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HomeMy WebLinkAbout032-2141-80-000 (2) Wisconsin Department of Commerce PRIVATE Q�WAGE SYSTEM County: St. Croix Safety and Building Division �., t a INSPECTION REPORT Sanitary Permit No: 453188 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: Corder, Albert Somerset Township 032- 2141 -80 -000 CST BM Elev: Insp. BM Elev: BM Desch ' Section/Town /Range /Map No: 03.31.19.1238 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing / / D / Alt. BM S Aeration BI Holding SUHt Inlet TANK SETBACK INFORMATION SUHt Outlet a y % • 9Y TANK TO P/L - WEL,L� BLDG. Vent "r Intake ROAD Dt Inlet —� Septic r \ 7S l � / Dt Bottom –� Dosing / 7 Header /Man. p Aeration Dist. Piper / q 0. G� 0, Holding Bot. System Final Grade p�� • (o PUMP /SIPHON INFORMATION q Manufacturer Demand S over GPM Model Number r TDH Lift Friction Lo ystem TDH Ft ForcemairT ngth Dia. Dist. to Well SOIL ABSORPTION SYSTEM ( = Z BEDITRENCH 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 anufacturer: INFORMATION CHAMBER OR Typ f System: > � O / / UNIT Model Numb&-f'04 i DISTRIBUTION SYSTEM Vs ar He anifgld Distribution x Hole Size x Hole Spacing Vent to Air Intake Lengt Dia 1 k Length Dia Spacing ( e --- 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 No Yes i1 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: -/ a / 0 Inspection #2: / / Location: 523 239th Ave Somerset, WI 54025 (NE 1/4 NW 1/4 3 T31N R19W) Deer Trail Estates Lot 13_�a Parcel No: 03.31.19.1238 1.) Alt BM Description = wa k t J 1•� k row f r' 2.) Bldg sewer length = �� � 3(Q �< �� 9,. - amount of cover =/1�' Plan revision Required? I Yes ' No ( c f O `1 d Use other side for additional information. �.- SBD - 6710 (R.3/97) Date Insepctor Signature Cert. No. Safety and Buildings Division County 201 W. Washington Ave., P.O?Bo x 082 N visconsin Madison, WI 53707 — 7 Sanitary Permit Number (to be filled in by Co.) Al De artment of Commerce (608) 261 -6546 P V_ RnL Sanitary Permit A P 1* ti on _ State Ian I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, persot al inro!!p may be used for secondary purposes Privacy!uw, s Project Address (if different than mailing address) I. Application Information — Please Print All Informatio Property Owner's Name Parcel # Lot # / Block # C /3 Ey2 �' , , .;, ;,� , : 3 3 i . l4 • Ia n Property Own Mailing Address Property Location ` City, State r _'A. ��' /., Section 3 ty. Zip Code Phone Number tivs, 1V S O 3 - 8 S (circle o II. Type of Building (check all that apply) N; — (circle o&—) ® 1 or 2 Family Dwelling - Number of Bedrooms 3 rvu,,s S S bdivision Name CSM Number ❑ Public/Commercial - Describe Use t o �i'C C ❑ State Owned - Describe Use u k aSGwft? / ity ❑Village &Township o C�42aE III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Trcatment/Holding Tank Replacement Only ❑ Other Modification 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. T e of POWTS S stem: Check all that a 1 2 10� w Non - Pressurized In -Ground C1 Mound >_ 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil At -Grade ❑ Single Pass Sand Filter ❑ I I� Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ 11 r 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 (sQ System Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stec) Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank o0 Aerobic Treatment Unit r Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature M mber Business Phone Number ce Plumber's Address (Street, City, rate, Zip ode) S 9 ` 6_ Z VIII. County apartment Ose Onl Approved 11 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is uin Agent Signatur No Stamps) Surcharge Fee) p ❑ O n Reason for Denial 2 ]V --- 1/ IX. Condition of Approva I SYSTE y _ r SCA 50 r` f/ENT 4 T ,f fp EST /o 1v T &73 To/' AN go/Res SysiEr! Ec - yo -� s� SYs��rl Ec. = 9o,zs'' T fI Q6� \ D2AinlAG -E EASE/"IE/� T� 3x9 $6,9 t7 'T2�acN 3 J 7,1A - /o0 F 1. .......... ALRZE - 12F CD/2/0c �/ -�-= 1741 S% 0 7 S86 IlAu-e y )/c//)SaAl- a,)i'- s Yd'�L5 It s sy02s v ,� y c/�/v ria/V 101/ ;eS i - - - A'4 /e Ao" O 4o7 -_/ 3 - EE2 T/tA�L - S�r4 TEs )or S TC /Y C - _ - 3x9 ? /y ► R�rcra � - Or`s p - - _ 3 8 E r9 - t X2/7 S A t 1237 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt 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 percent slope, scale or dimemsions, north arrow, and location and distance to nearest Parcel I.D. 030? 6wv Please t r y ��'' � li t o r n ' ' ( ; (I ) �By Date Personal informatan you provide r*y be u a l PI+YP Privacy Lbw, s. 15.04 (1) v Property Owner j 1 Property Corder, Albert And Katie MAY Govt. Lot NE 19 NW 19 S 3 T 31 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSW 1701 Industrial St. No. 7 u�,;,� 13 Deer Trail Estates City S umber s I City _ I Village f/ Town Nearest Road Hudson I Wt 1 54016 715 - 531 - 0845 Somerset I 239Th Ave f New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Out ash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.5 gpd/sgft rating. Possible system elevation for Area 1 is 90.25'. Slope is 3.5°x. — See attcahed Memo Boring # J Boring 01 Pit Ground Surface elev. 93.20 ft. Depth to limiting factor 98+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF •Eff#1 - Efl#2 1 0-6 10yr32 none sil 2fsbk mfr cs 2m, 2f .6 .8 2 6 -16 10yr3/4 none sil 2fsbk mfr gw 2f .6 .8 3 16-3 10yr5/3 none sicl 2msbk mfr gw 1f .4 .6 4 9-69 7.5yr4/6 none is Osg ml gw — .7 1.6 69-77 7.5yr4/4 none sl 2msbk mfr gw .6 1.0 o •Z 77 -98 1Oyr5/6 none ft Osg ml — .5 1.0 Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <30 mg/L and TSS <,0 mg/L CST Name (Plesse Print) Signature: f CST Number Thomas J. Schmitt 227429 -A ddress Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 4/7104 715- 247 -2941 1 SOIL AND SITE EVALUATION 1237 Page of 3 PROPERTY OWNER: Corder, Albert And Katie PAR LDJ OV - o 7 /S�/ - �0 —CM Tom SchniW REPORT MEMO The proposed house for this site was going to infringe on boring number 3, so boring 4 was evaluated to enlarge the area. Boring 1 and 2 were completed by Adam Schumacher and are described on his report which is attached. The soil in boring 4 was very similar to what Adam showed in his report for bores 1 thru 3, as were borings I have done on other lots in Deer Trail Estates. Use the information provided in the 2 joined reports when applying for a sanitary permit. Qe Page 3 of 3 Conducted by: Conducted for: Schmitt Soil & Site Evaluations Name AN, f ar, d 1CoLALP Cyr -ae, Thomas I Schmitt, CST 227429 Address / ?v / -rOl dvs!n,'& f 9:l • /L/, 1595 72nd St. Cry, State, Zi p 1 4 ta /s o ", ws ,S -V New Richmond, WI 54017 Pho : 715.247.29 1 Subd. Name &aer rix,'/ Cs�at�s Lot No. /.? N-F 1/4, NW 1/4, S 3 , T s'/ N, R ZW , gown Township of f3h'1 . 100.00' Nad 0'07 o? " 4- EL �l.Q2v ' Slope =. S % Contour Line EL Uar-e D Qo�e 2 N 20' / rOPoSed �o+re 3 9r.CO' Scale: 1"=40' Qa r e y 93 a3� 4," Ave. ' br0. +n'�9e �asfr+ow�' a' qt G� 1 s,� B3 ?y 103 y 30 � 1 33' He 9� M I 04/1911999 20 7152473622 REMAX TEAM 1 RLAL j .� 1 f i r E 2 x '�', ti E 24.12 V) N �, of s� .8 `' ' 4R q CIE t � � + \ �� 2'39' 17 ` N . X CIS NO • • x w 1 � A��Q ^ p Co a q 9 all 231. t7 Zg' lvw .f 66 Nonndvi4oble Wetland 6211112M 90.:90 * WINI! yrwp p rAdQ SM EVALUAY ►4 REPORT o+ M � � 3 i nrr.�a.9rrrr.n..s. 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VMIt~ Oia�M�A1wd� own 11MM �� DII� 1r/lOMrIM� 71M� �1I�M Q�1�10� ,rrwr nWlt i� IbenM {lt §L ama hM� v R • `�N.�pp`.MS��WT,I+�!'lA��l `M�MItR ■,Dp SaPpIIL�l01RlS7�aIN- = M} e�0/• ��Y�1�1�sKWopp�M01W� !'�'iir�al�• N��yyq��IMaO[ eri we.:l h a dnenY lbe,�t OreY�,oe IM Mrs � (NOIrit or 17Y ice• . too@ 'I 1.S �IdNA1O tuvrism YY3 11:9l go/G/40 I R love* •t° �teS�•ittr:..� LOFA- LQ2 &�tlSlll�TS[.*u�sraeT —O _ M I MXVATWN j S? _ _ CLA NWIN Bit i ussawnw x I BflI61lNA'f!@i _ 5H 2 OIItCRIf x1ldN e.�I iw ?�'_' SY"WSLBVATWti R j ALTWMATd BLBVATXM � 0 0. _ _ — Cmmm msvATmw Nib ' 0 • r►` 1 • 800 Taus DIdx)L10 EBE4£TSZT9 xvd LT 9T EO /6Z /L9 _ t wiscgnsie Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings ) ` in accordance with Comm 85, Wis. Adm. Code Attarch complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S /'0 / 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. p'$ Z. Z I — h"O — am 6 )2 Please print all - e ewed by Date Personal information you provide may be used fo purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner / ,, Property Location 1 �- G @vt. Lot E 1/4 i(!W1 /4 S 3 T N R E (or) 10 Property Owner's Wailing Address I Loj # Block # Subd. Name or CSM# (D_ fYlSu zuo �} . i l �i1Q' et° ' S c2 City State Zip Cod ,Phone p� City ❑ Village (Town Nearest Road b e-0I ck I W 1 S Q� New Construction Use: ER Residential / Nu of ►+� Code derived design flow rate O d GPD ❑ Replacement ❑ Public or commercial - . Parent material (S 0+LAJ 5 lood PI elevation if applicable /tJ ft. General comments Sy5A f—( -e. V • C 1 Z • O C, O . `f f and recommendations: e (� �, Cl Z .00 OkLatlt- '6 5 Boring # F1 Boring ® Pit Ground surface elev. '?& Pm ft. Depth to limiting factor 1 214 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 l 6 i. 5 1/ m G 5 � • 8 Z i o S I J 2ma.b C- 3 yo - /Q LS )M C . /.2 y I � - - 0 5 rn I 0. &L ;F c Y2 -0 .`� SI S 3� FZ-1 Boring # Boring Q ® Pit Ground surface elev. ft. Depth to limiting factor O 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. i *Eff#1 *Eff#2 l O- 5 fl c l v-C . Z q -1 13 — Sid 2 i C - . 4P / 3 LS .'] I.L 3Z• !.�• * 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) Signatur CST Number 'qc/am 253 30 Address Date Evaluation Conducted Telephone Number 2// 8D?� e - Viz — 9 / �7i5 Zy Property Owner Kv r k6ws k, I Parcel ID # Page 2 _ of _ A [3 Boring # [] Boring © Pit Ground surface elev. r, &6 ft. Depth to limiting factor ial 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 6-5 io s .8 3 l -qo 1 16 ' yJ`f - Ls - --7 Z 16 - -.. ( 0 , S) D•Q 0•x �D 3•L . Z F -1 Boring # F1 E:] ❑ 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 ❑ ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 -- T * 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. SBD -8330 (R.07 /00) Wscgnsin Department ofCommerce SOIL EVALUATION REPORT Page 1 of Division of Safety and Buildings ft • in accordance with Comm 85, Ws. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must 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. Please print all I n Reviewed by Date Personal information you provide may be used fo purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner - Properly Location +�tLl ` G vt. Lot E 1/4 4IW114 S 3 T 3/ N R lC( E (or) 10 Property Owner's Wailing Address Lot # Block # Subd. Name or CSM# El City State Zip - Phone tu� City El Village Town Nearest Road a e l Lot v �' � ` f` .ru, e. f S-3 .5 f ._mss [ j? New Construction Use: ER Residential / Nu�nbe[ o - tieroolhs, Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial 63 C Tlescrits€y Parent material 3+CW R S y ` Flood Plain elevation if applicable General comments SySkPA- C4 -e- • 9Z- and recommendations: A-,6,4. -e-( t if, q Z . Q d I--/] Boring # ❑ Boring ® Pit Ground surface elev. V I sa 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 ! . 6 -/o 5 1/ 2 rnab k C5 � • F 2 o /v i J 2mab C-5 - 3 - 14 L5 ) M c . 7 1. Z y - ll3 - 05 rn _ .7 /. Z a Boring # ❑ Boring / ® Pit Ground surface elev. y 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. i - Eff#1 - Eff#2 _ ,o-q & Z sa z nocibk mec C ivy .F Z 13 — 5i c.! 2 CS 3 / 3 y LS /m rrA c S — . Z /-Z .`7 l.L " 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) Signatur CST Number tqc1Qno 253 30 Address Date Evaluation Conducted Telephone Number 2/i3 8D e DL - - 13 - Ov 71S 2g7-y008 Y • ♦ C PAGE OF__ NAME ur ,tSL. ' LOT# 3 LEGAL DESCRIPTIONrr ' /4,S 3 T 3 /,N,R /9 E (or) �D SCALE: 1 "= BM 1 ELEVATION — MC—) • 0 BM I DESCRIPTION vow: (; - ZY " Mar,� t ' X BM 2 ELEVATION ArjQ . U 3 BM 2 DESCRIPTION �,,; SYSTEM ELEVATION 9 G 0 ALTERNATE ELEVATION g Z O y CONTOUR ELEVATION AIA VCLAI s a 3 �a z. �w 546.9' SIGNATURE G" �� DATE Il N POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS Owner — Septic Tank Capacity DO a l ❑ NA C Permit # c�� 1 �Si Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model _ ❑ NA Number of Public Facility Units ® NA Pump Tank Capacity a l IN NA Estimated flow (average) o gal/day Pump Tank Manufacturer M NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer 0 NA Soil Application Rate , S gal/day/ft'— Pump Model M NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 8 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD.,) 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD,) 530 mg /L ® In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ 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: ® ear( )(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ® Ye th(s) (Maximum 3 years) ❑ NA 3 Clean effluent filter At least once every: ® month ❑ year ) ars ) ❑ NA � ) Inspect pump, pump controls & alarm At least once every: ❑ y ear(s) month NA ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) ®NA Other: At feast once eve ❑ month(s) i NA 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 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 ant*ire contents of the tank shall be removed by a Septage Servicing Operator.and disposed of in accordance with chapter 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. \ � i Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: I♦ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must - comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name T, Name Phone _ Phone - SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name — Name -� Z .,1. Phone Phone 7 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. ST CROIX COUNTY SEPTIC TANK MAiNumiJANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer N lc - L �Orc� E.r �'r� - 14ii f- Q— CQrcie.y- Mailing Address \ - 1 01 �.,r- ,c�yS o.� l� c �I A u c� 5 on , -oT S ` 4 c) I co c1 elm �v jorv��t^5£ WT Properly Address J 3 (Verification required from Planning (V reel arming for new construction) City/State Jov�nCx�S e-�- v--�T. Parcel Identification Number LEGAL DESCRIPTION Property Location NE V4, N 0 V4, Sec. 3 , T T3l N -R lLW, Town of 5oM A.�'SC.t Subdivision t- r -'y-o� k Lot # ( 3 Certified Survey Map # . Volume , Page # Warranty Deed # 7 Y.Z3 62 , Volume 1 "/, , Page # 4; -33 Spec house ❑ yes 14 no Lot lines identifiable M yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification foram, signed by the owner and by a mastcrplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal 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. sal standards Uwe, the undersigned have read the above requirements and agree to ma intain the private sewage disposal syste m with the star s ep set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, S tate of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. / sidbiATuRB OF APPLICANT 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 owners) of the property described above, by virtue of a warrant deed recorded in Register of Deeds Office. C.. dl&L.-o g` ` SIG14ATLJRE OF APPLICANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds Office a co ma if reference is made in the warranty deed of the certified su Y P U A ,% ul 3 [(3 3 5 DOGUMENT NO. STATE BAR of W F ORM 1 -1982 4 .3 3 6 7 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO.. WI RECEIVED FOR RECORD This Deed made between JAMIE W. ATKINS AND K121BERLY 10/10/2003 01:30PH A. ATKINS, HUSBAND AND WIFE WARRANTY DEED EXERT N Grantor, and ALBERT' - O t7FR _TR_ AN KATIE C CORDER Gr HUSBAGr REC FEE: 11.00 AND WIFE TRANS FEE: 130.50 COPY FEE: CC FEE: Grantee, PAGES: 1 Witnesseth That the said Grantor, for a valuable consideration RETURN TO conveys to Grantee the following described real estate in ST_ CROIX `- V @c0f'dff)Qt3. 111C. County. State of Wisconsin: 2925 Country Drive Ste 2C if St. Paul, MN 55117 Tax Parcel No: 032 - 2141 - 80-000 Lot 1 , Deer Trail Estates I illll 1011111111 IIIII IIIII Illll IIIII liin IIIII IIII llllii III {I Iiillh liiii III IIIII IIII IIII u1S98637S 01 WARRANTY DEED REF# 100159P US R— rdingo This 1 homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And_ Graator warrants that the title is good, indefeasible in lee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this 25th day of Augmqt 20 (SEAL) SEAL) W. ATKINS KIMBERLY A NS (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF MINNESOTA e ss. County. J authenticated this day of • I y{tyAUSDAL Pe r came before me this 22nd day of r+ !�• �'' NOTARY PUBLIC - MINNE st 20 03 the above named r s on E xim es 1 .31 AND WIFE ■ w v r.n^^^^^^^ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the pars who excuted the authorized by § 706.06, Wis. Stats.) foregoing Instrument and ackno a ge the same. THIS INSTRUMENT WAS DRAFTED BY NETWORK TITLE INC 490 West Highway 96, Suite 300 Shoreview, MN 55126 Notary Public County, MN. (Signatures may be authenticated or acknowledged. Both My Commission is perms nt. (If not, state expiration are not necessary.) date: I 20 .) 'Names of persons signing in any capacity should be typed or printed below their signatures. NF 3573 WARRANTY nFED STATE BAR OF WISCONSIN Net— Forms, P,O. Box 10208, Green Bay, W154307 -0208 43,3 2 N89` i7 1 "E 58 oY� � ' A, D f i ��r .; .. .. ., , ....,,...., ..... x L or 13 pl. 0 J.00 AC ):FE- 9M2 ►viate, 1G1 4?• 42540' 106,95' N89 "50'27" 532.35' _ i {{ _ / n j� ---------- . - ----.----.. .--------------------