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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Buildin- Division INSPECTION REPORT Sanitary Permit N 4 1 0 GENERAL INFORMATION (ATTACH TO PERMIT) State PI ID Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Par I Tax No: Palmer, Art Somerset, Town of CST BM Elev: Insp. BM Elev: T Description: Se tion/Town /Range /Map No: CST BM Elev: Insp. BM Elev: . 1.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchm Dosing Alt. M Aeration BI g. S er Holding (*A14 let TANK SETBACK INF S Ht Outlet O ON - TANK TO P/L E BLDG. Vent to it Intake ROAD Dt Inlets" Septic Dtpott&m Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System PUMP /SIPHON INFORM 4ueff000, Final Grade 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. T uid De pth 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 IDistribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) 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 Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 630 210th Avenue Somerset, WI 54025 (NE 1/4 NW 1/4 23 T31N R19W) Gavin's Acres South Add Lot 23 Parcel No: 23.31.19. 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes No Use other side for additional information. Date Insepctor's Signature Cert fvu SBD -6710 (R.3/97) Safety and Buildings Division County ` 201 W. Washington Ave., P.O. Bo % . C to C) )C Madison, 'V� Sam t / Per Number (to be filled in by Co.) (608) 66 -3 CO��,� Department of Commerce Sanitary Per plicad �4 1 a pp State an I.D. Number In accord with Comm 83.21, Wis. Adm. de, u prude may be used for secondary purposes Privacy Law, s15.04(1 (m) ST r JXL ()UN roject ddress (if different than matting address) I. Application Information — Please Print All Information d'�-- IU(J lJ Property Owner's Name Parcel # v Lot # Block # AR 4Lirl 9 y/ T f 3 i > (� Property Owner's Mailing Address Property Location City, State © o x Zip Code Phone Number � ,4, Secti ° Z3 ST1 L L W ATEk S5_( Z 6,51 - 2 53 = A SO N; o T 3 I N; R� E or V II. Type of Building (check all that apply) Subdivision Name CSM Number L N 1 or 2 Family Dwelling — Number of Bedrooms 3 �(� c� /1u,, nJ-w ,04� El Public /Commercial — Describe Use _i / 6.4V P1 S 4(0�S St7NT'`� ❑ State Owned — Describe Use �� Q t ❑City_ ❑Village ®Township of Sca1c5e5 E 7 a III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl Non — Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter Recirculating Synthetic Media Filter Lea hamber ❑ Drip LiW ❑ r e ess Pipe ❑ Other plain) V. Dispersal/Treatment Area Information: r Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 9c y5p £), G'13 &. 53. ► 96 q0 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank /OCC � 000 ) $ J Aerobic Treatment Unit lWl Z - /pct Dosing Chamber VII. Responsibi Statement- I, the undersigned, as sume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb 's Si ature MP/MPRS Number Business Phone Number DHA) SL-14 rT c 2 -2376 0 71 ,stl y- G 6sl Plumber's Address (Street, City, State, Zip e) VIII. - County /De artment Use Onl Approved El pp Sanitary Permit Fee (includes Groundwater Date Is su Issuing nt Sign re Stam ) tsa r Surcharge Fee) M ❑ O n Reason o enial 3, ' 0 o - 5 ) 7 a5 � -x-, IX. Conditions of Approval/Reasons for Disapproval I xsTEM OW NER: 3) e Wlec AA. J64- v s.puc tank, effluent filler and �. dispstsal CO must ON " PK IIN"WIM P10n W*4d6d by PlWiW. 2 M wok MgUk n Wft MW to msintakW sn pK nPPb" 006 / andkWWn. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) t ii %^ ; NOT ?Yi, E Hsi l6a lwift t�r,�nai ^:2�sm• as +sure si�'!+sN1�p►� Marx MA .L aavtAbw awa nq C � k.:S T -R � rva ram *� Bm / DtrBm ® A r 31 L O , ) L4 LlIt, 'v s9 w�� zaeec � - roo t ,B� PRoa ©scr� / 3 g w'ctL G� K�E DR�v� way' a.. ��� Fcl2 FLL r ct - ' Tfo,9E) N �' 3x�, 8.3,' rl fy'iGDi��:uSEK Ti2ea'cF� It !I 800E fA COPY ALT- PVC Pile 14RT A2 1'n6 P, j�1tCWf TF/� JIJA) 5�5DV-2_ ���r ltlr ;? - :2 3 -76, �� G Av/ /V.5 Ce4r L6 T 31 d ur BL4 J, Le v B 1 s9� _ Ba _- PROaosc • - - Moe 5". 5L4 w etc i (/A4 f f0 n - N 1o8.3��' // B IODiAr , U 5B,; T2Ed)CN Y XIP2. /© '511) i tiu ro ■► B ORE 14u,6 JA B_ht CL.= >oo.a0 Tov - og= L''_ Pvc P,pF A . ALT. -Bn1 _EC.':= /oz.(!o z . Tor' 69 _- Z - PVc. Pr_Pc -- —_! 6 I PTA d_ttQ - -- — __ Q nC �i 5e-d 1234 Wisconsin Department of Commerce SOIL E Page 1 of 4 Division of Safety and Buildings in ac h Comm 5, Wis. Adm. Code Tom Schmitt Attach complete site plan on paper not less than 8' ize „�A AY 1 7 2 o�ounty St. Croix include, but not limited to: vertical and horizontal referent in a' percent slope, scale or dimemsions, north arrow, and location is a t road. Parcel I D. T.CROIXCOU T} Please print all information. ZONING OFFI By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15. mp. / Property Owner Property Location Palmer, Art Govt. Lot NE 114 NW IA S 3 T 31 N R 19 W Property Owner's Mailing Address Lot # Block # I Subd. Name or CSW P.O. Box 250 23 Gavin's Acres: South City State Zip Code Phone Number City Village ✓ Town Nearest Road Stillwater I MN 1 55082 651 - 253 -1680 Somerset 1 210Th Ave ✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design Flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sgft rating. See page 4 for system elevation. Slope is 5 %. Boring # Boring ✓ Pit Ground Surface elev. 99.92 ft. Depth to limiting factor 125+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' *Eff#1 'Eff#2 1 0 -8 1Oyr3/3 none sl 2msbk mvfr as 2vf .6 1.0 2 8 -21 1Oyr4 /4 none sl 2msbk mvfr gw 2f .6 1.0 3 21 -125 1Oyr5/6 none s Osg ml -- --- .7 1.6 Boring # Boring ✓ Pit Ground Surface elev. 99.92 ft. Depth to limiting factor 90 + in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF 'Eff#1 I 'Eff#2 1 0 -8 1Oyr3/3 none sl 2csbk mvfr as 1f .6 1.0 2 8 -15 1Oyr4/4 none sl 2msbk mfr gw if .6 1.0 3 15 -33 7.5yr4/6 none Is Osg ml gw - -- .7 1.6 4 33-90 1Oyr5/6 none s Osg ml gw ----- .7 1.6 Effluent #1 = BOD ? 30 < 220 mg/L and TSS X30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS <.,0 mg/L CST Name (Please Print) Signature: yy _ CST Number �"" Thomas J. Schmitt ___i 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St. , New Richmond, WI 54017 5/6/05 715 - 247 -2941 Property Owner Palmer, Art Parcel ID # Page 2 of 4 3 ] F Boring # Boring ✓ Pit Ground Surface elev. 97.72 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1Oyr3/2 none Is 1csbk mvfr as 2vf .7 1.6 2 9 -24 1Oyr4/4 none sl 2msbk mvfr gw 1vf .6 1.0 3 24 -38 1 Oyr4 /6 none Is 1 msbk mvfr gw - -- .7 1.6 4 38 -96 1Oyr5/6 none s Osg ml -- ---- -- .7 1.6 4] Boring # Boring of Pit Ground Surface elev. 97.72 ft. Depth to limiting factor 95+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1Oyr3 /4 none sl 2msbk mvfr as if .6 1.0 2 9 -24 7.5yr4/6 none Is 1csbk mvfr gw 1f .7 1.6 3 24 -46 1Oyr4/6 none s Osg ml gw - - - -- .7 1.6 4 46 -95 1Oyr5 /6 none s Osg ml -- - -- . 7 1.6 5] Boring # Boring Pit Ground Surface elev. 95.85 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1Oyr314 none sl 2msbk mvfr as 1f .6 1.0 2 9 -24 7.5yr4/6 none Is 1csbk mvfr gw 1f .7 1.6 3 24 -57 1Oyr5 /4 none S Osg ml gw - - -- .7 1.6 4 57 -96 1Oyr5/6 none s Osg ml -- - -- . 7 1.6 * Effluent #1 = BOD ? 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 -8777. f property owner Palmer, Art Parcel ID # Page 3 of 4 6� F Boring # Boring ✓ Pit Ground Surface elev. 93.37 ft. Depth to limiting factor 110+ in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD *Eff#1 *Eff#2 1 0 -14 1Oyr3/3 none sl 2mgr mvfr gw 2m,1vf .6 1.0 2 14 -32 1Oyr4/4 none sl 2msbk mvfr gw 1f .6 1.0 3 32 -36 7.5yr4/6 none Is Osg ml gw ---- .7 1.6 4 36 -110 1Oyr6/4 none s Osg ml -- ---- .7 1.6 a Boring # Boring ✓ Pit Ground Surface elev. 91.77 ft. Depth to limiting factor 111+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP *Eff#1 *Eff#2 1 0 - 14 1 Oyr3/2 none Is 1 csbk mvfr cw 2m,1 of .7 1.6 2 14-31 1Oyr4/3 none $l 2msbk mfr gw 1vf .6 1.0 3 3145 7.5yr4/6 none gdcos Osg ml gw — .7 1.6 4 45 -111 1Oyr6/4 none s Osg ml - -- ---- -- .7 1.6 F-1 Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GMT *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD <30 mg/L and TSS <.3O mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. Page 4 of 4 Conducted by: Conducted For: Schmitt Soil Testing Inc Name: Art Palmer Thomas I Schmitt, CST 227429 Address: P.O. Box 250 1595 72nd St. City, State, Zip: Stillwater, MN. 55082 New Richmond, Wl. 54017 Phone: 715- 247 -2941 Subd.Name: Gavin's Acres, South Lot No.: 23 S 1-6 3 -- Legal Description: NEU4 NWU4 S23 T31N R19W Soil Boring Township, County: Somerset, St./ Croix .Bench Mark El. 100.00' Top of 2" pvc pipe 0 Alternate Bench Mark El. 102.62' ton of 2" pvc pipe Slope= 5% .. System Elevation: /`/�y��s �(• y� Scale 1" = 40' 3 � ��� 3s� �J + ` �(aq f � � f �y Q LIJ Or. ' Va l. .40 ._ 'mss ou i p""o 1 • n - 4, w It •; tjj t� N It t 11 t t • - 33US H109- . 1234 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 4 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but riot limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Palmer, Art Govt. Lot NE 19 NW 1/4 S 23 T 31 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P.O. Box 250 23 Gavin's Acres: South City State Zip Code Phone Number City Village ✓ Town Nearest Road Stillwater MN 1 55082 651 - 253 -1680 Somerset 1 210Th Ave ✓ New Construction Use: of Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd /sgft rating. See page 4 for system elevation. Slope is 5 %. Boring # Boring ✓ Pit Ground Surface elev. 99.92 ft. Depth to limiting factor 125+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz *Eff#1 *Eff#2 1 0 -8 10yr3/3 none sl 2msbk mvfr as 2vf .6 1.0 2 8 -21 10yr4 /4 none sl 2msbk mvfr gw 2f .6 1.0 3 21 -125 10yr5/6 none s Osg ml -- ----- .7 1.6 F2 ] Boring # Boring ✓ Pit Ground Surface elev. 99.92 ft. Depth to limiting factor 90+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftZ *Eff#1 *Eff#2 1 0 -8 10yr3/3 none sl 2csbk mvfr as 1f .6 1.0 2 8 -15 10yr4/4 none sl 2msbk mfr gw 1f .6 1.0 3 15 -33 7.5yr4/6 none Is Osg ml gw — .7 1.6 4 33 -90 10yr5/6 none s Osg ml gw - -- .7 1.6 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 1 90 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 5/6/05 715- 247 -2941 .Property Owner Palmer, Art Parcel ID # Page 2 of 4 3] Boring # Boring ✓ Pit Ground Surface elev. 97.72 ft. Depth to limiting factor 96+ in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1 Oyr3/2 none Is 1 csbk mvfr as 2vf .7 1.6 2 9 -24 1Oyr4/4 none sl 2msbk mvfr gw 1vf .6 1.0 3 24 -38 1 Oyr4/6 none Is 1 msbk mvfr gw - -- .7 1.6 4 38 -96 1Oyr5/6 none s Osg ml ---- - -- . 7 1.6 1 Boring # Boring ✓ Pit Ground Surface elev. 97.72 ft. Depth to limiting factor 95+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1Oyr3/4 none si 2msbk mvfr as 1f .6 1.0 2 9 -24 7.5yr4/6 none Is lcsbk mvfr gw 1f .7 1.6 3 24 -46 1Oyr4/6 none s Osg ml gw - - -- .7 1.6 4 46 -95 1Oyr5/6 none s Osg MI - -- ---- -- . 7 1.6 i 5] Boring # Boring Pit Ground Surface elev. 95.85 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -9 1Oyr3/4 none sl 2msbk mvfr as 1f .6 1.0 2 9 -24 7.5yr4/6 none Is 1csbk mvfr gw 1f .7 1.6 3 24 -57 1Oyr5/4 none s Osg ml gw - -- .7 1.6 4 57 -96 1Oyr5 /6 none s Osg ml - -- - - - -- .7 1.6 I * 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 The Department of Commerce is an equal opportunity service provider and employer. If ou need assistance to access services or eP 9 PPo tY P Y need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. •Property Owner Palmer, Art Parcel ID # Page 3 of 4 6 ] Boring # Boring ✓ Pit Ground Surface elev. 93.37 ft. Depth to limiting factor 110+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP *Eff#1 *Eff#2 1 0 -14 1Oyr3/3 none sl 2mgr mvfr gw 2m,1vf .6 1.0 2 14 -32 1Oyr4/4 none sl 2msbk mvfr gw 1f .6 1.0 3 32 -36 7.5yr4/6 none Is Osg ml gw -- .7 1.6 4 36 -110 1Oyr6/4 none s Osg ml -- ---- -- 7 1.6 7 Boring # Boring ✓ Pit Ground Surface elev. 91.77 ft. Depth to limiting factor 111+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -14 1 Oyr3/2 none Is 1 csbk mvfr cw 2m,1 of .7 1.6 2 14 -31 10yr4/3 none sl 2msbk mfr gw 1vf .6 1.0 3 31-45 7.5yr4/6 none gdcos Osg ml gw ---- .7 1.6 4 45 -111 1Oyr6/4 none s Osg ml — - - - -- .7 1.6 F—I 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 *Eff#1 *Eff#2 Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD -i.30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. Page 4 of 4 Conducted by: Conducted For: Schmitt Soil Testing Inc. Name: Art pi Thomas L Schmitt, CST 227429 Address: P.O. Box 250 1595 72nd St. City, State, Zip: Stillwater, MN. 55082 New Richmond, WI. 54017 Phone: 715 - 247 -2 Subd.Name: Gavin's Acres, South Lot No.: 23 Legal Description: NEU4 NWU4 S23 T31N R19W ® Soil Boring Township, County: Somerset, St./ Croix ® Bench Mark EL 100.00' Top of 2" pvc pipe 0 Alternate Bench Mark El. 102.62' top of 2" pvc pipe Slope =- 5% - System Elevation: Ilyr -es TV-UeA 9wl- yO Li ev — r,,4 Scale 1 " = 40' die ,25' 37' I f BIODIFFUSER CROSS SECTION i 4 11 PVC Inspection + Vent Pipe I Approximate Grade ,. II El.= qq.7 � III - ' -- - - - - -_ I I I �I i ad - - --'-� 3 1 _— ' ArM09f Open A /f0 MOM ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer A /i % nA C /,lam a Mailing Address P, o, Rox ?SO Sig L Y Property Address L) a ' 1r (Verification required from Planning Department for new construction) City/State ,„�2rrE45, Parcel Identification Number LEGAL DESCRIPTION Property Location _IV&' '/., _A&I '/,, Sec. 7 - 3 .• T 3 > N -R ` -W, Town of b �D MEN s T. Subdivision A 1'NS i9C 12 r Q u7-H . Lot # 1 Survey Map # . Volume . Page # Warranty Deed # 7 2 3 R 6-C , Volume 2 7 9Y . Page # 5 �6 Spec house ❑ yes W no Lot lines identifiable 03 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. signed b the owner and b a The property owner agrees to submit to St. Croix Zoning Dep artment a certification form, sign y y P Pe � g eP 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 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 o thre year p' on 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 p rty descnbed 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Art Palmer Septic Tank Capacity 1000 al 13 NA Permit y Septic Tank Manufacturer Week C.P. ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Z a be l 0 NA Number of Bedrooms 3 ❑ NA Effluent Filter Model A -100 ❑ NA Number of Public Facility Units 11 NA Pump Tank Capacity a l 0 NA Estimated flow (average) g al/day Pump Tank Manufacturer ■ NA Design flow (peak), (Estimated x 1.5) gal/day' ' Pump Manufacturer ® NA Soil Application Rate 0.7 gal/day/ft' Pump Model 0 NA Standard In luent/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) O 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. r ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent. Other: 13 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 M vear(s) 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 3 ® year(s) Clean effluent filter At least once every: ❑ m ) tp eaa r(s) r(s) O. NA 1 Inspect pump, pump controls &alarm At least once every: ❑ month(s) 0 NA". " ❑ year(s) • ❑ month(s) R ❑ ush laterals and pressure test At least once every: O HA:. year(s) Other: ❑ month(s) At least once every: ❑ year(s) ❑ NA; Other: ' ❑ NA_ MAINTENANCE INSTRUCTIONS : iT./F•:wyk Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or ceitificatlons Maintainer• Se to r..:Tank Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS p 9 e Servicing O P erato inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or: lesks�;A measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground :surface'. Y.1. of effluent on the ground surface. The ponding of effluent on the v� The dispersal cells) shall be visually inspected to check the effluent levels in the observation pipes and to check for any,..pond r surface may indicate a failing condition and require]is t a i g. round y 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 ,entice 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 UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal call(s). If high concentrations are detected have the contents of the tank( &) removed by a septags servicing operator pri�jo use. System start up shall not occur when soil conditions arwfrozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater Isvels. When power is restored the excess wastewater will be discharged to the dispersal call(s) in one Large dose, overloading the coll(s) an d may *result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septaga 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. 'Raduction 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. p t The contents of all tanks and its shall be removed and properly disposed of by a Septage Servicing Operator. • d • 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 fads 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 boon. evaluated and may be utilized for the location of a replacement soil absorption system. The replacement was 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. O 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. O 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 '7 may be installed as a last resort to replace the failed POWTS. 0 Mound and at -grade sell absorption systems may be reconstructed in place following removal of the biomat at the.. infiltrative surface. Rdconstructions 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 ASEPTIC, PUMP dR 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' ohn Schtd� tt Name Owners choice Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name hoice Name St. Croix Ct . Zonin Rhone Phone ( 71 5) 386-4680 This document was drafted In compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.64(1), (2) & (3), Wisconsin Administrative Code. ?93655 • ,� 2 Z 9 9 P 5 9 8 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number Document Name 05/03/2005 10:10AN WARRANTY DEED EXEMPT # THIS DEED, made between Grand Properties, LP ( "Grantor," whether one or more), REC FEE: 11.00 and Arthur V. Palmer TRANS FEE: 238.50 COPY FEE: ( "Grantee," whether one or more). CC FEE: PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Recording Area interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Name and Return Address i 10 Lot 23, Plat of Gavin 's Acres South Addition in the "Own o „ I `,� ��.�. L ��f Sanerset, St. Croix County, Wisconsin. P.O. . ` _ Y v HUD:JV, VVI 54015 Part of: 032 - 1060 -40 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated 0 Grand Properties, LP (SEAL) L�-- (SEAL) * * Michael J. Ger sin (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Grand Properties, LP By: Michael J. Germain STATE OF ) authenticated on A I I,, ) ss. COUNTY ) * Kristine Oland Personally came before me on , TITLE: MEMBER STATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by W is. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Oeland Notary Public, State of Hudson, WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO -PROTM Legal Forms 800 -655 -2021 www.infoproforms.com w ` lap �� 4 , V) Ld Of CL �.. LL- • � z .��'' .ors ., -. h b • � t t �t�i• � • is � � . t 4 t t• L �� N •0.�' !7 N �. N ` • _ .133aS H109.