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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 487905 0 Ga NERAL 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: Happe,Dan I Star Prairie, Town of 038- 1213 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: �\ cis \ 11.31.18.1170 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (p Benchmark 200 1 lei eszti R.' 1 - 3- 1 Dosing Alt. BM P,)� &JtA. 17' AeFe W' j Bldg. Sewer i 2 I Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' 1 i Dt Bottom J A- 24 Zzl 17 7 Z .5 " -3 Dosing - 7 2 - 24 24 1 ` Header /Man. fe. as y3. q Aeration Dist. Pipe Holding Bot. System /r 6r 7 5� PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover 3S GPM Model Number TDH Lift„ fL Friction , � Syste Head TDy� ' t Forcema__inn Lengt j Dia. Z it Dist. to Well _ / ) `� SOIL ABSORPTION SYSTEM � BEDITRENCH Width ! Length . ) INo. Of Trenches PIT DIMENS% NS No. Of Pits Inside ia. Liquid D, epth DIMENSIONS 3 ��1Z 7 SETBACK SYSTEM TO D P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: r� INFORMATION CHAMBER OR .�.. v��. t 1��7 T e OfNSlys�tem: -'- '3,5 ! 1 3,3 ! ] UNIT Model Number: C N DISTRIBUTION SYSTEM 2 _ ` 6 4 - v `,- -[� Header/Manifold �� Distribution x Hole Size x Hole S acing Vent to IntakL 9` Pipes) \ (` G Len th ` ol Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 1 Depth Over xx Depth of xx Seeded /Sodded xx Mul ed Bed/Trench Center Bed/Trench Edges Topsoil 1 Yes i " No i - "'' Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2218 124th Stre t Star Prairie, WI 54026 (NW 1/4 SE 1/4 1111-T31N R18W) River Place Lot 9 P aarcel No: 11.31.18.1170 1.) Alt BM Description =!" 2.) Bldg sewer length - amount of cover = 1� d�p !✓�A� �-� V ( c� n ; Gc,Q� ®fj _ -- _ 1 _ Yes Use other de for additional in Ion: o 1b �__. i� - - —- Date Ins is igna a Cart. No. SBD -6710 (R.3/97) i Safety and Build i DIN*oe County ` 201 W. Washington A O. X82 Cu l sevnsin Madison, WI 7 - �NG OFD nary P it Number (to be filled in Dep artment of Commerce (608) Z Sanitary Permit Applicati s tate Plan l.D. Number In accord with Comm $311, Wis, Adm. Code, personal information u pro�do may be used for secondary purposes Privacy Law, sI5.o40 X ` roject Address (if different tW mailin )address) I. Application Information - Please Print All Information Z?/ S 1Z 5 +' Property Owner's Name • //7'0 Parcel k Lot M Block M Property Owner's Mailing A c o S / Property Location City, State Zip Codc Phone Number ! f i, ' Sxtion �_ � ?C /-63 - o irc 1 ) II. Type of Bull g (check all that app T N; R E o 01 or 2 Family Dwelling - Number of Bedrooms s ,� Su 'visiap Name CSM Number ♦ ❑ PublicJCota =W - Describe Use PAl �"� t , ❑ State Owned - Describe Use ❑City Village ippof UL Type of Permit: (Check only one box on Une A. Complete line B if appUcable) yS A. New System ❑ Replacement System eP ys ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System a• ❑ Permit Renewal jl: omit Revision Change of Permit Transfer to New List Previous Permit Numbs and Date Issued Before Expiration Plu ber er 2 0 3 F J � • o ?•tJD S IV. Type of POV✓TS Syst Check all that s 1 2 A - Pressurized In -Ground ❑ Mound 2:24 in, orsuitable soil ❑ Mound < 24 in• of suiuble soil ❑ At -Grade ❑ Single Pau Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculaziog Synthetic Media Filter Leachin ❑ Drip Line Q Grave )es P ❑ explain / 9� . V. Dispersal/Treat ent Area Information• : Design Flow (gpd) Degn oil Application te(gpdso Dis s ersal Area Required is i S P 9 (Q s SysterriElevation gs7 9 g� � 1 � 3'. VI. Tank Info Capacity in ToW Number Manufacturer Prefab Site Steel Fiber pia ti 2 Q Gallons Gallons of units s I Concrete Constructed Glass Ncw Ecisting �^ Ttnks Tanks I �J Upuc a Holding Tank ^— / ` Asiobic Trsurttnt Unit Dosing Cb niba POO VII. Resp onsibility Statement- 1, the undersigned, assume responsibility for 10141lation of the POWTS shown on the attached plans. Plumber's &1& Name (Print) Plumber' ignature P PRS Number Business Phone Number Plumber's Address (Street, City, Sut , Zip Cod VIII. Coen /De artment Use Onl Approved ❑ pi Sanitary Permit Fee (i ch Groundwater Date Issued Issuing Agent Signature o Stamps) Surcharge Fee) / l7� ❑ Owner tven Reason for ial IQ 2 IX- Conditions Approves l SYSTEM OWNER: -3� 1 Septic tank, effluent filter and dispersal cell must all be serviced f maintained as per management plan provided by plumber 2. All setback requirements must be maintained as per applicable code /ordinances. qo l ow a = Tel //1 /I/L 9z.Sv uao� z ak� -0 T, o� is I �a X -3 13- ao3.5� 1341, (-Ce-tAA Nom. V�� - ,a s-o i 1 yo , 1311, - / = J f ta T , �a a� X �3 Prl z TZ S Z3 3S1 COMBINATION SEPTIC/DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of cover, Access Opening, not top of cover, must extend to a point no greater must eidend at least than 6" Balm Finished Grade 4" Above Finished G ade . j Cover uuith W&A'lN - Y ���� � '�.���- Lochin Device �j�l SAS' PPS` �� (typ� alj Finished Grade lZ "/yiN�� vm t I I.b1A1 � = i Min. 23" ) 30 r-r- Access Opening O P_ LAS 1Iv5U Min. 23" Access Opening N Oulet Effluent Filter Union �o,2oY� PI R6 3 Pr. Inlet Baffle eel i Pu p 3 ",Sa or ra vr. l 'n �y UP7 e f w i th �en4er 2 /suer 'ar' pdSP.s Two ComparFment Septic/PumpTanh ( , v ) we/QhA on P4,Vs1We GUaI�) SPECIFICATIONS TANK MFR: I DOSES PER DAY: 3 TANK SIZE: SEPTIC OCR GAL. DOSE VOLUME: GAL. DOSE GAL. (INCLUDES FLOWBACK & <20% OF DWF) ALARM MFR: CAPACITIES: A = I. INCHES = GAL. MODEL # PA V Switch type: B = 2_INCHES = PUMP MFR: C = h 7 INCHES = a08 GAL. MODEL #: D SWITCH TYPE: D = C INCHES = GAL. REQUIRED DISCHARGE RATE 0( GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) _ FT. MINIMUM NETWORK SUPPLY PRES RE (DISTAL & NETWORK PRESSURE) _ + ----- FT. FT. OF FORCEMAIN x / FT. /100 FT. FRICTION FACTOR ...... _ + & 77 FT. TOTAL DYNAMIC HEAD (TDH) = FT. INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH 3 MP/MPRS SIGNATURE: A FLICENSE NUMBER: 4�22 [(5]GOULDS PUMPS Submersible Effluent Pump EPO4 & EP05 S er i es APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for tic enclosed design for following uses: lubrication and efficient improved performance. g heavy duty ball bearing • Effluent systems heat transfer. construction. • Homes IN Casi.t�g and Base: Rugged • Farms Available for automatic and thermopAp-h ,lesign provides AGENCY LISTING • Heavy duty sump manual operation. Auto. superior and corrosion • Water transfer matic models include resistance, S R Canadian Standards Association Mechanical Float Switch _ File # LR38549 • Dewatering ■ Motor Housing: Cast iro assembled and preset at the for efficient heat transfer Goulds Pumps is I50 9001 Registered. SPECIFICATIONS factory. strength, and durability. ■ Motor Cover: Thermoplastic • Solids handling capability: FEATURES cover with integral handle and ' /," maximum, ■ EPO4 Impeller: Thermoplas- float switch attachment points. • Capacities: up to 60 GPM, tic semi -open design with 0 Power Cable: Severe duty - • Total heads: up to 31 feet. Discharge size: 1' /z" NPT. pump out vanes for mechanical rated oil and water,resistant. • • Mechanical seal: carbon- seal protection. rotary/ceramic- stationary, BUNA•N elastomers. • Temperature: 104"F (40°C) continuous 140"F (60"C) Intermittent, METERS FEET • Fasteners: 300 series 10 stainless steel. • Capable of running 9 30 (�—� —� dry without damage to -4 - 5GPM components. a 25 - 2.5 FT o 7 Motor: a W • EPO4 Single phase: 0.4 HP, v 6' 20 1 15 or 230 V, 60 Hz, 1550 — -- RPM, built in overload with i 5 automatic reset. 15 •P05 Single phase: 0.5 HP, 1 4 15 V or 230V, 60 Hz, 1550 ° RPM, built in overload with 3 10 EPOS automatic reset. P ower cord: 10 foot EPO4 standard length, 16/3 5 S1TW with three prong 1 ,.... .............. . grounding plug. Optional 20 0 0 20 0 foot length, 16/3 S1TW with 10 30 -- — three prong grounding plug 40 50 GPM (standard on EP05). 0 2 a 6 8 10 12 ml/h ACITY t Z 2003 Goulds Pumps D3:� Pumps V EHect,e July, 2003 83871 t> ITT IndUstri POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of ?' FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity Q a l ❑ AA Permit # 0s Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms L ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ' A Estimated flow (average) 40 g al/day Pump Tank Manufacturer &rNA Design flow (peak), (Estimated x 1.5) 6O0 g al/day Pump Manufacturer EjbNA Soil Application Rate i gal/day /ft= Pump Model q� NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit (S. NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (SOD.) 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 (SOD.) 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 /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 0 W 13 month(s) (Maximum 3 years) ❑ NA y ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y,) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA y ear(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA j@ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA O year(s) Flush laterals and pressure test At least once every: ' ❑ month(s) ❑ NA ❑ earls) Other: At least once every: ❑ month(s) 13 earls) 13 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 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. Z START UP AND OPERATION Page 2 of 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 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. I • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area 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. T . alua ' t b e ai a ?921'5 nE , nR- Alm✓ 40fJS - RUC ank 1}.( ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat a 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 u E6: Name Phone ti �� Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 15t. 20till/ij Phone Phone This document was drafted in compliance with chapter .Comm 83.22(2)(b)(1)(d) &(f) and 83.540►, (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address (Q yz-5 j9 y= Property Address 2- / � / Z 61 f 4 5;t- `�y`y' `?*-, zee t_ L10 (Verification required from Planning Department for new construction) City/State Parcel Identification Number t0 "&M LEGAL DESCRIPTION Property Location Ii- I/,, Sec. (I T 3 i N - R W, Town of `E) ? "°tZrTL Subdivision _ P c o-c"t PLAC`i -. Lot # Certified Survey a # �- _- Y P Volume , Page # Warranty Deed # bs6' 7-s— Volume E 3 Page # Spec house Oyes ❑ no Lot lines identifiable 4 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 force, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. w �� y�- / 23/ u� 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. Q, 1 ? / Us 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 U; 2883 P 162 4s go Z5 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS ST. CROIX Co., WI WARRANTY DEED RECEIVED FOR RECORD Document Number Document Name 09/07/2005 09 : 50AK WARRANTY DEED EXERT # THIS DEED, made between LaCasse Development. Inc.. a Wisconsin Corporation REC FEE • 11.00 TRANS FEE; 123.30 ( "Grantor," whether one or more), COPY FEE: and Dan Harme Construction, Inc.. GC FEE PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is d, please attach addendum): L L -1 0 - 01 Plat of River Pla ce in the Town of Star Prairie, St. Croix County, Wisconsin. V TaCn 038 - 1213-0 -000 Parcel Identification Number (PIN) This is not homestead property. ' (is) (is not) Exceptions to wa ties: ements, restrictions and rights-of-way of record, if any. Dated (SEAL) (SEAL) * * aCasse Development, Inc. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF ) ) ss. s TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on O ) (If not, the above -named LaCasse Develo men nc. a isconsln authorized by Wis. Stat. § 706.06) Corporation to W known to be the erson(s) who executed the foregoing THIS INSTRUMENT DRAFTED BY: ins an g d e s e. Attorney Kristina O land Hudson, W154016 racy N Pub�►� No Publ , State of { W isconsin My Commission (is permanent) (expires: S ta te (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.00m Wisconsin Depaftmentofgommerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No 463303 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 LaCasse Development I Star Prairie, Town of 038 - 1213 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 11.31.18. 0 TANK INFORM A N ELEVATION DATA TYPE ANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATI SUHt Outlet TANK TO P/L WELL B G. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. stem PUMP /SIPHON INFORMATION F al Grade Manufacturer D and St Cover GP Model Number TDH Lift Friction Loss System Head TDH Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Tren es PIT ENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L YLDG WELL LAKE /S EAM 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(. Length Dia Length Dia Spacing SOIL COVER ressure Systems Only xx Mound Or At -Grade Syste Only Depth Over epth Over xx Depth of xx Seeded/ ded xx Mulched Bed /Trench Center Bed/Trench Edges Topsoil Yes No Yes I;-.<' No COMMENTS: (Include co discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2218 124th Street Star Prairie, WI 54026 (NW 1/4 SE 1/4 11 T31N R18W) River Place Lot 9 Parcel No: 11.31.18.1170 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ] Yes U No Use other side for additional information. Date Insepctor's Signature Cert No. SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ,SConsn Madison, WI 53707 - 7162/ Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 / 0) O .� Sanitary Permit Application �/�J State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide maybe used for secondary purposes Privacy I aju ql _04LJ f dill nt than mailing address) I. Application Information - Please Print All Information Property O er' Name 0 t� arcel # Lot # Bkmk -# - IV I s 1 o`s8 i - 90 -� C• 1 �o Property Owner's Mailing Address r v i X "U ' Li Property J#auon ZONING OFF ICL City, S Zip Code Phone Number V., �,e /,, Section N; R -2 cUCle o ) E o� II. ype of Buildi check all that apply) ubdivision Name C I or 2 Family Dwelling umber of Bedrooms QI t um r ❑ Public /Commercial - Descri se El state Owned - Describe Use ❑City ❑vii 0o ship o III. Type of Permit: (Check only olkbox on line A. - Complete line B if applicable) J A. New System R ep lacemen stem El Treatment/Holding Tank Replacem Only Other Modification to Existing System ❑ B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit T sfer to New List vious 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 suitabl\'I ound < in. of sui ❑ At -Grade ❑Single Pass Filter ❑ Constructed Wetland 11 Pressurized In- Ground El HoldinPeat Fi ❑ AeroUic Trea ent Unit 11 Recirculat' SkFdter ❑ Recirculatin S nthetic Media Filter achin Chamber Gravel -less Pipe Recirculating Y g p ❑ Other (e in) V. Dispersal/Treatment Area Information: Z X Z CLUTT%. 10 Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispe al Ar quired (sf) Dispersal Area op stem El tion 7 VI. Tank Info Capacity in Total Number Man turer ro..1 Site Steel Fiber Plastic ke Gallons Gallons of Units nstntcted Glass New Existing A Tanks Tanks Septic or Holding Tank 1 Aerobic Treatment Unit 7 � Dosing Chamber VII. Respo sibility Statement- I, the undersigned, asJure responsibility for installation of the POWTS wn on the attached plans. Plumb am (Print)` Plum s S MP/MPRS Number Business Phone Number i�1M w , /,/ - - - I 1 tier's Address (Street, City State, Zip VIII. Coun /De artment Use Onl % Approved ❑ D' pproved Sanitary Permit Fee includes Groundwater Date Issued Issuin ent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Reason f Denial 2 �__. J ,Q IX. Conditions o Approva SYSTEM OWNER: 1 Septic tank, effluen Iter and dispersal cell mus II bg serviced I ftntained as per manage nt plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances, Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) ,. . s I :i c�4,J I S�6Il, r a73 zz i , _ Ka , rya ` i�D OFD 37 / q co f 4)j,—r16 e5k,t wl r ate' a;J�ztn x ! l f o� Wisconsin Department of Commerce SOIL EVALUATION REPORT Page �_ of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pendin Please print all information. a ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 3 Property Owner Property Location LaCasse Development Inc. Govt. Lot SE 1/4 SW 1/4 S 11 T31 N R 18 E(or)W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 573 Cty. RD "A" 9 T na River Place City State Zip Code Phone Number ❑ City ❑ Village W Town Nearest Road Hudson WI 1 54016( 715 381 -5405 ® New Construction Use:0 Residential / Number of bedrooms 4 Code derived design flow rate GPD ❑ Replacement Pub ouL4J or commercial - Describe: J ' Parent material Flood Plain elevation if applicable ri A f� General comments RECGN and recommendations: trenekes @ el. 93.70' c ' l Boring � OFF1 5-1 Boring # 97.00 I� '- ® Pit Ground surface elev. ft. Depth to limiting factor 1 20 in. 4 i ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary i P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 •Eff#2 1 0 -11 10 3/3 none L cs 2f 2 11 -33 10 4/4 none sil •� 3 3 -120 7.5yr4/6 none ms Osq ml na 12 ` } Boring # El Boring 2 ® Pit Ground surface elev. 97 ft. Depth to limiting factor 120 -- - --in. Soit Itcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 1 sil 2msbk mfr c •� 2 10 -33 10 4/4 none sil •� 3 33 -90 7.5 4/6 none cos 0 4 90 -12 7.5 4/6 none ms 42 so 93 �� Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mg1L ' E e t #2 = BOD < 3 g/L and TSS < 30 mg/L CST Name (Please Print) Signature . C Number Gary L. Steel 02298 Address valua n Conduct d I Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -24 -2001 715 - 246 -6200 Property Owner T ara G cry Dave 1 o pment Parcel ID # Pending Page 2 of 3 E Boring # Boring ® pit Ground surface elev. 97' 00 ft Depth to limiting factor 120 in, Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Eff#1 'Eff#2 L mfr Cs 2f .5 8 •�� 2 2 -4 10yr4/4 none sil 1ms mfr gw if 3 - 7.5yr4 6 none Cos Osg ml - - ,7 1.2 17-,'90 ( 1% und surface elev. ft. Depth to limiting factor in. Soil Application Rate o epth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Effluent 1 = BOD s > 30 ent m L and TSS >30 150 mg /L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L S _ 220 9/ The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 -8777. SBD•8330 (R.6M) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 LaCasse Dev., Inc. New Richmond, W1 54017. MPRSW -3254 SE4SW' S11- T31N - R18W (715) 246 -6200 town of Star Prairie lot O -River Place %his soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shaven as permnent lot lines were not established at the time the test was conducted. N 1 =40' 6 BM.= top of NW lot corner @ el. 100.00' alt. BM.= top of 1" pvc pipe @ el. 98.90' ?.-3 Yb ilk 1� �f Gary L. Steel 6 -24 -2001 I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page d -of _c_ - 2 FILE INF RMATION SYSTEM SPECIFICATIONS Owner( s i Septic Tank Capacity gal ❑ NI u ) Permit 1/ 3 Septic Tank Manufacturer ,va- ❑ Ni, 3 3 i DESIGN PARAMETERS Effluent Filter Manufacturer ' O Ni - Number of Bedrooms ❑ NA Effluent Filter Model © NA I Number of Public Facility Units j3 Pump Tank Capacity gal NA Estimated flow (average) 0 gal/day Pump Tank Manufacturer ray, Design flow (peak), (Estimated x 1.5) al /da Pump Manufacturer Z NA ` Soil Application Rate al /da /ft2 Pump Model [ANA �! Standard Influent /Effluent Quality Monthly average* Pretreatment Unit �Nf. Fats, Oil &Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration (3 Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection O Other: _j Monthly average Dispersal Cell(s) ❑ N �' ed Effluent Quality Y g Pretreat Y Biochemical Oxygen Demand (BOD S30 mg /L Dtin- Ground (gravity) Ci in Ground (pressurized) Total Suspended Solids (TSS) S30 mg /L NA ❑ At -Grade © Mound Fecal Coliform (geometric mean) S10' cfu /100m1 ❑ Drip -Lino ❑ Other; ~ Maximum Effluent Particle Size Y in dia. ❑ NA Other. Q NA Other: ❑ NA Other: ❑ NA I , *values typical for domestic wastewater and septic tank effluent. Other. El NF; MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) " (Maximum 3 years) ❑ NA inspect condition of tank(s) At least once every: _3 J ears)'< Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volumo ❑ NA ❑ month(&) (Maximum 3 years) ❑ Ni, Inspect dispersal cell(s) At least once every; 1$ year( &) ❑ month(s) O Ni Clean effluent filter At least once every: �� year(s) ❑ month(s) ` Inspect pump, pump controls & alarm At least once every: fD ear(s) ❑ month(s) ,.. Z - Ni, ..� Flush laterals and pressure test At least once every: p year(s) Other: 13 month(s) L�-NA At least once every: Q year(s) Other: Q 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 surfa.cE. 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 thu 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. `±' ¢ t 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 (a/o 1 r,r,::; Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. - System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cells) In one large dose, overloading the *oil( #) and may result- In•the backup or surfoos 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 arc& 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 systern 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 a ealed. • 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, 0 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. - 0 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. 0 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. 60 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 INSTALI POWTS MAINTAINER } Name _ Name Phone — Phone SEPTAQE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone - _ � (his aocument was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.64(1), (2) & (3), Wisconsin Administrative Code, ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address , 9'7 0r Property Address a V (Verification required from Planning Department for new construction.) Ci ty /State y1.rt.cLi i2. e— � k ' Parcel Identification Number n 3S 12-1 - M- 10 l 1 LEGAL DESCRIPTION Property Location ice /a , S 1 / a ,Sec. , T 3 > N R W, Town of G 4 v ICVl A , Y-i Subdivision Q.y- �� , Lot # �. Certified Survey Map # , Volume , Page # Warranty Deed # 6 3 1 5 2 - C p Volume 1 5-12 , Page # 4 qf Spec house yes no Lot lines identifiable & 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. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal, system with the standards set forth, herein, as set by the Department of 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 Department within 30 days of the three year expiration date. AsIdNATURE OF APPLICANT DATE OWNER CERTIFICATION I/we certify t all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the p describ a ve, b y virtue of a warranty deed recorded in Register of Deeds Office / SIdMOTURE OF ICANT DATE * * * * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. jo STATE BAR 00 WISCONSIN FORM 2 -1998 KATHLEEN H. WALSH REGISTER OF DEEDS Document Nunlhe� WARRANTY DFFD ST. CROIX CO., WI This Deed, made between Kevin Patrick Campeau, Jeffrey Allen RECEIVED FUR RECORD Campeau and John Michael Campeau, as tenants in common, Grantor, and 02 -2? -2001 11:00 AM LaCasse Development, Inc., a Wisconsin Corporation, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee WARRANTY DEED the following described real estate in St. Croix County, State of Wisconsin (The EXEMPT N "Property "): COPY FA Y FEE: TRANSFER FEE: 1290.00 The Northeast Quarter of the Southwest Quarter (NE 1/4 SW 1/4) lying west of the RECORDING FEE: 10.00 Apple River, EXCEPT the west three (3) rods thereof; that part of the Southeast PAGES: 1 Quarter of the Southwest Quarter (SE 1/4 SW 1/4) lying west of the Apple River and cast 122 " Street; and the Northwest Quarter of the Southeast Quarter (NW 1/4 SE 1/4) lying north and west of the Apple River, all in Section 11, Township 31 North, Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin; and Recordin • Area EXCEPT Lot 1 of Certified Survey Map filed November 3, 2000, in Volume 14 Natne and Return Address Page 3988, as Document No. 632964. rejyN rLr gam_-.•. r- 5 3 2 Kn (t=s A dN So - Above described land is subject to an easement for ingress and egress to said Lot N - C ( :5 1 `7 1 as described on deed recorded in Volume 1555, Page 37, and subject to all other easements, restrictions and covenants of record. Part of 038 -I 8 -10 & 038 - 1048 -40 Parcel Identification Number (PIN) This is not homestead property. Exceptions to warranties: Subject to all easements, restrictions and covenants of record. Dated this Z � �z of February, 2001. C .�l-u• � Dv�—/ vin a pea John Michael Campeau rck C *Je,f y At en Campeau — AUTHENTICATION ACKNOWLEDGMENT Signature(s) Kevin Patrick Campeau, Jeffrey Allen en Campeau and John Michael STATE OF WISCONSIN ) Ca mnPart ) ss. �����....I.. W� County ) au day of February , 2001. �: r - - day of - .r,-� /J Personally came before me this y �� • f �r 2001 the above named =1C t na •O rand to me known to be the n F -M BM S:P TE BAR OF WISCONSIN person(s) who executed the foregoing instrument and acknowledge f7 (if ctcst? _ the same. ! mo t ° '•authorized`by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Hendrik W. Van Dyk V A DY K O 'BOYL E & S1LER S.C. Notary Public, State of Wisconsin My Commission is permanent. • N Post Office Box 118, New Richmond, WI 54017 (It not, state expiration date. ) (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity should be typed or printed below their signatures WARRANTY DEED STATE. BAR OF WISCONSIN FORM N•. 2 - 1998 INFORMATION PROFESSIONALS COMPANY FOND OU LAC, WI 800 -655 -2021 (1.815 ACRES) x 9 46. 5 � �1 ! � .'66' AU E 943.2 94�60T il X 1."l ACS E It / LOT 6 0 (1.537 AC ES) ' , LOT . ES 2 AdwiCIE % 04 A R (1:6 ACR) SOUTH LINE O�THE � � 1. 31 R / r; ' X 950.3 NE1 / 4 OF THE..I�Wl /4 f • � f NOFITH LINE F TH ! 936.4 t SE1 /4 OF `I H SW 1 � � � x 1 X �' -r/ 315 -- 948.7 9461:7 45.1 1 / 94.8.8 X X J 938.7 _ LOT- 7 \ LOT 4 0 ,C � z• f `x.31 O C�RE f 2 A REST 1, a4 / ORE ' yi ,;A I , 1,A95 C+�$ 1.549 A RES (1 ,AC l / ( x l {' 940.1 949.2 ,; } i \,I J ,,�� X ,�2Cf� L X 943.3 fir" y f r. ' -- ,.. 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