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HomeMy WebLinkAbout032-2163-01-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 506174 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: CSC Development CO. I Somerset, Town of 032 - 2163 -01 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: 'l1 .9 A4- (3A G S ( 14.31 . 19.1393 TANK INFORMATION ELEVATION DATA ti TYPE MANUFACTURER ,Ar CAPACITY STATION BS HI FS ELEV. Septic 'r Benchmark 9„�• Q(m F,•► L QQk9ir 1A b Alt. BM Ft Qe -_� ,- i.d T i8l l�0 3 •� �i 9 r Aeration BI g. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION StlHt Outlet ZP • TANK TO P j l WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 5D 0 /o � + Dt Bottom Dosing �7 l!J Header /Man. $ �D3 ��7 - 1 3 Aeration Dist. Pipe Holding Bot. System 9 • t4 &?I, / Final Grade PUMP /SIPHON INFORMATION ( 0- 15 17• Manufacturer Demand St Cover GPM IF, GOJQ.J` 9 Model Number 77 , Friction Loss System He TDH Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width , Length + No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 . r- - _ ' I,,,* SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: (► INFORMATION CHAMBER OR - 1rJ'� ��I Type Of System: • 4� # w A— A) ^ UNIT Model Number: J , DISTRIBUTION SYSTEM 4 4711L Header /Manifold 11 IlDistribution le Size x Hole Spacing Vent to Air I/ttak � Pi e s Z_ + l �f Length �` 5 Dia Length ` Dia \ Spacing \ w SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded r Mulched Bed/Trench Center • p t Bed/Trench Edges NS Topsoil . Yes a No Yes a.F No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 2104 62nd Street Somerset, 1 540 5 (SW 1/4 SW 1/4 14 T311N R1 9W) Gavin's Acres Lot 1 L Parcel No: 14.31.19.1393 1.) Alt BM Description = , Id Sek,e�.. �" G O J e�►D .,J� JG �et�S 1 2.) Bldg sewer length = ZI 1 - amount of cover = d ,'a Plan revision Required? 11 Yes No Use other side for additional information. "C� 7 Date Insepctor' Signatur Cert. No. SBD -6710 (R.3/97) 1 commerce.wi,gov Safety and Buildings Division Co ty 201 W. Washington Ave., P.O. Box 7162 sco n n Madison, WI 53707 -7162 Sa ary Permit Number (to be filled in by Co.) t i nepartment of Commerce 5 17 1 - Sanitary Permit Application St Transaction be In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the approp over to unit is required prior to obtaining a sanitary permit. Note Application form e WTS Pr t Address (if different than mailing address) submitted to the Department of Commerce. Personal info �ryaidL' ed fo idary p urposes in accordance with the Privacy Law, s. 15.04(1)(m), St ts. CV G 1. Application Information - Please Print All Informa ion Property Owner's Name M 0 2 ' # f z- Z1co3- of -000 Property Owner's Mailing Address OIX CO Pr rty Location s cR �. / 3 1 13 ) Go . Lot City, State Zip Code Phone Number y, - y, Section ircne T N; R�le o Eo &) 11. Type of Building (check all that apply) ak Lot # V 1 or 2 Family Dwelling - Number of Bedrooms p Su ivision Name °a~ Block # 1 ' ❑ Public /Commercial - Describe Use _ r ! .L. " '. ❑ ity of le— AZ ❑ State Owned - Describe Use CSM Number ❑ Willage of / o I own of A III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System y El Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ I t her Modification to Existing System (explain) B Lis revious Permit Number and Date Issued El Revision Change of Plumber Transfer to New Owner 4 3 C / S IV. Type ofPOWTS System/Component/Device: Check all that appl Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil 4ound < 24 in. of suita s ot ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Devic (explain) V. Dis ersairrreatment Area Information: EJ5 Design Flow (gpd)� Design Soil Application/ ate(gpdsf) Dispersal Area Required (st) Dispersal Area r osed (st) System Elevation v / VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o o Existing Tanks '« c Y New Tanks Q R eSd- F'l /✓ a. U in y Ln Septic or Holding Tank _ Dosing Chamber 1_�_ VII. Responsibility Statement- I, the undersigned, assume responsibikW for installation of the POWTS shown in the attached plans. Plumber's N e ( nt) Plumber's S nat MP /MP Number Business Phone Number Plumber's A dress (Street, City, State, Zip Code) � Vll ll l. Count /De artment Use l Al }!Q"Approved ❑ isapp Perm t ee Date sue Issuing gent Si raturY iven Reas r Denial IX. ConditM10easons for Disapproval 3> J. a J2lo (`6J . 1 - }p,M ` t. Septic tart, effluent fNter and a ; ->., N e t.v 1 Tot^^�o dispersal cell must all be services / maintained as per management plan provided by plumber. 2. AN setback requirements must be maintained Attach to complete plans for the system and submit to the County only on paper not less than 8 11 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 .4o '30VW. M3TZY8 1111-3 Arf : Aoa t , G l 0.a � 2 _j Nr (� 4 Q �J 2 _ lu PHONE NO. --'152 i F70G Tun. 26 22Wv 11:11Hti P1 ��q .'P'iYG,11Y iY .YatGwelilrxa+lu :RS■su �----- .•_._..� .._._._--- -- ----� �� .. —_�. Z � 1 i j i � xw WNwom -Ma .0SY3NOS JO N1,40 It momm y IR. -" ZT. � 1421M;151'R� 11 °t .... .............. ................ ozl all Q' :r wb, Em ah ILL FJ I I C 4 , La DOW, S.W.W"4 % ri Q} i 14 -41 ° I d aa 0 ki v -6 sit �•e r •, I � "� � � II �I'1�+ +'� t g :,a.; �a'y�q,. 1 I �j� �x � .�� 1 AXW.. - M T. N t Gar► -¢ / � c�r�•� G'`'� 1113 Wisconsin ,DepartmentofCommerce SOIL EVALUATION REPORT / P age 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code 02/ig G d JT, 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 pant (BM), direction and percent slope, scale or dimemsions, north armw, and Location and distance to nearest road. Parcel .l. . Please print all information. h e Date Personal infmr oa6on you provide may be u for 04 (1) (m)). '7 1( f Property Owner roperty.Location Grand Properties, LP Povt. Lot SW 114 SW 1/4 S 14 T 31 N R 19 W Property Owner's Mailing Address JU N 9 20 t # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 1 1 Gavin's Acres City State ip Codg N rGtklilth `i City Village Town Nearest Road Somerset i WI 54 G F Somerset 60Th St. ✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Plain Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system witha 0.7 gpd /sgft rating. Possible system elevation for Areal is 95.0'. Slope is 7 %. Boring # Boring ✓ Pit Ground Surface elev. 98.62 ft. Depth to limiting factor >1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPQM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-16 1Oyr3/2 none sl 2fsbk mfr cs 2f .5 .9 2 19 -27 1 Oyr4 /4 none sl 2fsbk mfr gw 1 f .5 .9 3 27-66 7.5yr4/4 none lcsbk mvfr gw - - - -- .7 1.2 4 66 -101 10yr516 none ms Dsg ml ---- - - - -- .7 1.2 ❑ Boring # Boring ✓ Pit Ground Surface elev. 98.62 ft. Depth to limiting factor >100 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 1 0-8 1Oyr3/2 none sl 2fsbk mvfr cs 2f .5 .9 2 8 -19 1Oyr4/4 none 1s 1csbk mvfr gw 1f .7 1.2 3 19 10yr5/4 none ms Osg ml gw 1.2 4 1 44 -100 Oyr5 /6 none ms Dsg ml - - -- - - ---- 7 1.2 1 3. qq 46" * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: , ,, CST Number Thomas J. Schmitt , 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valley View Trail, Somerset, WI 54025 6/5/02 715 -549 -6651 Property Owner Grand Properties, LP Parcel ID # Page 2 of 3 F Boring # Boring ✓ Pit Ground Surface elev. 96.41 ft. Depth to limiting factor >96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr3/3 none S1 2fsbk mfr CS 2f .5 .9 2 8 -22 10yr4 13 none sal 2msbk mfr gw 1f .4 .6 3 22-42 10yr5/4 none ms Osg ml gw --- - -- .7 1.2 4 42 -96 10yr5/6 none ms Osg m1 --- - - -- .7 1.2 Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 U 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ' Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD E_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 naafi .mntawj�l in .in �lra.nn4a fn,+n�t nla�oa r.nnt.�nt the ilan�dmant �} lJl 7!_1. = '21 G1 n� TT'y . l._/lit_7.f_.A 4'1'7'7 1 1 6avllld Acees p 3 Q6 a 14- o 63 /Say 76 � 90 f � cos �8' ss -IFf P id' /o PrcpO�ua N'1 p urc...l,, 7X �, s .T, se 7V liei JG,d s1 • G 5 TM a?d 7 9 5c - e ✓ -d &.n S i/Oa.2S` ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C E C ,De ✓e/ d1*4 - Mailing Address ' Property Address (Ve f cZt"7 ed from Planning & Zoning Department for new construction.) City /State - Parcel Iden tification Number LEGAL DESCRIPTION Property Location - jij 1 /4 , ��ilr 1 /4 , Sec. , T - .-YJ — N R_Z9_W, Town of Subdivision . _ �A��.�:uS��E/.°E� , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # Volume - ,.2 Z , Page # Spec house no Lot lines identifiable no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system Owner maintenance responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein. as set by the Depar of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our 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. Number of bedrooms 3 i / i SI ATURE OF APPLICANT(S) DATE *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department * ** _ _ certified survey ma if _ i ude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certif'i p - PP -ence is made in the warranty deed. - 7 ` - . 0 8 0 -9} POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of 12— FILE INFORMATION SYSTEM SPECIFICATIONS Owner 7 _ Septic Tank Capacity a l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer O NA Number of Bedrooms ❑ NA Effluent Filter Model Aln O NA Number of Public Facility Units J�NA Pump Tank Capacity a l Z1 NA Estimated flow (average) g al/day Pump Tank Manufacturer 1 -NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer Z NA Soil Application Rate gal/day/ft' Pump Model 2i NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit 19 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L t ❑ NA O 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 tYin- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L _,O(NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: O NA Other: ❑ NA Other: O 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) 13 month(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume O NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA Oyear(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA 0 year(s) Inspect pump, pump controls & alarm At least once every: ❑ mo nth ❑ eaarrls) (s) ) ANA Flush laterals and pressure test At least once every: 13 ye ar(s) ) m L NA s) Other: At least once every: ❑ month(s) .0 NA ❑ ear(s) Other: O 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 (Y3) 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 Septa go 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 INSTALLER POWTS MAINTA Name Name Phone / -- Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone 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. 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 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 collie) and may result In the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. 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: Id 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 Name Phone / Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone 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. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430154 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan I ' o: Personal infdrmation you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township X ax No: Grand PrQperties L. P. I Somerset Townshi CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 14.31.19. TANK INFORMA ON ELEVATION DAT TYPE NUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. S er Holding St/ nlet TANK SETBACK INFORMATION Ht Outlet TANK TO P/L WELL BLDG. \to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System _ PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to ell SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS N f Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEA ING Manufacturer: INFORMATION CHAMB OR Type Of System: UNI Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribute x Hole Size x Hole Spa Vent to Air Intake Pipe(s) Length Dia Lengt Dia Spacing SOIL COVER OF 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 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 2104 62nd St Somerset, WI 54025 (SW 1/4 SW 1/4 14 T31 N R1 9W) Gavin's Acres Lot 1 Parcel No: 14.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = revision Plan Required? Use otherside foradditional information. ] No -- SBD -6710 (R.3/97) Date Insepctor's Signature Geri. No. r -- - — Safety and Buildings Div Cit y C m 201 W. Washington Ave., P.O. ���0��,� Madison, WI 53707 - 7Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 -6546 _ a / Sanitary Permit Application f > . ; her In accord with Comm 93.2 1, Wis. Adm. Code, personal information you provid may be used for secondary purposes Privacy Law, s l5.04(1)(m) Project Address 0 d' ent than mailing address) I. Application Information - Please Print All Information Property n4 ame 4_ Parcel � Lot # Block # Property Owner's Mailin ddress petty Location 7,19 r - 1 S40 %, S w Y., Section City, State Zip Code Phone Number circle o e) J �^ T _U_ N; RAE c� II. Type of Building (check all that ly) / l�a� ®1 or 2 Family Dwelling - Number of Bed s 3 Su Name CSM Number ❑ Public/Commercial - Describe Use v /Nr A" 6 ❑ State Owned - Describe Use ❑City ❑Village *Township of - r III. Type of Permit: (Check only one box on line Complete line B if ap cable) - A. New System ys ❑Replacement System ❑ tment/Holding T Replacement Only ❑Other Modification to Existing System B. ❑Permit Renewal ❑Permit Revision ❑Chang Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil Moun 24 in. of suitable soil 11 At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland 11 Pressurized In- Ground ❑ Holding Tan l ❑ Peat Fill e ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Ching Chamber rip Li ❑Grave s Pipe Q Other (explain V. Dispersal/Treat - ent Area Information: - / Design Flow (gpd) Design Soil Application Rate(gpdsf) ispersal A=rRequired(sO sal Are a Proposed (sf) System El vation _ G 53, VI. Tank Info i=apacity in Total fflumber Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons f Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 00 Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement I , the ullPersigned, assume responsibility for installation of the POWTS shown on the ched plans. Plumber's Name (Print s Signature /MPRS Nu r Bu ess Phone Number o z / - -GG Plumber's Address (Street, City, State, Code) 6�F !. VIII. unty /De artment UiffOnl pproved ❑ Disapprov Sanitary Permit Fee in Groundwater Date Issued ssuing Ag t Si ature (N to ps) ir Surcharge Fee) t' a 7/ y t7 ❑ Owner Given Reason for Denial / ` � I Conditions of ApprovaVReasons for Disapproval �,�GL(.x.� H� d� - >•'lP.*:�� 1 � �07.111'lft/L/ �/ f 2 �� U --r � " t !!!ice 3 f Lam- F3 5� � Attach complete plans (to the County only) rortl&iXtem on paper Rottels than SIM x 11 inches n size SBD -6398 (R. 08/02) rtr�UG VEwTe� �NS/�ECj /O/V /0 /�c S FT _ _a 1317 %p loo "6p rop a/r / CAv INS �lc�2cS / f3� r /000 G L S T. C' 9 Rao a/1 A/Y,O P/1d�E/1TicS - WA ffj'VARO l/AUiF y V16W . _T/1. jo S� i G(�i ` y oz � i r�� s,�577 OX SAO s UjC- /rspcTion� /�C s ov '. � PR47,v 470 / — Aj 9q�' _ 13oAo llAll�IVG_d G 30 , 7/A &OAka -5T . cle 016 T2 _ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r1?1011r19 f?a �- / k / c Mailing Address 2 7 /9. gi`11,41?19 '5 7 - 1 �t� l`�t2 SET /J > Property Address a 1 0 9 'A-s (Verification required from Planning Department for new construction) 032 /O 00 s ut, City/State c�C� C%f/ S T L./,/ ~ Parcel Identification Number e-j .sa. - w v/ - io - wo T EGAL DESCRIPTION Properly Location V4, '/4, Sec. /`P . T (._N R F W, Town of Subdivision A //o I v AC ,F S' . Lot # Certified Survey Map # , Volume . .Page # Warranty Deed # c 7.x.3 7 , Volume / 9S,�L , Page # SBS� Spec house 0 yes ❑ no Lot lines identifiable ® 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 form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper 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. 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE F 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 warranty deed recorded in Register of Deeds Office. Q j /- 130le3 SIGNATURE OF 'PLICANT DATE « « « « «« A 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 copy of the certified survey map if reference is made in the warranty deed f POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of A FILE INFORMATION SYSTEM SPECIFICATIONS Owner 6 1palylo /1) _ _ Septic Tank Capacity a l 13 NA Permit # �� ��- Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer L ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model A _ D . ❑ NA Number of Public Facility Units M NA Pump Tank Capacity gal ® NA Estimated flow (average) gal/day Pump Tank Manufacturer ® NA Design flow (peak), (Estimated x 1.5) S gal/day Pump Manufacturer M NA Soil Application Rate , al /da /ft2 Pump Model M NA Standard Influent /Effluent Quality Monthly average` Pretreatment Unit ■ 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. 13 NA Other: ❑ NA Other: ❑ NA Other: ❑ NA A ll "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: 3 ® month(s) (Maximum 3 years) ❑ NA earls) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 3 ■ year(s) ❑ month(s) ❑ NA Clean effluent filter S �EJ] At least once every: ■ ear(s) ❑ month(s) It NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ' ❑ month(s) ■ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) III NA At least once 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 on IY 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 S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cellls). 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 INSTALLER POWTS MAINTAINER Name C — G Name — Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name j Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)lb)0)(d)&(f) and 83.540), (2) & (3), Wisconsin Administrative Code. ll U �,952P 585 687537 STATE BAR OF WISCONSIN FORM 2 .1999 KATHLEEN H. WALSH " WARRANTY DEED REGISTER OF DEEDS Document Number This Deed, made between Walt E. Ger and Debra C. — RECEIVED FOR RECORD Germain, husband wife, _ _ .._ _ 08-20 -2002 9:30 AN —. — WARRANTY DEED —. _.. _ ...... - -- EXEMPT If Grantor, and Grand Pr perties, LP _ _ -- _ —.. —__ • REC FEE: 11.00 — ._..___— _-- ._ - - - -- — -- — TRANS FEE: 916.50 — -- — COPY FEE: _.. -_ -.- --- - - -•— — — __ CERT COPY FEE: - - -- — — -- -- PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St . Cro _ County, State of Wisconsin (if more space is needed, please attach addendum): The W I/2 of SWIM of section 14, Township 31 North, Range 19 West, Recording Area St. Croix County, Wisconsin, EXCEPT: 1) Lots I and 2 of Certified Survey Map in Vol. I, Page 236, Doc. No. Name anKR�t�t�t �s OGLAND 332995; H ORNEY A7 LAW 2) Lots 3 and 4 of Ccnificd Survey Map in Vol. 3, Page 746, Doc. No. A P 0 , BOX 359 353786: WI 54016 3) I.ot 5 of Certified Survey Map in Vol. 9, Page 2454, Doc. No. 480266; HUDSON, 4) lots 3.4 and 5 of Certified Survey Map in Vol. 10, Page 2889, Doc. No. 526637. 032. 104 0.80-000_032.10 41 - -0 — Parcel Identification Number (PINT This — is not -- homestead property. E) (is 0 not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. (< Dated this - day of June ,— 2002 • Water E. Germain • • — - — -'— — • Deb ra C. Germa ACKNOWLEDGMENT AUTHENTICATION — STATE OF WISCONSIN ) Signaturc(s) Walter E Ge M d Debra C. Germain_ ) ss husband wife, -- — - — — County ) M1. authenticated this day of _June — —, —•— 2002 _ Personally came before me this — day of � — — ^the above named • Kri stina Ogland - —_ _ - - - -- - -- _.. — — - - - ^ —�. TITLE: MEMBER STATE BAR OF WISCONSIN t 1 110 known to be the person(s) who executed the foregoing (1f not. _ — instrument and acknowledged the same. authorized by § 706.06, W is. Slats.) THIS INSTRUMENT WAS DRAFTED BY • —_ —•• — Attorney Kristina Ogland -- -- Notary Public, State of Wisconsin Hu son, 1 54 1 — My Commission is permanent. (If not, state expiration date: (Signnures may be authenticated or acknowledged. Both are not necessary.) -- — — -- v,awWan c F a W. wt • Na11KS of persons signing in any capacity muss be typed or printed below (heir signuure. aooasa ;u+ STATE BAR OF WISCONSIN WARRANTY DEED FORh1 No. 2.1999 Parcel #: 032 - 2163 -01 -000 05/02/2007 04:57 PM PAGE 1 OF 1 Alt. Parcel #: 14.31.19.1393 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - CSC DEVELOPMENT INC CSC DEVELOPMENT INC PO BOX 268 SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 2104 62ND ST SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 3.380 Plat: 1971- GAVIN'S ACRES LTS 1/16 032/03 SEC 14 T31 N R1 9W PT SW SW GAVIN'S ACRES Block/Condo Bldg: LOT 01 LOT 1 (3.380AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 14-31N-19W SW SW Notes: Parcel History: Date Doc # Vol /Page Type 11/29/2004 780998 2703/352 WD 05/19/2003 721974 2245/509 EZ -U 03/09/2003 714143 9/54 PLAT 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/14/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.380 49,900 0 49,900 NO Totals for 2007: General Property 3.380 49,900 0 49,900 Woodland 0.000 0 0 Totals for 2006: General Property 3.380 49,900 0 49,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 0 ® ° 2 / _ k § /\] \ (D _ z z E z �� of ®2 8 Q �• ® ®` ° \ ® § E E \ 7 81 & j (D - E E y s E$ 7 S / \ \ \ \ � \ \ ) O ^ CL - / z \ 0 2 E § } ® ( c % CL � (D OD \ / } I� f \ $ ° 0 ® � (n � 2 � J o o 3 �• m -a f f * ) \ \ ° cn e e z < 'U 2 0 2 0 / 77 § ( fT \ \ / 0 g 0 ƒ w k e % ; \ � 0- \ 2) ƒ ^ / \ { z \ p 2 � \ ca - \ § » 0 § { \ § ± % / z t t W $ { � I k 0 % \ C ; z 7 \ , � \ � � $ � ; ƒ � a � \ � � 9 0 p < \ \ TP o w \ CD � \ « ° .� OEM �vJ � �J !f�■ Z & fT 3 o \ ± 7! m / _+ m E \ § } 2 co, A �, � ®a 7 ���•® � � 2 =!a i & B 2 / » R \ o E F/ w 6 7 J / I _ƒ ƒ k � � CL � 0 / /! 8 �� k 0 ® 3 �- o J p ) } \ 0 ƒ J J Ca J J \\ e \ /02\ \ 9 J E 2 C, \ / % } } � 2 7g0 @ I o o 7 0 = $ ƒ \} E ƒ } } / 7 / t 3 B 2 z (D cx � \ G. \ e z � � y ; 3 e / / J } � ■ » ƒ CL 0 § \ } ' ; 0 r ] W } � } � } - � � � { $ v \ \ bd \ _ � ) { ■ ad out S9 / f Inv . o m oa avia p £e �«