
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 descried above, by virtue of a warranty deed recorded in Register of Deeds Office.
C r . r "' , L I Zl aB
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
/A'1 s 2- 2- 2- 07Z
U 2 8 1 4 P 5 3 1 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO -, WI
DOCUMENT NO. WARRANTY DEED RECEIVED FOR RECORD
06/03/2005 12:06PH
WARRANTY DEED
EXERT t
This Deed, made between David A. Ball and Kimberly A. Ball, husband REC FEE: 13.00
and wife and Dennis F. Ball and Nancy A. Ball, husband and wife, TRANS FEE: 3185.40
Grantors, and Gerald J. Smith, a married person, Grantee, CC COPY FEE:
WITNESSETH, Tha a ntors, for a valuable consideration PAGES: 2
convey to Grantee the following described real estate in St. Croix
County, State of Wisconsin::
RETURN TO:
Parcel 1: The East Half of the East Half of the Southwest Quarter Loberg Law Office
(E %. 359 West Main Street
1EY2 Ellsworth, W 1 54011
/SW %) of Section Twenty Eight (28), Township Thirty (30) North, PID #026- 1082 -40 -000
Range Eighteen (18) West, Town of Richmond, St. Croix County, 026- 1082 -70 -100
Wisconsin, EXCEPT Lot One (1) of Certified Survey Map filed April 026 - 1082 - 95-000
24, 1990, in Vol. 8 of C.S.M., pg. 2199, as Doc. No. 457843, being 026- 1083 - 10-000
part of the Southwest Quarter of the Southeast Quarter (SW' /,/SE'/.)
and part of the Southeast Quarter of the Southwest Quarter
(SE'/./SW %), both in Section Twenty Eight (28), Township Thirty (30)
North Range Eighteen (18) West.
Parcel 2: The West Half of the outheast Quarter (W' /.
Section Twenty Eight nship Thirty (30 North,
Range Eighteen (18) West, Town of Richmond, St. Cro x ounty,
Wisconsin, EXCE T the following described parcels:
1. Lot One (1) of Certified Survey Map filed April 24, 1990, in Vol. 8
of C.S.M., pg. 2199, as Doc. No. 457843, being part of the Southwest
Quarter of the Southeast Quarter (SW' /./SE%) and part of the
Southeast Quarter of the Southwest Quarter (SE' /. /SW %), both in
Section Twenty Eight (28), Township Thirty (30) North, Range
Eighteen (18) West;
2. Lot One (1) of Certified Survey Map filed August 13, 1981, in Vol. 4
of C.S.M., pg. 1093, as Doc. No. 372738, being part of the Southwest
Quarter of the Southeast Quarter (SW' / ✓SE'/.) of Section Twenty
Eight (28), Township Thirty (30) North, Range Eighteen (18) West;
3. Commencing at the Southwest corner of Lot One (1) of Certified
Survey Map filed August 13, 1981, in Vol. 4 of C.S.M., pg. 1093, as
Doc. No. 372738, for the point of beginning; thence N89'59'1 V' West
20.00 feet; thence NO'01'41" East 262.00 feet; thence S89'59'15"
East 224.00 feet; thence SO'01'41" West 15.00 feet; thence
N89'59'1 5" West 209.00 feet; thence SO'01'41" West 242.00 feet to
the point of beginning;
4. Commencing at the Northeast comer of the Northwest Quarter of
the Southeast Quarter (NW' / ✓SE' /4) of said Section 28; thence South
16 feet; thence Northwesterly to a point 10 feet West of the point of
beginning, thence East to the point of beginning.
This is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And grantors warrants that the title is good, indefeasible in fee simple and free and clear of
encumbrances except easements, restrictions, covenants and conditions and will warrant and defend
the same.
U 2814 P 532
Date �thiss16th day of MJayy�, 2005.
(SEAL) • SEAL)
David A. Ball R / Kimbert A. B alk
D� '' A2 &' Z (SEAL) (SEAL)
Dennis F. Ball Naficy A. Bair
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) '� �i STATE OF MINNESOTA }
)SS.
authenticated this ay of COUNTY OF
20 Personally came before me this 16th day of
May, 2005 the above named David A. Ball
Kimberly A. Ball and Dennis F. Ball and
TITLE: MEMBER STATE BAR OF WISCONSIN Nancy A. Ball to me known to be the persons
(If not, who executed the foregoing instrument an
authorized by §706.06, Wis. Stats.) ackno the same,
THIS INSTRUMENT WAS DRAFTED BY `
LOBERG LAW OFFICE Notary Public County,MN My
Robert L. Lobero Commission is permanent.
(Signatures may be authenticated or acknowledged. Both are not necessary) (if not, state expiration date: , 20 _ )
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