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HomeMy WebLinkAbout032-2163-08-000 (2) oCAo oNO 0CA0 3 On tz r_ 3 7 O A N A f a CD v d CD 3 I 3 3 \ .l j Z ° A Z j Z ° A 2 Z Z ° A= 0 :r• ! O N O W I O N O W 0> ( O N O W d p A W C]Il 3 O N cn d O- fD f CWO N 2 N y v N W m o m o ? N m ' m m M. ° @ � a N a Ni °° CO �. O ! co D y c a N I cn D ' C. o CL co D y CL C c. CD IW ° a I C) o. 1 v O o O 0 N O A a 3D X0 ( t0 f3 N D O o °° C4 o °° 1 o ° CD { n 0 c w U) w _ fn � � • o ! 3 Z 3 v v M CD v , o Ln v v O O O CD O O O o O O O o = 3 Ch ca LO N to to 3 y Cl) N < � �vv I �•Q boo Mvo ID - 00 C o CA _ m _ m < 3 °—' I a 3 d I 3 d N c I CD CD CD fT CD o ? o 1 j D o cp n O ' O :3 'o 3 ( tD m a a m CD N I N N M n c X ,. c c m v : I fD :3. m �. N ' 0 Q a I v a @ a 0 3 ? 3 C4 M vo' �z m o a a A Q I I Z - q -' I e�D A W� w A 3 I ° 3 ° Z 3 I 3 �� 3 (1) � N Z N i fD i fD N? a ! c J a T O a Q� n a N CD T CD n (D j• n _ M — F o a 3 o a v o a v y N I co 61 m ! 3 y o I �c N v c� 3 CD CD 0 ° — a a I 0) = TJ f o o 10 4 � C N n y Q 2 CD N O 01 CD co N C I CD v a ° co tw CD 1 ° p I I I � o I o o b ! fD I m CD `moo o c o e V CD 6 CL CD Safety and Buildings Division County q No r 201 W. Washington Ave., P.O. Box 7162 k �seons�n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) (608) 2-66-315 3 Department of Commerce State Plan I.D. Number Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code rInn( - � , " p ( ,�y , de - " °"1 may be used for secondary purposes Prival L- 7 , ft LX Project Address (if different than mailing dress) 1. Application Information - Please Print All Informati n 2 l j/ Nc� S'� 0 04 i i i� ,r Property Owner's Name Parcel p Lot # Block # Property Owner's Mailing Address Property Location s l El J "t - ' /., Section City, State Zip Code Phone Nu r )_1 J / circle one) r�d T �[ N; R /� EorW II. T f Building (check all that apply) _ a S e�•% �, /� Subdivision Name CSM Number LAY) or 2 Family Dwelling - Number of Bedrooms A CS ❑ Public/Commercial - Describe Use � ❑City_ ❑Village ❑Township of ❑ State Owned - Describe Use IiI. Type of Permit: (Check only one box on line A. Complete line B if applica le) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System ll List Previous Permit N ber and Date Issued � B. ❑ Permit Renewal ❑ Permit Revision Change of ❑ Permit Transfer to New / Before Expirat& lumber Owner 3 -C / r r 63) IV. Type of POWTS System: Check all that apply) Non -Pressurized ❑ Mound 2:24 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 ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) ystem Elevation Manufacturer refab Site Steel Fiber Plastic VI. Tank Info Capacity in Total Number Glass Gallons Gallons of Units /' (� Co Crete Constructed New Existing Tanks Tanks Septic or Holding Tank t� U G (� e S e le Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersi gned, assume res ponst bility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum vs Signature /MFRS Number Business Phone Number �23�75'— Plumber's Address (Street, Co State, Zi ode) / R d , 1.3o 7c ! �* 3 Gcfoo c� u 1 (e YIII. County/ e artment Use Onl pproved ❑ Disapproved Sanitary Permit FeJcludes Groundwater Date Issued I su' Agekt Signature (N tamps) Surcharge Fee) 0 ?AA ❑ Owner Given Reason for Denial IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: 3) C 1 Septic tank, effluent filter and dispersal cell must all as per management plan provided by plumber. V _ �F 2. All setback requirements must b maintained as per applicable code/ordinances C Attach eompieh plans (to the County only) for the system on paper not tea than 9112 :11 inches in sift � ^S ? -Q _ rV"- t� 6 SBD -6398 (R. 01/03) 1 11 J U Cnv� R v G!� l�► Y+9 g�r,S o� t Gwh 4� S G hq eRS'ei�'. EJ ' Cop G f of � � 19 of NAP Anx ��b p o 3Z I SI G r 1 4 0 P-1 f- :-- tr s 6 )t I, 0 � it 0 C0 4,0 y gees r�rwr�sW % s �qt31 ? I fe t �wh �� Sant �►�SG.L'. ti3` b �+ IOU t-V 4� P Q� ` Safety and Buildings Division Coun45 a. W. Washington Ave., P.O. Box 7082 �J / IN 201 W . ��a �• x iseonsin Madison, •DWI 5370'1 - 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 -6546 D Sanitary Permit Application State P lan I.D. Number In accord with Comm $3.2 1, Wis. Adm. Cade, personal information you provide may be used for secondary purposes Privacy Law, s15.04(1 Xm) Project Address (if different than mailing address) I. Application Information - Please Print All Information G f YQ b �, A-J Property Owner's Name Parcel # v Lot # Block # i C 4Maili�ng 1A, 8 Property Ownerdress Pro perty Location Ci , State 3 �w UN Zip Phone Nu r T J 1 N; Lt E c� II. of Building (check all that apply) �1G U or 2 Family Dwelling - Number of Bedrooms S 'vision Name CSM Number ❑ PubliclCornmercial - Describe Use ,V i N S ❑ State Owned - Describe Use ❑City ❑Village Xownshnp o fs, fIL Type of Permit: (Check only one box on fine A. Complete line B if applicable) - A. ew system ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System st B. ❑ Permit Renewal ❑ Permit Revision of Permit Transfer to New Previous Permit Number and Date Issued Before Expiration Plumber Owner /� f J ✓f �� �� �j IV Type of POWTS System: Check all that apply) 1 i / on - 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 ❑ TC Recirculating Synthetic Media Filter P,I.eaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ O#Ier exp in) V. DispersaVrreatment Area Information: - f r Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dis Proposed (st) S MOGW ` 5-D - 4 Y3 (0 64 7? 7 0 VL Tank Info Capacity in Total Number Manufacturer Prefab Sr S ocl- -fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing Tanks Tanks Sc Holding Tank OCI � Aerobic Treatment Unit Doting Chamber VII. Responsibility Statement -1 , the undersigned, assume responsibility for Install the POWTS shown on the attached plans. lumber's Name (P ' ) lumber's Signature MP Number Business Phone Number �E dw �S Z Z- Z Z- z 5f Z / umber Address (street, City, State, Zip e) ll VIII. Coun /D epartment Use Onl .Approved ❑ Disapproved ' Sanitary Permit Fee cludes Groundwater D to Issued I i Agent Signature tamps) Surcharge Fee) <P 570 ❑ Owner Given Reason for Denial / IX. Conditions of Approval/Reasons for Disapproval ,,}_ SYSTEM OWNER: 3) S? f�19� 1 Septic tank, effluent filter and 1 D 1 _ D S dispersal cell must all be serviced I maintained 'tom 'C t as per management plan provided by plumber. 2. All setback requirements must be maintained 1 as per applicable de /or i es. L _ n _ �'et? . 4 A� S r \ Attach ` (tor the Catwty ) fir the system eu paper not kuthaull/21NII hes is SBD 398 (R. 08/02 ` N ' N V d ; '\ O ri W loo h J ` 0 W ►J � � V n � d ~ M Ll 4 0 p c � •O o b N M `� h N Jd o o N p PY ------- ----- `N N ri J Q el C I e w � 3 L o 0 L 0 p e o N tA I� � o � c POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 'e; C 4 "Y0" Septic Tank Capacity fOd 0 al ❑ NA Permit # # 3 0 2 ' Septic Tank Manufacturer 5 Kd �,,,/ ❑ NA DESIGN PARAMETERS J Effluent Filter Manufacturer Z q 6C r 13 NA Number of Bedrooms ❑ NA Effluent Filter Model A/ d O ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capac al 019A Estimated flow (average) Y3U gal/day Pump Tank Manufacturer �A Design flow (peak), (Estimated x 1.5) G75 g al/day Pump Manufacturer Q-NA Soil Application Rate ` — 7 al /da /ftz Pump Model 0-NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit Gf4A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L f NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average ispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L (n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L VNA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510" cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. NA Other: ❑ NA Other: N A Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) 11 NA Inspect condition of tank(s) At least once every: pj earls) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell ❑ month(s) (Maximum 3 years) ❑ NA s) At least once every: , / loyear(s) month(s) ❑ NA Clean effluent filter At least once every: ❑ year(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: t e�year(s) ..- month(s) ❑ NA Flush laterals and pressure test At least once every: Z- ❑ year(s) Other: ❑ month(s) ❑ 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 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) 71Ac 4- 9 7. a &I- !`7q - — - -- -- - -- -- -- ------ - - -- - - -- -- - -- - ---- PRIUPasAo - OD w�u --- - - - - -- - - - -- - - -- - - - - - -- - - -- - - -- _ -- -- - - - -- P -epos -- - - -- - -- . _ _ _ _ - -- - _ _ - - 3 i3E0 lvoafe ' / f %cTeQ - -- - _ -- -- - - - -- - -- - - - -. — -- - -' - - - �- �. �G-T- 1317 - - -. Y -0. -- - - -- = - -- ' - -- -- -- - - -- -- - - - - -. N i � o ._L2.l�i�l�1/y�- .� ' -- -- .._ --- - - - - -- .�_- -Q3 - -- -�1P . _ /NG_��/ • _ __ .. __ _ :_ —. __ ._. j --- ------ - - - --- I I 1 4D a /P I I l i I _ i I , i i - _ 0 9 7.10 r -. -- - i 1 i i i I I - I I I I I I i I I I I I I i -- - - ' •' - -- - I I it i I I — PR on c= 2 Sy L A n�tT ��, r s► -- I j I O� 1� Safety and Buildings Division N VIllsoconsin 201 W. Washington Ave., P.O. Box 7082 C U Madison, WI 53707 - 7082 San it Number (to be filled in by Co.) (608) 261 -6546 3 Department of Commerce lStgl_e P� Ian I.D. Number Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code, personal information you provi e may be used for secondary purposes Privacy Law, sl5.04(1 xm) Project Address tfferent than mailing address) , I. Application Information - Please Print All Information �� � "v„ ; property Owner's Name CP�arGe) Lot # Bloc ss property Owner's Mailing Address Pr rty tion y., Section City, State Zip Code Phone Number (circle QjW 0/`7& y ' / T � N; RaLE o II. of Building (check all that apply) , �(/t �"' ubdivision Name CSM Number at" ily Dwelling - Number of Bedrooms s o ❑ Public/Co ia1- Describe Use vbr� U/N A ct ES ❑ State Owned - Use 1 Q f ❑City ❑Village ®Township of !✓� T III. Type of Permit: Tkeck only one box on line A. Complete line B if appli le) A ' ® New System Replacement System ❑ Treatment/Holding Tank lacement Only ther ification to Existing Sys vious Permit Number and Date Issued B. ❑ Permit Renewal ❑ P evision ❑ Change of cant Tran to Before Expiration Plumber er IV. Type of POWTS System: Check afthat apply) M Non - Pressurized In -Ground ❑ Mound > 2 of suitable soil ❑ ound<24 in. of suitable ❑ At -Grade ❑ e s and Fi ❑ Constructed Wetland ❑ Pressuri Ground kung Tank Peat Filter ❑ Aerobic Treatment Unit ❑ R g S er Recirculating Synthetic Media Filter hing Chem ❑ D Line vel -less Pipe Other (expla' V. Dis ersaVI reatment Area I formation: ' v El Design Flow (gpd) Design Soil Application Rate(st) ersal Area Required (sf) D' 1 Area P s (s m evatio ggd ys p t y3 9 . VI. Tank Info Capacity in tal N M f ter Site Fiber Iastic Gallons Gallons nits - trot onstruct Glass New Existing / Tanks Tanks Septic or Holding Tank 0001 Aerobic Treatment Unit Dosing Clamber VII. Responsibility Statement I , the an igned, assume responsibility for Installation oft OWT S shown o eat d pia Plumber's Name (Print) P 's Signature PRS Num B ess Phone Number -.S G Plumber's Address (Street, City, State, Z' e) VIIIL//County iDe artment Us'effnly Approved ❑ Disapprov Sanitary Permit Fe (includes Groat water vat Issued uing A ent 'gnature (No ps) Surcharge Fee) ) �� O ❑ OwnerGi Reason for Denial Ul IX. Conditions of_ApprolVResons for Disapproval ©G � / �, � -_ �/� /v[s�� X � A � tt aa c complete plans (b t ettaty on for the t em so paper not less than 51 z 1l taehes to sltt m , ^ !'^ / T /", G1 SBD -66398 (R. 08/02) (ice !�- �' 7 /? s ' i/ ! � U Berri 61A %- %jUll1 I SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address !<. S (Verification required from Planning Department for new construction) City /State 5a.- , +i,c-s c, �/ . Parcel Identification Number ` LEGAL DESCRIPTION - Property Location %, !L t /4, Sec. / r , T 3 l N -R // W, Town of cJo.� Ce s`c Subdivision �Zu;t ` r"/LC 6 - Lot # Certified Survey Map # Volume a e # Warranty Deed # - Volume , Page # Q Spec house ❑ yes Ono Lot lines identifiable Qk 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 mastprplumber, journeyman plumber, restricted plumber or a licensedpumper verifying that (1) the on -site wastewaterdisposai 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 Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has bebu maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of the three year expiration date. SIGNATURE 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. C f 163 SIGNATURE OF APPLICANT L ANT � 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 copy of the certified survey map if reference is made in the warranty deed I 1 • h tit o O A \\ +�''! �" G a� I S © \ \ 1 A. � W U - • . a cd 4) o\ Q . U 'F. b xT � 1 V) rA •� .. (y� r ', • � �' 1 II 1 II II v 8 I � M O O > ,G .2 A V ra Document Number V T + a LL` iu L $'1'U 1 CROIX UV U LE I I This Deed, made between Grand Properties, LP, RECEIVED FOR RECORD Grantor, and 08/21/2003 09:30AN Eric A. Hanson WARRANTY DEED Grantee. EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE: 11.00 the following escribed real estate in St. Croix C ounty , State of Wisconsin TRANS FEE: 177.00 g tY. COPY FEE: (if more space is needed, please attach addendum): CC FEE: PAGES: 1 t 8, lat of Gavin's Acres i n the Town of Somerset, St. Croix County, consin. Recording Area Name Return Address 1 17 TI"I L IPJC, FCAD FILE NO. ..2 �;3 I- z F� Part 032 - 1040 -80 -000 & 032 - 1041 -100 -000 Parcel Identification Number (PIN) This Is not homestead property (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any Dated this day of August , 2003 Gran Properties, P * * Y. M MG anage ment, LLC, by Michael J. Germain * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Grand Prope rties, LP, MMG M anagement, LLC, STATE OF ) by Michael J. Germain _ - -- ) ss. County ) authenticated this day of August , 2003 Personally came before me this day of -- - -. - -- _ _ the above named * Kristin Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ __— — — — to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Slats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Og_land Hudson, WI 540 16 Notary Public, State of 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., Fond du Lac, wI STATE BAR OF WISCONSIN 800. 655 -2021 Z) IN PART OF THE SOUTHWEST QUARTER OF THE (A COUNTY PLAT) OF SECTION 14 AND IN PART OF THE NORTHWEST QU R ER OF QUART THE AND PART OF ORTHWEST QUARTER OF SECTION 23, ALL IN TOWNSHIP 31 NORTH RANGE 19 WEST, �. , S . I (� NOT£.• LANDS NOR 4 " MA Y BE AN AREA LO T 1 CONTACT AD✓O /N /N I ATTORNEY REGARL VO 8 , PAGE 2363 UN PL A T7 I - - N 89'03' 49 "E N89 "E N 98 03'4? " 373.69'" x 600-< 484.36' (RECORDED AS 484.40') CA a ; 80' RADIUS TEMPORARY LO T 5 `° n CUL—DE—SAC EASEMENT ' TO BE EX77NGU /SHED UPON 6 V - 10, PAGE 2889 �,, EXTENSION OF THE ROAD WA Y. to 0, o L T 8 Z" • I .0 3.02 ACRE L" 1 4 FT. v A TTED LANDS — p ; - - - - -- ca N88026'41 "E Z 373.67' 0 I w 1 , LO 4 f V OL. 10, _PAGE 2889 � W �' w LOT 7 0 3.04 ACRES Z ol 132,455 SO. FT. o , w w I " Wisconsin Department of Commerce county: PRIVATE SEWAGE SYSTEM St. Croix Safety and � Building ivision INSPECTION REPORT » Sanitary Permit No: 430156 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 older's Nam • City Village X Township Parcel Tax No: Grand rties L.P. L Somerset Townshi CST BM EI . Ivi ion: Section/Town /Range/Map No: 14.31.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM uid Depth BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liq DIMENSIONS SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHA OR Model Number. Type Of System: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil No ® Yes j No H Yes COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2148 62nd St Somerset, WI 54025 (NW 1/4 SW 1/4 14 T31 R1 9W) Gavin's Acres Lot 8 Parcel No: 14.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ffi Yes ® No Use other side for additional information. I _ SBD -6710 (R.3197) Date Insepctor's Signature Cart. No. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of A FILE INFORMATION SYSTEM SPECIFICATIONS Owner _ Septic Tank Capacity a l O NA Permit # / f Septic Tank Manufacturer C� ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ` c 13 NA Number of Bedrooms 3 O NA Effluent Filter Model - p ❑ NA Number of Public Facility Units M NA Pump Tank Capacity ga l ® NA Pump Tank Manufacturer ® NA Estimated flow (average) al /da Design flow (peak), (Estimated x 1.5) � gal/day Pump Manufacturer ®NA Soil Application Rate gal/day/ft' Pump Model ®NA Standard Influent /Effluent Quality Monthly average` Pretreatment Unit ■ NA Fats, Oil & Grease (FOG) 530 mg /L 1 ❑ Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BODJ 5220 mg /L ❑ NA ❑ Mechanical Aeration O 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 (TSSI 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 51W cfu /100ml ❑ Dr)p -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: O NA Other: O NA Other: ❑ NA `values typical for domestic wastewater and septic tank effluent. Other: 13 NA MAINTENANCE SCHEDULE Service Event Service Frequency O month(s) (Maximum 3 years) O NA Inspect condition of tank(s) At least once every: M year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ monthls) (Maximum 3 years) 13 NA Inspect dispersal cell(s) At least once every: ® year(s) O month(s) O NA Clean effluent filter At least once every: ® yearls) ❑ month(s) M NA Inspect pump, pump controls & alarm At least once every: O year(s) '0 month(s) ■ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: O year(s) month( ■ 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 call(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 1.13, 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. on of any service event. A service report shall be provided to the local regulatory authority wlthin 10 days of completi y Page of START Ui`' AID dPERATION For new construction, prior to use of the POWTS check treatment rankle) for the presence of painting products or other chemicals that may impede ede 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 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 rgles in effect at that time. 13 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>> C ONTAIN SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY LETHAL ENTER A SEPTIC, UMP 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 l,. Name Phone S _ — _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name t C fy C IF Name Phone Phone ?JS —;. F This document was drafted in compliance with chapter Comm 83.221121(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. r - - ST CROIX COUN'T'Y SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer - Mailing Address Property Address (Verification required from Planning Department for new construction) o32--10 Bo -ood City /State ; �� RS'E % (,/,!� . Parcel Identification Number _0-7 - /0 y1 - 0 -000 LEGAL DESCRIPTION Property Location &(2.) ih, sS 1 0 V4, Sec. /Y •, T -R I W, Town of Sa;,nZ" j T__ Subdivision _ (� jlvS' �4C S Lot # Certified Survey Map # , Volume . Page # Warranty Deed # G 8 7 5 - 3 7 , Volume Page # :CBS Spec house 8 yes ❑ no Lot lines identifiable 8 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 cm 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 Departm ent a certification form, signed by the owner and by a mastorplumber, 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. 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 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 o wner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. J-- -&- - I � - to 130 / a 3 SIGNATURE 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 copy of the certified survey map if reference is made in the warranty deed ll U 1952P 585 66'7537 STATE BAR OF WISCONSIN FORM 2.1999 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO-, MI This Deed, male between Walter E. Germain and Debr C. — RECEIVED FOR RECORD Germain, husband wife, — .. - - -... - - -- — 08 -20 -2002 9:30 AN MRRMM DEED —. —.... _.. _.......— EXE)DT 1 Grantor. and Grand PK2perties, LP- REC FEE: 11.00 TRANS FEE, 916.50 - -- — -- —.—.— COPY FEE: — CENT COPY FEEt - - - -- — — — — PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Crol: _ 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: a �rc 1) Lots 1 and 2 of Certified Survey Map in Vol. 1, Page 236, Doc. No. Name and RY T�N OGLAND 332995; 2) Lots 3 and 4 of Certified Survey Map in Vol. 3. Page 746, Doc. No. ASP BOX 359 W 353786 WI 54018 3) Lot 5 of Cenified Survey Map in Vol. 9, Page 2454, Doe. No. 480266; HUDSON, 4) lots 3.4 and 5 of Cenified Survey Map in Vol. 10, Page 2889, Doc. No. 526637. 032.1040.80- 000;03 - 1041.10 -000 __•-- — Pualldemiftutton Number (PIN) This — is not __ homestead property. 0fi) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. 2002 Dated this day of June __ -` • Walter E. G - — - — - -- • Debra C. Germa • AUTHENTICATION — ACKNOWLEDGMENT STATE OF WISCONSIN ) Signatures) Walter &Germain !nd De bra C. Ger main, — ) ss husband wife, — - County ) authenticated this , day of June — -__ - -. 2002 _ Personalty came before me this _ .— — day of the above named • Kris,ina O.PeI °nd.. TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the peraon(s) who executed the foregoing (If not _ instrument and acknowledged the same. — authorized by j 706.06, W is. Stats.) THIS INSTRUMENT WAS DRAFTED BY • _ — —.•— — -- — Attorne Krlstina Ogland Notary Public, State of Wisconsin Hu son, WI 54 16 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary .) —' -- —� eanpa.q co a to sN • Names 4 persons signiog in any capacity must be typed or'prinled below their signature. aooesa.;+u+ STATE BAR OF WISCONSIN WARRANTY DEED FORh1No.2.1 1 '» Properiy &rler Grand Properties, LP Parcel ID # Page 2 of 3 F Boring # Boring — ✓ Pit Ground Surface elev. 99.01, ft. Depth to limiting factor >97 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 1 0-18 10yr312 none I 2fsbk mvfr as 2f .5 .8 2 18 -30 10yr4/4 none I 3fsbk mfr gw 1f .5 .8 3 30-45 7.5yr4/4 none sl 2msbk mfr gw ---- .5 .9 4 45-97 10yr5/4 none fs 2msbk mvfr - -- . .9 Boring # Boring ,✓ Pit Ground Surface elev. 99.57 ft. Depth to limiting factor >9$ in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDr In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-14 10yr3/2 none I 2fsbk mfr as 2f .5 .8 2 14 -24 1Oyr4 /3 none Sid 3fsbk mfr gw 1f .5 .8 3 24 -38 10yr4/4 none sal 3msbk mfr gw ----- .5 .9 4 38 -98 10yr5/4 none ms Osg ml --- ----- .7 1.2 F-1 Boring # -J Boring ft. Depth to limiting factor in. Soil q Pit Ground Surface elev. pplication 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? 30 < 220 mg/- and TSS >30 < 150 mg/L ' Effluent #2 = BOD <_30 mg/- and TSS <30 m9/- The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or "PP.I . on oitP++,•tP f—# n1.— rnntort the f>t1R_74! Z 1 ';I nr TTV lr1R -')AA -8777 d G cvv s f# c fe s Al JA _ - V© _ /d i i i i I i o y3, i8 i i ! - p arilpS G57'W► a �? �1��- - S d � jV - - 2` cJ ' S } '' uy f1 v ,( Y iti i ; 4p N � <r• Y 4 III ' J� li y #4L 1 t��oM :,•ia' J Fn `II i � ''{• LR 1 vi j i ti ti �\f, i � oil Nt 4 " f I � � -n r f I ............._� �y i� I I J. I ti _ ' A -Ft' t3�I t a 3 i. fill LIV 5 '�8�� '�i -- -- ._ - - -. .«. '>;t�rj �u•.ery,��?p_ ' - '-Z � ��.� [� I t 'r� K.., �'� Y �q•• tNtrYtil4'•5 ..a,- I � ;�a •y�C� jlo ( p `�, ' ,?C,.' 3 , t �' ;:L r ! 1 1 1 +'� ..... ,;.- -,' V+ F .r { ' � i i __ - .° ^ ,. a te.• «� � � � . � ? ! Jy nz +� I . I .1� L. Rte'- �i 3' v i' ' I h 'iF '• �kI , 5 1 ' ............. 1 JA � -� -- _ •�. - .- -. _ „.... sv- . «Stri- - - nEG'.•n'SS'[ A NI mom W &At R.a,pf },. _ �Eaav �LryCAmAY�O•r3l�wit w sE.r _.. — LYN7DYMP- ? TM! mss rte �...- .�...sJ _, �_: A9 DYl71t1A11� - -•-- "y. / _� • �_. n -� �•� aw . •p/ 1M. yp�pf!/ -- r ^.:a•i =Y =.ui -.. - VA”' tl ! 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D \ i ■ 0 0 » � < CD t k S9 0 f ? ~ 8k 8� �2 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and @gilding Divis{m INSPECTION REPORT Sanitary Permit No: 430391 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: Hanson, Eric I Somerset Townshi CST BM Elev: Insp. BM Elev: T Description: Section/Town /Range /Map No: CST BM Elev: Insp. BM Elev: 14.31.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR _ Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil g p Yes No — U Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2148 62nd Street Somerset, WI 54025 (NW 1/4 SW 1/4 14 T31 R19W) Gavin's Acres Lot 8 Parcel No: 14.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes E No Use other side for additional information. SBD -6710 (R.3/97) Date insepctor's Signature Cert. No. ` Safety and Buildings Division 201 W Count T m W. Washington Ave., P.O. Box 7082 J 0 r. ��LG; •�( iseonsin Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261 -6546 0 Sanitary Permit Application State P lan 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, s15.04(1Xm) Project Address (if different than mailing address) I. Application Information - Please Print All Information Z A+CL Property Owner's No Parcel # v Lot # Block # i C J�vcS ®>+-� 8 Property Owner's Mailing Address Property Location X13 a// Lam, /V State Zip ` Phone N t �`' ��`' Section V &4 AA) cS� X CL Urrl ? ,p (circ T N; R EM II. of Building (check all that apply) NG 511 2 Family Dwelling - Number of Bedrooms A Subdivision Name �j CSM Number ❑ Public/commeroial - Describe use �V i 5 0'64.1 ❑ State Owned - Describe Use ❑City ❑Village Wownship o tzAA_- III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - A. ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑Permit Revision ge of Permit Transfer to New stPr Permit Number and Date Issued Before Expiration Plumber Owner !�( ) ✓/ �� �� 0 ? IV Type of POWTS System: Check all that apply) 111 ✓ 1 / A blon - 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 KLa. Itin Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other expl in) V. DispersaLlTrestment Area Information: - 3 C V' ,- Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dis Proposed (sf) r 7 -7 . y,56 . ( 1 (0 8� 'a VI. Tank Info Capacity in Total Number Manufacturer Prefab Sn S tsa- -riliff Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Se Holding Tank 00 a Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for i nsW the POWTS shown on the attached plans. lu =re" mber's Name (P ' ) MP Number Business Phone Number .41 umber Address (Street, City, State, Zip e) V l 1 - h c,260 , QV C_ /,Ue �V- VIII. Court /De artment Use Onl Approved ❑Disapproved Sanitary Perm ' A it Fee chides Groundwater a Issued ZiAgent Signature tamps) Surcharge Fee) ❑ Owner Given Reason for Denial / IX. Conditions of Approval/Reasons for Disapproval ,,.}}--- SYSTEM OWNER: �� ': 4 �� ^� 1 Septic tank, effluent filter and � r r 4&u dispersal cell must all be serviced / maintain®d as per management plan provided by plumber. 2. All setback requirements must be maintained as p� S ap p licable de 40r i� es. Va _ e 2 Y r AltaeY mpk (to tYe county o for � tYe system on paper not less rhea 81R 11 Yes `E S �� e-- K� S t�y P SBD- 398 tR. 08102 C 1�►-� �,�. � CI � � � _ 5�-Q T� � t�Q� . w � v �N N a Q C- Il k— Ira v C ti 0 I ° r vJ � ti 0 00 � � N a I� o � o Ad w o Y lu Na Ll U 0 A a w v 0 N►J � � 4 \ M tKZI C� 0 � N � � w o� , POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner C 4��6 Septic Tank Capacity /6,4 al ❑ NA Permit # 112 Septic Tank Manufacturer 5 K'a � ❑ NA DESIGN PARAMETERS J Effluent Filter Manufacturer z q 6C 1 ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 41 6 D ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity a l 919A Estimated flow (average) g al/day Pump Tank Manufacturer ET Design flow Ipeak), (Estimated x 1.5) g al /day Pump Manufacturer 0-NA Soil Application Rate - 7 al /da /ft2 Pump Model n_NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit Grl�A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODJ 5220 mg /L NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ` ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average ispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L Xn-Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L VNA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia.1 NA Other: ❑ NA Other: n{ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Y' Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: Er-year(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: [3 month(s) (Maximum 3 years) ❑ NA . / 2- Clean effluent filter At least once every: — very: Z� m ❑ onth(s) ❑ NA year(s) Inspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ NA B�year(s) - Ermonth(s) ❑ NA Flush laterals and pressure test At least once every: Z ❑ yearls) E3 monthls► Other: At least once every: ❑ year(s) ❑ 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 I C 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 INSTALLER LL'' POWTS MAINTAINER Name l�Gv i N� T c Tt/�'! Name 0, n ,'t"r f; C. �f s Phone 71,-r - Y7L . Z Y / Phone 7� - y'7L -Z VZ / SEPTAGE SERVICING OP ERATO R (PUMPER)) LOCAL REGULATORY AUTHORITY E me �� - OYL.t 74 .0 Name r X D one �/ -3t}b D/ / Phone /J 2 - 7'cp rDJ This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. I f' PVC V El - . 1AI'5 p EC710,1 . PIPES Ra O 0, O - 9 7. a & - — - - -._ _ - -- -- - - - -- - -- - - - -- PRopos - - - -- - - 3 i3EO /DOO G FiLrc2 VA � o cc S y Y ?,- 7 - - - -- 01 - 41 - �flp�ir 2iy L�Ntr Ic /SS -� l 6_-30 -03 -- f�tP _ 4, V( C G -- - �r� _- QJ�'!E!t S- all Y Y t, - o P ?moo I FiLrc/1 p�lWE YO T�cr .1n v_c_ - -- - _ - - !, c-2i LIMtT f f _...__ � . +� ,} ,�. ` _ _ _. _.... _.. _.. _... .. ... _. .. ._ .. .... .. ... ... ..... _ .. .. Safety and Buildings Division Nvislo m 201 W. Washington Ave., P.O. Box 7082 G` U onsin Madison, WI 53707 - 7082 Sam it Number (to be filled in by Co.) Department of Commerce (608) 261 - 6546 3 Sanitary Permit Application ate Plan I.D. N umber In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provie may be used for secondary purposes Privacy Law, at 5.04(1 xm) Project Address ' ifferen( than mailing address) I. Application Information - Please Print All Information `�` ,ai�� ��nd T Property Owner's Name Pa Yet , Lot # Bloc k 1 L - / - 16 70 Property Owner's Mailing Address Pr rty Lion City, State S Zip Code Phone Number r ��'' 5'0�1. Section ;CSM _ 6 01 5 y (circle ojW T � N; R�E o II. of Building (check all that apply) �A . ubdivision Name umber i 1 or ily Dwelling - Number of Bedrooms S ❑ PublidCo ial - Describe Use U/N /`7 C ❑State Ownod - 'be Use f f ❑City ❑Village Township o �,Q T III. Type of Permit: eck only one box on line A. Complete line B if appli le) A. ® New System Replacement System ❑ Treatment/Holding Tank lacement Only ther ification to Existing Syst B. ❑Permit Renewal ❑ P evision 11 Change of 41-mit Tran to vious Permit Number and Date Issued Before Expiration Plumber er IV. Type of POWTS System: Check alkbat appl ® Non - Pressurized In -Ground ❑ Mound > 2 of suitable soil ❑ ound < 24 in. of suitable ❑ At -Grade ❑ s and Fi r ❑ Constructed Wetland ❑ Pressuri - Ground Iding Tank Peat Filter 11 Aerobic Treatment Unit ❑ R g S er Recirculating Synthetic Media Filter hing Chain ❑ D Line G yel -less Pipe U Other (expla' VT V. Dis ersaUTreatment Area I formation: /• Design Flow (gpd) Design Soil Application Rate(ggdsf) rsal Area Required (sf) D I Area P os (s m Elevatio q so V3 V y- VI. Tank Info Capacity in tai /Zer Ma fac rer Site Fiber lactic Gallons Gallons ts X- cret onstruct Glass New Existing / Tanks Tanks Septic or Holding Tank OQ� O I; Aerobic Treatment Unit Dosing Clamber VII. Responsibility Statement I , the undIfigned, assume responsibility for installation oft OWTS shown o e at d pla Plumber's Name (Print) P er's Signature PRS Num B ess Phone Number Plumber's Address (Street, City, State, Z' e) VALI - /acv E VII Coun /De artment Us Approved ❑ Disapprov Sanitary Permit Fe (includes Grou water �7/ Issued uing A ent 'gnature (No ps) Surcharge Fee _) Z // C1 Owner Gi Reason for Denial UI 7 IX Conditions <Approjrlteasons for Disapproval , - 1 ,J� �j� /1 _ UU�x//JJ L " U ✓/7t of 6 L/ r � v %'fit. 011�� e4��, JF3. 1 0 4 aC - a- r- hn��u -11� -rte,. J`•� -" Attach complete plans (tot County only) for the s stem on paper Rot less than gl 1 11 Inches In size SBD -6398 (R. 08/02) (ice : `7� iZu s . % %Z . ? 7- D {( �fa �F O 1.� 7 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT ` AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address / -5r13 r !f ,?L" � ,,�, Property Address lt,. , (Verific required from Planning Department for new construction) City/Stat ,_!/t, ' Parcel Identification Number LEGAL DESCRIPTION S E O V4 L , 2! '/4, Sec. / , T 3/ N -R // W, Town of S O= c,Gsc Subdivision a, ' �- s Lot # Certified Survey Map # , Volume a e # Warranty Deed # Volume 2 5 6 3 , Page # g Spec house ❑ yes 0 no Lot lines identifiable Qk 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, journeymanplumber, 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. 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 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 day, of the three year expiration date. SIGNATURE 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 owner(s) of the property described -above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE 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 copy of the certified survey map if reference is made in the warranty deed I w •`� o fi � 4 ° a � �A cd 000, 000000000000x I 4) O\ A ol3 ' cn c B \ �1 ri Na v� SNZ U � \ J • °' � b ClJ 1 H rb r� VOL 2383 PA,,�E 736679 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Grand Properties, LP, RECEIVED FOR RECORD Grantor, and 08/21/2003 09:30AK Eric A. Hanson WARRANTY DEED EXEMPT t Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE: 11.00 TRANS FEE: 177.00 the following described real estate in St. Croix County, State of Wisconsin COPY FEE: (if more space is needed, please attach addendum): CC FEE: PAGES: 1 t 8, lat of Gavin's Acres i n the Town of Somerset, St. Croix County, consm. Recording Area Name�ttdRetum Address LA ND M T LE, INC. 1 ^ .CAD td c.... :::.. --112 FILE NO. 7 h I Part 032 -1040 - 80-000 & 032 - 1041 - 100 -000 Parcel Identification Number (PIN) This is not homestead property (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any I Dated this day of August 2003 Gran Properties, P * * Y. M MG a LLC, by Michael J. Germain I * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Grand Prope rties, L_P, MMGM anagement, LLC, STATE OF ) b_ y Michael J. Germ ) ss. — County ) authenticated this I - _day of August , 2003 Personally came before me this day of the above named * Kristin Ogland _ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stars.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Atto rney Kristin O Ig and ._ _.. H udson, WI 540 16 Notary Public, State of 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., Fond do Lac, Wt STATE BAR OF WISCONSIN 800 -655 -2021 A vHVIN'ti ACR � IN PART OF THE SOUTHWEST QUARTER OF TH (A COUNTY PLAT) O OF SECTION 14 AND IN PART OF THE NORTHWEST QUARTER 31 NORTH, RANGE 19 WEST, Q F ARH R AND PART OF ORTHWEST QUARTER OF SECTION 23, ALL IN TOWNSHIP E NORTHWEST QU J. I I I NOTE LANDS NOR I " MA Y BE AN AREA LOT 1 CONTACT AD ✓O /NIN ATTORNEY REGARL � VOL. 8, PAGE 2363 UN PLA Ti — — N 89'03' 49 "E _ N89'03'49 "E N 98 03'4?E 373.69'" x s oe'< 484.36 (RECORDED AS 484.40') 00 w q . ` s• o ; 80' RADIUS TEMPORARY _:_� I LO T 5 n CUL —DE —SAC EASEMENT ' ` I ' TO BE EXTINGUISHED UPON _ PAGE 2889 EXTENSION OF THE ROAD WAY im L T 8 o .u' I M ° 3.02 ACRE 0 n 1 , . FT. %J A TT ED LANDS - ,cw� N88'26'41 "E Z 373.67' I 0 ; � w ; I LO 4 VOL. 10, PAGE 2889 0�', i w A LOT 7 0) P' 3.04 ACRES :01 Z ol � • 132,455 SO. FT. o I � ' W I ' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: , - 430156 0 GEEIS&RAL 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 Ajoiders Nam � City Village X Township Parcel Tax No: Grand rties L.P. L it15p Somerset Townshi CST BM Ele . ion: Section/Town /Range /Map No: 14.31.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing HeaderiMan. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes � No f ]Yes ', _] No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 2148 62nd St Somerset, WI 54025 (NW 1/4 SW 1/4 14 T31 N RI 9W) Gavin's Acres Lot 8 Parcel No: 14.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ': Yes C No -- — -- - - - -- i I- - i Use other side for additional information. '�_ L -- SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of h r FILE INFORMATION SYSTEM SPECIFICATIONS F _ _ Septic Tank Capacity a l ❑ N # ` / j Septic Tank Manufacturer ly 'dF&71ts O NA DESIGN PARAMETERS Effluent Filter Manufacturer Z � ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model — 0 ❑ 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) ty O al /da Pump Manufacturer ® NA Soil Application Rate .7 gal/day/ft 2 Pump Model ® 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. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA 1 MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ M earls) month (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: ❑ month(s) (Maximum 3 years) 13 NA ®year(s1 ❑ month(s) ❑ NA Clean effluent filter At least once every: ® ear(s) ❑ month(s) O 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) ■ 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 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. Page of START YP AND pPERATION 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 i 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 re lacement area has been evaluated and may be utilized for the location of a replacement soil absorption P e infringed upon b should not b P Y system. The replacement area should be protected from disturbance and compaction and 9 Y P 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. ed to identify a suitable replacement area. Upon failure of the POWTS a soil and site ❑ The site has not been evaluated Y replacement area is available a holding tank If no re 9 replacement area. P evaluation must be performed to locate a suitable p 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 r Name L O C Phone S _ — _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name �� C� — Name Phone Phone 5 - — V6 AQ 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 MAINTENANCB AGREEMENT AND OWNERSHIP CERTIFICATION FORM owner/Buyer C a &AQ ,1 oa r .aES Mailing Address `U - _ Property Address (Verification required from Planning Department for new construction) o3 �L-/0V0- 60 - 000 City/State �n t Parcel Identification Number 03 X - io y/ - io -000 LEGAL DESCRIPTION Property Location [140 V4, S10 '/4, Sec. ZX T L N- R–Y —W, Town of 1;S� T Subdivision (� A /�vS Lot #. Certified Survey Map # . Volume . Page # Warranty Deed # G 8 7 S 3 7 . Volume / 9 _ Page # SB Spec house 8 yes ❑ no Lot lines identifiable 8 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 masterplumber, joumeymanplumber, 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. 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 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. 1 Q�- l 3o1d3 SIGNATURE 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 warranty deed recorded in Register of Deeds Office. j— - .�: 4130103 SIGNATURE 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 warranty deed ' reference is made in ty a copy of the certified survey map if N U 1952P 585 • 667537 STATE BAR OF WISCONSIN FORM 2 .1999 KATHLEEN H. MALSH + WARRANTY DEED REGISTER F DE Document Number VI This Deed, male between Walter E. Germain and Debra C. — RECEIVED FOR RECORD Germain, husband wife, — .__. .._. _— ...__ -.. _ -_. -. — 08-20 -2002 9:30 AN WARRANTY DEED EXEMPT I Grantor, and Grand Properties, 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. Cr _ County, State of Wisconsin (if more space is needed, please attach addendum): The W IR of SW 1/4 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 and RetetfOlt OGL AND 332995; 2) Lots 3 and 4 of Certified Survey Map in Vol. 3, Page 746, Doc. No. ATTOR W BOX 359 353786: WI 54M 3) Lot 5 of Certified Survey Map in Vol. 9, Page 2454, Doc. No. 480266; HUDSON, 4) Lots 3.4 and 5 of Certified Survcy Map in Vol. 10, Page 2889, Doc. No. 1. 526637. 032 - 104080 - 0 00032.10 41 . 10 . 0 00 Parcel Identification Number (PIN) This — is not homestead property. oil (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. (� u `' Dated this —, day of June _- 2002 • Walter E. Germain 0 —.— — - - — — — —_ —. —' � - • Debra C. Germa - • —..— ..— — - AUTHENTICATION ACKNOWLEDGMENT ) Signatures) Watter E Germain Ond Debra C Germain STATE OF WISCONSIN ) ss husband wife, - -. -- - — ` — -- County ) authenticated this day of _June — —. —._, 2002 _ Personally came before me this __..._ __ day of the above named Kristina Ogland. -- - - - - - -- - -- -- - -- TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not. _ — instrument and acknowledged the same. authorized by § 706.06, Wis. Seats.) - - -- TIi1S INSTRUMENT WAS DRAFTED BY • —_ — — — — Attorney KristinaOgland - -. Notary Public, State of Wisconsin Hudson 4 1 —_ My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) reormMim Pra"S&W. • c anp". Pone a W. wl • Names of persons signing in any capacity must be typed or'printed below their signature. aoot5a ;u� STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2. 1999 1120 SOIL EVALUATION REPORT Wisconsin Department of Commerce Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt County Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimemsiors, north arrow, and location and distance to nearest road. Please print fl !n _ "` r yy ; Date Personal informabon you provide may be us r secondary Purposes � tZv, s.15. (1) (m)). Property Owner Pr perty Location Grand Properties, LP J 1 9 2002 . Lot NW 114 SW 1/4 S 14 T 31 NR 19 W Property Owners Mailing Address L # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 sr. c zoix = oU ^' rY 8 Gavin's Acres City State Zip Coe City Village ✓ Town Nearest Road Somerset WI 1 54025 715 -247 -5900 Somerset I 60Th St. New Construction Use: y Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement I Public or commercial - Describe: Parent material Outwash Plain Flood plain elevation, if applicable na General comments and recommendations: Area 1 is suitable for a conventional with a 0.7 gpd /sgft raing. Area 11 has a 0.5 gpd /sgft. Possible system elevation for Area I is 9710'. Slope is 3 %. Boring # Boring be Pit Ground Surface elev. 100.22 ft. Depth to limiting factor >9 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD& in. Munsell Qu. Sz. Cont. Color GE Sz. Sh. *Eff#1 *Eff#2 1 0 1Oyr3/2 none I 3fsbk mfr as 2f .5 .8 2 9 -26 1 Oyr4 /4 none ] 3fsbk mfr cw 1 If .5 .8 3 26-33 7.5yr4/4 none 1s 1csbk mvfr gw ---- .7 1.2 4 3-96 10yr5/6 none ms Osg ml -- ---- 7 1.2 o t tvp 162A^ s Boring # Boring G% ❑ -- g Pit Ground Surface elev. 100.22 ft. Depth to limiting factor >98 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Str Consistence Boundary Roots * ff#1 PD!(P ff#2 in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-9 10yr3/3 none I 2fsbk mfr as 2f .5 .9 C 2 9-31 10yr4 /3 none sic] 2fsbk mfr cw 1f .4 .6 3 31-41 7.5yr4/6 none Is 1csbk mvfr gw - - - -- .7 1.2 4 1 -98 10 r5/6 none ms 0 ml ---- ---- 7 1.2 I )d)i in e - - Y uJ �7 0' Yrvl" . = �l * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <_30 mg/L 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 6/13/02 715- 549 -6651 I � Prgperfy,OSnwer Grand Properties, LP Parcel ID # Page 2 of 3 U Bo Boring # ring Pit Ground Surface elev. 99.01 ft. Depth to limiting factor >97 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 1 0 -18 1Oyr312 none I 2fsbk mvfr as 2f .5 .8 2 18 -30 10yr4/4 none I 3fsbk mfr gw 1f .5 .8 3 30-45 7.5yr4/4 none sl 2msbk mfr gw --- -- .5 .9 4 45 -97 1Oyr5 /4 none Ifs 2msbk mvfr - - -- - ---- .5 .9 FT I F41 Boring # Boring ✓ Pit Ground Surface elev. 99.57 ft. Depth to limiting factor >98 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -14 1Oyr3/2 none I 2%bk mfr as 2f .5 .8 2 14 -24 1 Oyr4 /3 none sic] 3fsbk mfr gw 1 If .5 .8 3 24-38 10yr4 /4 none sd 3msbk mfr gw ---- .5 .9 4 38 -98 1Oyr5 /4 none ms Osg ml --- --- .7 1.2 F-1 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 GPDAP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = SOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or matt matAr+ol in an olta+natr+ f-* nl.- -tort t5,s. `2anae•f.nant of r.nQ- 1!.!. -T 1 S 1 - 7 rV fAR -71.A -2777 34-3 `r / ovc"/ /* �� 1 gq P p 0 /a! 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