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030-2055-70-000
Wisconsin Departmeht of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building division INSPECTION REPORT sanitary Permit No: 538792 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: Jewell, Kenneth A. I St. Joseph, Town of 030 - 2055 -70 -000 CST BM Elev: Insp. BM Elev: t BM Description: Section/Town /Range /Map No: 1A 27.30.20.547 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic LJ •7JV Benchmark 7 ZT I � V /S• Cl g Alt. BM 3• Z 5 S Aeration J Bldg. Sewer (�. Z '73 Holding St/Ht Inlet 7, / crz -n TANK SETBACK INFORMATION St/Ht Outlet 7.35 4-2 ` TANK TO P/L4 WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 19Z 0 / � Dt Bottom Dosing Header /Man. Aeration Dist. Pipe 9 9 S Holding Bot. System Pil— Final Grade PUMP /SIPHON INFORMATION Manufacturer GP Demand St Co � ?. Z a� • g� Model Number J �O TDH Lift Friction Loss System He TDH 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 3 1 66 S - Z-- SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: t ^ Z� /t UNIT Model Number: J s DISTRIBUTION SYSTEM I, .A Header/Manifold Distribution x Hole Size x Hole Spacing lVent to Air Intake q Pipe(s) 1 1 Length a Dia Length Dia Spacin �' Z)e SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only CAICZY Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center r• Bed/Trench Edges ` Topsoil ` Yes 0 No es g No r l COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 28 Church Street�oul on, WI 5408 (SE 1/4 NW 1/4 27 T30N R20W) Village Houlto Lot 3BIk5 Parcel No: 27.30.20.547 1.) Alt BM Description = �' ✓ 2.) Bldg sewer length = 6 " - amount of cover =� 3 ` Plan revision Required? ❑ Yes X No Use other side for additional information. _ �V Date Insepctor's ignat/11f Cert. No. SBD -6710 (R.3/97) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538792 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: Jewell, Kenneth A. I St. Joseph, Town of 030 - 2055 -70 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 27.30.20.547 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM uid Depth BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liq DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length 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 T Mulched Bed/Trench Center Bedrrrench Edges Topsoil ❑ Yes ❑ No ❑ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 28 Church Street Houlton, WI 54082 (SE 114 NW 1/4 27 T30N R20W) Village of Houlton Lot 3BIk5 Parcel No: 27.30.20.547 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes No F] Use other side for additional information. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) Co mer I, Safety and Buildings Division County �c OUNTY 201 W. Washington Ave.,,�.O oAW2 ' Iii �ING OF ICE Madiso '7 7 i t napa s _.... ---� Sanitary Permit Number (to be filled in by Co.) 538 79z- with s. Comm. San 83.12) Wis. Adm. Permit Application Sta te Transaction Number L�e i 2(, . . Code, submission of this form to the appropriate governmental ed prior to obtaining a sanitary permit. Note: App lication forms for state -owned POWTS are Project ddress (if different than ailing a resthe Department of Commerce. Personal information you provide may be used for secondary p } cordance with the Privac Law, s, 15.04 1 m Stats.� O G� few. t on Information — 'Please Pr' All Information Properly Owner's Name Parcel # e ..tom . �`'� w � If Property Owner's Mailing Address Q9 p h Property Location a- S� City, State 7i Code Govt. Lot Zip Phone Number s� f�J r ,�^ �v 'A �4J Y,,, Section Z 7 14A11 J GS (circle one II. Type of Building (check all that apply) Lot # T _ �/S N; R E K I or 2 Family Dwelling — Number of Bedrooms /� 3 Subdivision Name Public/Commercial — Describe Use Q �aCAJtn Block Y ` /a a'/C' ❑ City of ❑ State Owned — Describe Use 51_IfA,%,�✓ ems• CSM Number Village of . � t A. " 2 C S ti 1 54-IS ❑ Town of III• Type of Permit: (Check only one box on line A. Complete line $ if applicable) A. em Replacement System ❑ Treatment/Hoiding Tank Replacement Only ❑Other Modification to Existing Syslem (explain) B ❑Permit Renewal ❑Permit Revision Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date ]ssued Before Expiration Owner IV. Type of POWTS S stern /Corn onent/Device: Check all that appl k N::o essurized In- Ground 11 Pressurized In- Ground ❑ At -Grade El Mound > 24 in. of suitable soil El Mound < 24 in, of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) El Pretreatment Device ( explain) V. Dis ersalfrreatment Area Information: Design Plow (gpd)/ Design Soil Application Rat ds o G �® �� d ✓ Area Required (sf) Dispersal Area ¢ p se (so System Elevation ` COd S Vi(. 'Tank Info Capacity in 'total # of Manufact urer Gallons Gallons Units New Tanks 2 c $ v Existing Tanks G U sZs Al P. )a/� rte' Septic or Holding Tank C- Dosing Chamber 7S� ` r�ceo"gY VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWT wn on the attached plans. Plumber's Name (Print) Plumber's Signature MP PRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) °1 ? VIII. Court /Department Use Onl Approved ❑ e Permit Fee Date Is ued Issuing nt Signatu ❑ Given P.— r Denial X75. z3 IX. ConditrAQMNV4Zeasons for Disapproval Q 1 I__ I. ':Septic tank, effluent finer and `3 �'` �`( �'�% �b �+� 4 CIL e a p dispersal cell must all be servicesbe services / maintained as per management plan provided by p(utnber. 2. All 344*ck regi*ements must.be maintained Attach to complete plans for the system and submit to the County only on paper not less than g rl2 x i t inches in size SRI.) -6398 (R. 02/09) Valid thru 02/11 `4 1 � v Y tom COVI CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Owner's Address: $" t� 7-a,t1 g �ll r Legal Description: Township: County: Subdivision Name: Lot Number: 9 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 Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: �/ /,L•_._� icense Number: X2117 Date: G /mil 1! Phone Number 7s Signature Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01). Page 1 'Y f � 1 y D 6VA9 yG vv M �m J 4 1 Soil Absorption S VStem Cross Section l ft Final Grade L*d ' shle 40 g Leaching Chamber ft Y System Elevation _ft - ft Soil Absorgtlon System Plan View ft Ce ft { �^ Leaching Trench 1 ft Vent Or Observation Pipe Chambers 4" Dia. Trench 2 Header Leaching-Chamber Saecifications Manufacturer And Model Gtk - A `z' Al EISA Rating _ _ sq ft per chamber Soil Application Rate gpd/sq ft �a gpd Design Flow c s Soil Application Rate + 2- d' EISA = �� Chambers 2 rows of ��� chambers each. 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I Il Iii _ _ • ���� / � / / / jj / �� r��ri ll� r lr�� // r li • • May. 20, 2009 8:59AM Nc.7903 P. 1 The uic Q k4 S#andar d Chamber I NFILTRATOR" systems Inc. N li:. iirf:l I.. 1 i • : ,J %' �,� The Quick4 Standard The MuitiPo End Cap Offers y � " Chamber Offers You These These Unique Benefits: Unique Benefits: - Patent- pending tear -out seals an inlet • Advanced contouring connections ports provide a tight fit to the pipe swivel 10- degrees, right or left • Eight molded -in inlets/outlets allow • Latching mechanism allows for for maximum piping flexibility quick installation - Multiple ports eliminate pipe fittings - Compact nesting' provides more and make looping ends easy trench length in an equivalent stack • Patent- pending MuitlPort end cap height fits on either end of the Quick4 • Four -foot chambers are easy to Standard Chamber handle and install Infiltrator is the number -one septic The Quick4 Standard Chamber leachfield chamber system in the supports wheel loads of 16,000 Ibs/ onsrte industry, with over 42 million axle with only 12 of cover units in ground in all 50 states and , ,;'• ° -" ,• ? �,,� • Certified by the International .24 countries. "u;;h mar t Association of Plumbing and Mechanical Officials (IAPMQ) Approved in ;,y, •., '':''* ;, I + , N 7.1i a `V •',�'M:,,•,:'.k• . NI` POWTS OWNER'S MANUAL & MANAGEMENT PLAN page _ lu _.� FILE INFORMATION SYSTEM SPECIFICATIONS ❑ NA Owner [ tic Tank Capacity � - 7-5 -4 - -2—al - 0 NA a-- ❑ NA Permit # - - tic Ta M j, `�„yer _ FFilter M anufacturer ,� ,/het ❑ NA DESIGN PARAMETERS Number of Bedrooms D NA uent Filter Mo de! pl� (lumber of Public Facility Units ❑ NA mp Tank Capacity 4 0 al NA Estimated flow laveraee) aQe' a1 /da mp Tank Manufacturer Aj ;dfe_,y - ❑ NA '- 11 NA Des flow (peak), (Estimated x 1 -W 3o d al/d pump Manufacturer �' Pump Model L NA ScA Application R _ ^ jai /da /ft - - -- - -- - Standard InfiuentlEtfluent Quality Monthly average" Pretreatment Unit 0 NA Fats, Oil & Grease IFOGi <30 mg /L M Send /Gravel Filter 0 Peat Filter 13.ochemical Oxygen Demand (800 x220 mg /t PJA q Mechanical Aeration ❑Wetland Total Susp Solids (TSS) c 1 SO Mgi L. ❑ Disinfec ❑ Other: ^ �_ R pretreated Effluent Quality Monthly average Dispersal Cants) �❑ NA Biochemical oxygen Demana (BOD <_30 mg)L An -Ground dprevity) ❑ In- Ground (presaurized) Total Suspended Solids (TSSI s30 mgli` IjVA ❑ At -Grade 0 Mound Fec al Colif l e mean) 510' cfu /1OO Q Drip-Line 0 Other; _ Maximum Effluent Particle Size l 1 8 in d'ia.�� -- 0 NA other - ^ - - ...�... —�M Cl NA - thor. C7 NA Other: ❑ NA "Values tvo cal, for c±omestic wastewater and septic lank effluent. ate'' _ — D NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every, � a th(s) (Maximum 3 yearsl T ❑ NA Pump out contents of tankis) �` When combired sludge and scum equals ono-third (y,) of _tank volumeC_ NA — -- ❑ month(s) (Maximum 3 vowel U NA Inspect disperse, wilts) M At least once every: years) _ -- -' © onthis) ^ NA Clean effluent filter - At least once every'. - `, j earls) month(s) 0 NA Inspect pump, pump controls & alarm At least once every: R lysafle) _.__ - -- . _— r . �. ___.� _ _, .,. �...._.....--- -•---- ❑ month(s) Flush laterals and pressure test At least once every: Q yearis NA __ _.__�._ ..._._..-._.. _......._- .___........._.__�mon (s) 0 NA Umer.�__�~__-- _-- •- -..._ ___. _____. At leant once every: ether: -�_ — f ---- ______- ... -•- — D NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or cert+ficstions: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visuai inspection of the tank(s) to identify any missing or broken hardware ldentifv nny cracks or teaks. measure the vo lume of combined sludge and ,ciim and to check for any hack up or riondfng f ettitiont on then grotind 5urfa f "Cite dispersal cell(S) shall be visually inspected to check the effluent levels in the observation p l es and to check far any p g 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. Wnen the combined accuMulatior. of sludge and scum in any tank equals one -third (y or more of the tank voiurne, the entire contents of the tank shall be removed by a Septago Servicing Operator and d isposed of in accordance with chapter NR 113 Wisconsin Administrative Code. 10 other services, including but not limited to the servicing of effluent filters. mechanical 01' pressurized caniponams, pratreatmonr nests, and any es, including in intervals of Y17 months, shall be performed by a certified powTS Maintalner. ity within 10 days of completion of anY Servicff evenk. A service repoft shall be provided to the local regulatory aut)�or Page ___ of .... START UP AND OPERATION For new construction, prior to use of the POWTS ehopk tr #Xtrlrif►llt tr nkloi fvr the presence of painting products or other chemicals that may impede the treatment process and /or ftho f iii( pA 1.� I(A } . If high concentrations ere detected have the contents of the tankls) removed by a septage servicing operalor prior td U00. System start up shall not occur when soil conditions 01 t i~hir WlF Otive surface. During power outages pump tanks may fill above ntllrheilh�I7til I�rf>�i, When power is restored the excess wastewater will be discharged to the dispersal cell(al In one large doddk Od may result in the backup or surface discharge of effluent. To avoid this situation have the contents Qili l;rf:titdy) by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Flumbdr pF II?r~f"f "`i�idt$IdtaY 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 00110, 06 no . t 1� 1yi► tIt'park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grads i1ok 0 tlo Aroo Reduction or elimination of the following from the ptjy Improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts;IdMI34i!E�t1[NI degreasers; dental floss; diapers; disinfectants; fat: foundation drain isump pump) water; fruit and vallpiAl ' M1 grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tdrdial1 ,$ItPt fl�lfiMF trine• ABANDONMENT When the POWTS fails and /or is permanently taken poll; ;nl dleriltrt this' fellpijlti!ng steps shall be taken to insure that the system is properly and safely abandoned in compliance with 00--or d-0 fl`)1 1, � SAly�p i�nsin Administrative Code: • All piping to tanks and pits shall be disconntlotod At1d hg abd ipit+aC# pipe openings sealed. • The contents of all tanks and pits shall be r0001 ihdo 1*0pIllply rij0posed of by a Septage Servicing Operator. e After pumping, all tanks and pits shall be 40140 t00 a #nd Olt. 00 Or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the fcillY yirljlp f 04 ltot44 i )dive been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evalitAto' find; irttaiy' 0 tl�ijlj for the location of a replacement soil absorption system. The replacement area should be prpi;ilii t �Nr rrt �ilrttij.oj► ad Pnd compaction and should not be infringed upon by required setbacks from existing and propadi � dot j lilId' wells. Failure to protect the replacement area will result In the need for a new soil and site eufi�ujt ti.`IldMkt�!>I a replacement area. Replacement systems must comply with the rules In effect at that time. ❑ A suitable replacement area is not avai lifl� 000 10 1 k dihlAr soil limitations. Barring advances in POWTS technology a holding tank may be installed a$ .��ll� r r q I!ijfi #ltd the failed POWT ��Q❑ The site` as not en evaluated to identl a aUltrfliP► p��lglr , Ait area. Upon failure of the POWTS a soil and site evaluation be performed to locate a si�lita 'IlR lfX I d. If no replacement area is available a holding tank may b toile s a last resort to replace #hdI+i:" ❑ Mound and at grade soil absorption systerfii Clylriir 11. r�ii011# acid In place following removal of the biomat at the Infiltrative surface. Reconstructions of such iv. 6 t 00'..I�iY the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS N>E,I�Y' 0 I " &SEES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT M{!TANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE . [ki ADDITI COMME POWTS INSTALLER 4 4AI INTAINER Nam IATw _ S e.1�v.o. +t. ftlelrrt, Phone ? SEPTAGE SERVICING OPERATOR {PUMPERI I ATORY AUTHORITY Name 64% Cr Zo„ Phone i4srrig . S • 3� i o - g This document was drafted in compliance with chapter Comm sswilo: illlcii) add 4`3, 12) at 431, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK. MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ovvner/Buyer Y e . S , 0& -V „ Mailing Address Property Address D� (Verification required from Planning & Zoning Department for new construction.) City /State Y� r �_ �,,.� Parcel Identification I�ulnber LEGAL DESCRIPTION Property Location _ '/a , ,&IAJ / , Sec. a, T N R . -Vol W, Town of Subdivision_ Lot # 3 — Certified Survey Map # — , Volume , Page # Warranty Deed # _ ----- -____� __- __ Volume _ , Page _ -- Spec house yes no Lot titres identifiable & no SYSTEM MAINTENANCE AND OWNER CERTIFICATION trnproper use and maintenance of your septic system could result in its premature failure to handle waste's. Proper maintenance consists of pumping out the septic tank every three years or s(mn.er, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in. §Connm. 83.52(1) 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 (i£ necessary), the septic tank is less than 1/3 full of sludge. Ilwe, 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 &. Lotting Department within 30 days of the three year expiration date. 1/we certify that all statements on this form, are note to the best of my /our knowledge. Uwe atniam the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Dee Office. 0 ' ,Ne l j� Number of bedrooms T SIGNATURE O APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds office and a copy of the certified survey snap if reference is made in the warranty deed. (REV. 08105) MUM No 3AI :O ►- MCOTtON- 00WM =_Z *AMANTYAD ED TritB' Sfj;+iC� Nk ItRYlT) E!nrl R C.flif;tl•lfi - DAi I _4th °r PAGE 4 SY THtS`17Ea;U; Fr.r ,e-. Je thy. Willia'4 S_. Dower. of attorney ¢ for 'Y4>Rh _ I 4 v r_h a _ _Jewe.11 _ 2:40. P-1. ,' C C'aa.rtl:or eoziveys.arsd warrants to K�--.� - - - .:_ - _ for valuable _oasiderat�on - - RE;ridRft T9 - - - r"llo aina described real eirtste In. �St (:rO i71 County, State of irieeonsln: Lo 3 r $1GCtc 5 r 1 c. - i 't 7 * ^n This As �_ _homestead property: ETM Exception to warranties: - - Executed at Stillwater_ Minnesota day of December SIGNED AND SEALED IN PRESENCE OF 4 - ras•ar_-' Ferri E. J46well by illialii Sh Jewell. Att -r-ney 4 m °Ac* r SEAL) (SEAL) (SEAL) Signatures of a _theta *sited this _ day of _ 19 - Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 viz. s E y r i r" is riweiti M INNESOTA Washington count y Personally came before me, this_, l ith day of December 19$4 the above named tarn E. Jewell by William S. Jewell. by power of attorney to me known to r- ". - - _ , n_ who executed the foregoing Instrument and acknowledged the same. .: . ".'AAA 'hNJ.; .V� ^t.MAPN•v'v:.r � / `!r_ KC-.CL NEY This instrument was drafted by i =- 'i NOT' •- Y!'I1nL IC.- MIN,Ic�OTA j y' tl'- y I:IGrcNCCl :jNTY - lo lsten Law Of ; yr, � F . "res May 10. 191;5 � Notary Public W `-;� h ngr _On CountyXIVI*X ?7 Z! 206 N� N�f r, Minnesota w � t fi�It'nPSEeLf 3s'6pt3'dh.! My Commission (Expires) (Is) r of persons aatr-aag Ln any taP".-'•,_ - T be typed or printed below their signatures. ' ncrn�.tonsan vt WARRANTY DZED -STAY; BAR Of - VT *CnN81N, Tc.:'= ? - 1971 {.. ����'�� sir 6� iLv 6 " �.'�•i '"� r '� :. T '#' � '•v � N '. I- • "lf.1Gt � y e .K '34^#• C Y� � j` k r. • fit.; y ' w y y� z - �y�/ ..°+�^k�' .r ' � � ��/ y #eat• ,t t!' r t}���+r' i x � , . _. � +'q . �p ��,�.± �• * �'.�.. 1 �„� T..m 14", ,1 's 3 {'"# 4",yyy,,. �`M d..,.X°, �f W ?� •(`,1ftf � '�•.' } ,.r �� ,ii �• ✓ ��".� p.wlp ���� liy�'�Q� : r i� � ,�'Y� +�Yt t� rs a i � A t re ��,� ±Y a$�y,ri � 4 y+.{T+� �. • T' �! �j «'+`.iy,S .! '+� '. fA 4 �•%'*rr,'$'-•.+rt. 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C ,k t: r .,i : �" ' , �{•sP - �,. -tfi z �F'"°�''w:". �.,s�.,�.� - � .b,,��)�p.IY*rw . ° y v , � i . .. ��� ' '`} . .. • I `.w r �. .4' �''�''S. `�- ' A � � .- � ± ��,�,, .- (°#� ] k. , �� l * T" 1r y � r' p $ 4M R 4 0 Fr J y" � }�i;. � ,.._..G� .}X r +Yt7 �xf•' •� '<. � � � / � j � � � {+�'' � > a x y � R (� �y,,ti ' 4F �j tf+° �", i �,�,g„r{ L;•f•�ura+ �` '` r } a ¢ � r �r i � � .'s % ^�� +F.l :�n fi•. * +"Y �, - q4t �$G' t � r � J�' :!�°��,' . �. f . �+ y K.,�'. O'er r` . • w .,�; *y' hr 1648 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page t 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. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 030- 2055 -70 -000 Please print all information. a awed B Date �s Personal information you provide may be ., or`S@conderK,purRoses (Privacy Law, s. 15.04 (1) (m)). 0 2'M Property Owner " r�`3 roperty Location Ken Jewell Povt. Lot 3 19 19 S 27 T 30 NR 20 W Property Ch Church 20 � 3 I Owner's Mailing Address r ;: Lot Block # Subd. Name or CS M# 28 Houfton City Statj Zip Code Phgw, Number City I Village 1I Town Nearest Road Saint Joseph WI i= St.Joseph Church St. New Construction Use: 01 Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD N' Replacement J Public or commercial - Describe: Parent material Glacial outvvash Flood plain elevation, if applicable na General comments and recommendations: Install two trenches at elev. = 92.50' using 20 leaching chambers. M Boring # Boring l/ Pit Ground Surface elev. 96.09 ft. Depth to limiting factor >108" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fty in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -7 10yr3/2 none sil 2fcr mvfr as 2f,1 m 0.5 0.8 ( 2 7 -22 10yr4/4 none ob sl&gi 1 msbk ml cw if 0.4 0.6 , 3 22 -36 7.5yr4/6 none s & gr 0 sg ml cW - 0.7 1.2 4 36 -108 10yr4/4 none cos &gr 0 sg ml - - 0.7 0.6 `l z • SU Lf 3• X9. Boring # J Boring Am Pit Ground Surface elev. 96.99 ft. Depth to limiting factor > in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-6 10yr3/2 none sil 2fcr mvfr as 2f,lm 0.5 0.8 4, 2 6 -26 10yr4/4 none ob sl&gi 1msbk ml cW 1f 0.4 0.6 3 26-44 7.5yr4/6 none s & gr 0 sg ml cw - 0.5 0.9 �'��p� 4 44 -98 10yr4/4 none cols &gr 0 sg ml - - 0.5 0.9"d r H# 3 & sand grains coated c ay sla . Loading rates reduced to reflectireduced permiability associated with clay skins. * Effluent #1 = BOD ? 30 < 220 mg/L a TSS >30 < 1 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mg/L CST Name (Please Print) Signatu CST Number Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 6/142003 Property Owner Ken Jewell Parcel ID # 030 - 2055 -70 -000 Page 2 of 3 3] Boring # j Boring A6 Pit Ground Surface elev. 96.29 ft. Depth to limiting factor > 102" 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 -8 10yr3/2 none sil 2fcr mvfr as 2f,1m 0.5 0.8 2 8 -19 10yr4/4 none sil 1msbk ml cw 1f 0.2 0.3 3 19 -37 7.5yr4/4 none cob sl&gi 0 sg ml cw - 0.5 0.9 4 37 -60 7.5yr4/6 none cols &gr 0 sg ml gs - 0.5 0.9 5 60-102 10yr4/4 none cols &gr 0 f sg ml - - 0.5 0.9 H# 3, 4 & 5 sand grains coated with clay sldns. Loading rates r ced td re reduced permiability associated with clay sldns. F Boring # J 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F—I Boring # J 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <.30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. ' ■ So7 P�a�ua�on P, t /lo cippeeC- a"tf' S /oot tlnoc� nys ar'e4 loe&&o oC ys nt r¢ /To/Yf �Orol° 4w �� ga /do � � 112i�1t6bfir�q OC 3 will >,sa'��om 3 0► c �ts�� -c/ a�eq. '0 cnch ark' T ° l ITO law 160 - �, 3 0� 3 o m ° o O� °� c 5c a� � � o c`t c � o Q O �� rn .0 CI. czC: y N c d C W a c ZS Co O ° c ° 0)y Lo - C Z Y O N O (0 U O C LL. C O O CD L co E E ¢ o E - °° N U I ° co N c N Z i w o m I Z £ a� d N N H U a m o a c+ N N O O Z :!t fA F - r- p N T -• Z c O Y U c M O 61 N m E L O N a m 0 Q o U ° Q - V Z Z p N , Z �l ° _ j V N N ° is Y ) O G 'm C O Y 0 d E 0 @ N N N N O U w °' d O O O d U Z •w ;; "'aaa 0 CL z O N ° (1) J U ° 0 0 � Z 75 N N Lo �V O 00 00 z v� pp _ _ O N C L Q N� O 0 C U N C 3 O p ° W ° a°i p n 00 L" p ~ N O N U p p p L h w t6fJ ON N Y r C Ur N c j aO N • C N p O BI 0 N > N N • y' o N o N Y Z U, CL � � d 7 • M G d 4. C E "�� A U d O N U I h 0 °64). M � c ei a+ 0 w tl h O H � I �O c N CL CD @C > tC N 0 C O C Z `O C 7 N O > LL O m t C O M f�6 E Q O E m I _ M � � N N Z r O z a m N H fn 0 2 c V E c c N ~ C U o Y N U 9 N CL N O p C z = z N _ o I E U) m Y IL a N y m O C c o o a o ' X55 E O I N O O O • � R C) a L U) to J U o Z 75 0 i C N O 0 O _ O D O U) 'O m Q O_1 t m Q Z U �r 0 7 w ° 0 3 U to C O O O co H N C O � N v O L O � ° N N C, N O N N y N ' • O O N (/) V LO 0 O Z S Z ID v� Y m a #6 a ' � a • a d .w m c .� w E L 'c c r t� Li am 0U) t A � Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453217 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan 10 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: Jewell, Ken I St. Joseph Township 030 - 2055 -70 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: CST BM Elev: Insp. BM Elev: 7 27.30.20.547 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head I T DH Ft Forcemain 17gt7 Dia. Dist, to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution T ole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing 1 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/ Tench Edges Topsoil 0 Yes 0 No [] Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 28 Church St Houlton, WI 54082 (SE 1/4 NW 1/4 27 T30N R20W) Village Plat of Houlton Lot 3 Parcel No: 27.30.20.547 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? I I Yes 0 No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. Safety and Buildings Division cunt 11 fi scon � 201 W. Washington Ave., P.G. Box 7162 T �j� Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by C o.) Department of Commerce (608) 266.4131 TJ 7 2 � 7 Sanitary Permit Application - Slate Plan LD. Number In accord with Comm 83,2 1, Wis. Adm. Code, personal inlbrmation you provide ?AID maybe used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mating address) I. Application Information -Please Print All Information R � � F v Property s Name t Parcel #� Lot # Block # Property thvner's Mailing Address Property Location +, ., Section CiVSta Zip C p 3 (circle ) T ,i� N, )I '�? E of II, ype of Building (check all that apply) 0 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CS Number ❑ Public /Commercial -Describe Use - ❑ State Owned - Describe Use = I / ❑City_ ❑Vill e Township of III. Type of Permit: (Check onl one box un line A. Complete lioc 8 it'applicabie) A. ❑ Now System Replacement System ❑ Treatment/Holding Tank Roplucement Only ❑ Other Modiflc4don to Existing System - B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl X Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Ck istructed Weiland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed Of) System Elevation -2 V . Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plas i, Gallons Gallons of Units ncrete Constructed Glass Na isting Tank Tanks Septic or Holding Tank Aerobic Treatment Unit Dos ng Chamber Vll. Resp nsibility Statement- 1, the undersigned, umc responsibility fur luslallutiun of the POW I'S shown on late attached plans. Plumber's am (Print). Plumb s Si r MP /MPRS Number Business Phone Number S' 77 / 5 - Plumber's Address (Street, City, State, Zip Cod e / -<0V L2 ,tom VIII. Coun /De art ent Use Only X Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Iss in gent Signatu o Stamps Surcharge Fee) ❑ Owner Given Reason for Denial IX. Conditions o Approv SYSTEM OWNER: ( �Y�wQ� . 1 Se tic k, effluent filter and A-�- dispersal cell must all be serviced / maintained as per management plan provided by plumber. �) t� 5 - �D 6e & 2. As etback requiremen must be maintained as per applicable cod /ordinances. ' G+R2 • Attach complete plans (to the County only) for the system on paper oe less than 81/2 x 11 Inches In siu- SBD -6398 (R. 01/03) 9 / /,c'a�Oas za A �f /Jk5 S 12' ,��-, o-�'S.:�.��,c� -� 9.s;s /" L� /�S- 3 �3•Xf/�' .� r I I q ,✓� yi�de <S W eal E , Q z zle0.6 .tAZI 1i/leC c� Nv a t s, o.� p G�.e �S ; �/ �ic s- 3 3 X '/8 J r 1648 Wisconsin Department of Commerce SOIL EVALUATION REPORT p 1 of 3 Division of Safety and Buildings A.C.E. Soil & Site Evaluations in accordance with Comm t35, Wis. Adm. Code Attach complete site plan on paper not less than 8'/ County x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 030 - 2055 -70 -000 Please print all information. a By Date Personal information you provide may be y�u�osass (Privacy Law, s. 15.04 (1) (m)). f ZQD Property Owner ° ' ;r v rs roperty Location Ken Jewell PovI. Lot 3 19 19 S 27 T 30 NR 20 W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 28 Church St j 6 2003 3 5 Village Of Houlton City Stat Zip d;PhoAe,Number City _J Village tI Town Nearest Road Saint Joseph WI St.Joseph Church St. I New Construction Use: If Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD 11 Replacement J Public or commercial - Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Install two trenches at elev. = 92.50' using 20 leaching chambers. M Boli # _j Bori 1 08" in. Soil Application Rate II' Pit Ground Surface env. 96.49 ft. Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -7 10yrM none sil 2fcr mvfr as 2f,1m 0.5 0.8 ( 2 7 -22 10yr4/4 none ob sl&gi 1 msbk ml cW 1f 0.4 0.6 , 3 22 -36 7.5yr4/6 none s & gr 0 sg ml cw - 0.7 1.2 - 4 36 -108 10yr4/4 none cos &gr 0 sg ml - - 07 0.6 12- $O Boring # Boring 1/ Pit Ground Surface elev. 96.99 ft. Depth to limiting factor >98 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 I 'Eff#2 1 0-6 10yr3/2 none sil 2fcr mvfr as 2f,lm 0.5 0.8 4, 2 6 -26 10yr4/4 none cob sl&gi 1 msbk ml cW 1f 0.4 0.6 3 26-44 7.5yr4/6 none s & gr 0 sg ml cW - 0.5 0.9 4 44 -98 10yr4/4 none cols &gr 0 sg ml - - 0.5 0.9 H# 3 & sand grains coated y sla .Loading rates reduced to reflect reduced permiability associated with clay skins. ' Effluent #1 = BOD 30 < 220 mg/L a TSS >30 < 1 mg/L ' Effluent #2 =BOO S 30 mglL and TSS < 30 mg/L CST Name (Please Print) Signatu ' pe CST Number Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 6/1412003 Property Owner Ken Jewell Parcel ID # 030 - 2055 -70 -000 Page 2 of 3 3] Boring # Ong 01 Pit Ground Surface elev. 96.29 ft. Depth to limiting factor >102" 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 1 0 -8 10yr3/2 none sil 2fcr mvfr as 2f,1m 0.5 0.8 2 8 -19 10yr4/4 none sil 1msbk ml cw if 0.2 0.3 3 19 -37 7.5yr4/4 none cob sl &g 0 sg ml cw - 0.5 0.9 4 37 -60 7.5yr4/6 none cols &gr 0 sg ml gs - 0.5 0.9 5 60 -102 10yr4/4 none cols &gr 0 sg ml - - 0.5 0.9 Ys•Y8 St•�r H# 3, 4 & 5 sand grains coated with clay skins. Loading rates reduced to reflect reduced permiability associated with clay sldns. F—I 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 F—I 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 GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. r - r P, t �1 t4c f • �' /(048 /1 o Q,opie e,a -b /r S /opc tlrouol 5 s-&tn, Q re z loe &o of Ae ys &M "or44 hwe �- 7.0'CF»6*A`' /I Ile $� . �a� dar, � 3 �tet�k6o��•,� oe d 4i O'er 3 3 c �� 5•E� a�ea. � � J EXisE. � ao e 1 6`dre�^ b CYIC.G► Q/7�� rn Of S;dr ssuMe �' �rclt S�eez� - POWTS OWNER'S MANUAL & MANAGEMENT PLAN, Page of , ,2 FILE INFORMA I .. � , '.' ..'err Ott `tn 0,7 `" 7,1 ru f SYSTEM'SPECIF`ICATIONS' ` Owner Septic Tank Capacity 1 1 6 a t 9 a l O NA Permit # Septic Tank Manufacturer fir• ❑ N A DESIGN PARAMETERS Effluent Filter Manufacturer O NA Number of Bedrooms t , O NA Effluent Filter Model er, :,, ❑ NA Number of Public Faoility'Unita ` ANA Pump Tank Capacity a l _A NA Estimated flow (average) " gal/day Pump Tank Manufacturer ,f NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ZNA Soil Application Rato al /da /ft2 Pump Model ; , j -NA Standard Influent /Effluent'Ouality Monthly average" Pretreatment Unit ,ANA Fats, Oil Grease (FOG) 530 mg /L O Sand /Gravel Filter D 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 Dema4 (BOd 530 mg /L In- Ground (gravity) O in- Ground ( pressurized) Total Suspended Solidw; (TSS) , 130 mg /L g NA ❑ At - Grade CI Mound Fecal Coliform (geometric.mean) .510' cfu /100ml ❑ Drip -Line ❑ Other Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: C3 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: month(s) ) (Maximum 3 years) El PIA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ ► IA Inspect dispersal celi(s). + At least once every: E3 ear1sl(s) (Maximum 3 years) ❑ 11A Clean effluent filter At least once every: ❑ month(s) ❑ f A M - y ear(s) Inspect ump, pump controls & alarm At least once eve ❑ month(s) -0 NA p every: O year(s) Flush laterals and pressure test At least once every: [I 13 mo nth(s ) Flush CIA s► Other: At least once eve ❑ month(s) every:., ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to Identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels In the observation pipes and to check 'for any ponding of - Iffiuent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the im iediate notification of the local regulatory authority. W' en the combined accumulation of sludge and scum in any tank equals one -third (Ys) or more of the tank volume, the entire cc tents 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 un s, and any servicing at (ntervahi of 512 months, shall be performed by a certified POWTS Maintainer. A , ervice report shall' be" provided'fd'the`locll "(egulatory authority within 10 days of completion of any service event. GMW (4/01) Page of ST ART UP AND OPERATION' F or 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 celltsl. If high concentrations are detected have the contents o' the tank(s) removed by a septage servicing operator prior to use. S stem start up shall not occur when soil conditions are frozen at the infiltrative surface. Q tring power outages pump tanks may fill above normal highwater levels. When power Is restored the excess wastewater will be d!seharged to the dispersal call(s) in one large dose, overloading the collie) 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. D , not ,hive 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. P , )duction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of the P')WTS; antibiotics; baby wipes; cigarette butts, condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; fir undation 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 Vv yen the POWTS fails and /or Is permanently taken out of service the following steps shall tie 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 ;''ell 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 rerflacernent system: S 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 -omply with the rules in effect at that time. O A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in 1 toohnology 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. O 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 PFISON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADC TIONAL COMMENTS I POV TS INSTALLER POWTS MAINTAINER E Jame 'hone _ Phone SEPYAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name p S AP r Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.640),(2) & (3), Wisconsin Administrative Code. J ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer �er�� i ewe ke Mailing ,^A�ddress Property Addr iVerification required from Planning Department for new construction) City /State -�1flCt� lr� , � Parcel Identification Number A — S LEGAL DESCRIPTION Property Location . :5"� %A LA--- '' /a, Sec. , T3 - b Town of _ I as ep h . Subdivision , Lot # - i _ lk — Certified Sure Njap # , Volume � , Page # Warranty Deed 5 &9 , Volume T IC ) 2- , Page # 3S9 Spec house 0 yes X no Lot lines identifiable 0 yes O no SYSTEM MAINTE gANCE lmproper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of puanping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a 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. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set farth, 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 trust be completed and returned to the St. Croix County Zoning Office within 30 days of the tluee year expiration date. SIGNATURE G PPLICANT / / DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the prop describes above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF PLICANT pAIP Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. +sss♦as ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ,+ v r ,¢� 4 � �yl' � 'fir a •�+'��# �. = �k t :, .^ <yt�:. }t"yr. �,�� t Z � t�*:.� i°'..?,. .�. d, .+ � ".�} � � .�ay -... M% . x µ .. 'r Vii' �a s A,,. -� ✓ # y rS'•, ���, (� y a ', � .�" ',L,b 4 ,.# 1.,3f■e> y y ;T t�t + r �� A ��-,+, > . l�.�I /[i ~ f ,j `�' "�,� .fH1.�'F► �.;'� ��{, °�i`. te 5 `,. 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Jewell by ST. GROM CO., WI& power of attorney i"'CL fOr RPA*rd We, 14th dar �Bac.192 Greatar conveys and warrants to Kenneth A. Jewell 2:40 P' Grantee__ fm a valuable consideration R – T — Us" To tho following described reel estate in St. Cro ix County, StottofMisconaln: Tut Key R Lot 3, Block 5, Village of,,.Houlton This Is h"Wsteed rt props y,, FM Exception to warranties: I Executed et Stillwater. Min nesota thia_l- day of December 191L. SIGNED AND SEALED IN PRESENCE OF �•� , ��1.� (S •r)° Fern E. well by William Si Jewell, Att orney in Fact (SEAL) i f ` r SBAL) J ' (SEAL) Signatures of authenticated this _ day of 19__. j Title: Member State Bar of Wisconsin or Other Party Authorised under Sec. 706.06 via. STATE OF 12W& SMMINNESOTq' Washinaton lY County. Personally came before me, this 13th day of December 19 , the above eased Fern E. Jewell by William S Jewell by power of attorney to me known to be the person— who executed the foregoing Instrument and acknowledged the same. li : -itF hi. NEY Vals instrument was drafted by � ,' 0, 10T .'–f PI10lIC– MINNcCOTA ' V .X)GfcVcc':"IV Holsten Law Offices ; ;YCemm. E,,-res!hay 10. 19r,5 Notary Public Washington Count X1<MOC r PO Box t II� rr((��pp �nrvwr ,v..n`NNrvvv�nnn,v.n�n.�r,. Minnesota TNt`dleF Wtt i�dptY�al. My Commission (Expires) (IS) Names of persona signing in any Capacity should be typed or printed below their signatures. wMrw.ew.�® WARRANTY OgxD –sTAt; OAR OF 11tfCON81T1, FORM NO, ?. – 3971