HomeMy WebLinkAbout030-2141-00-019 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
. Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 515262 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:
Doll, Stephen I St. Joseph, Town of 030 - 2141 -00 -019
CST BM Elev: Insp. BM Elev: Description: 2 Section/Town /Range /Map No:
/ .. — r rJ� G5T 36.30.19.2069
TANK INFORMATION n ELEVATION DATA
TYPE MANUFACTURER �t CAPACITY STATION BS /O HI • FS ELEV.
G. 37 Septic �,ti 3 Benchmark
ems•. L F;� /L5o 1 /Q3,S /�
Alt. B L 1. 1 T P. 16 �� f
Aeration Bldg. Sewer , 6 Z. Z
Holding St/Ht Inlet l
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO ���P //L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
S �
Septic 7 c I .1 Dt Bottom \
$ 7
Dosing Header /M n. �o ae + n
Aeration Dist. Pipe
to . T4 5'S • 5
Holding B y g Sy$ tem
Final Grade
PUMP /SIPHON INFORMATION L-0-. 7.71 9 %•
Manufacturer Demand St Cover
M
Model Number
TDH Lift Friction Loss ead TDH
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia.
I lLiq ' Depth
DIMENSIONS 3. 2
SETBACK SYSTEM TO I P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer
INFORMATION Type Of System: c CHAMBER OR
T Model Number
DISTRIBUTION SYSTEM
Header /Manifold of Distribution x Hole Size x Hole Spacing Vent to 'r Intake
I Pipe(s) �� \` \` ✓t
Lengt Dia 1 1-ength Dia Spacing ` 1 ei.O
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
'/ , ` \ Yes R No Yes [Z No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 825 126th Ave New Richmond, WI 54017 (SE 1/4 NW 1/4 36 T30N RI 9W) Natalie's Rid a Lot 1 Parcel No: 36.30.19.2069
1
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1.) Alt BM Description = � 7y{t��^.� -- ^'�� �''s �C � "t p 1 - 7
2.) Bldg sewer length = U c,( p GO J r 6W, � V �•• S O w JG 4 P A t�_
- amount of cover = Lj
Plan revision Required? Fal Yes No r♦3 /�
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepc o Signatur Cert. No.
Ib 1 NJ I O vl C:,
UJ /L1 /vo IM tc:za r' AA 115 J80 415515 ST CKA CU ZONING 10003
Safcty and Buildings Division Cvunlj -
AW 201 W. Wavhingwri Ave,, P.O, Box 7162
isevnsin Madison, Wl 53707 - 7162 Sanitary P erm it Number (to be filled in by Co.)
Department of Commerce (608) 266 -3151 I _ - ^
Sanitary Permit A jl-w,�=.1)4 RECEIVE
In accord witll Comm 83.21, Wis. Adm. Code, sn I.D. Numb r ✓� /JrZ
e per provide
may he used for secondary purposes Priva Proj Address (itdifferent than mailing addrusa)
i, Appliestion Information- Please ntAll lnfurmat
MAY
Zulu
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Property Owner's Name d PLANNING 8 ZONING OF JICE K Lot # Block k �`C xzor 'Do 19
ror-1Y Owner's Mailing Address i l.tx anon
L••r, .. -,•. �g W 1
Zip Cede ~ pl ne N
b,'-, -•'�- Y•, AW. Y. Section
N �► s �aY, 51 8 0 — T sZ"
0271 �� N: R pp (circle ,4e, (2 Alp,
II. Tyne of Building (check all that apply) -- W `
.,,1
J1. ore
iY1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name X
Number
❑ Public/Commcreial - Describe Use tl " q_ 1 L
❑ Slate Owned - Describe Use , ❑City_❑Vivage 0TOwns �ff 5� L
IIN_ Type of Pet-suit. (Check only one box on line A. Complete Kne B if applicable)
A. ew S otc,,,
' Y• ❑ RA01*0ement System ❑ TreatmentJHolding Tank Replacement Only ❑ Other Modification to Fxisring System
B• ❑ Pcrmit Renewal U Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Pcmtir Nuuibe, Anil n.ta Issue -
Before Lxpimt,bn ` Plumper Owner �' to
h t
IV. Type of PO __ System Check all that a 1 _
kNon - Pressurized In -Ground ❑ Mound >24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ M -Grade ❑ Single Pass Sand Filter ❑� '
Constructed Wetland Pressurized In -Ground ❑ Holding Tank ❑ Prat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating S nthetic Media llitler ❑ Leaching Chamber ❑ Drip Linc ❑ 0ravol -le$s Pipc ❑ ether (explain)
V. Dis rsal/Treatment Area Info lmstdon:
Design Flow (gpd) Design "oil Applic,9lio lc(gpdst) Dispersal Arco Rcquircd (s Dispersal Area Proposed � SyAqn t l ton
111 '/ b oa I (A 2 9 �awJ C7tq /,
VI. Tank Info Capacity in Total Number Manufncu,r Prefab Site Steel Fiber Plastic q}lot�1
tlallons Gallant ufUnits jj Concrete Constructed Glass
Ncw Tanks �✓ #0 O `
/ /d k
Septic car I loldin�• Tnnk Ta
Tanks Tanks -'-
AerohieTneatn,riuUuil •7 `—
77osil% C'hambcr -
VII. Responsibility Statement- I, the undctsigoed, asseme responsibiti(y fee iostallatioa of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's S turn MP/MPRS Number Business Phone Number
G— 2 Z s�i6 711 Z Y! - 2&Q
Plumber's AdOrcsiq (Street, y, State, Zip Cod` -
VIII. Cu unt- c rtment Use only
Msproved isapprov SaniMry Permit Pea includes Groundwater Date Issue sT s�i��.a ��t Sian. u n Stain
wen ttmon f� Surchar Fee) l 7 �j 5 Id
IX. (:onditions of Approval/Reasons for Disapproval .._..__.. ___ / t I
OY M OWNER � Se t (3a r ; /tC l G(c ✓4 al' K e✓► z
1: Septic tank, effluent ltbr and �� �� J f �+ ip
dispersal cell must all be services J maintained P �''� +'�'1"av S • -`^�
as per management plan provided by plumber.
2. All Setback tegta emw is must be maintained
as per axomd* code
t
Attach complete plow (to ore C-Ottallty poly) rep the ty sle m m Imper cent kss thaw 3113 a 11 Inc ice sine
SBD -6398 (R. 0I /03) 4
4�1 a r,�l, +MArk L a ao' 9 o 1p 2 eye,
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1336
SOIL EVALUATION REPORT
• Wisconsin Department rce O O Page 1 of 3
Division of Safety and ildin
T. CROIX Clb�ldc�6rdan with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete NiN� PEKE chesinsize. Plan must County
St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel L D. 0 3
Please print all information. Reviewed By `7 Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). c G
Property Owner Property Location
Grand Properties, LP Govt. Lot SE 1/4 NW 19 S 6 T 30 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CS
712 Rivard Streeet, Suite 300 19 Natalie's Ridge
City State Zip Code Phone Number City Village ✓ Town Nearest Road
Somerset I WI 1 54025 715 - 247 -5900 St.Joseph I Cty. Rd. A
✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement Public or commercial - Describe:
Parent material Outwash (stream terrace) Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sgft rating. Possible system elevation for Area 1 is
97.20'. Slope is 7 %. f ,,, fe��'
Boring # Boring t •4 6-7 5a.
✓ Pit Ground Surface elev. 1 2 ft. Depth to limiting factor 116+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /f?
'Eff#1 'Eff#2
1 0 -10 1Oyr3/3 none sl 2fsbk mfr as 1f,1vf .6 1.0
2 10 -29 1Oyr4/4 none sl 2msbk mfr gw 1vf .6 1.0
3 29 -56 1Oyr4/6 none s Osg ml cs .7 1.6
4 56 -87 1Oyr5 /6 none s Osg ml cs - -- .7 1.6
5 87 -116 1Oyr6/4 none s Osg ml --- ----- .7 1.6
u
Boring # Boring
✓ Pit Ground Surface elev. 98.37 ft. Depth to limiting factor 96+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
'Eff#1 'Eff#2
1 0 -9 1Oyr3/2 none sl 2fsbk mfr as 2vf .6 1.0
2 9 -17 1Oyr4/3 none sl 2msbk mfr cs 1vf .6 1.0
3 17 - 25 7.5yr5/6 none sl 2fsbk mvfr gw 1vf .6 1.0
4 2543 1Oyr5/6 none ms Osg ml cs - -- .7 1.6
5 43 -51 1Oyr4/6 none sl 2csbk mfr cs - -- .6 1.0
6 51 -96 1 Oyr5 /6 none ms Osg ml ---- -- --- .7 1.6
tj
' Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD - 30 mg/L and TSS <30 mg/L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
1595 72nd St., New Richmond, WI 54017 420/05 715- 247 -2941
Property Owner Grand Properties, LP Parcel ID # Page 2 of 3
3 ] F Boring # Boring
V Pit Ground Surface elev. 7 ft. Depth to limiting factor 112+ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
*Eff#1 *Eff#2
1 0 -11 10yr3/4 none sl 2fsbk mfr as 2vf .6 1.0
2 11 -20 1Oyr4/4 none scl 2msbk mfr gw 1vf .4 .6
3 20 -33 1Oyr4/6 none Is Osg ml gw ---- .7 1.6
4 33 -78 10yr5/6 none s Osg ml cs - -- .7 1.6
5 78 -112 1Oyr6 /4 none s Osg ml — -- . 7 1.6
F-1 Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
*Eff#1 *Eff#2
I
F-1 Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD
*Eff#1 'Eff #2
Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <30 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777.
Page 3 of 3
Conducted by: Conducted For:
Schmitt Soil Testing, Inc. Name: Grand Properties, LP
Thomas J. Schmitt, CST 227429 Address: 712 Rivard Street
1595 72nd St. City, State, Zip: Somerset, Wl. 54025
New Richmond, Wl. 54017
Phone: 715- 247 -2941 Subd.Name: Natalies Ridge
Lot No.. _
Legal Description: .Sf" 1 /4NkA /4 S36 T30N R19W
—
Township of St. Joseph, St Coix County
® Soil Boring
® Bench Mark El. 100.00` Top of 2" pvc pipe --
0 Alternate Bench Mark El. Top of 2" vc pipe
Slope = Contour Line El.
Scale 1 "' = 40'
A
110
� nn �
� y
This soil report was done to fulfill a zoning requirement. It may or may not be in a location suitable fa' your use.
i � 1
. . . . . . - - - - - - - - - - - - - -
A h
� �75
OT 9
A I
3. 5.
(3.0 A .)
LOT
.. �� 3.0 A .�
a .95 Aa. I
LB.O.= 923.1
X 920.8
. 9
.. 3
H.W.L. =921.1
LOT 1 _
22 AC.
L (2.94 AC.) .
' -V 918.8
. 3 RAD = 80'
N m� 475
Fly k
918.8
x 918.4 •i
918.2
*LOT 17
.011 AC 917.7
( 1 A L�
X 916.6 16.5 / 3.1
L.B.O.= �
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C L.B.(
/ 4z
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a
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Stephen Doll
Owner's Name: Stephen Doll
Owner's Address: 3 Churchill Drive
Woodbury, MN 55125
Legal Description: SE 1/4 NW 1/4 Sec 36 T30 R19 W
Township: St. Joseph
County: St. Croix
Subdivision Name: Natalies Ridge
Lot Number: 19
Parcel ID Number:
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross - Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix C Septic Tank Maintenanc Form
p
Page 8 Warran�Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer /Plumber: Paul R. Koehler License Number: MP225410
Date: May 19, 2010 Phone Number 715- 246 -2660
Signature
Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01).
Page 1
Soil Absorption System Cross Section
k Schedule 40 Final Grade
VC Vent Pipe L ith Vent Cap ft
Leaching --♦►
Chamber f '7 y ft
System Elevation
.3 ft 3 ft
Soil Absorption System Plan View
ft
ft
— ft Vent Or Observation Pipe Leaching Trench 1
Chambers
4" Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model how /°eC, /L G�ndu �� /b oy
EISA Rating �— sq ft per chamber Soil Application Rate gpd /sq ft
o gpd Design Flow _ I Soil Application Rate + 20 E I SA = v Chambers
2 rows of SD chambers each.
Page of
.
Palo 111111111111
M� .
INSTALLATION INSTRUCTIONS
h' °` "``ryS " °` 0r °` na¢a z,r. PL- 525/PL -625 FILTER
§ fYastewaf.r, roc.cts A Civisicn of ?olyiok I?�c.
PL- 525 /PL -625 FEATURES & BENEFITS
Features & Benefits:
. Rated for 10,000 GPD
• PL -525 = 525 Linear Feet of 1/18" Filtration
PL -625 = 625 Linear Feet of 1/32" Filtration
PL -525 PL -625 •Accepts 4" and 6" SCHD. 40 pipe
The PL- 525/625 Effluent Filter should operate efficiently • Built in Gas Deflector
for several years under normal conditions before ,Automatic Shut -Off Ball when Filter is Removed
requiring cleaning. It is recommended that the filter be
cleaned every time the tank is pumped or at least every *Alarm Accessibility
three years. If the installed filter contains an optional
alarm, the owner will be notified by an alarm when the +Accepts PVC Extension Handle
filter needs servicing. Servicing should be done by a
certified septic tank pumper or installer.
RECOMMENDED PRODUCTS
Polylok PVC Filter
Extension Handle
tz
Risers & Riser Covers Extend & LokM Riser Safety Screens Filter Alarm Panel and
Polylok risers bring your Polylok Extend & Lok'ry' Polylok safety screens SmartFllterTM Control
septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch
This allows locating and solution that can extend from happening by children Polylok filter alarm panels
servicing your filter easier the inlet or outlet pipe and and pets falling into open and switchs provid a visual
and time saving by elimi- make filter and /or baffle septic tank entrances. and audible notification of
nating digging to find tank installation a snap. impending filter and tank
entrance. Fits 3" and 4" pipe. servicing.
For a full list of Polylok products please visit our web site at: www.polylok.com
.M
FD40L I
INSTALLATION INSTRUCTIONS
tnaoraticnsy, Precast Dra„ eye ; Z ibel PL-525/PL-625 F I LTE R
&#Jsrewai.r. A c`roK,k!nc.
INSTALLATION INSTRUCTIONS
Center filter
h with opening
J 7
LL O
x
e
Additional pipe or
Polylok Extend & Lok'" Glue
for centering.
Step 1: Step 2: Step 3:
(A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
is positioned so the filter can be housing, making sure the filter
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS
ty
Step 1: Step 2: Step 3:
Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back
if necessary. into the the housing making sure
�s s
filter properly (B) Pull the filter out of the housing. the is p p erl y ali g hed
•
(C) Hose off the filter over the septic tank. and comp letely inserted.
USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover
WHEN CLEANING FILTER septic tank.
UJ /L1 /UO lun 1L:zv rJ%A /1.7 386 4000 aT lJlCa UIJ GUN1NU Lai 0u5
• Page Z of 2_
START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankis) 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 eell(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; fist;
foundation drain (sump pump) water; fruit. and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; (ail;
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:
El A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkrn
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 m ill
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 POWYS
A technology a holding tank may be installed as a last resort to replace the failed POWTS.
!" T NUMA
nk
alua ' o tng ar►k
7TLQ ��- A/✓ (,aN$Tj2i1GTl D
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the blomat 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 NCT
INTER 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 Cdr/ fi Ste" / Name Go�,i f' ti' x 1
Phone y` ��`d Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name sc `�G Name s—r,
Ku
Phone Phone
This document was drafted in compliance with chapter Comm 83.24214b)(1)(d1 &(f1 and 83.54(11. (21 & (3), Wisconsin Administrative Code.
1
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of �!
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner S e
Septic Tank Capacity 2S ga l ❑ N q
Permit #
Septic Tank Manufacturer O NA
DESIGN PARAMETERS Effluent Filter Manufacturer ( Lte d NA
Number of Bedrooms y 0 NA Effluent Filter Model Nq
Number of Public Facility Units RNA Pump Tank Capacity g a l N4
Estimated flaw (average) Qb gal /day Pump Tank Manufacturer .t NA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer NA
Soil Application Rate al /day /ftz Pump Model m
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg /L CJ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD s220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) .15150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cells) 0 NA
Biochemical Oxygen Demand IBOD S30 mg /L A In- Ground (gravityi ❑ In- Ground 1pr essurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510" ofu /100ml 0 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 tankls► At least once eve : ❑ month(s)
ry year(s) (Maximum 3 years) ❑ NE►
Pump out contents of tank(s) When combined sludge and scum equals one -third IY,) of tank volume ❑ N/�
Inspect dispersal cell(s) At least once every: 3 ❑ month(s) yearlsl (Maximum 3 years) ❑ Nit JZ Clean effluent filter At least once every: O y ear (s)
❑ Nit
Inspect pump, pump controls & alarm At least once every. ❑ month(s) N�
❑ year(s ,
Flush laterals and pressure test At least once every: p month(s)
► (s)
Other: At least once every: 13 month(s) �N1
Other: 13 year(s)
❑ NFL
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 tankls) 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 surfac 9.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pending
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires it le
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 11:3,
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 S12 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.
VV/ vI nnl/ ta: ran 110 JOO 4000 NT L;KA W ZUNING 19 001
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address i d J O �U 4 ,C�1
Property Address _9 L a 6 +� AJ4
(Verification required from Planning & Zoning Department for new construction.) �
City /State Parcel Identification Number
LEGAL DESCRIVIJON
Property Location �' '/< " VIA ) '/ , Scc. , T _2N R /9 Town of f;
Subdivision W 7`a /� S' �• ' , Lot #
Certified Survey Map # , Volume , Page
Warranty Deed # _ , Volume , Page #
Spec house ❑ ycsARno Lot Iines identiftableKyes ❑ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 arc specified in §Comm. 83.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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 Planning &
Zoning Department within 30 days of the three year expiration date.
I /we certify that all statements on this form are true to the best of my /our lmowledge. T /wc am/are the owner(s) of the
property described above, by virtue of a 7my deed recorded in Register of Deeds Office.
Number of bedrooms
_;�� A
l _ rl lb to
SIGNATURE OF AP1'LICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Z oning Department. ** �
Include with this application a recorded warrens deed froin the R e g ister of Deeds Office and a co of the certified survey tntiap if
PP Y !a PY
reference is matte in t warrant dee
tie y d d.
(RE V. 08105)
- 1 111111 Illil IIlII IIIII IIIII lllli Illl 111111 Ilil Ilil
* 9 1 1 0 5 3 1
911053
STATE BAR OF WISCONSIN FORM 1- 2000 BETH PABST
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
THIS DEED, made between Grand Properties; RECEIVED FOR RECORD
LP By: Michael
01/28/2010 11:10AM
Germain, Grantor, and Stephen E. Doll and Nancy E. Doll, husband and WARRANTY DEED
wife, survivorship marital property, Grantee. EXEMPT #
Grantor, for a valuable consideration, conveys to Grantee the following REC FEE: 11.00
described real estate in St. Croix County, State of Wisconsin (the TRANS FEE: 142.80
"Property"): PAGES: 1
Lot 19, Plat of Natalie's Ridge, in the Town of St. Joseph, St. Croix
County, Wisconsin. Recording Area
Name and Return Address:
1'R�OO� Sr ter► L�Ctr Pc 31r2Ct0
Bra hhnn. tull�l 12
� 33 5Is�-
Together with all appurtenant rights, title and interests. 030- 2141 -00 -019
Parcel Identification Number (PIN)
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants, and conditions of record.
Dated this 2 day of December, 2009.
Gran roperties, LP
* *
BV: Micha4Gerniain
Partner
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
COUNTY ST. CROIX ) ss.
authenticated this Personally came before me this 2" day of December, 200*
the above named Grand Properties, LP By: Michael Germain
* to me known to be the person(s) who executed the foregoing
TITLE: MEMBER STATE BAR OF WISCONSIN
ins ent and acknowledged the same. *Pa er
(If not, A BEVF
authorized by § 706.06, Wis. Slats.)
THIS INSTRUMENT WAS DRAFTED BY Notary Public, Ma of Wisconsin a �
My c mmissi n is permanent. (If IN s e e)cp a te:
Robert L. Lober
Loberg Law Office almo
(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 OF 0
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-200
1 of 1
... ... . ... ..... . . .. . ..... - - ----
• DRAINAGE LOT 9
EASEMENT 00* 3.000 ACRES
130,W2 SO, FT.
,4 DIREC 770V DIST LB.0.- 928.0
GI 5'89'51'06 "E A969'
G2 N14 5146 77: 54' H.W.E.•
Gi 58951'08 60,00' Gi 93&0
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L4
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LOT 21
LOT 19
3.045 ACRES
132.637 SO. FT.
LOT 20
3.008 ACRES
131,031 SQ, FT.
L&O.- 923.1
M
LOT 22
m
m DRAINAGE
o EA-srmmr V
LOT Is
1022 ACRES
131.6448 SO. FT, C15
ti
LOT 23 6-22-E
LOT 17
3.011 ACRES
131.141 SO. FT. L
m m LS 0.m 916.5 3
13(
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m LOT 24r,--
m