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HomeMy WebLinkAbout032-1032-10-050 County Safety and Buildings Division 201 W.Washington Ave.,P.U.Box 7162 Sanitary Permit Number(to be fisted in by Co.) f�D Madison,WI 53707-7162 R� State Transaction N mber ST.GRUIp �ennit App1i (`{ Wis.Adm.Code,submission of this ro �unit In accon� S 383.21(2), is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of safety and Professional Servies. Personal information you provide may be used for secondary u in accordance with the Priva Law,S.15.04(1 m Sats. I. A lication Information-Please Print All Information Parcel# Property Ow is Name ? / Property Location 3 A/� Property Owner's Mailing Address Kl Govt Lot Zip Code Phone Number -/,-,:LL Section _ City,State circle one T �31 N; R .Eo Lot# H.Type of Building(check all that apply) Subdivision Name 011 or 2 Family Dwelling-Number of Beds i �x Block# ❑Public/Commercial-Describe Use ❑City of CSM Number ❑Village of T ❑Sate Owned-Describe Use Town of m6CZ411 III.Type of Permit: (Check only-fine box-ond!tip A. Complete line B if applicable) A' ❑New System Replacement Sys ❑T�ro��olding Tank Replacement On1Y ❑Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued owner Before Expiration IV.T e of POWTS S stem/Coro onent/Device: Check all that a l Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil ©Mound<24 in.of suitable so ❑Pretreatment Device(explain) ❑Holding Tank ❑Other Dispersal Component(explain) V.Dis ersalfrreahnent Area Information: Area Required(� Dispersal Area Proposed( System Elevation , Design Flow(god) Design Soil Application Rate(gpdsfy r/ Capacity in Total #of Manufacturer VI.Tank Info Gallons Gallons Units ° New Tanks Existing Ter 3 — a�U iA Ca t: C7 G Septic or Holding Tank Dosing Chamber VII.Res o ability Statement-I,the undersigned,assume responsibility for installation of the POWTS shown the attached l p��Number Plum 's ame( t) � Plumber' i l Plum s A dress(Street,City,State,Zip Code) V Coun /De artment Use Only Permit Fee I Dayt Issued t Issging Agent S Approved ❑Disapproved $ ❑Owner Given Reason for Dental Ix, avgMasons for Disapproval 1.Septic tank,effl e Iter and / Awe dispersal cell must be., !maintained j as per management plan provided by plumber. ri f�j 3 �MvK 2.All setback requirements must be mai . �� leas for the system sa wit to a County only on aot less ehsa 8 1R x 11 iadws ja sizes, p_ 4 W�_� CONVENTIONAL COMPONENT DESIGN Residential application INDEX AND TITLE PAGE dex. r .: 'Etl e:::::::::::::::::::::::::.:::<.:<.::::::::.: Pro'ect 1 .FF Name. S X. ...:..:...::: ::f• .:.....:::::::::.::::.:...... :......::::::::. Owner s ::.; ; .:<.;:,:. Name: to>q a h,I'd r. .> i is < ><? Owner's er s b ><?< < >! .... Address:ar Pt #rr M .......................... ae.F�rnn_::::: IP A.. tte....rr.:...:.....:......... .:... .....: ...................... :::::::: Legal Description: % -= tf � ��1�/- elgR ! Subdivision: i /7—'�/c�g Lot# Town: 71- County: ��L2,6�X Parcel ID# Designer/Plumber: License # Signature: e� /%7i Date: S;/o - Comments Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 Index+Title 2/2/2012 L - � ! � _ - -- I � 1 I I I r , I i I I II I I ( I I I , i r , I I y I .I I 1 b�f�i1'6G. i f I I ; I I I I I : i I I r , I L � I - I { : i : I I Soil Absorption System Crags SmSon ft Final Grade 4°Schedule 40 PVC Vent Pipe cy With Vent Cap Leaching cI/ �,t Chamber system Elevation 3 ft Soil Absorption System Plan View ft 3 ft 1 teaching Trench 9 ft Vent Or Observation Pipe Chambers DA) 6�VDS-- . r IMM I I I I[I I I I I I I I Maw 47 Dia. Trench 2 Header Leaching Chamber Slaectfications Manufacturer And Models-( r �� EISA Rating sq ft per chamber Soil Application Rate gpolS4 ft gpd Design Flow+ • � Soil Application Rate EISA= �' .Chambers 2 rows of chambers each. Leo VMPr X Page (-f� of 6 ui Z 0 U' w Q ~lL 1 1 N CL N F— wU- d/ tz V) ono LL r� Q ih 85 (D C14© Q O O O W r- r- co LL LL. LL m 0 CD C7 „( L1J O o "( H _ u,�Lu mow�// r J _ {1 Q LL <O Q W LL O LL LL r rn r 0 0 N Z O¢¢ w K H J_ O LL LL W d� O� LL O LL LL �m rn cV m 0 O O N \i1 O O rn r F O a w -- Y U p ¢O co 0 Ow w w LL LL w ma ® N O co of J POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pagrror_ FILE INFORMATION SYSTEM SPECIFICATION Owner ,,/ Se tic Tank Capacity aI n NA Permit# Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Model ❑NA Number of bedrooms ❑NA Pump Tank Capacity al 6 NA Number of Commercial Unit ❑NA Pump Tank Manufacturer .rat NA Estimated flow (average) gal/day Pump Manufacturer n NA Design flow(peak), (Estimated x 1.5) al/d Pump Model o-NA Soil Application Rate gal/day/ft" Pretreated Unit Influent/Effluent Quality Monthly Average* o Sand/Gravel Filter o Peat Filter Fats, Oils & Grease(FOG) <30 mg/L n Mechanical Aeration o Wetland Biochemical Oxygen Demand(BODs) {220 mg/L o Disinfection ❑ Other: Total Suspended Solids(TSS) <150 m Manufacturer Pretreated Effluent Quality ❑ NA Monthly Average** Dispersal Cell(s) �In-ground(gravity) ❑In-ground(pressurized) Biochemical Oxygen Demand (130Ds) <30 mg/ ❑ At-grade ❑Mound Total Suspended Solids(TS S) <30 mg/L ❑ Drip-line o Other: Fecal Coliform(geometric mean) <104 efu/100mL Maximum Effluent Particle Size '/s inch diameter * Values typical for domestic(non-commercial) wastewater and septic tank effluent. ** Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every o months ears (Maximum 3 rs) 'Pump out contents of tanks When combined sludge and scum equals one third(1/3)of tank volume Inspect dispersal cells At least once every o months jd ears (Maximum 3 rs) Clean effluent filter At least once every ❑ months year(s) Inspect pump, tun controls &alarm At least once every ❑ months ❑ ear(s) 0 NA Flush laterals and pressure test At least once every o months ❑ ear(s) cd NA Other: I At least once every o months ❑ ear(s) NA Other: At least once every ❑ months in year(s) ANA 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 ('/3)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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components,pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION For new construction,prior to use of the POWTS check treatment tank(s)for the presence of painting products or other chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s)removed by y-a septage servicing operator prior to use. i Page(of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scrap's; 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. i • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area w)T 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 —1, ology a holding ank may b�%�ms a ed a I t reso to re lace tt�e failed POWTS _ Lps):evaluation The 'site a not bee eva ua e o identify a suitable replace nt area pon failure of the POWTS a soil and site 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 IN 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 INSTALLERo POWTS MAINTAINER Name - Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.2421(b)(1)(d)&(f) and 83.54(1), (2) &(3),Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MALNTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address SCE (Terification required from Planning&Zoning Department for new construction.) City/State_�F�s Cv��s � Parcel Identification Number�� - .1031 - LEG-AL DESCRIPTION Property Location 1 X1L 1/4,,�u J 1/4 , Sec.�, T,ZLN R__,�2_W,Town of Subdivision Plat: /7 — %f:A ,Lot# �. f fertified Survey Map # ,Volume / 7 ,Page# Warranty Deed# :Z`7 / % (before 2007)Volume Z Z ,Page Spec house 0 yes$r o Lot lines identifiableeyes 0 no SYSTEM NLA_]ENT 'ENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS.383.52(l)and in Chapter 12-St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we.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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix County Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s)of the property described above,by virtue of warranty deed recorded in Register of Deeds Office. Number of bedrooms All 1 ' up i- I d I V V IG A OF APPLICANTS) 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 map if reference is made in the warranty deed. (REV.04112) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) located — at: xjo) 1/a, i/4, Section_/l , Town _N, Range J9 W, Town of �'6e�6 , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab Concrete Y Steel Other Manufacturer (if known): /'I f=, -5 Age of Tank (if known): 3 Permit num r (if known) -s (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 V. gH "7 3 P, 31H � �\ II'' u p 1 u 74 1 X48 STATE LIZZF W�C�N5IN F&I{S 2l 1999 WARRANTY DEED KATHLEEN O DEEDS Document Number REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Richard Plourde, a/k/a Richard L. RECEIVED FOR RECORD Plourde, Grantor, and Michael S. 09/30/2003 10:15AK Peterson and Lvnsev L. Peterson,husband and wife, Grantee. Grantor,for a valuable consideration,conveys and warrants to Grantee WARRANTY DEED the following described real estate in St. Croix County, State of Wisconsin EXEMPT # (if more space is needed, please attach addendum): REC FEE: 1l.00 Part of the NEIA of SWIA and Part of the NWIA of SWIA of Section 11, TRANS FEE: 138.00 Township 31 North, Range 19 West, St. Croix County, Wisconsin COPY FEE: CC FEE: described as follows: Lot 3 of Certified Survey Map filed September 11, PAGES: 1 2003 in Vol. 17, page 4608, Doc.No. 739713. Together with Joint Driveway Easement as shown in Vol.2398,page 532, Doc.No. 738643 Recording Area Name and Return Address River Valley Abstract&Title,Inc. 1200 Hosford Street,Suite 201 Hudson,WI 54016 032-1031-95:032-1032-10 Parcel Identification Number(PIN) This homestead property (is)(is not) Exceptions to warranties: Easements, restrictions and rights-of-way of record,if any. Dated this 9t day of September 2003 * * Richard Plourde a/k/a Richard L.Plourde AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) _ )ss. St.Croix _ County ) authenticated this day of Personally came before me this 2r day of _ September , 2003 the above named Richard Plourde,a/k/a Richard L.Plourde TITLE:MEMBER S ISCONSIN (If not,— 'PIA to me known to be the person(s)who executed the foregoing authorized by _1jCgKP . i trument an ac ged the same. ,,,,t�pp�� of w '�+� THIS OWMENT WAS DRAFTED BY _ Attorney Kristina Ogland 304 Locust Street Nota13 Public, tale of _ Hudson,WI 54016 My Commission is permanent. (If not,state expiration date: (Signatures may be authenticated or acknowledged.Both are not necessary.) — ) *Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co.,Food du Lac,w1 STATE BAR OF WISCONSIN 800.655-2021 WARRANTY DEED FORM No.2-1999 �s t. {' 0 qlit ;va ` N CO Q ' (Y) c� N 00 r o LO Z LgE ! L egg It N g�O t- i Wisconsin _Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety aj1A Building Division Sanitary Permit No: F INSPECTION REPORT 430383 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: Plourde, Richard I Somerset Townshi CST BM Elev: Insp. BM Elev: BM Description: _ Se tion/To ange /Map No: -p' �,�� QtrC = CST%uw � 11.31.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 12.60 Benchmark ' 3 Dosing Alt. BM Aeration Bldg. Sewer 9 77 , 3q' Holding SUHt Inlet �� r � TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , �r 7 }S / r Dt Bottom Dosing (O Header /Man. / Aeration Dist. Pipe 9 . 0 9 9S . 22 9 -z .o Holding Bot. System I C • 35" 9 95 PUMP /SIPHON INFORMATION Final Grade 30 i Manufactur Demand St Cover PM Model Nu ber TDH Lift F<ction Loss System Head TDH Ft Forcemain Leng Dia. Dist. to Well SOIL SORPTION SYSTE RENC idth f Length No. Of Trenches PIT DIMENSIONS No, Of Pits Inside Dia. Liquid Depth DI S 3 19 . s ea. Z SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Man Fture Z INFORMATION Type Of System: ' I I f CHAM OR Model N � DISTRIBUTION SYSTEM Header /Manifold t Distribution x Hole Size x Hole Spacing Vent to Air Intake Pi e(s) Length Dia Le Dia S 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 � �; No COJETITS (I `c e e discre en p rsons present, etc.) Inspection #1:� /� Inspection #2: / Loc Ion: 632 222nd Avenue Somerset, WI 54025 (NW 1/4 SW 1/4 11 T31 N RI 9W) NA Lot 3 Parcel No: 11.31.19. '� 1.) Alt BM Description = � aP � S'� ( &,G&, , 2.) Bldg sewer length =46 - amount of cover = j 19 If Plan revision Required? [J Yes X No Use other side for additional information. 44ij� SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. r Safety and Buildings Division County ` 110 m 201 W. Washington Ave., P.O. Box 7082 isconsin Madison, WI 53707 — 7082 Sanitary Permit Number (o be filled in by Co.) Department of Commerce (608) 261 -6546 330 3 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, sI5.04(l)(m) Proje Address (if different than mailing address) i. Application Information — Please Print All Iniormatio ` V`�` ^� /S Property Owner's Name SEP 19 2003 Parcel # Lot # j oak # Property Owner's Mailing Address S1, C R O I X C U U N T Y Pro Location ZONING OFFICE &I ' /. City, State Zip /Z Code Phone Number _ . s y / � (circ ow) ) T � N ; R) - E o(. II. Type of Building (check all that apply) 1 or 2 Family Dwelling - Number of Bedrooms J� t " ,f Subdivision Name CSM Numb ❑ Public/Commercial - Describe Use p / / El Owned - Describe Use �� �j I }� O -� ity_❑ V i go �kownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/HoUng Tank Replacement Only g System Ys ep ys Other Modification to Existin S rem B, List Previous Permit Number and Date Issued ❑ Permit Renewal ❑permit Revision ❑Change of ❑Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl Non — Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber Q Drip Line ❑ Gravel -less Pipe Q (ex lain) V. Dispersal/Treatment Area Information: — 00 Design Flow (gpd) Design Soil Application Rate(gpdsf) bispersal Area Required (sf) Dispersal Area Proposed (sf) yttem Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersign d, assume responsibility for installation of the POWTS shown on the attached plans. Plumber' Name (Print) Plu er' i re MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) q VIII. Coun /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued sui g Agent Signatur o Stamps) Surcharge Fee) , ❑ Owner Given Reason for Denial 2 � �J IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER, 1 Septic tank, effluent filter and �oca� 1 c + iS (11" CST - dispersal cell must all be serviced / maintained �'�1 u V as per management plan provided by plumber. � _ St,+\C� 2. All setback requirements must be maintained 13nn as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 Inches in size SBD -6398 (R. 08/02) L .i- 21 n 0 0 b i I AIM 1 . ............ 4 zb I / i � .7 r ' 'Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County C Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. lkft Please print all information. R v Date Personal information you provide may be used for secondary purposos (Privacy Law, s. 15.04 (1) (m)). 'Z(p 3 Property Owner Property Location p i t /� � t''jQ Govt. Lot NW 1/4S� 1/4 S // T3/ N R 7 ! (or Pro pe Owner's Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code ( Phone Nu er [3 city E) Village 2] Town Nearest Road 0►" tfe t,�1� Y /S z S 7 z 7� 7- 5 /`i 2�Srr ❑ New Construction Use: R Residential / Number of bedrooms Y Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material y i W e ) O u r L- e- S S Ps. z Flood Plain elevation if applicable IV ft. General comments and recommendations: © Boring # E] Boring Q ® Pit Ground surface elev. / �� yS ft. Depth to limiting factor Z Z 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 Z - 2G 7sr� /1/A S/L 2,1 P. P C w e D b S a , 8 -3 U �� 75 IVA c `'' Z r� O 7 1, 122 7. Sfi/e C 0 -71 I . Z ° _7 . Z Al Z-- F21 Boring # E] R] 8S © pit Ground surface elev. � ft. Depth to limiting facto 2 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I 'Eff#2 o_ SG /6 JS /C r L c 2 C O, y o. 6 iv Z - 2 Y 7,5 k AIA S i G 2 /hc ,- c w 2 c O. S 0,9 3 2 Y 5"1 7,-r r/ % /V.* ^ S OS )Pl L c 44, r 0,7 I /b ; i /VA 6 s 0 -r? k — -- 0-71 1. 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 liame ( Pr� .signature 2 C ember /!70 -'� 4 e �l ! Address Date Evaluation Conducted Telephone Number 2 Cc e A ►"L��S -r l�L 6 - �2 S' e-7 7 /J =zY7- -72o-7 SBD -8330 (R07 /00) j 1 i l i " Property Owner 2 I ccd e Parcel ID # Page 2 of a Boring # ❑ Boring ®pit Ground surface elev. , 2 S ft . Depth to limiting facto /2 C� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDt t in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 3 32 -1 71r i7r /n Z- C- w >� 0,7 /, 2 �� 61 - 1 2 v 16 �,4 its Ds n Z- — 0 .7 1 F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F1 Boring # ❑ ❑ Pit Boring Ground surface elev. ft. Depth to limiting factor 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 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.07100) I� `0 v."NE R Page 3 of 3 Nadie. & Jr Brian Parnell Address 6 ZY 2 2 o 'I -r,4 CST 231314 Date 6- Benchmark 1 0 4 2 82'- �L Benchmark 2 -r e e, Soil Boring Suitable Area 1 40' Scale 0 —1 -MP7� s 1",4 !7� j L i i 1 — I i 7 — ---- - L n W, FBI Al NAV A, Ms Mon �►� � _ •r r � � �� `.� �t POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page -I- of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity a l ❑ NA Permit # O� Septic Tank Manufacturer �� S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 1/ ❑ NA Effluent Filter Model O ❑ NA Number of Public Facility Units 12-NA Pump Tank Capacity a l -I NA Estimated flow (average) gal /da Pump Tank Manufacturer EYNA Design flow (peak), (Estimated x 1.5) �i gal /day Pump Manufacturer 0-NA Soil Application Rate al /day /ft2 Pump Model -9 NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit MNA 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 .0 In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfU /100m1 ❑ 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 3 Oyear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 0 year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA J► year(s) C Inspect pump, pump controls &alarm At least once every: ❑ month(s) NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) 0 NA ❑ year(s) Other: At least once every: ❑ mont ►(s) 0-NA 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 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 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS 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 INSTALLERJ POWTS MAINTAINER Name 22 Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL RE ULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND 1 OWNERSHIP CERTIFICATION FORM Owner/Buyer �(f.)erd /Out- C4�- Lo I Mailing Address 62- 2 ZU ,r c- orner - U 2 S Property Address (Verification required fr m Planning' epartment for new construction) City/State �s��' h �,5 Parcel Identification Number LE GAL DESCRIPTION Property Location A�A2- ' /4, -5L,) '/4, Sec. �L, T-ZLN -R LW, Town of Subdivision _ Lot # Certified Survey Map # ����� /� , Volume /7 , Page # Warranty Deed # �'�.�3// , Volume �, ,Page # Spec house N yes O no Lot lines identifiable 0 yes O no S YSTEM 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 form, signed by the owner and b} a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposa I 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 standa :s set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certtficattott stating that your septic system has been maintained inust be completed and returned to the St, Croix County Zoning Office within 30 dais of the three year expiration date, 7 1 17 1 U SPINATURE OF APPLICANT DATE O WNER CERTIFICATION 1 (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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office, SIONA "f RE OF APPLICANT DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department.'• " * *• ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Doaxvint No. TRUSTEES DEED x 52311 VIx 1209MUJIT REGIJTE7, V iZ . � cacuc coy vn Firstsr Bank VVfa=nIn, aWa Firstar Trust Deparbnent, Trustee of the bust cxeated under the Wfii of Ralph Wilfred Plourde, taN 1$ 1996 for a valuable cc tvideradon, oonveys, wf xo wan dy. to Rk;hard Plourde, ft following deuxibed real estate in St. Croix County, a t 4 0 0 �P P. M State of Wisconsin.r ' SW % of Sec. 11, T31 N, R1 9W Except that parcel contained in CSM Volume 3, Page 847 Filed on 8-20 -1979 : Retum to: Richard Plourde 624 220th Ave. Somerset, W1 54025 032- 1031 -95, 032 - 1032 -10, 032-1032-30, 032 - 1032 -40 (Parcel Identificadon Number) This is not hor. stead properiY. Dated this day Of g, V f NL6C r . 1996. FIRSTAR BANK WI - SIN BY. i STATE OF WISCONSIN);, Eau Claire County - carne before me this day of L4 1996 the above -named ' • ��l_ . to me known to be the person who executed the forspoirp i�strumsnt and acJcnowled�ed the earns. . O fd Notary Pubic, State of Wisconsin_ My conunisakxt ' A A M.,rw.aon+�-- THIS INSTRUMENT DRAFTED BY: �k A. y My EW . m it IM . R. Sch - La wyer E Stephen � State Bar 001013907 110TARY 9 PUBLI ) ♦f s el Vl �is�� '• TY R. DODGE S•2484 r 7 3 9 1 9 CLEAR LAKE, : �� VOL 17 PAGE 4608 <� •.,.,, wl •••' o \,� KATHLEEN H. wALSN -- %, Np SUpv �t� REGISTER OF DEEDS rrrurinnnntu��' "��° ST. CROIX CO.. wI CERTIFIED SURVEY MAP RECEIVED RE CO R D 09/11/2003 3 01:00PM Located in part of the Northeast Quarter of the Southwest Quarter and part of th SURVEY MAP Quarter of the Southwest Quarter in Section 11, Township 31 North, Range 19 Wesi AEP 13.00 Somerset, St. Croix County, Wisconsin. COPY FEE: Prepared for and at the request of: A special exception use permit is required gAGWV dis3urbance of slopes RICHARD PLOURDE 20% or greater not Identified on the approved plot or CSM. This permit 624 - 220TH AVE. is applied for through the zoning office and is reviewed through a public SOMERSET, N 54025 hearing process by the St. Croix County Board of Adjustment. Drafted by. Michael H. Lynakey U_N L A N DS --S88'33'59"E 5339.80 - East /Wes 114 line 588 "E 269.36' r C 588'33'59 "E - 1158.21' CONTIGUOUS 000 0 •' {' r ' N w N - � BUILDABLE AREA: 4 N 3912.23' 98,472 sq. ft. o 2.26 acres l O n �n N X 1 ,, C p� Z -P , p �O W 47 W W W W D [ 3 O W -4 �4 W W W 0 Q. v O avv Ct Ct Ct q N c �� 113 = � a 1 � l Z � 0 0 � ;. �" APP V D � 3 � w� 1 -0 W • p, W W - x' o 0 r* �G2 ? C � ST. CROW; OIJNTY � �' j' I D L-4 o W ni o n ? O `' �o �'lannlno Ionina s� arks Comr,itlee W 3 —� U1 4h. U1 o .P � -+ s �° ����, S E P 2003 (n o W -16 -P, `t.fD«fv o n \ c�D V D _ If not recorded 001 in 30 days of t Z cn o P oo y co y u, \ �Z approval date � oval shall hR :r j+ oo w O E �� null vW old U) 0) C7 a O v J �► J J J C: M I ° ' LOT 2 P 9DO 4 � P0 . J O = < o' o L 0 Ln L '`r f< r« 5 S88'24'11 "E Tt7TA AREA: =' `� ' 168,187 s ft. I • • �, v' A N�� W CD o =r%a 260.70 4 3.85 acres 0 D 0 CL ZZ 16 0 N w cn � 0 l v °O �' S2 Q ' L . ° v1 6 � ++ v1 o m i 16.e wo. owe' = w o W �a 2 LOT W W C9 Ln W M O a h" T EA: , t^ i s Ln N irk L! D 0 �O 13,3, 136 sq. ft. 3, 06 acres °oW CONAGUOUS 10 a_`D 3n r� �305�5 sq. AR ., o ��� . � $�rts \ �2 J. 00 acres N c Z a �� � rvF , i o �m n�a� �� D) nN 4%, v y m C� so rn to D LA Obi N (A N ;0 150 0 150 Z w g w $ N GRAPHIC SCALE •<D / SCALE IN FEET: 1 inch 150 feet / ��j 00b- r NO TH a , , 1 16 ef t �3 OW q e x/ / �p S 96' LEGEND Section Corner Monument JOB # W1057SD25 <` of Record. Prepared by. � Set 1" x 18" Iron Pipe weighing NW !Z - r/4 1.13 pounds per linear foot JUU ConsuV 1V GMUP, Ina SW 1 /4 -sw 1/4 — Areas of 20R or Greater Slope Phone No. (715) 246 -4319 Fax No. (715) 246 -3830 P.O.. Box 325 BEARINGS ARE REFERENCED TO THE EAST/WEST QUARTER New Richmond, N 54017 LINE OF SECTION 11, TOWNSHIP 31 N., RANGE 19 W. Sheet 1 of 2 WHICH IS ASSUMED TO BEAR S8833'59 "E, Vol.17 Page 4608