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` AS BUILT SANITARY SYSTEM REPORT
OWNER-
ADDRES ► TOWNSHIP - SEQ . T G N , R_W
, ST. CROIX COUNTY YW WISCONSIN. ZVI SUBDIVIS ON , LOT LOT SIZE
PN
Distances & dimensions to meet requirements H62.20
SHOW EVERYTHING WITHIN 100 FEET'OF SYSTEM
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� I I I di a e Ro#h Arrow '
SC L :
SEPTIC TANKS)MFGR. ,• CONCRETE STEEL
N0. o rings on cover �� Depth
PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO.
GALLONS Per Cycle _
' TRENCHES NO. of width length area
*BED NO. of lines width length area
dept to top of pipe
NUMBER OF SE WAGE PITS Outsi e ameter total pit area
AGGREGATE
PERK RATE AREA REQUIRED / % < "� AREA AS BUILT
Disclaimer: The inspection of this system by St. (Croix County does not imply
complete compliance with State Administrative Codes. There are other areas the
it is not possible to inspect at this point of construction. St. Croix County
assumes no liability for system operation. However, if failure is noted the
County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
INSPECTOR
i,
,.; DATED 169 - //d PLUMBER ON JO$ ���, ;
LICENSE NUMBER �,SC
REPORT OF INSPECTION_INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit- 309
S Septic/
NAME
To n,6 h� p St. Cno.Lx County
Locatio 4 4 06X.1,%, Sect.Lo&
SEPTIC TANK
size gattonb. Numbers o6 Compantmentd
D.i.6tanee Fnom: We.2t /2 8 it. 12% on greaten e.2ope `— it
Building _ 6t. We tt and.6
DISPOSAL SYSTEM Highwaten t.
Di.6tance. From: Wet it. 12% on greaten .6.2ope 6t.
Building 6t. W ettandd .10 f Ft.
Highwaten�4ix.
FIELD DIMENSIONS:
Width o6 tnench it. Depth of rock below tite/-9— .in.
Z
Length of each tine - it. Depth of tcock oven tite i n.
Numbers, o6 tines Depth of tite be.bow gnadeig -in.
Totak. .2engzh of tine.6 ° f it. Stope of trench in pen 100 it.
Diztance between ti.ne.6-1—it. Depth to bedrock St.
Totat ab.6onbtion anea ]` 6t Depth to gnoundwaten it.
Requited anea �t 2
PIT DIMENSIONS:
Numb en o6 pits G a et around pits— no
Out.6ide diameters De below inlet it.
2
Tota.Z ab.6onbtion a it a
A
2
Area ne g m
INSPECTED y TITLE
APP ED / ,')ATE o / 197"
REJECTED ;DATE 197_. .
I
4
M
EH 115
It WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: ' /o, ����..77
/4, Section, T�N, R [��'(or) W, Township or Municipality �- �• "r�
Lot No. , Block No. County .!SF- ���1 /,l
!1 �. Subdivision Name
Owner's Name: ���''���'
Mailing Address: Y^ ` s" 0
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS f/ 7 _ PERCOLATION TESTS
SOIL MAP SHEET 3-5 SOIL TYPE Le� EkX -Gy, c "`- �
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- SINCE HOLE HOLE AFTER INTERVAL
INCHES THICKNESS IN INCHES
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
i
P3
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
I A j Y — / J ^
-3 leg 0 _ L c
O "' ZY to '
O — ! $G ` /
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square f et f suita le areas. Indicate number of square feet of absorption area
needed for building type and occupancy. c Indicate scale
or distances. Give horizontal and vertical reference ions. ndicate slope. ` 0 1
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and belief.
Name (print) _A Certification No.
�. Address 1
Name of installer if known C 2
CST Signature
COPY A —LOCAL AUTHORITY
I ,
State and County State Permit # a0Z
P Permit Application County Perm)*
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LO ATIO : � ' / n w '/4, Section, T N, R E (or) Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family _ _ Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder_YES )LNO # of Bathrooms
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY j13C)C) Total gallons No. of tanks )
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify) _
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / + T 2) _Total Absorb Area sq. ft.
New_ Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 15"Z Width I Depth Tile Depth 2 O f I No. of Lines Z.
11
Seepage Pit: Inside diamette�r Liquid Depth Tile Size 9
Percent slope of land 9 p t2 Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil Tester,
NAME C- L V C.S.T. # - S';'z3) and other information
obtained from ( ner Ider►.
Plumber's Signature MP S # 1 S� Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space FOR DEPARTMENT USE ONLY �C'J
Date of Application / Fees Paid: State 6 C O County f ate
Permit IssueeI/R ed ( te) ol Issuing Agent Name
Inspection Yes — No Valid# Date Recd
1. county (wh' a copy)' 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. st ate (pink copy) 4. plumber (canary copy)
` Revised Date 6/11/76
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
463245 0
GENERAL INFORMATION . (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide rt ay be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Simon, Richard & Angeline St. Joseph Township 030 - 1062 -70 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
16`0 A)() (- � G��x 24.30.19.223
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Z Cx ;cad
Aeration Bldg. Sewer J `
Holding St/Ht Inlet
Q 3 1
TANK SETBACK INFORMATION St/Ht Outlet Ib,15
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD i3tinlet : \-
-� la.gl 83.73
Septic / i
r , 7 Header /Man.
M6 / u Zb
Aeration Dist. Pipe
Holding Bot. System IZ .SV
(�
PUMP /SIPHON INFORMATION Final Grade T" 57A
Manufacturer G M Demand St Cover
x}. Ci -6
Model Numr
TDH Lift Friction Loss Sys ead :J !H Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches * PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 9 z N�e�C.� /' \ `� __� \
SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: ff . 1
INFORMATION CHAMBER OR . :, c i
Type Of System: 7 1 &1 / ' / /'50 A � UNIT Model Number:
C c,,c i � � a , Y-
DISTRIBUTION SYSTEM J 36
Header /Manifold �/ Distribution x Hole Size x Hole Spacing Vent to Air !
`
Pipes)
Length�l Lengt Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mul ed
Bed/Trench Center I Bed /Trench Edges \ Topsoil yes [� No Yes j No
� J
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 809 150th Ave New Richmond, WI 54017 (NW 1/4 NW 1/4 24 T30N R19W) N Lot Parcel No: 24.30.19.223
1.) Alt BM Description = �"7 � �
I C' �
LL
2.) Bldg sewer length = /' I1 1
_ �,, , n
- amount of cover - o� A `"`r" `'
cj Lj
Plan revision Required? Yes o - - T -- - -
1
Use other side for additional informati8n. — Z _._ -� - - - -- — -
Date Insepct Sign a Cart. No.
SBD -6710 (R.3/97)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving the
c�wa! ��� �e �:•� o»� Bo9 /,so gAcAe residence located at:
/160 ' /a, /14Z '/4, Section . 2,V Town 3o N, Range � W, Town
of 56. I-s t oA , St. Croix County Wisconsin. Upon
inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of service )A ' // 5// 0 /
Did flow back occur from absorption system? Yes t� No
(if no, skip next line.)
Approximate volume or length of time: / gallons & 0 minutes
Capacity: 01�9 ,
Construction: Prefab Concrete ✓ Steel Other
Manufacturer (if known): dam,-,
Age of Tank (if known): 19fa
(Licensed Plumber Signature) (Print Name)
Iq A� S z z- 5'O 3 G
(Title) (License Number) MP/MPRS
/S 6
(D te)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Administrative Code)
r
Safety and Buildings Division Cody
201 W. Washington Ave., P.O. Box 7162 St. Croix
visconsin Madison, 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608 266-
Sanitary Permit Applica on Plan I.D. Number
In accord with Comm 83.21, Wis. Aden Code, personal info you ject Addr (if different than mailing address)
may be used for secondary purposes Privacy Law, s15.0 I
2004
L Application Information - Please Print All Information ST. CROIX COUNTY 09 150'' Ave.
ZONIN
Property Owner's Name ED D arcel # Lot # Block
Richard & Angeline Simon #
I E - - — D 030 - 1062 -70 -000 (, 223)
Property Owner's Mailing Address Property Location
809 150'' Ave. Gov't lot . NW ' /4, - NW 1 14, Section 2-4
City, State Zip Code Phone Number
(circle one)
New Richmond, WI 54017 (715) 246 -5390 T 30 N; R 19 E or W
IL Type of Building (check all that apply)
sub&vis� csr
❑ 1 or 2 Family Dwelling - Number of Bedrooms 3
❑ Public /Commercial - Describe Use
❑ State Owned - Describe Use ❑City ❑ Village ownslup of St.
IIL Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. El Permit Renewal ❑Permit Revision El change of ❑ P 't.-3:rat>sferto-New---
List Previous Permit Number and Date Issued
Before Expiration Plumber weer
IV. Dme of POWTS System: Check all that a 1 Z
Non - Pressurized In- Ground ❑ Mound 1 24 in. of suitable soil ❑ �d < 24 in. of s lesoit Q At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holdin eat Filter El Aerobic Treatment Unit 11 Recirculating S
Recirculating Synthetic Media Filter him r Drip Line ❑ Gravel -less Pipe ❑ other (explain)
V. Dispersal/Treatment Area Informa ' n: 0 11" d Bio Diffusers at 31.1 . ft. EISA/c ber = 9 3.00 . ft. E
Design Flow (gpd) Design Soil Applicati Rate(gpdsf) Area Required (sf) Dispersal Area Proposed ( yttem Elevation
450 gpd 0.5 gpd sq. ft 900.00 sq ft 933.00 sq It EISA 92.00'
VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete onstructed Glass
New Existing
Tanks Tanks
Septic or Holdu g Tank Na 1,000 1,000 1 Wieser Concrete X
Aerobic Treatment Unit
Dosing Chamber
VIL Responsibility Statement - I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plerm
Plumber's Name (Print) s Si MP/MPRS Number Business Phone Number
Mike McDonell MP #225036 612 865 -1927
Plumber's Address (Street, City, State, Zip Code)
1070 Hunter Ridge Road, Hudson, WI 54016
VIII. County/Department Use Onl
Approved ❑ DisamxQved Sanitary Permit Fee (includes Groundwater Date Issued uing ent Signature (No Stamps)
Surcharge Fee) �`
❑ eason for 'al `fi' 2SU 0
DL Condition Approv --� o . 1.so........, ,or � � v n - -b u "� j i A*,
SYSTEM OWNER:+C_ GkrtM J q r
1 Septic tank, effluent filter and �-
_
dispersal cell must all be serviced /maintained /
as per management plan provided by plumber.
2. All setback requirements must be maintained �/1 � e . (2e") I � ZJ--,.6C A
as per applicable code /ordinances. E /� - � iz n _ r1 - ,
Attach complete plans (to the County only) a system o paper n less ` n 81� 11 ' hes in size�
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lutcsc,nCan cr�Ee �'fEc�
EXisfina�lw�ga.Q. �+s� w/ �,a- b� /i4 -/ca
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Wisconsin Department of Commerce SOIL EVALUATION REPORT p age 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 8% x 11 inches in size. P County St. Crob(
include, but not limited to: vertical and horizontal reference point (BM), di
percent slope, scale or dimemsions, north arrow, and location and dis to r7( . Parcel I.D.
030- 1062- 70 -000
Please print o B Date �i Personal information you provide may be u for —pa9 dF�( . s. 15. . d�
'4 �Z
Property Owner Pri perty L ocMien
Richard D. & Angeline Simon NOV 0 4 2004 Go t. Lot NW 1/4 NW 19 S 24 T 30 N R 19 W
Property Owner's Mailing Address Lo # Block # Subd. Name or CSM#
809150th Ave. 5T. CROIX COUNTY N Na
City State Zip City _] village 01 Town Nearest Road
New Richmond I WI 1 54017 715 - 246 - 5390 St.Joseph 1 809 150Th Ave.
J New Construction Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement J Public or commercial - Describe:
Parent material Glacial outwash 1=" plain elevation, if applicable na
General comments
and recommendations: Install 2 trenches at 92.00' using 30 leaching chambers. Existing dispersal cell elevation = 92.83'.
6:). 4-e `. a,( r�
❑ Boring # Boring
1I' Pit Ground Surface in. Soil Application Rate
ace elev. 96.71 ft. Depth to limiting factor
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 -37 1 Oyr3 /3 none Is/sl fill 2fsbk mfr as 2f,1 m na na
2 37 -42 1Oyr3/2 m1d 5yr4/6 sil 2thinpl dsh as 2fm 0.0 0.2
3 42 -50 1Oyr5/6 none grIfs 1msbk ds ci 1fm 0.5 1.0
4 50 -96 1Oyr5/6 none s/ls Osg dl - - 0.5 1.0
�2•
Horizons #4 consists of an irregular, discontinuous mixture of s & Is, each comprising approximately % of t_ hehori? n. Loading rate adjusted to reflect
reduced permiability associated with subtle textural changes within horizon.
Boring # Boring
101 Pit Ground Surface in. Soil Application Rate
ace elev. 97.05 ft. Depth to limiting factor
Horizon Depth Dominant Color Redox Description Textur Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color 1 'j r. Sz. Sh. 'Eff#1 *Eff#2
�p �P 1 0 -7 1Oyr3/3 none sl 2fsbk mvfr cw 2f na na
2 7 -18 1Oyr32 none ell 1msbk mvfr gW 1vffm 0.0 0.
3 18 -25 1 Oyr516 none gr Is 1 msbk ml cW 1 vffm 0.5 1.0
4 25-41 10yr5 /6 none s/Is Osg dl gw lvffm 0.5 1.0
5 41 -99 10yr5/6 none s Osg dl - 1vf 0.7 1.6
1 i Horizons #4 consists of an irregular, discontin of s & Is, each comprising approximately 5096 of the horizon. Loading rate adjusted to raftect
reclugeQ permiability 4sociated with subtle textural changes within horizon.
' Effluent #1 = BOD 30 < 220 mg/L an TSS X30 < 150 L ffluent #2 = BOD < 30 mg/L and TSS <�30 mg/L
CST Name (Please Print) Signature: CST Number
James K. Thompson _ �- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, 54020 10292004 715 - 248 -7767
Property Owner Richard D. & Angeline Simon Parcel ID # 030 - 1062 - 70-000 Page 2 of 3
3] Boring # I Boring e. Pit Ground Surface elev. 97.38 ft. Depth to limiting factor > 106" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -17 1 Oyr3/3 none ISM fill, 2fsbk mfr as 2fmc na na
2 17 -28 1Oyr3/2 none sil 2fsbk ds cw 1fmc 0.6 0.8
3 28-43 1Oyr5/4 none sil 2fsbk de cw 2fmc 0.6 0.8
4 43 -60 7.5yr4/6 none sUls 2msbk dsh gw 2fm,1c 0.6 1.0
5 60 -72 7.5yr4/6 none Is Osg dl gw 20m 0.7 1.6
6 72 -106 1 Oyr5/6 none s/ls Osg dl - 1vf 0.5 1.0
% of the horizon. Loading rate adjusted Horizons #6 consists of an irregular, discontinuous mbcture of s & Is, each comprising approximately 50 9 to reflect
1
reduced permiability associated with subtle textural changes within horizon.
F-1 Boring # I Boring
_J 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
❑ 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 QP
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 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opportunity service provider and employe r. If y ou 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.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner << N� 5 ( Septic Tank Capacity a l ❑ NA
Permit # 7 Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer mil_ ❑ NA
Number of Bedrooms 3 ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units NA Pump Tank Capacity al A
Estimated flow (average) 3CPD g al/day Pump Tank Manufacturer AN A
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer e8fTIA
Soil Application Rate Q . al /day /ft2 Pump Model r QCNA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit f WNA
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: q
Other: ❑ NA Other: A
* Values typical for domestic wastewater and septic tank effluent. Other: 0?Nq
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑
month(s) (Maximum 3 years) ❑ NA
Inspect condition of tank(s) At least once every: earls)
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
i;Xyear(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
` � year(s)
Inspect pump, pump controls & alarm At least once every: 11 month(s) A
❑ year(s)
❑ month(s) A
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once ever ❑ month(s) A
Y: ❑ year(s)
Other: PMA
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 h ardware identi 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 JY 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 :_12 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.
Page 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 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
hnology a holding tank may be installed as a last resort to replace the failed POWTS.
T
alua a o m9 ank
b e ai a ?R Tl1✓� V0 R_ A/ CaN S'TR(JC -- t D"
❑ 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 L L Name
Phone 6 1Z , v 19 Z�- Phone
1 rZW I— SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name ` Name s-(', C l dVd 2QAJIAl
Phone Phone '7 /S— 3e, - fo (�
This document w s drafted in compliance with chapter Comm 83.22(2)(b)(1)(d )&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner �' a fc✓ ire �i'mon
Mailing Address
Property Address c5ale,
� / (Verification required from Planning Department for new construction.) / \
City /State Z 9 462 'r 0) Parcel Identification Number 6 1 6&?- 7 D t�Z l •22 J
LEGAL DESCRIPTION —�-
Property Location 0 VIJ '/4 , 4IJ '/ , Sec. 21 , T 30 N R /5� W, Town of 56 •��
Subdivision A OL , Lot # _lq-
Certified Survey Map # A2 , Volume n4 , Page #
Warranty Deed # 6993Zl`� , Volume /9. , Page # SZ
Spec house ❑ yes Bala Lot lines identifiable i4-5e ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and
by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal
system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge.
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
ent 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
pr rty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
i
U 1864P 258
K
H.
STATE BAR OF WISCONSIN FORM 1 - 1998 K A A
MALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX Co., MI
This Deed, made between Richard D. Simon and Angeline C. RECEIVED FOR RECORD
Simon, husband and wife, 04 -01 -2002 10:40 AN
WARRANTY DEED
EXEMPT # 16
Grantor, and Richard D. Simon and Angeline C. Simon, Trustees, or their REC
succes in trust, under the Richard D. and Angeline C. Simon Living TRANS E FEE : 13.00
T rust, dated January 18, 2002, and any amendments thereto. COPY FEE:
CERT COPY FEE[
PAGES: 2
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in Saint Croix County, State of
Wisconsin (The "Property "):
RccordinK Area
Name and Return Address
Joseph P. Earley 0
orated herein. New South Knowles Avenue
See Exhibit A attached hereto and incorporated New Richmond, WI 54017
030 -1062- 20-000 is homestead, all others are
not
Parcel Identification Number (PIN)
This above homestead property.
(R�)
Together with all appurtenant rights, title and interests.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
easements and other encumbrances of record.
Dated this 15th day of March , 2002
.. Richard D. Simon +
+ Angefihe Simon
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
as.
signature(s) Richard and . Angeline Simon, husban _ _ County. )
and wife, Personally came before me this day of
the above named
authenticate his 15th day of March , 2002
+ se P. Earle
TIT : MEMBER STATE �B�AROF WISC ONSIN to me known to be the person(s) who executed the foregoing
(If not, instrument and acknowledge the same.
authorized by § 706.06, Wis. Stets.)
THIS INSTRUMENT WAS DRAFTED BY +
Joseph P. Earley, Attorney
New Richmond, WI 54017 Notary Public, State Wisconsin
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not , )
necessary.)
'Names of persons signing in any capacity should be typed or printed below their signatures
STATE BAR OR WISCONSIN
WARRANTY DEED FORM N -.1 - " INFORMATION PROFESSIONALS COMPANY POND [x/ LAC. WI i00. 655 -021
U 1864P 259
Exhibit A
Richard and Angeline Simon
PIN 032 - 2047 -95 -100
Part of the SW1 /4 of the SE1 /4 of Section 13, Township 30N, Range 19W, described as
follows:
Being Lot 1 Certified Survey Map, Volume 12, page 3273
Town of Somerset, St. Croix County, Wisconsin
PIN 030 - 1056 -60 -200
Part of Government Lot 4 of Section 23, Township 30N, Range 19W, Town of St.
Joseph, St. C unty, Wisconsin; being part of Lot 1 of Certified Survey Map,
Volume 340
030 - 1062 -70 -000 30- 1062 -60 -000 and 030 - 1062 -20 -000
e Northwest quarter (NI/2 of N W 14) and the Northwest '/4 of the
Northeast '/, (NW 1/4 of NE 1 /4) EXCEPT South 535 feet. Section 24, Township 30N and
Range 19W, in the Town of St. Joseph
PIN 030 - 1057 -10 -00
Part of Government Lot 4 being Lot 5 Certified Survey Map, Volume 13, page 3676,
Section 23, Township 30N and Range 19W in Town of St. Joseph
PIN 026- 1052 -70 -000
A parcel of land located in the Southwest Quarter of the Southwest Quarter (SW 1/4 of
SW 1 /4), section Eighteen (18), described as follows:
Beginning at the Southwest corner of said Section Eighteen (18),; thence North 03 38'
24" East (assumed bearing reference to the North -South Quarter Section Line, recorded
bearing North), 1315.36 feet along the West line of said Southwest Quarter to the North
line of the South Half of said Southwest Quarter (S 1/2 of SW 1 /4); thence North 890 37'
13" East, 678.00 feet along said North line; thence South 0038' 24" West, 1313.56 feet to
the South line of said Southwest Quarter (SW1 /4); thence South 89:128' 06" West,
678.03 feet along said South line to the Point of Beginning. SUBJECT to existing town
road right -of -way.
PIN 026- 1052 -50 -000
Southwest Quarter of the Southwest Quarter, (SWI /4 of SW1 /4) Except 214
PIN 025 - 1052 -70 -000
Part of SW' /, of SW' /. of Section 18 -30 -18 described as follows: Commencing at the SW
Corner of said section 18; thence N0 "E 1315.36 feet along the W line of said
SW' /, to the N line of S '/Z of said SW' /,; thence N089°37' 13 "E 678.0 feet along said N
line; thence SO °38'24 "W 1313.56 feet to the S line of said SW' /.; thence S089°28'06 "W
678.03 feet along said S line to point of beginning.
r0 (o - /452 7v Z 7,3G
44 U 1921P 052
• STATE BAR OF WISCONSIN FORM 1 -1999 6 8 3 2 4 6
' KATHLEEN H. MALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., NI
This Deed, made between Richard D. Simon and Angeline C. RECEIVED FOR RECORD
Simon, husband and wife, 07 -02 -2002 9:30 AN
WARRANTY DEED
Grantor, and Richard D. Simon and Angeline C. Simon, Trustees, or EXEMPT t 16
their successors in trust, under the Ric D. and Angeline imon REC FEE -t 13.00
Li ving rust, dated anuary 1 , a any amendments thereto, TRANS FEE:
HOY COPY FfiEs
CERT COPY FEES
irantee. `f I 0/ 7 PAGES.- 2
Grant, for a valuab a consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
See Exhibit A attached hereto and incorporated herein.
Recording Area
This is a corrective d egd, the � urpose of which is to correct the legal Name and Return Address
desc ptions contained in Exhibit A of that wan-anti deed recorded in Volume Joseph P. Earley
_ 1864, Page 258 on April 1 200 as Document number 675025. 539 South Knowles Avenue
New Richmond, WI 54017
�1
t.
030 - 1062 - 20-000 is homestead,
_ _
all others are no
Parcel Identification Number (PIN)
appurtenant with all rights, Together To a ri is title and interests. This (see above) homestead property.
g PP
4W *]No
Grantor warren the t 't e i indefeasible in fee simple and free and
clear of encumbrances except
G is t e h le to the Propert s good, e p P
easements and other encumbrances of record.
Dated this I qA day of J vile 0 2002
Z r �
• R e ichard D. Simon
`i1�6A�c.i?.v►�.C� C
• Ana ne C. Simon •
AUTHENTICATION ACKNOWLEDGMENT
S STATE OF WISCONSIN )
(+. - ) ss.
_ County )
authentica ed this N 4% day of A P , 2002
Personally came before me this day of
2002 the above named
Q seh P. Earley
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY •
Joseph P. Earley, Attorney Notary Public, State of Wisconsin
New Richmond, W1 5017 Commission 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. wonnalbn Promeaw a Comwnr. Fond a+ Lac, VN
STATE BAR OF WISCONSIN eoo�as5 -Mi
WARRANTY DEED FORM No. I -1999