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HomeMy WebLinkAbout032-2131-40-000 t 4 . Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 0168 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: Lowe, Cynthia I Somerset Township 032 - 2131 -40 -000 CST BM Elev: Insp. B J BMDes ription• Section/Town /Range /Map No: /Q0- 0 b V , D ;L�o j� _ 03.31.19.1166 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark d Dosing ��� Alt. BM 0 n a o 36 Aeration ! I•CJ f, I/ Bldg. Sewer C' � T g Holding St/Ht Inlet . SCI-t 3 gjM 9.1 -S St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG Vent t�ntake ROAD Dt Inlet v a Septic � 3 � Dt om / VCJ Dosing ad r /Ma , Aeration Dist. Pipe 3 9 � Holding Bot. Syst ,' Final Grade / bas PUMP /SIPHON INFORMATION Manufacturer Demand St Cover r[ • Cj Model Numb TDH Lift � on Loss System Head TDH Ft 31 +�' y D i! Forcemain Length ia. Dist. to Well S OIL ABSORPTION SYS 7" I>TT1'1� BEDITRENCH Width +, Length Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 �� SETBACK SYST TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manu c INFORMATION r / CHAMBER O T e Of System: .r / j Model Number: DISTRIBUTION SYSTEM )'t, Li_ _A;, C Header /Maa�niif Id Distribution Q� Hole Size I x Hole Spacing Vent to Air Intake 9 �(L_ — Pip9s) �17i I I n� �� �r3 7 Len th Dia Len th v� I `Dia Spacing J l !r SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over r Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center - ►�,y, Bed/Trench Edges Topsoil Yes No 1 Ye COMMENTS (Include co a discrepencies, persons present, etc.) Inspection #1:D/ 03 Inspection #2: Location: 518 239th Ave Somerset, W t 54025 (NW 114 W 1/4 3 T31 R19W) Oakwood Estates Lot ll8 Parcel No: 03.31.19.1166 1.) Alt BM Description = N ( d '�r4yl w n 2.) Bldg sewer length � = �� f � � Z U GC Yj3 - amount of cover = X49 M ll", revis Plan o Use other side for additional information. . L� T o ✓� r _/ _ � � 5 � ( -- SBD -6710 (R.3/97) Date Cert. No. Insepctor s S gnature ii Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 14 sconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce p (Submit completed form to county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach co mp l ete p (to the co unty c opy only h m on paper not less than 8 -1/2 x 11 inches in size. County �� State aril© Permit Number Check if revisio to previous application State Plan I. D. Number I. Application Inform - Please Print all Informat Location: Property Owner Namp H e L t� �Property Location ( �AJT A LT)VE /" p I r 1/4 h W114, S 2 T3 1,N, R 11L q (or) W Property Owner's Mailing Address Lot Number Block Number 21 E 9Ti � 15 City, State Zip Code Phone Number Subdivision Name or CSM Number SNr.S� Y�� SqGZS ( > 6t\W DDD s T A T s II. Type of Building: (check one) p p pqr.5 VA t ❑ city 1 or 2 Family Dwelling - No. of Bedrooms: Z I __ QS, ❑ Village ❑ Public /Commercial (describe use):_ Yom+ 1LTown of 3 NAE � ET ❑ State -Owned / Nearest Roa I 23 C1 A��r J S� / N Sr K 33 a Parcel Tax Number(s)D3-�-_Zi 3 i - yO III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. VWew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) Permit Number I Datelss ued 11 A Sanitary Permit was previously issued 21 2., 3. IV. Type of POWT System: (Check all that apply) `I iNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: I F U - fl.IVI E(CS r.S AW 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) 95. — 9S. U Elevation 3Q� /&T 16A)s 0 94. S 9 VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks S�l�T1C tob IWO t 1 JCS ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement 1, the unde rsigned, assum responsibility for installation of the POWT,8 shown on hed plans. Plumber's Name (print) Plumber's Sign (no stamp ): PRS o. Business Phone Number Err �b� 223 Zb Z?A °3 Plumber's Address (Street, City, State, Zip Code) 5 9 Opp IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Is uin gent Signature (No ps) P l�kpproved ❑ Owner Given Initial Adverse Surcharge Fee) Determination 5M ' . 24 2M X. Conditions of A�Droyal /Reasons for Disapproval: 3 EUt St f p Vv�tr SYSTEM OWNER: 1 Septic tank, effluent filter anti �� .b St[�; . dispersal cell must all 1 as per management plan provided �y C�lutllbA�• S S; )— n�.DiOercwc[_ 2. All setback requirements must be maintained as per applicable code /ordinances• Ze- SBD -6398 (R. 07 0-3 0 - M IA, LNVE WWVy NW��� s -� rt 3 A/ , P /a V Z199 Sq - r " S - 1 "76Wn1 O Se Mr=k -< r X1( X03 ` � akKVV'bt)X 2! 5! STAME 54025 v t F SM Q&AQ-b S31 13 [ N s c 9 6 ffAW ,26kl i t l h / 2 - 1 ► L $6q kooM 4-1 rov SG G RRt�V t- a6EAC fL009 I � go cc) i r , Cym - rH)A Lt wAe WrLIVY Njw 3 1 t�l - /9 h/ Z)99 5q - rN �T -'atulo op �bmrk -cgr 5L /8 0 i l 1 � i i L $ E 20 0 fin. rov SG et1�2Ry `r2� � � JUd ` 9,K (, t- ? &sEh %civr F10CV2 a - 40 Jim Ir s ;t e. �Qr�S'�na.� �CrL aoN� ►I ) _99... ?��S ire -a_. 5-1-'. t► t�s�tblc� bvfi {•ors` citiar.5t 'r ti's Flo 4t.7 .. . <r Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ( of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code �pt�� ty � Attach complete site plan on paper not less than 81 /2 x 11 inche in sizRtQaG&V E D include, but not limited to: vertical and horizontal reference point M), direction and I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 3 ` D -Q0 O O Please print all information S E P 16 2003 Re 'e by Date Personal information you provide maybe used for secondary purposes (P tvacy 504 ( . f - (IC)3 Property Owner '�- gtn 1 4 V Govt. Lot trJ 1/401,,/4 S 3 T 3' N R Jq E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1 3 S 9 ©l W f , L „ . C d 0 4- j<W* 0& a.-'e city State Zip Code Phone Number ❑ C'dy ❑ Village ERTown Nearest Road 44 60 v W � � ( ?I S`lg- o. Some r se--E Q 3 9 1' u c ❑ New Construction Use: [% Residential/ Number of bedrooms Code derived design flow rate 0 0 GPD [3 Replacement ❑ Public or commercial - Describe: Parent material e W it e m. 1, T ko6d Plain elevation if applicable tt. Genera( comments = S v 5 5 e 5 -+ 3 - ( 09. and recommendations: - S 9Y.78' - r.a 9y.►a' T•3 93.51 b' Boring # Boring pit Ground surface elev. '! ! IO ft. Depth to limiting factor �_ in. Soil Application Rate Horizon Depth Dominant Coke Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I O- S; L a 5 b k L q a nor la- o SI S. L- aFSbV- I ot cw r . s Fs L aF SbV Vk CW 10F 5 9 •3 S Boring # Boring L ' I V Pit Ground surface elev. X00 . ) ft. Depth to limiting factor ► 5 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 3 1-A — --- a F66 LL , s 3 15 -H 7 ,51p0 �St- �t Fe > ) q ti '18-1 is .----- , � O ld 10-11e lf- w s F .S L —1nn Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L 15 Name (Please Print) Signature CST Number h V1 Y) 51 k. a 17 Address O-r 5fi • ate Evaluation Conducted Telephone Number ktoa 71-S A Properly Owner 1' ! l4 h L. Parcel ID # Page of 3 131 Boring # ❑ Boring f- Pit Ground surface elev. f7 I ft. Depth to limiting factor $ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 V its 4 01P- S. ��' M r S 3 s Y ._ s � aFSb� � e IT, LY 51 03 6 ❑ Boring # Boring ❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 � Boring # ❑Boring g Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate ti 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 r Effluent #1 = BOD > 30 5 220 mg/L and TSS >30 1150 mg/L • Effluent #2 = BOD, < 30 nVL and TSS < 30 mg/L The Department of Conunerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (8.07/00) B OO _ N W ly �S w lN� 3ec . 3, T 31►�, I� I q w r � yu N S a e.. ( 3,O) o ZU e S-twA a► CIL 17 L l O t .ti � f fi + U. 51 '�- $,aS'ID - 5 ao V ` 60 o 0 . C6 A a CO cQ rd th �D c4 cQ It K� 4 i x`b 6are G .A e 2 ° u � � A v c. ........._._.__. -. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and BL#iding Division I INSPECTION REPORT Sanitary Permit No: 430168 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: Lowe, Cynthia I Somerset Township 032 - 2131 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 03.31.19. 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 TDH Ft Forcemain Length 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 x Hole Size I 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 Bed/Trench Edges Topsoil 1 Y es E] No j;M Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 518 239th Ave Somerset, WI 54025 (NW 1/4 NW 1/4 3 T31N R19W) Oakwood Estates Lot 8 Parcel No: 03.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Use other side for Yes No additional icy { information. -- SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. I Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 isconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County S to Sani P it Numb ❑ Check if revision to previous application State Plan I. D. Number S r . ---�_ I. Application Inf mal - Please Print all Inform ion Locatio 3 Property Owner Name rope cation J 9 141VW1 A, 5 T,3 I ,N, R I ?(or) W Property Owner's Mailing Address umber Block Number I `� 9 1 ST S h' _ 6 City, State I Zip Code Subdivision Name or CSM Number ONNEKL T \AJj I 5 0 25 ( ) OUX400 CSC NTCS II. Type of Building: (check one) �flp� ❑City 1 or 2 F Dwelling - No. of Bedrooms :_ / ` ` ❑ Village ❑ PubliclComme (describe use):_ own of �jIVAE ❑ State -Owned Nearest Roat , a , Parcel Tax Number(s) Q_ III. Type of Permit: (Check onl a box on line A. Check box on line orf applicable) A) 1. ew 2. ❑ Replac ent 3. ❑ Replacement of 5. ❑ Addition to System System X Tank Only I A l e f Existing System B) Permit Numb a Issued ❑ A Sanitary Permit was previously issu IV. Type of POWT System: (Check all that app lNon- pressurized In- ground VATreatment S Fil onstructed d ❑ Pressurized In- ground Si P s rip Line ❑ At -grade Unit ❑ Re 1 Other: V. Dispersal/Treatment Area Information: siz k0 R16 I �' S C� 1. Design Flow (gpd) 2. Dispersal Area 3. DispeZal 4. So plication 5. Percolation Rate 6: ste ion 7. Final Grade Required ProposeRate ( ay/s ft.) (Min. /inch) ATAV Elev ' �i5 © 9 VII. Tank Capacity in al # of Manufac Prefab Site Steel Fiber- is alk Information Gallons ions Tanks t Con- Con- 1 s New Existing Dom" crete structed Tanks Tanks A $ 160C) �� l W16c� iks ❑ ❑ 7 %MOO ❑ ❑ ❑ 0 ❑ VIII. Responsibility Statement I, the undersig assume resp tbility for installation of the POWTS shown o ched plans. Plumber's Name (print) JF I Plumber's . natur� stamps . o. usiness Phone Number .:J F /I : D (' a I & Plumber's Address (Street, City, te, Zip Cod ) �bX 5 bk& W1 5g66 IX. County/Depart % ft Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Da Issued suing Ag nt Signa stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) �/p ��� / / G 3 < Determination X. Coltditions of Approval /R for Disapprova ' ,C ?eU7S 2 D W nah- r C'e - U ,5­ 2- y �orv /Lt SBD -6398 (R. 07/00) KW* S-3 T31 Q k- 1 q w � Y� — rN ia ® E Sir 7vVS-. 2l 9 % 59 TH S r' LOT 8 ©AKWtOb ES ,SO NNE T W/ 5` /DZS Afts zz' 2?—`fz R tiff .1 `T6C' or I K60 PcP� ok S_ oT L i a =kd TC)P or 1 ._T"K OtJ PIPE C-L : 100 Gf S[�!L t3b�l fJ LSS 3 .RED - e • GARAL & ` Zc� t-(- Id Qio - DrFvSE� C�lAM3�2S � A `.too' ST �78' ��99 I r.• Rk v �i L Wosconsin Department of Commerce SOIL AND SITE EVALUATION 3 Division of Safety and Buildings -- Page of Bureau of Integrated Services in accordance with s. ILHR`83.09, Wis. Adm. Code A Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan must ' County include, but not limited to: vertical and horizontal reference point (BM), direction and S�. C percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel' LD..' . APPLICANT INFORMATION - Please print all information. Revi ed y ` Date 2 , Personal information you provide may be used for secondary purposes (Privacy Law,�s.15.04 (1t,(t}) , C1Fl .. G�rYh f °Z bJ Propert Ow__n//er Property Location J / o Cj _ C m f vt.. Lgt ltjf 14,S T3/ / ,N,R / 9 @(or) V� Property Owner's Mailing Address L ^t c # Subd. N or CSM #//�� 1 .3.57 CA- � �fCA City /, State Zip Code / Phone Number Nearest R /v 6, 4'So�., l,(�� �yD�l� ( �J9— _r"y17 El Village ® Town Road k OYn Pl d �Q New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement El mo 4� � Public or commercial - Describe: d, O Code derived daily flow q r1�� gpd RecommerTde design loading rate 0 L bed, gpd /ft • trench, gpd /ft Absorption area required .Gl 00 bed, ft l6ao trench, ft Maximum design loading rate ° S bed, d /ft g g gp trench, gpd /ft Recommended infiltration surface elevation(s) 7' b ft (as referred to site plan benchmark) Additional design /site considerations / Parent material J u -(4 0 C 2 J'/� 2 Flood plain elevation, if applicable 1 / 4 ft S = Suitable for system Conventional Mound In Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system I ® S ❑ U 0S ❑ U �q S ❑ U R1 ❑ U EIS ©U ❑ S Er U SOIL DESCRIPTION REPORT eexcr Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 1 G w Z C T 2 D-3Z -75 X /�!/ -f S/° Z mab Ground 3 2: ' 7, S// 0 S /z L Iv 5ft. ! ) _75)1X% A /1, Depth to limiting 2 ! 2 h factor x /02 in. Remarks: Boring # 2 2 8 j-y 7,sV 6 °Z Al �— Sri c i s `, s �,' ©f /�i� — G m Ground © y , S; / /� AA S ©�, S �L • . 6 (v if 3 -92`' Z 7 2 Depth to limiting factor !_W in. Remarks: CST Name (Please Print) Signature Telephone No. r i 7j �PC /�� 441 7 Z j20� Add ess c- �� v � J � Date CST Number 3/3, 1,41 J SOIL DESCRIPTION REPORT PROPERTY OWNER G - - . 74 c' Page _,� of PARCEL I.D.# 0'i- Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench y S y i � Ground 3- 7TS X 37 PX I "Sl3n�Jr Off lev. q• 169 75� X A Depth to limiting Ao t Qr ` in. Remarks: Boring # l b -7 /0/ VA SL lAfh/c cc, 17 C '0 <S y 2 ro 7 s M / 511 L 2M4 hA h'1 '✓ w /fit S Ground elev 9�ft. Depth to limiting f 7 `� in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # G - l ©"� �j2 �� S` lly j C ZC , S 5 2 - . 0 6 A Ground 97 �7,ry y� • 7 ft. Depth to limiting V fa for 7 7 in. Remarks: Boring # ......................... Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I OWNS Page 3 of 3 Name 74- G �/1Co Brian Parnell Address CST 231314 GvZ _� y o l, 4 1 Date //_ 7 9? AL Benchmark 1 / UjP �i icy �Q� d� lo-'th 1 ,:4 c !�L. /0 v r �(U:.°!.(�L Benchmark 2 ❑ Soil Boring Suitable Area 1" = 40' Scale If Lot Ad Vi I � I D �E E E T- � i i a � of l i8 04 ° ' 4 Ib V�(r� 1p x -- SO TN S rgEFt sip SN 8.7 338' lb fp •� I Z � Im i o a a IL e -o too' K IN w w 200' a Ir g r �. O tt � ►w ---- _.•�,.� ,0 � � , u ' �� � •• �v 4 r I � � Gi �j IS jw 36B' '.► I I i 116' � I � I Q 021 10;42 7152473038 BELISLE EXCs"VAT =PdG I PAGE 01 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIF "ICATION FORM Owner/Buyer Mailing Address Propeny Address ( Verification required from Planning Department for new construction) City/Stat WTP&rcel " Identification Number 6-12- 07 � ' ' Q &0 L GA_ L DE �J o Property Location f—W '/,, Sec. 3 , T �3 ( N -R _ /? W, Town of ,Subdivision K , Lot # Certified Survey Map # Volume �3 , Page # 364 Warranty Deed # . Volume ,Page # Spec house CJ yes no Lot lines identifiable Lit" yes CJ no SYSTEM MATI�IT_ENANCF 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 Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restricted plumber or a licensedliumper verifying that (1) the on-site wastewater disposal system is in proper operating condition ond/or (2 after inspection and pumping (if necessary), the septic trtnk is less than N3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system.. with tbo 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 mainia.ined must be completed and returned to the St, Croix County Zoning office within 30 s of the true year expiration dot Q. `'� � I G TURF OF APPLICANT l DATE �1YEYt CEFt2['IFICTIpN • 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 WATURE scribed a by vi u of a warranty deed recorded in Register of Deeds Office. F APPICAN / I --T- - T DATE 610 Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Depai ni nt. 04 ' 06 *• �• include with this application_ a stamprd warranty deed from the Register of Deeds office a copy of the certified survey map if releroace is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa / o f ?� FILE INFORMATION SYSTEM SPECIFICATIONS Owner C`104/ A Lp vX Septic Tank Capacity Permit # 4 1 �0 gal ❑ NA 3 Septic Tank Manufacturer VU tL> ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer NA Number of Bedrooms ❑ NA Effluent Filter Model 1d0 0 NA Number of Public Facility Units I? NA Pump Tank Capacity gal ❑ NA Esimated flow (average) 3� Pump Tank Manufacturer 11 NA gal /day Design flow (peak), (Estimated x 1.5) � gal /day Pump Manufacturer ❑ NA l Soil .Application Rate 5 gal/day Pump Model ❑ NA Standard /Effluent Quality Monthly average* Pretreatment Unit VNA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) :5220 mg /L a NA ❑ Mechanical. Aeration ❑ Wetland Total Suspended Solids (.TSS) 5150 mg /L ❑ Disinfec ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOO 530 mg /L J;_(4n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L NA ❑ At- Grade ❑ Mound Fecal Coliform (geometric mean) _510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑`NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA years) Pump out contents of tank(s) When combined sludge and scum equals one -third %) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA years) Clean effluent filter At least once every: ❑ month(s) ❑ NA Z year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) ❑ NA Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: D NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined . accumulation of sludge and scum in any tank, equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page �of T 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 call(s). If high concentrations are detected have the contents of the tanks) 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 lovers 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. El A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T site has not been uated to ide a suitable replacement ea. Upon f ' of th �il -aAd site I ation st be rform to loc a suit le r pt ce nt ar . I no repl ment is available a holding tank y e stall s a last reso place the failed POWTS. und and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone : 2 - 4 J Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 1 �/ s Phone Phone t-,, This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. J 2 2 9 9 E 5 9 9 - 71 28596 a �w STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX Co., WI This Deed, made between Michael P. Goveronski / RECEIVED FOR RECORD G— 0710212003 03:55PH WARRANTY DEED EXEMPT I Grantor, and Cynthia Lowe REC FEE: 11.00 TRANS FEE: 147.00 COPY FEE: — CC FEE: 1 Grantee. PAGES: Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 8, Oakwood Estates, St. Croix County, Wisconsin. Name and Return Address Coy n p kwi� rt -e- '40o Sou, e atn(9. �r 3g12g--� u 032 - 2131 -40 -000 Parcel Identification Number (PIN) This is not homestead property. CK) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this ` day of July 2003 * + Michael P. Goverons i AUTHENTICATION ACKNOWLEDGMENT Signature(s) Michael P. Goveronski STATE OF WISCONSIN ) ) ss. County ) authenticated this � of July , 2003 Personally came before me this day of the above named * Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN — (If not, to me known to be the person(s) who executed the foregoini, authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY * _ Attorney Kristina Ogland Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) I •) ' Names of persons signing in any capacity must be typed or printed below their signature. information Profess onais company, Fond du Lac, wi WARRANTY DEED STATE BAR OF WISCONSIN 800.655 - 2021 FORM No. 2 - 1999 r AND EROSION CONTROL_ Prepared for and at the request of: Being part of the Northwest Quarter of the Northwest Quarter of OWNER: Mike Germain t, St Croix County, Wisconsin. P.O. Box 68 Somerset, WI LEWD .\ � % ,Wet) ®......» ` o xxxx utftw D aina a ase ent ® DoMm Ohm z 121 aN �9OX 2 AR H. E. =11 .0 1"— 0 -10 u..d.. / S di ent ti Pond � f JW a, M la wo a w AT" oA1ur o aaUws M2 sawi All 2 rorn ■tea N � � I Stra 19G 1 g0 } / 1 2 + �� X9 6 % L 9 PONT II Er B10A it ^ Z 0• n Firs 200' of Swale N �9e\ ' + 0 12 +00 13 +0 �9 ,96\ 84.00 9 +0 10 0 g rn x xkxx xxxx )( xx x !i O Silt Fence • _85 � 1 NMN POINT j ; 200.2 19a \ 83 12% an _ 09 B2 B J Drains Easement 2 YEA H.W.E. =172.6 Wetl nd T OF IR N PIPE THE SE LAT ORNER — 171.73. [� CANCEPT 8TORMWA - MR MCAT. AND CONTROL 9* No" 991 lI�NMMY 91 raddIONWASO UM QW#A + 2 w� O FlNAL T W0001401 ac-mo siefr tl06 2 a r r ' 04/07/2003 23:50 17152473622 PAGE 02 4 - (DAKWOOD ESTATES Lot 4 of a Certified SurweY Mop Recerd6d in Vei11ma 13. Page 3647. Going part of the Fractial1w Nomwest Ouar'ter of the Northwest Ouorter of section 3, Township 31 North, Range U West, Town of Somerset, St Croix County, Wisconsin. kP4'TM1►$$r CD,ANER . 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