HomeMy WebLinkAbout030-2117-30-000 r vVisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Sy,fety and Building Division
INSPECTION REPORT Sanitary Permit No:
515136 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:
Brolin, Mark & Lynda I St. Joseph, Town of 030 - 2117 -30 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
( b Q.- I,- d,4 ) 19.30.19.964
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 6 V Bench k
25 Z 7. log, /oo.
Dosing �• Alt. B
fhS!
Aeration Bldg. Sewer t �3y G • /0 /.
Holding StJHt Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / Dt Bottom
lc3b� 20 % � "
Dosing Header /Man. S • S
5
Aeration Dist. Pipe A
2.
Holding . System 2f # 3
D v
Final Grade
PUMP /SIPHO INFORMATION _ '
Manufacturer and St Cover i p 105', GPM 3 �
2 • 1
Model Number lil 5
TDH Lift Fricti ss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length f No. Of Trenches PIT DIME SIONS No. Of Pits [Ins de Dia. Liquid Depth
DIMENSIONS D
SETBACK SYSTEM TO P/ BLDG WELL LAKE /STREAM LEACHING anufa er: / INFORMATION Type System: / CHA UN R O Numberrl
DIS UTION SYSTEM Svc <41e Age
"Header/ ifpld / Distribution x Hole Size x Hole Spacing Vent to it Intak _l Lj pipes) / / a'�� / _ a Length O Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of Seeded /Sodded Mulched
Bed/Trench Center Bed/Trench Edges Topsoil r H Yes ��s No xx Q Yes 0 No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 0 / !'3 Inspection #2: / /
Location: 305 144th Ave Houlton, WI 540082 (NW �1 /�4,S�W 1/4 19 T30N R1 9W) �Whitetail Ridges Lot 3 Parcel No: 19.30.19.964
1.) Alt BM Description = 1 ' M81K" (�011/ C — / 1 " izit'17_0_4�c
2.) Bldg sewer length = 20 �. ► (,� _ SGL�c J � ,, - /�A
- amount of cover = 7,�. 2Y
_ll
Plan revision Required? Yes I f /;
Use other side for additional information. �[D I�
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Cot11111ermwLgo1/ Safety and Buildings Division Comity
WI 53 P
�5������ Mad
201 W. Washington Ave:, P.O�x�62�
ison, 7 Sanitary ermit Number (to be Mail in by Co.)
• of a
Sanitary Permit Application State T r ansaction
In accordance with s. Comm. 83.21(2), Wis. Adm. code, submission of this form to the appropriate governmental
unit is nxp&td prior to obtaining a sanihuy permit. Note- Application fexms for sUde owned POWTS are Project Address (if diBerent than ms0ing address)
sulunbed to the Depufinent of Comiamwee. Personal information you vide be for sceoadary J�
purposes
in accordance with the Law, a.15 I m State. '" 3 / y� t A��
L Iaformation — Please Print An I n f essnInhan
Property Owner's Name Parcel #
+� 1,✓o f 1411,✓ A'.ili 2'8 2009 a p
Property Owner's MailmgAddress „, ;ROIX CUUN c Property Location
7S 1 . 3_ / W PLANNING&ZONINGOFFIC� C ( ' 0 Govt. Lot
/
vE; (, I
NG/
City, State Zip Code Phone Number ,
£ w Id i�,v ro,✓ /V SS / /.? � �,� _ �ti x. semen
H. Type of Banding (ileeck all that apply) EC. Lot # ( � 2 � T 26 N R circle l
.
o�
o r1ne2 Family Dwelling —Number ofBedrooms 7 Subdivision Name
f 5 e alotti# AI tar - c
❑ PWkComm=W — Deaexibe Use V o 3-Sp Dt GLV". �
❑ State Owned — Describe Use CSM Number a Of
l � t �5 �"1J� � Town of S r. ✓ os'r'o wy
"L Type of Permit: (Check one box on use A. complete roe B if applicable)
A New System ❑ Rat System ❑ T S ( mom )
� Tank R Only ❑ Other A to
B. ❑ Permit Renewal ❑ Pembt Revision ❑ C Wmr of Phanber ❑ Permit Tmosfa m New List Pis K= Permit Number and Doe Issued
t� owner ,z r"' f c-+v -L . Ov. -Jr. 14 IV. of POETS S Check all that a
�Noa- Prexsariad In -Gm�d ❑ premed Ia -Ground ❑ AWnWe ❑ Mouod> 24 in ofsmitabk sor7 ❑ Momd <24 m. of said soil
❑ Holding Tank ❑ Older Dispersal Component (explain) ❑ Pretreatment Device (earpb&)
V. Dispersaiffpeaftesoll: Ana Lformatiion:
DesiM Phew way DcsiW Soil AMlicn ioaa Ra pdsf) D Am (sfl > Mn y�
G °O ✓ S7. ,/ X71. 9 ,/ 9S.8 9 s o yY. L
VL Task Info Capacity in Tod # of ManufacWra
Callous Gallons Units PI
New Tests Tanis AA � � � �
SepheorUddagWank
Dosing ,?DO /a7AS L✓iE,SE �o..�e.e�rE �'
VIL Responsibillty Statement- i, the read . assame respoo dbHity for butaWtion of the POWTS she" es the snacked @lama.
Plumber's Name (Print) Plumber 's NFAMM.S Number Business Phone Number
a ,�✓ ELKF a 71S C7,2 -s,7GL
Plumber's Address (Stress; city, State, Zip Code)
L.798 fi i✓ �" 14&C4 .4
400rl" .5 y73t:
VlII Coen tat Use
X A - ..v.d ❑ PermitFee Dat lssuiug tSignatnne
❑ L r Denial s q75 9 05
IX. Condill t&#W for Disapproval
I . Septic tank, effluent filter and
dispersal cell must all be services / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as code / ordinances.
Attadr t. c@mp1eee picas tar the s>qm andsubukletbeCenaty9mW paper net taws tbas s lax 11 looses i■ stn
SBD -098 (R. 021)9) Valid tlnu 02111
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Wisconsin Department of Co __ IL EVALUATION REPORT Page 1 of 3
ngs
Division of Safety and Buildi In accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8'/2 x 11 inches in size. Plan must St. Croix
Include but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 030 - 2117 -30 -000
Percent slope, scale or dimensions, north avow, and BM referenced to nearest road.
Please print all information ft Viewed b Date /, E
Personal information you provide may be (Privacy Law, s. 15.04 (1) (m)) �� V
Property Owner I Property Locati on
Evan Vieregge f Govt_ Lot NW '% SW v. s 19 T 30 N R 19 w
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1208 Namekagon Loop Sr cR i j' . � r 3 Whitetail Ridge
Fr-ICE
city State zi one ❑ City ❑ Village 0 Town Nearest Road
Hudson WI 54016 715- 386 -8699 St. Joseph 144' Ave
0 New Construction Use: 0 Residential / Number of Bedrooms ___ Code derived design flow rate 600 GPD
❑Replacement ❑ Public or Commercial — Describe:
JIM f_S/ Of) (
Parent Material Loess over Till/outwash Flood Plain elevation if applicable N/A ft.
General comments and recommendations:. 0 ����Lv�
AJ
CGS --ice �'. � �� - � ,,,,�,►�� 9`� 11 �' T
Boring
El FBring # 0 pit Ground Surface Elevation 99.8 ft. Depth to Limiting factor >116 in.
Soil Aix9ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl�
in_ Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -7 10YR3/3 - SL 2 -f -gr mfr gs 3f 0.6 1.0
2 7 -13 10YR4/4 - CL 3 -m -bk dvh gs 2f -m 0.4 0.6
3 13 -28 7.5YR4/4 - SL 1 -co -bk dvh gs 1f 0.4 0.7
4 28-40 7.5YR4/4 - SL 0 -m dvh cs if 0.2 0.6
5 40 -55 7.5YR4/4 - GRS 0 -sg ml gs - 0.7 1.6
6 55 -116+ 10YR4/4 - GRS 0 -sg ml - - 0.7 1.6
a Boring # 13 Boring
OPIt Ground Surface Elevation 96.$ ft. Depth to Limiting factor >128 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
1 0 -13 10YR3/2 - SL 2 -f-gr mfr cs 3f 0.6 1.0
2 13 -23 10YR3 /3 - SL 1 -m -pl dh CS 2f 0.4 0.6
3 2 10YR4/3 - LS 1 -m -bk dh gs 1 f 0.7 1.6
4 48-69 1 7.5YR4/4 - GRS 0 -sg ml cs 1f 0.7 1.6
5 69 -128+ 10YR4 /4 - RS 0 -sg ml - - 0.7 1.6
tl
* Effluent # I = BOD5 > 30:5 220 mg/L and T S > 30:5 150 mg/L * Effluent #2 = BOD5 5 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Si ature CST Number
Mark Iverson 46672
Address Date Evaluation Conducted Telephone Number
P.O. Box 155 Hammond, WI 54015 July 21, 2009 715- 796 -5664
i
Property Owner Evan Viereeee Parcel ID# 030- 2117 -30 -000 Page -- —of 3
31 Boring # 13 Boring
Wit Ground Surface Elevation 98.6 ft. Depth to Limiting factor 29 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD/fe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2
1 0 -8 10YR3/2 - SIL 2 -f-gr mfr cs 3f 0.6 0.8
2 8 -19 10YR4/3 - SIL 1 -m -bk dsh gs 2f 0.4 0.6
3 19 -29 7.5YR4/4 - SL 2 -m -bk dsh gs 1f 0.6 1.0
4 29-60+ 7.5YR4/4 7.5YR4/6 c -2-d SCL 2 -m -bk mfr - - 0.4 0.6
Boring # 13 Boring
Wit Ground Surface Elevation 100.1 ft. Depth to Limiting factor >136 in.
Soil ADolication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2
1 0 -8 10YR3/2 - SIL 2 -f -gr mfr cs 3f 0.6 0.8
2 8 -19 10YR4/3 - SIL 1 -m -bk dsh gs 2f 0.4 0.6
3 [46-136+ 9 -29 7.5YR4/4 - SL 2 -m -bk dsh gs 1f 0.6 1.0
4 9-46 7.5YR4/4 - S 0 -sg ml gs - 0.7 1.6
5 10YR4/4 - S 0 -sg ml - - 0.7 1.6
5] Boring # 13 Boring
OPit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil ADDlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots WWI?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
*
Effluent #I = BOD5> 30 <_ 220 mg/L and TSS > 30:S 150 mg/L * Effluent #2 = BOD55 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.
Page 3 of 3 Oft. 24 ft. 40 ft. 80 ft.
N
Property Line
approx 160' to property line C approx 300' to property line `
13M#2 - Top of 3/ "PVC Pi
100.0'
B-3
B-4 98.6
100
S, OP
g 10°
:w
°Qa
SE
- - 96.8 '
comer of
proposed I
house
B -1
99.8
BW1 - Top of 3/ C Pi
Approx. 100
O nj O q p�j (d feet to
° property line
BM# & De scription = Bench Mark V Elevation = Boring Location & Elevation
Owner: Evan Vieregge Site Information: Completed By: Mark Iverson, PSS #197
1208 Namekogon Loop NW1 /4, SW1 /4, S19, T30N, R19 680 Larcom Street
Hudson, WI 54016 Town of St. Joseph Hammond, WI 54015
St. Croix County 715 -796 -5664
Phone: 715 -781 -1850 CST# 46672
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Private On -Site Wastewater Treatment System (POWTS)
Index and Title Sheet
Owner: '4� 4 K 0 L Y.✓ DA Quo 1..,.r
Project Name and System Type: A,1K 3 A . I.✓tRa40.,✓o �o�1r
Location:
Street Address
VAI Sz.J /9. 36 ! 4 19 c/ Zor 3 l✓Nir�r•►�� �o�E
Legal Descn tion
40,1.1 of .ST.
Township /County
Contents: Page 1:
Page 2: G'L a r L...✓ `Ae.rr • S.-c 1'ii .✓
Page 3: �0 a; 0� �.�ti `s irs.✓s�.� �" /Yi.✓t «.,«...r ia..✓
Page 4:
Page 5: -- - -
Page 6:
Page 7:
Page 8:
.Page 9:
Attachments: row Wzo. ga r
Z A,Ct'L w it r�.c ��,✓ j-e- ,✓�rsr � .✓�'e
Plumber j £zX Signed:
Credential Number: IXI- ,?&1 J?Y4 Date: 8 - a?S- 41 9
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 3 of y
v FILE INFORMATION SYSTEM SPECIFICATIONS
Owner /yA114
L y.1,00 �lLo4i.✓ T an k Manufacturer ❑ NA
Permit # X'Septic ❑ Dose ❑ Holding Vol. / ,7o0 gal
DESIGN PARAMETERS Tank Manufacturer ❑ NA
Number of Bedrooms ❑ NA ❑ Septic ❑ Dose ❑ Holding Vol. gal
Number of Public Facility Units ❑ NA Effluent Filter Manufacturer ZAB64 ❑ NA
Estimated (average) flow o6 g al /day Effluent Filter Model 4-1,00
Design (peak) flow = (Estimated x 1.5) LoD g al/day Pump Manufacturer [7R7NA
In Situ Soil Application Rate .7 al /da /ft2 Pump Model
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit j W NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
4
Biochemical Oxygen Demand (BODO :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Manufacturer
Biochemical Oxygen Demand (BOD5) :_30 mg /L Dispersal Cell(s) ❑ NA
Total Suspended Solids (TSS) 530 mg /L ❑ NA x In- Ground (gravity) ❑ In- Ground (pressurized)
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ At -Grade ❑ Mound
Maximum Effluent Particle Size in dia. ❑ NA ❑ Drip -Line ❑ Other:
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tanks At least once eve [I month(s) (Maximum 3 years) El NA
P O �' 3 year(s
Pump out contents of tank(s) ❑ When combined sludge and scum equals one -third (X) of tank volume ❑ NA
❑ When the high water alarm is activated
Inspect dispersal cell(s) At least once every: E] month(s) (Maximum 3 years) ❑ NA
3 [g year(s)
Clean effluent filter At least once every: months) [I NA
❑ year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ;<NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ( NA
❑ year(s)
Other: At least once every: p mon th(s) e ❑ NA
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 (pumper). 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 a 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 treatment tank equals one -third ('!3) 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,
that require servicing at intervals of 12 months or less require documentation recorded on the deed regarding maintenance requirements.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW (12/02)
Page —3/ of y
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or othell
chemicals that may impede the treatment process and /or damage the soil 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 extended power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting 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) discharge; 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 ✓i✓ GrL,E'�' O - 3 / t�L Name ./ .✓ �EL /« C ��t.�er 1u�r.�ia�
Phone /s Phone /r 17.E
SEPTAGE SERVICING OPERATOR PUMPER - .✓X.✓ou•✓ LOCAL REGULATORY AUTHORITY
Name Name S>^ Z!etoi Zo 2.,.✓l,4 &A/c.r
Phone Phone 11.5 381. - J14 80
This document was drafted by the Chippewa County Zoning Department in compliance with chapter Comm 83.22(2)(b)(1)(d) &(0 and 83.54(1), (2) & (3),
Wisconsin Administrative Code.
Page __�/ of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals that may impede the treatment process and /or damage the soil 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 extended power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting 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) discharge; 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 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 �GKe� O- ,7J /3YL Name
Phone /S 72 _ ee Phone Ell
SEPTAGE SERVICING OPERATOR PUMPER - LOCAL REGULATORY AUTHORITY
Name Name S>" Gite� �o A v,- 4 AW&ir
Phone Phone 71S 386. V4 8d
This document was drafted by the Chippewa County Zoning Department in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3),
Wisconsin Administrative Code.
, - I
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ST. CROIX COXJNTV
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner(Buyer / ./IZ, �
Mailing Address Z 7 S / AU E N S N E-w 6 R.l G *Ter A) MA.)
Property Address
(Verifrcahm rerpdmd from Planning & Zoning ikputnrcut for new coastyuetion.)
City/State Parcel Identification Number � 1 / � -S C U U
LEGAL DESCRIIP7 M
y 3.otrac�tinflL W
1 /4, 15 v. , sm. L L , T R.w,'Fowm of
Sabtlivision �'J`�, ` t�-� , Lott!
J
Certified Survey Map # , Volume . Page #
Warranty Deed # Volume , Page #
Spec house yes I.ot linmes identifisb1q0M no
SYSTEM MAINTENANCE AND OWNKR CERTIFICATION
lmpropw use nand wW=M mce of yaw septic system could scsult in its premature failure to handle wastes. Proper
maiaetaoaoca consists of prmopmg outdo septic tank every tluee year, or sootier. if needed, by a licensed pumper. What you put into
the sysrsrn cm affect tote fttmedw of the septic tank as a treatment stage in the wastis disposal system. Owner arkuaurce
resposasburtfes are specified in §Comtm. 8352(1) and ire Chapter 12 - St. tkoik County Sanitary Ordbunce.
77re property owner agrees to t kwit to St. Croix County Plasmimg & Z ft Depuftyant a doer form, signed by the
owner and by a master ptnunbet, iourmltnmaa pltaoaber, resttidod pinmaba to a liceasea pans verifying that (1) the oo site
wastewater disposal system is in proper operating condition and/or (2) after isnrpt c ioa cad Pumping (if necessary). the septic tank is
less than 1/3 MR ofaMdge.
i/we, the undersigtwd have read the above requieetneno and agree to maistom the private sewage: dkposal system with the
standards set forte, herein, as Rat by the DepsrosrcaR of Coanmesce amt the Depncmxnt of Natural Resources, Stara of Wisconsin.
Certification staling that your septic system bas been minniaimed most be completed sod retuned to the St. Croix County Phase rg do
Zoning Department widda 30 days of fist gum year expiration date:.
Vwe certify that all statcroe sh on this form are true to the best of tny/our knowledge: Uwe any/am the aw ner(a) of the
property described above, by virtue of a vaipanty deed recorded inRe&w of Deeds Oilice.
Number of bedrooms
7h,� 4 zq,� &--) ?
SIGNATURE OF APPL CANTS) DATE
* "Any mformatiom that is mid resented may resoh m the sanitary permit being revoked by the Planning do Zoning Deperbacut "I
Wade vrith tins application a recorded warranty deed Gorr the Register of Deeds Office and a copy of the comfwd survey rap if
refereaoe is made in the wantway dad-
(REV- U810S)
STATE BAR OF WISCONSIN FORM 1 - 1998 I «I`I Intl III 1 1111 dill 10111111111111111 I
WARRANTY DEED 9 03304
Document Number BETH PABST
This Deed, made between .vi er Construction Company. Inc a REGISTER OF DEEDS ST. CROIX CO. , WI
Corporation Grantor, and Mark A. Brolin and Lynda L. RECEIVED FOR RECORD
Brolin, husband and wife 09/04/2009 10:45AM
Grantee. WARRANTY DEED
Grantor, for a valuable consideration conveys to Grantee the following EXEMPT N
described real estate in SAINT CROIX County State of REC FEE: 11 .00
Wisconsin (the "Property "):
TRANS FEE: 259.50
PAGES: 1
Recording Area N�
Name and Return Address
THE RIVERBANK
PO BOX188
OSCEOLA, WI 54020
030 2117 30 000
Parcel Identification Number (PIN)
This is homestead property.
(is) (is not)
Lot 3, Whitetail Ridge, Town of Saint Joseph, St. Croix County, Wisconsin
Together with all appurtenant rights, title and interests.
Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances
except
t11t
Dated this day of August 2009
(SEAL) (SEAL)
Vie gge on tr ' in Viergge Construction CoMblany, Inc.
Don Viergge President Chris Viergge Treasurer
(SEAL) _ — (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ State of Wisconsin,
Ss.
St. Croix County
authenticated this day of _ V-k
Personally came before me this l3 day of
August , 2009 the above named
Vieregge Construction Company. Inc. by its President
Don Vierqqe and Chris Vierqqe its Treasurer
TITLE: MEMBER STATE BAR OF WISCONSIN / „QQs�'E
` (If not,
+ I authorized by §706.06, Wis. Stats)
Notary Public. State of Wisconsin
THIS INSTRUMENT WAS DRAFTED BY
Coldwell Banker Bur net /Robert Nicholson My commission is permanent. (If not, state expiration date:
1301 Coulee Road
Hudson, \N1 54016 I I M )
9 -14068 Notary Public
(Signatures may be authenticated or acknowledged. State Of Wisconsin
Both are not necessary.) My Commission Expires 51311201(?
Names of persons signing in any capacity must be tyeed or printed below their si nature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc.
WARRANTY DEED FORM No. 1 - 1998 Milwaukee, Wis.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT e N of 3
Labor and Hui Relations Page
oivisisn of s_afvry s Buildirx3s in accord with ILHR 83.05, Wis. Adm. Code - �-
000NTY
•Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), % of slope, scale or PARCEL LD. # pry �)
d 3�Z8
mensioned, north arrow, and location and distance cf( 0 3 0
APPLICANT INFORM TION- PLEASE PRI INFORMATION R IEWEDBY DATE
2_ _
PROPERTY OWNER:
PROP TY LOCATION �
EN /f iv V \EiZ _ 114 S LV 1 /4,S 1°1 T 3 O ,N,R 1 Q E (or ^ 1
PROPERTY OWNER':S MAILING ADDRESS • f {ICJ L07- - BLOCK # SUBD. NAME OR CSM ;R
NZ oe Nt�'�I P, 6ar.� ST C — W t_ I�Z1p G`.
CITY, STATE ZIP CODE ONE p�,� Y ❑
NTVILLAGE ETOWN ' NEAREST ROAD
v�SOiJ LJ 1 S4 01 N't4 "iE T • S� S:'P�
QQ New Construction Use P4. Residential ! Nu m 4 be tai 4- \ [ J Addibgn to existing building
O Replacement [ ] Public or commercial decal e
Code derived daily flow - gpd Recommended design loading rate • `I bed, gpd/i - 3 trench, gpd/ft
Absorption area required - bed, ft - trench, ft Malamum design loading rate • S bed, gpd$ • b trench, gpd/ft
Recommended infiltration surface elevabon(s) TD BE _'f�'�I" mj k2L) It (as r ferred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain ekvation, if ap licable N A • ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT GRADE SYSTEM IN RLL HOLDING TANK
U =Unsuitable for stem ❑ S UU 0,S ❑ U ❑ S oil I E s 11 U ❑ S ICU C i s ® U
SOIL DESCRIPTION REPORT t & 7b
Depth Dominant Color Mottles I I Structure GPD /ft
Boring # Horizon Texture Consistence Boundary Roots rends
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.
i � 1 oaf tz- 3 t i — s i 1 z s vv� I�- c w —• s • 6
F
Z 1Z -Z8 10"t \Z
Ground [
elev.
93--±n y -?_ b S 1 o Lt f?__
Depth to limiting CZ"J NS �*Wq> OV:- Z.S L t 1 1 S13
factor —
3�
I
Remarks:
Boring #
o -t0 10`� R 3/Z
s biz
Ground `'r ra- 31
e lev.
�D lo`'l fz 316
Depth to
limiting
factor
Remarks:
CS T Name-Please Print Arthur L. We erer Phone:
ress: 715- 425 -0165
egerer Soil Testing & Design Service -P.O. Box 74 River.Falls,WI 54022
Sgnature: ! ` %, _ Date: - -� CST Number
�ti r�u � ��, �.� �`l -q7 3 I S-C)q 220254 i
IL
i
PROPERTY OWNER SOIL DESCRIPTION REPORT
PARCEL LD. # - O F Page Z of 3
Boring # Horizon Depth Dominant Color MotUes
in. Munsell Qu. Sz. Cont. Color Texture Structure Consistence GPD /ft
t b `1 13 Gr. Sz. Sh. Y Roots Bed T
I s
Ground 3 23 3 b - . S � cL y/
elev. — S)
V o ft.
SU -1$ S
Depth to
S Z.y2 o sg
limiting _ y/� — S �' s � � � S b!T � lm V !- , � f
factor ; - S
I
Remarks:
Boring #
Ground
elev. i
ft.
Depth to
f limiting
factor !
Remarks:
Boring #
i
Ground j
elev.
ft. €
Depth to
limiting
factor i
Remarks:
Boring #
Ground
elev.
ft.
Depth to
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Remarks: _
r•rl a•r •rnrr+ .r ..
PLOT PLAN Pa 3 of 3
SCALE 1 "= 30
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CST Signature Date Signed Telephone No. CST #
Labor and Human Relations %J %J 1 L- P% I v 1J 01 1 c c v M L U M I I U N f1 C r U rt 1 rage 1 of
Division of Safety a Buildings in accord with ILHR 83.05, Wi Adm. Code
• CQUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
'not limited to vertical and horizontal reference point (BM), `� % of sloe scale or PARCEL I.D. 0 T O
dimensioned, north arrow , and location and distance 3
o l 0 0 .. o
APPLICANT INFORMATION PLEASE PRI NFOR5 ATION', . REVIEWED
PROPERTY OWNER: �, CL t PROF TY LOCATION
EN N V \EZZ k GG E 1J'� 114 S l V 1/4,S \� T 3 p ,N,R. 14 E
PROPERTY OWNER':S MAILING ADDRESS • -- �9 LO BLOCK SUED. NAME OR CSM;I
\'Z. (3 ST C 2\D G
CITY, STATE ZIP CODE nNE NTY ❑VILLAGE 2JrOWN ' NEAREST ROAD
NvpSt LJ 1 S
1 4 01) I NeE
'P� 1zUPo
PQ New Construction Use M. Residential / Num � Sejr r£i � (] AddibQn to existing building
(] Replacement (] Public or commercial descri
Code derived daily flow — gpd Recommended design loading rate • q bed, gpd/ft - 3 trench, gpd)ft
Absorption area required — bed, ft — ign loading rate • 5 bed, gpd/ft • b trench, gpd/ft
Recommended infiltration surface elevation(s) TD BE - D � (as referred to site plan benchmark)
Additional design / site considerations Ley L Gw 'R
Parent material Lo k, -S Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for stem ❑ S EN CAS 11 U 11 S f�U I E9 S ❑ U ❑ S EU [Is
® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color I _ Mottles (Texture I Structure Consistence Barrl
in. Munsel ary Roots GPD /ft
I Qu. Sz. Cont Color Gr. Sz. Sh. Eled
13", terldt
1 o - ' z 1 0 ktZ 3iZ sil Z �s b1z mom-
Z 12 2. It,) `'1 \Z �l 1 S t ] Z� � ): yyl `t''r - s ^ �
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elev.
9 tt y -7 - b s m�
Dep g u NS
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Remarks:
Boring #
o -t.o 10`1.R 31Z — Sl `Z sb wl'� � �•, - . S € .6
o
3 �
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Ground
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\.O"
Remarks:
CS Name Print phone:
Arthur L. We erer 715 -425 -0165 '
rss:
e Soil Testing & Design Service — P.O. Box 74 River.Falls,WI 54022' _
Sgnature:
jq:c� Date: CST Numb -3 °{ S�g9 -
20254
I
PROPERTY OWNER V \yTZk-
SOIL DESCRIPTION REPORT -
PARCEL LD.# nT- p� Opp_ 1pyp_ Page? of 3
Boring # Horizon Depth Dominant Color Mottles
in. Munsell Qu. Sz. Cont. Color Texture Structure Consistence GPD
Gr. Sz. Sh. Y
Roots t
Bed Trend
Ground 3 Z3 3 b 7, S c t R y/y
elev.
c
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limiting — Sly
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Remarks:
Boring #
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Remarks:
Boring #
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Remarks: I
Boring #
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It.
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Remarks: _
PL P LAN Page 3 of 3
• SCALE 1 "= 30 '
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CST Signature Date Signed Telephone No. CST #
, W
Parcel #: 030 - 2117 -30 -000 05/11/2007 08:36 AM
PAGE 1 OF 1
Alt. Parcel #: 19.30.19.964 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner
O - VIEREGGE CONSTRUCTION CO
VIEREGGE CONSTRUCTION CO
433 NEW CENTURY DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ` = Primary
Type Dist # Description " 305 144TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.086 Plat: 2614- WHITETAIL RIDGE 1 99
SEC 19 T30N R19W NW SW FRL LOT 3 Block/Condo Bldg: LOT 03
WHITETAIL RIDGE
Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
19- 30N -19W NW SW
Notes: Parcel History:
Date Doc # Vol /Page Type
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.086 55,400 0 55,400 NO
Totals for 2007:
General Property 3.086 55,400 0 55,400
Woodland 0.000 0 0
Totals for 2006:
General Property 3.086 55,400 0 55,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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