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Home My WebLink About026-1149-17-000 r Wisconsin Depattment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division tNSPEC1�70td ' . REPORT Sanitary Permit No: 453186 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: Anderson, John & Lori I Richmond Township 026 - 1149 -17 -000 CST BM Elev: Insp. BM Elev: BM Description: I I L�� Section/Town/Range/Map No: l6 0 , c7 to t .o 36.30.18.1117A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Ma _G 2 91r /02-1 a Dosing Alt. BM Aeration Bldg. Sew r �.zo 44.7 Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATIONV v S•� 9" ], TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic >�Ob , K„ Q01 I Dt Bottom Dosing 7 Header /Man. Aeration Dist, Pipe T .e. s s Holding Bot. System do : � ;7- o � PUMP /SIPHON INFORMATION Final Grade Q Manufacturer Demand St Cover 3,7 9q.2 p�L �ro-d r D D e e 3' /a /, Model Number In 1 TDH Friction System Head TDH F orcemain LD roW — ell SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. OfTrenches cal PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Dept DIMENSIONS . SETBACK SYSTEM TO P/L BI- WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: h0� �jo 52 Model Number: DISTRIBUTION SYSTEM UA4+ Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) L ngth SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth o xx Seeded/Sodde xx Mulched Bed/Trench Center r Bed/Trench Edges Topsoil 3, � ' 5, 24 G s No s [jfl No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_ E 'L 117- Location: 1422 126th Ave New Richmond, W 54017 (SW 1/4 NW 1/4 36 T30N R18W) Torey Pines II Lot 17 Parcel No: 36.30.18.1117A 1.) Alt BM Description = �1� rZ C '" 1 r 3) 0106, U" ,�/ iV4 I H (NR' 2.) Bldg sewer length - L( 1/ l q) V PiY4'ed V 4 ZZC - amount of cover Plan revision Required? Yes No Use other side for additional informa ion. SBD -6710 (R.3/97) Date sepctor's Signature Cart. No. Safety a „d Buildings Division County 201 W., Washington Ave., P.O. Box 7162 I visconsinMadison, WI 53707 - 7162 Sanitary ermit Numlaer (to be filled in by Co.) (60S)266 - 3151 ent of C Sanitary Permit A_ lie tion { ate Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Ce,perso 1 infor nation you provide may be used for secondary pure r w, sl .04(1)VAY 2 4 2004 oject Address (if di Brent than mailing address) H A I. Application Information - PleasePrintAllIn matio �I CRO�XCOUNf` /� 2Z 126 Ave. "e' Property Owner's Name rcel # Lot # Block n -- eha zzn s- //'Y 4 17 - Property Owner's Mailing Address Property Location . 'lJl� n Q ` ��' / <, / /� �, section City, State Zip C�od e Phone Number `f jf Pik /�/ ��/yi c SWIZ aV4_,Pe T,= N; � Ecle II. Type of Building (check all that apply) �. �or 2 Family Dwelling - Number of Bedrooms _ Su l - l"ion Nam � ' CSM Number El Public /Commercial - Describe Use �� ^ 1 - ❑ State Owned - Describe Use 4 A2 d ❑City_ Vill -- hip of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A, ew System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑ Permit Renewal it Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Nu�ymb /er and Date Issued Before Expiration Plumber Owner J /� 3 J X /., � D IV. Type of POWTS System: (Check all that apply) ? N on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Veaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) / V. Dispersal/Treatment Area Inf ation: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation 1. VI. T ank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existi Tanks Tan ks ep c oldingTank Aerobic Treatment Unit t Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) r Plu r ignature MP /MPRS Number Busi Phone Number h r� Plum s Address (Street City, State, Zip te /VG VIII• oun [Department Use Onl 11 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued suing o Si r tamps) Approved Surcharge Fee) 0/ / / 0 u �2 ❑ Owner Given Reason for Denial � 7 /^ IX. Conditions of Approval/Reaso alv� sa �h, d oC Attach compiete plans (to the County on for the system on p er not less than 81lZ s II inches L ' �/Zlliria�cQ.t�ihcQiit Go f0 5ys SBD -6398 (R. 01/03) I � � t ' PLOT PI At PROJECT John ANDERSON ADDRESS 44fLaurel Dr. NewRichmond Wi. 54017 SW 1 NW 1 /4S 36 /T 30 N/R 18 W TOWN Richmond COUNTY POLK MPRS Byron Bird Jr. 220529 -- DATE 5 -23 -04 BEDROOM 4 CONVENTIONAL XXX At rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE E3 LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 BENCHMARK V.R.P top of stake r etaining pond ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Same as BM Vent SYSTEM ELEVATION T- 1= 94.8T -2 =94.6 > 12" Of Bio Diffuser with Alt BM top of Retaining Pond Elv. 100' Cove 3 1. 1 ft ^2 per chamber 6 " Long 34" Elevation 100' PL ' PL , 98' ��p� 40 oi l • 50, BM a o F� 4 bed 1 st house PL �o B 3 b L )dln Drive Cauldasack Cvl-de- c s"3 ' WiisconsinDepartment ofCommerce SOIL EVALUATION REPORT Page I Of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code 1 _ ^a Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ! include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. r '1 7 � percent slope, scale or dimensions, north arrow, and location and distance to nearest road. l Please print all information. Reviewalvoi fDate Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner _ Property Location —3 f7 f'1 G7 Govt. Lot 1/414074 S K T Q N R lfrE W Property Owner's Mailing Address Lo # Block # Subd. CSM# , / I � Gc r e /^, / � 3 City late -Zip Code Phone Number ❑ i Village ERTAm Nearest Road r 2 ( ,2T ` v 1-2 1 A10 fti Sri P K New Construction Use.oResidential / Number of bedrooms Code derived design flow rate B GPD ❑ Replacement ❑ Public or comme 'al - D tribe: Parent material F, 5 Flood Plain elevation if applicable ft General comments and recommendations: T- — / Boring # Boring F Pit Ground surface elev. 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 . S 5' 3(0 Ul Boring # Boring ❑ pit Ground surface eiev. Depth to limiting factor in. Soil Appl ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 'Eff#2 VZO ,5 r 1 /. ' Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 rng/L and TSS < 30 mg/L CST Name ( Print) Signatur \ CST Number Address y� Date Evaluation Conducted Telephone Number 76� Property Owner o of, < Parcel ID # Page 2 of Qk Boring # _Boring ❑ pit Ground surface elev. ft. Depth to limiting factor 7 in. Sal 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 A �S F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil 40cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/11 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. Sal Appication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/1F 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 530 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 OL07 /00) I` PLOT N AN • PROJECT John ANDERSON ADDRESS 443 Laurel Dr. NewRichmond Wi. 54017 SW 1/4 NW I /4s 36 /T 30 N/R 18 W TOWN Richmond COUNTY POLK MPRS Byron Bird Jr. 2205217 DATE 5 - 23 - 04 BEDROOM 4 CONVENTIONAL XXX At rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 BENCHMARK V.R.P. top of stake r etaining pond ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL 1H.R.P. Same as BM Vent SYSTEM ELEVATION T- 1= 94.8T -2 =94.6 >12z Of Bio Diffuser with Alt BM top of Retaining Pond Elv. 100' Cove 3 1. 1 ft ^2 per chamber 6 " Long 34" Elevation 100' PL ' PL 98/ _f32 $?, 40 , B a� 509 BM o � R 4 bed st house PL �0 B 3 b 11 b`� Drive n 0 S v� Cauldasack �1-de54 101 Ctk LOT 26 :� LD 2.0 ACR ' \ (2.3 ACR S) 4 / (1.7 ACR i 490 - , f / 436 30 bR � LOT 25 j—• �-� / / LOT 11 i o \ 1 2.3 ACRES ,�' N I / / 2.O-4Z:RES,/ �a / \� (2.3 ACRES) -49U 7 I LOT 24 i..Q,ACRES (2.0 ACRES) - — - - �o / / �6T A / - . ' / r / .v / �' �� j/ �Cp ,� / MIN F� LOT123 .' / = 1 00 p AC ES '� / / ,� ,� `' l / 'OT 7 / 2.0 ACR ) �5 A RES• (2.8�CRES) 317' 11.63 r ' � %.� 1 2� � 496' � ... _� // / , / / 409'( ( �`` 6G / L5)+ 1 7.Oy� LOT 18 �2. Rig / ;% 1000. 1 /2 81 AICRE�S (1. A ES ) ACRES) TORM WATER t o 1 �� R TION AREA, I �, 1 MIN J E I o I 1 nm 0 ', = 1 nn I Sanitary Perm Application Safety & Buildings Division In accord with Com l2; Wis. Adm. Code 201 W. Washington Ave. NNW See reverse side for instructions for completing this application PO Box 7302 ISCOMin Personal information you provide may' be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County _ , S State Sanitary Permit her ❑ Check if revision to previous application State Plan I. D. Number li�e�rX S3 I. Application Information - Please Print all Information L ation: Property Owner Name operty Location Property Owner's Mailing Address / G Lot Number Block Numbel City, Stat Zip Code Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) o, 6 1 ,;2 _ 7 1 ❑ City • 1 or 2 Family Dwelling - No. of Bedro s: �� ❑ Village • Public /Commercial (describe use):_ S A�bwn of ❑ State - Owned Nearest Road Parcel Tax Number(s) III. Type of Permit: (Check only one box on line A Nbeck box on 1' e B if applicable) . 117 A) 1. PkNew 2. ❑ Replacement 3. ❑ Rep cement of 4. 5. 6. ❑ Addition to System System Tank Onik n Existing System $) Pe 't Nu er Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) on- pressurized In- ground ❑ Mound ❑ S d It Constructed Wetland b Pressurized In- ground ❑ Holdin ank ❑ S ngle Pass ❑ Drip Line ❑ At -grade ❑ Aerob' Treatme Unit ❑ Recirculating ❑ the. i V. DispersaUTreatment Area Information: .o A4 B 1. Design Flow (gpd) 2. Dispersal Area 3. Dispers ea Soil Applicatio 5. Percolation Rate 6. System Elevation Final Gra Required Propos to (Gals. /day /sq. (Min. /inch) j� -� 92 • Elevation -7 — �r— ql• O VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks C\rete n- Con- glass New Existing structed Tanks Tanks �. VIII. Responsibility Statement I, the undersigned, assume responsibility for nstallation of the POWTS shown on the attached plans. Plumber's Name (print) ` Plum be ature (no stamps): MP/MPRS No. Business Phone Number Piu er's Address (Street, City, State, Zip Cod 00 er - IX. unty/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No stamps) pproved ❑ Owner Given In' al Adverse Surcharge Fee) $ �� Determination (/ X. Co "9t Ya (� '� 1 Septic tank, effluent filter and 3b `� J dispersal cell must all be serviced Jm S � aintained -C-9 as per management plan provided by plumber. w.cc�p �acr 2. All setback requirements must be maintained �J d x as per applicable code /ordinances f � � -�-1- SBD -6398 (R. 07/00) V PLOT PI,AN z PROJECT John ANDERSON ADDRESS Laurel Dr. NewRichmond Wi. 54017 SW 1/4 NW 1 /4s 36 /T 30 N/R 18 ' W'TOWN Richmond COUNTY POLK 4 -25 -04 4 MPRS Byron Bird Jr . 22052 " ", � � DATE BEDROOM CONVENTIONAL XXX At Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 BENCHMARK V.R.P top of PVC Pipe ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Same as BM Vent SYSTEM ELEVATION T- 1= 92.OT -2 =91.0 >12 " of Bo Diffuser with cY Cove 31.1 ft A2 per chamber 6" Long 34" Elevation / 100' PL / '40' B 1 5 9 J / 50 ' W B3 I� ��/ BM rte' \�L> / 10' B2 1501 s 30' 4 bed house PL, Drive Cauldasack AW -0 �_ PLOT PLAN: - PROJECT John ANDERSON ADDRESS 443 Laurel Dr. NewRichmond Wi. 54017 SW 1 /4 NW 1 /4s 36 /T 30 N/R 18 W TOWN Richmond COUNTY POLK - 4 -25 -04 BEDROOM 4 MPRS Byron Bird Jr. 2205 DATE CONVENTIONAL XXX At -Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 857 # of chambers 28 ,, BENCHMARK V.R.P top of PVC Pipe ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL *H.R.P. Same as BM Vent SYSTEM ELEVATION T- 1= 92.OT -2 =91.0 A Bio Diffuser with 3 1. 1 ft ^2 per 6 „ chamber Long 34" Elevation 100' PL 501 87 4 4 I j 60, �o B3 BM 644' L B2 lo' i s r 30' 4 bed house PL Drive Cauldasack r r a PAGE 3 OF 3 NAME b LOT# L EGAL DESCRIPTION - y /Uw ,S 36 T 3 N R. E(or)19 SCALE: I"= /-Ad I BM 1 ELEVATION /60 BM 1 DESCRIPTION - 6 C) o �' , v c.. �. Iv 0 e +. ----v BM 2 ELEVATION 9, 0 0 BM 2 DESCRIPTION o -P U c- -�aG. 3 G SYSTEM ELEVATION A q RZ •° Loy.• {� `(1. d0 ALTERNATE ELEVATION N i j!- CONTOUR ELEVATION �1�.0� , $',�, �R•�" =` c �.3 Vi 8V „ 2 ( ka r 5 �r ,e a X SIGNATURE % DATE `-� Properly Owner \U e� ( L..L Parcel ID # Page - 2 - of Boring # ❑ & pit Ground surface elev. �� tt Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz In. Munseli . Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2 f x-12 to SL— 2—rr,abk "r C 3 I v- G J 2 IZ F-1 Boring # Boring ❑ pit Ground surface elev. R Depth to limiting factor in. Soil Application Rate Horizon Depth . Dominant Color Redox Description Texture - Structure Consistence Boundary Roots GPD1ft In. Munsetl 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 . Structrue Consistence Boundary Roots GPDtft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i I ' Effluent #1 = BODS > 30 < 220 mg& and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/4 and TSS < 30 mg/L f .. 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. son -113" OL07M) a t ' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 2 ee, �� Septic Tank Capacity 4400 a l ❑ NA Permit # S 3 Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model /mod ❑ NA Number of Public Facility Units A Pump Tank Capacity al A Estimated flow (average) al /day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) p� t gal/day Manufacturer A Soil Application Rate al /day /ftz Pump Model A Standard Influent /Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA W ears) 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: ❑ month(s) ❑ NA year(s) Inspect pump, pump controls & alarm At least once eve ❑ month(s) year(s) ❑ NA Ins P P P every: 13 years) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ 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 provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of START UP AND OPERATION y , R f, 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 rep ant system: suitable replacerent 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 shou i nged uaon by required setbacks fro Failure to protect the replacement area will resu t �n t e 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 not been ev ated identify a s 'able placement area. upon lure of the WTS soil and site evalua ' n m t be per rmed to to to a su' le replace ent area. no replace nt ar is available holdin nk may a installe ast resort to rep a failed POWT ound 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 Name Phone �G/6 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ' Name G .–oi Phone �� 1 Phone – — � This document was drafted in compliance with chapter Comm 83.22(2)(b )(1)(d )&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. l ST. 0 %611 COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND 1. h OWNERSHIP CERTIFICATION FORM Owner/Buyer uyer o 411 1,5_0 1-�7 J � ll Mailing Address a q at �- r �- / ��"' i �� / CC C h !n Property Address / V ->- - e- / � & ch:� (Verification required from Planning Department for new co ction.) City /State Parcel Identification Number tl LEGAL DESCRIPTION Location �� ' /4 Sec. T N R W Town of L�J a •�, c/ Property Lod /4 , �_, � / Subdivision / D r d h e,�s , Lot # Certified Survey Map # Volume , Page # �-- Warranty Deed # Volume Sao Page # T ?Z Spec house yes Lot lines identifiable 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. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. 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. Uwe, 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 Department within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the prop e de 'bed 1, ov by irtue of a warranty deed recorded in Register of Deeds Office *A"s F;, 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. U 25�4P -992 7S 1ni93 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Docurrtent Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI ' This Deed, made between Ames Irivestment Corpwration, a RECEIVED FOR RECORD Minnesota Limited Liability Compann Grantor, 05/04/2004 11:25AN and John A. Anderson and Lori L. Anderson, husband and wife WARRANTY DEED Grantee. EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00 TRANS FEE: 179.70 ace is needed, please attach addendum): COPY FEE: =-' , t of Torey Pi nes H in the Town of Richmond, St. Croix CC FEE: PAGES: 1 Recording Area Name and Retum Address First National Bank of New Richmond PO Box 89 New Richmond, WI 54017 026 - 1149 - 17-000 Parcel Identification Number (PIN) This ig not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of r ord, if any. Dated this day of April 2004 !r * * Ames v ment Corporation s * AUTHENTICATION CKNOWLEDGMENT Signatures) STATE OF k ) ) ss. cJ`f County ) authenticated this day of Personally came before me this ..day of April , 2004 the above named Ames Inves Cor or 'on, a Minnes Limited Liability * Company TITLE: MEMBER STATE BAR OF WISCONSIN (If not Ro (jer D . B ove me known to be the persons) who executed the foregoing authorized by § 706.06, Wis. Stats.) �� }} otary PublI instrume and wledgea the same. THIS INSTRUMENT WAS DRAPE cc b%Q Of WiSCOnSi Attorney Kristina Ogland " Hudson, WI 54016 No ry Public, State of .0 Commiss is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) • Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, WI STATE BAR OF WISCONSIN 800355-2021 WARRANTY DEED FORM No. 2 - I999 it LOT I —•� 2. 0CW AMS J07=0 80. Fra $ 1 MW PFE - 1008.00 1 w ; NWS)"!0'E4mw �� . .. r A. LOT le ! . ,,�..... ISISACM I 0 1 3, 802 80. FT4 'r MNFR s Iooaoo,� I ,0 .. r s , a479 ,2vei 80. FT.) f E ...."... , MIN FFE - oa ..................... ........... . 4 0' MA MM 7881! SAM TO IM ALPFCWA6%= of laki %16 tm a y 'F r {• 4F 8 W6l%8r W 627AV 1p E N W*14r E d21 A& •� /`. ..i LOT �� ..r ft j ...;.. 2. 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Plan must 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. ` Date Personal infarinatlon you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1 / - d a Property Owner .:: -. Property Location LAC GovL Lot Z- 1/4 NLv1 /4 S T N R (g E (or) Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# � m in 1. __ Tor P city State Zip Code Phone Number ❑ City _ ❑ Village a Town Barest Road e� N 1 1 0 c 1 ) - 2� `l Rich I yO T � `sf 0-New Construction User Residential / Number of bedrooms - Code derived design flow rate �O - - ❑ Replacement ❑ Public or commercial - Describe: ` a Parent material I I Flood Plain elevation if applicable I AJ 4 General comments S�S� erY) 2 1- f v 4 l 9 9Z . 1 2 2002 and recommendations: tr �l' () �jgZ �L ST. C CO P Boring 11 I � Boring I ty3 Pit Ground surface.elev. 9 �U It. Depth to limiting factor 16 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 2 . 2 - 1 1c) \ft-4itf) m q .0 v/ . 10 ( � F2--]BoFing # ❑ Boring / pit Ground surface eiev. -7- r fL Depth to limiting factor ZD in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. '01#1 'Eff#2 1 20 10 rNZ ' -si 2rna&, r C 1 5 8 Z- 20- IOVrf I , si cJ &n5-q- nor c5. 1 '4 �0 3 420 10, LfJ t, — m s O m � _ - , - 7 I - z 9z. o 4 Effluent 01 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = SOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature ��NNumber_ 2Y ✓ Address Date Evaluation Conducted Telephone Number 2113 °��-e �� 1 ZS _ ri –�z C�c�)z`47 -1-f60 2� Property Owner Atyw S Parcel ID # Page 'of Boring _'�� Boring # a t surface elev. 9� ft. Depth to Fmiting factor _ �( in. i . Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfitz In. Munsell Qu. Si. Cont lor Gir. Sz. Sh. 'Eff#1 'Eff#2 b I 31 �) - ry p rr r C • 5 2 IZ 7] Boring Boring # ❑ ❑ Pit Ground surface elev. fL Depth to limiting factor in. Soil Application Rate Horizon Depth • Dominant Color Redox Description...... _ Texture _-Structure Consistence Boundary Roots GPDtft In. Munsetl 13u. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring - ❑ Pif • Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPDtft in. Munseli flu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BOD, > 30 < 220 mgA_ and TSS >30 < ISO mgll- • Effluent #2 = BOD < 30 mg/4 and TSS < 30 mglL 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. SB"330 tR07rooi