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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 8 1/2 x 11 inches in size. Plan must
inducts, but not limited to: vertical a ferenc� p�iot(13,ML direction and Parcel I.D.
percent slope, scale or dimensions, orth aRE " D d dista ice to nearest road.
. Piease rint all information. Reviewed by Dat
K
Personal information you provide may used fo nd u rivacy w, s. 15.04 (1) (m)). g
Properly Owner r Property Location
b a f. CROIX COJNT'� Govt. Lot 1/4 1/4 S, T N R �. E (orQ
Props Owner's Mailing Address Lqi& Block # Subd. or CSM#
tat Zip Code Phone Number [:3 city ❑ lage own Nearest FAad
7 , New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate � _ GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material _ A Rond UPW&vbtion if ap
General n ' o `11 /w t7 � Qo �?o w � /
and recommendations- ons:
# Boring /
a � Pit Ground surface elev. f. �� �!�—ft. Depth to limiting factor �� in.
Sal Applicabon 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
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In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `042
` Effluent #1 = BOD > 30 < 220 mg/L and TSS > < 150 mg/L Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
n is G:lle 60"'c 2 Z/y 7
Address Data Evaluation Conducted Telephone Number
3 s z Ya C/ 44- 5'a y. o w 6 6 37
Property Owner— Parcel ID # Page of
F-1 Boring # [] Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil AMppli cation 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
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in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F B oring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil ApNication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Lure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
'
Effluent #1 = BOD > 30 1220 mg/L and TSS >30 1150 mgA- ' Effluent #2 = BOD, 130 mg/L and TSS 130 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.
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 420398 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal inforrndtion 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:
Jacobs, Jeff I Star Prairie Township 038 - 1194 -80 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTU CAPACITY STATION BS HI FS ELEV.
v-
Septic Benchmark
!0•c43 10ta 4 e 3 /od. a
FD i Alt. BM
tio Bldg. Sewer ing St/Ht Inlet
60. o /oo� y
TANK SETBACK INFORMATION St/Ht Outlet (o. 3 /OD• /3
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
6 7'
Septic �7 � l (�h ;n Dt Bottom
s
Dosing Head , Man.
Aeration Di . pe d u 75-
Holding Bot. System \ b Z ' _ �3•(�� 'rte
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St over
PM CGifvn 3- a
Model Number
TDH Lift Frictio ss I ystem Head TDH Ft
..2
Forcemain gth Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width / Length_ INo. Of Tres PIT DIMENSIONS No. Of Pits lasfde Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL_ LAKE /STREAM EACHIN Manuf�t rer /r�
INFORMATION CHAMBER O J 1
Type f System: 2q' - ;�07 UNIT
� & - Pxk,L" - 1 1 bX6.g V
/ /J� Model Number:
DISTRIBUTION SYSTEM VAb_O `) ,6rA'Lt q%J
I Header /Manrfold� Distribution x Hole Size x Hole Spacing Vent to Air Intake *f
Pipe(s)
Length Dia Length ' Dia h � 5`p�'ac
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only �� S trx SC1tC�l
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx u c J
Bed/Trench Center 3 Bed/Trench Edges Topsoil Yes ] L� No :3 M.t f
es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: f/ 1 Inspection #2:
Location: 2185 134th St New Richmond, Wl 54017 (SW 1/4 NW 1/4 13 T31 N R1 8W) Pine Acres Lot 18 Parcel No: 13.31.18.1013
1.) Alt BM Description �n - /�n ,,f�,y �'f /SaG-L'et�QS �32 <Y►�_
2.) Bldg sewer length = �Q r 0(T(Sll7 1 � � � / -�Y�Y� Xsz 'r"`�fr'""- SY7T�"l 7(,AA 4a2 ' onk--
-amount of cover = ' 3 So k_�'ol' -� f�1� 01L gi S
�o tZ C.t:N
da ✓- ihd•�a 9 a 4
- -- - - -- -
Plan revision Required? Yes I I
Use other side for additional information. No
SBD -6710 (R.3/97) Date 7i/ , Insepctor's Sig= aturg &c CrvQ at-4 C ert. No.
in � C�rCtirn row+ e 4s�- ��
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�Visconsin - Safty and Buildings Dhision t xiurlty
201 W. '4'V'liallugtan Ave:.. P.O. laox , 7082 S % C. n / �L
r uiffian, 'M 5V07 -. 7082 Sito Ad&ess
Departme3rit of C
+��D317+ �t�1ry Pee�'�ft Apphi>✓` ti Sjrtrltury ?erudt 1Viuulxai'
Irr award wills Convu 753 2l, W1h. Adm. Cody, persu'nul itdt rmddon you provide 0 CUck ititevisltal
nay be used fw 6 purpDow Privar,-y' .4-w. s'1 5.Ur1(1)(;n�
ApPlicatlori bdor lorr measo I'rcnt Au rnforir►ution State Its'15. wullbar
_._ RFCF1V : .n
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ruperty dwI18 '6 I�lFlttl I�aYC{ Z+T7lriilattt —
'cap ' b ]V Il7b Address Prapartg Locati
CROI
ST. X COUNTY" 1 s Y , b' t
_ • L�, , o 2 Z _ ._ �_ lA A* S t3 •r 3i N, > r8" �,
t7, Slate 'Lip Code l rat r 13ky k Naudw
Salads / " tlrtr� CSIA Number
S • � � C �/'Ct / r" "C. �..li Syd rl � /J 1 /+1.t Q- • C�tit> '
1. T yp4 of :Building (C".herlc all the apply.) � r Cl city
J 1 or 2 Fancily Dwelling - Number of Jm&ooLwi
- 1 1?uba /Cmtunarciul - 1)=ibo Uso 0-ruwww
I Strw Clwnerl
H.1Ype ar Pertnit. Who& only BUB bait a n line X. AlI11t1herIrtg is for ixtl � util uytr.3 (Complete line 13, if applicable.
1i Df nc ement oY 6 G AddWori to
steer '2 0 Repiauenreut Systsau Tank On] l3rclstisa 5ystesn Poe County Usty
1' L'1Che&if9=1tuy I'erwk Previously Lowed Pernift Number Date Issued — ��
V yljts of P0'W X bysten . (Cliacic all that apply. Nwriberi;ng is for interiud use.)
Nou -- Prmsurued bi Crround 2111 bdourrd 4 Cl Sand L 50 0 Conslzuuted Wettand
:2 1J Prwsurind la- ritound dl 0 Holdiag Tank 48 tl SIna Pues 51 mip I,irte
65 tT At- Ur°udo 116 QAerublc 1rwtmeat UpIt 4 13 0 It narculating 3G OO(uor
y.. DIsAc rsktl/Trss�ttn Area T�>n rulution: /j'! - _ 2f IrY�
)LAWL'Plow fgpdy Dispersal Area 171sport al Area Sod Applicatiou Pe:rcolulon Mae 5yciern 131evz,t1 I-b,11 (mule 3
Required Prullwed Ituta�fe;. /lea s/Sq -Vt (Nliu.11dth) 3 Bievutiuu
.__
8S7 g'�l 11'7 S `iS;
VZ. Tarrk info , in Total Nunrtasr ae er Prof ib Silo Steel Fiber Pluck
UUUDns Oidons of 3'w s µll � l Da Conarue Comtructed ct
Now whthig
T uiks 'r anks
rl
7usls�g Ctui[utwr
V.U. Resp2! siI Mly 5tateruont r, t he uadursigaW usb uu inwimu f or Lus t i — �Y the lxt)"l�'tS x bowu ou tl/o attudied pkuw.
'Sumber's Ma u; (Print) Pjurtt j s Sigsurta tvil Business Phu= N'umbw Q, j
AUMber's Address (street. City. State, Zip Cu(te)
2pprlivled Cuun /llo �urtruent T7su OW
D 1}lsapprovad Sanitary PUrjUh Pw (lucludw Gmuud outer Oat Issue Ibsuinb A nat 51 Gue "tarups)
Owrtc Calves IrrIHst Advt3r6ts Sltrcteasga P60) i d l l �?i� d
T InI- Mirstrtiun
M C n t ruval/Roasnrrs for Wma rovul
�� I►n �o�c,5" oni�y �� 7a�9�•��' elr,(ia. a>1
1 Septic tank, effluent filter and Ce�vl.d � �5/ �'�
dispersal cell must all be serviced / maintained y ,�+ f eV
as per management plan provided by plumber. r� �� o 0 , r T /
2. All setback requirements must be maintained
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Z
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
q�roa ounty S '
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.
include, but not limited to: vertical and horizontal reference point (BM), direc 'o7an � I.D.
percent slope, scale or dimensions, north arrow, and location and distance n S/ . " �t , or e7 Please print all information eviewed Date
002
P ersonal information you provide may be used for secondary purposes (Privacy Law, . 15.04 (1) (m)). (p Q
Propert w rope L6WMCOUNTY
ZONI S /3 T N R/ J E (or61/ (�J4 �UVL. U-Vrr�
Pro pe er's i Address Lot # Block # I Subd. Name or CS
I
City State Zip Code Phone Number ❑City ❑ ' lage pq Town Nearest RoaCL
ew C struction Use: ❑ Residential / Number of bedrooms Code derived design flow rate — GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation 'f applicable ft.
General comments �Qc,ca d� S f? p QG� � (7h F,t v/`Ak� inn
and recommendations: w � !T
F Boring # I❑ Boring
[a Pit Ground surface elev. Depth to limiting factor S in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
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❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /l- and TSS >30 < 150 mg /L * Effluent #2 = BOD, < 30 mg /L and TSS < 30 mg /L
lot- CST Name (Please Print) Signatu CST Number
n 1 ' 221W .
Address Ja nation Con u Telephone Number
SBD -8330 (R07 /00)
r I
Property Owner Parcel ID # Page of
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
p:
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F ❑
Boring # E] Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
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-
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 S�. �ttrc.iC e
isconsin Madison, W1 53707 - 7162 Site Address
De e,rtment of Commerce _z y-d Z 3 el'X 4 2185 /3
Sanitary Permit Application Sanitary Per 20 N umber
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
ma be used for ses Privac ❑Check if Revision
I. Application Information - Please Print All Information State Plan I.D. Number
Prope 's Name v 9 2 0 0 Z Parcel Number
P is Mxffim Address S f Property Location a D
A KW
7 �f o - - -A;s 3 T3/ N. R/8' E
City, State Zip Code Phone Number Lot Nu4ihpr Block Number
Subdivision Name CSM Number
U. Type of HAilding (check all that apply) 4". tv c ❑City
Al
91 or 2 F y Dwelling - Number of Bedrooms []village
8
❑ Public/Commercial - Describe Use ❑Township
❑ State owned C-29)4 ( 3 6 z • sv I ( J, Nearest Road �
`1'" Q �L� 3' A 50.0' C 9 J\"—" 3 y s 7'
M. Type of Permit: (Check only due dox on line A (numbering scheme for internal use). Complete line B if applicable)
A. IpKNew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use
stem Tank Onl 'Exist ' stem
B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) - ` 100
444 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other
V. DisperrsaLlTr eatm Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate Astern Elevation Final Grade
Required Proposed Rate(Gals./ Days /Sq.Ft.) (Min./Inch) Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Sepd r Holding Tank
/ ;Leo La c?
Dosing Chamber ITI
VII. Responsibility Statement- I, the undersigned, assume responsibility for instaggdo of the POWTS shown on the attached plans.
Plumber's Name (Print) P
n w,_ �V 1 ZZ1 It -r
s Signature bee Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
3 yo 11 S - r V ty j — S
VIII. Count /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Fee
Surcharge g )
11 Owner Given Initial Adverse f U <
Determination It —
IX. Conditions of Appro aeasons for Disa proval n n L a _t
, a 6 O � � S 1t.Cll t -4 a:l
S eta M AA
1L Attach complete qlans (to the County only) for the ayat on paperno than 81/2 x 11 inches In Alze
-' tfowtpet,n ,n.w cJ�u�^t+�MarAr
SBD -6398 (R. 05101)
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of .j
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8'fz size. Plan must County
include, but not limited to: vertical and horizonta eke cep int (B .direction and
percent slope, scale or dimensions, nort=r d io tion and distance to nearest road. parcel L D.#
APPLICANT INFORMATION - , r mafiblh Pendm
Personal information you provide may be used or:s�condary Otimoses (P t cy Law, s. 1 .04 (1) (m)). R iewed By Date
. Z ZriO
Property Owner perry Location
Lakes & Hills Develo ment " vt. Lot 114 NW 114,6 13 T 31 AR 18 W
Property,Owner's Mailing Address t # o Black # Subd. Name or CSM#
__� g� -- Pine Acres
lty , State Zip Code PhoneNumber ` [� City aqe k]Town Nearest Road
4 �7c �fcrr� ✓yi✓ i��4 �7 t �10r< , G 134 TH. ST.
New Construction Use: Z Residential / Number of bedrooms 3 ❑Addition to existing building - - - - --
❑ Replacement El Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ftz 8 trench, gpd/ftz
Absorption area required 643 bed, fF 562 trench, T Maximum design loading rate .7 bed, gpd/ftz .8 t rench, gpd/fF
Recommended infiltration surface elevation(s) 95.4 it (as referred to site plan benchmark)
Additional design / site considerations Alternate Area Elev. 94.2
t Parent material - - - - -- Flood plain elevation, if applicable ----- -- ft
ble for system Conventional Mound In - Ground Pressure AT - Grade 7ysle m in Fill Holding Tank
uitable for system ❑ S ❑ U ® S ❑ U ❑ S ❑ U ❑ S El S ®U ❑ S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ftz
Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots i Trench
1 1 0 -10 10YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5
2 10 -20 1 OYR /4 ------------ - - - - -- I 1 msbk mvfr gw 1 of .4 .5
Ground 3 20 -53 7. 5YR4/4 ----- - - - - -- cs osg ml gw - - -- .7 .8
elev - - - - - - - -- - - --
99. ft. 4 53 - 9 10 YR5/6 ---------- - - - - -- s osg ml - - -- - - -- 7 8
Depth to — -- - - -- -- - -- - -- - -- - - -- —
limiting 4S. YO r T!I 3• gS �/
factor
>95 So •�( Fr:
Remarks: _
2 1 0 -9 10YR ------------ - - - - -- I lmsbk m vfr as if 4 .5
2 9 -19 l 0YR4 /4 ------------ - - - - -- 1 1 ms bk mvfr gw 1 of .4 .5
Ground 3 1949 7.5YR4/4 ------- - - - - -- - - - -- cs osg ml gw - - -- .7 .8
elev - -
98.7 ft. 4 49 -95 10YR5/6 ------------ - - - - -- s osg ml - - -- - - -- 7 .8
Depth to
limiting 9 • c . 2
factor
>95"
Remarks:
CST NaLue ase Print) ignature: Telephone No.
Jac Hawkins - _ ►! % 7Z - �I/�/�
Address �- / Date CST Number Ref#
!Luc' v , Y 8T3 4/8/00 �?a.� 87 7- 386
r—
PROPERTY OWNER: Lakes & Hills Developme SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL 1.0.# Pendiae
Depth Dominant Color Mottles Structure GPD1ft
Horizon in Munsell Qu. Sz. Cord Color Texture Gr. Sz. Sh. nsistence Boundary Roots
Bed Trench
3 1 0 -10 10Y R3 /3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5
2 10 -20 10YR4 /3 ------------ - - - - -- I lmsbk mvfr gw lvf .4 .5
Ground
3 20 -51 7.SYR4 /4 - - - -- cs os ml gw - - -- .7 8
elev ------- - - - - --
99.9 ft, 4 5 69 1 10Y /6 ------------ - - - - -- cs osg ml - - -- - - -- 7 8
Depth to « `
limiting
factor
>93
Remarks:
4 1 0 -10 10YR3 /3 ------ - - - - -- 1 lmsbk mvfr as if .4 .5
2 10 -19 10YR4 /4 ----------- - - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground
eleV 3 9 -52 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - -- 7 8
------------------ - ----- - - - - -- - --
97.6 ft. 4 52 -80 10YR4 /6 cs osg ml - - -- - -- 7
.8
Depth to
limiting — —� �J3. `� - - - -- -- - - - - -- - - -- -
factor /
Remarks:
5 1 0 -9 10 YR3 /3 ---- - - - - -- 1 lmsb mvfr as if .4 .5
2 9 -19 10YR4/4 ------------ - - - - -- 1 1 msbk mvfr gw 1 of .4 .5
Ground - - - - - --
3 19 -5 7.5Y ------------ - - - - -- cs os g ml gw - - -- 7 8
elev _
97.6 ft. 4 5 -82 10 /6 ------------ - - - - -- cs osg ml - - -- - - -- 7 8
Depth to
limiting - -- - - --
factor c
>82 19 — f
O Remarks:
Ground --
elev - -- - - - - -- - -- — - -- - - --
ft. - - -
Depth to
limiting -- — -- - -- - - - - -- - - -- - — —
factor
Remarks:
P16
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ry POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _L of Z/
R E INFORMATION SYSTEM SPECIFICATIONS
E r ' 6 = K3 Septic Tank Capacity ? lam a l E3 NA
# ZD q,� Septic Tank Manufacturer �-1 13 NA 1
DESIGN PARAMETERS Effluent Filter Manufacturer u_ ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model _ I W ❑ NA
Number of Public Facility Units CIA Pump Tank Capacity a l (12 NA
Estimated flow (average) qOO g al/day Pump Tank Manufacturer I MA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer CIA
Soil Application Rate (� • al /da /ft2 Pump Model I JA
Standard Influent/Effluent Quality Monthly average` Pretreatment Unit PIA
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 Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD :530 mg /L fiCf 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 t ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: 13 NA
Oa ❑ NA Other: ❑ NA
• i wastewater and septic tank effluent. Other: ❑ NA
Values typical for domestic stew p
MAINTENANCE SCHEDULE
Service Event Service Frequency
f tank (s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Inspec condition o to () ear s
pec � I 1
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) e (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
—'Z Iff year(s)
❑ month(s) ❑ 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)
Ot ❑ month(s)
the 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
identify an cracks or leaks,
n hardware ide Y
f the tanks to identify an fY
inspections must include a visual inspection o tank( s) Y Y missing or broke
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.
h
Page 2 of
• START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals
that may Impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the iankls) 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:
Iff A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name C-A t C.6 Name
Phone 415-- 2 6 Q _ (A, 3 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name T, (_%b LK : b8N N(/
Phone Phone !K4 _ �((
This document was drafted in compliance with chapter Comm 83.22(2)(b)11)(d) &M and 83.5411), 12) & (31, Wisconsin Administrative Code.
IIIL
II -
• - ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer A 't, Y � � �2, K� �9 --
Mailing Address 0 t 1- 0
Property Address Lp� "" ' e . s .21 n - s S�- - /
(Verification required from Planning Department for new construction)
a
City /State S ( iI -t- T Parcel Identification
LEGAL DESCRIPTION
Property Location %4, A A1 %4, Sec. , T 3 I N -R)W, Town of
Subdivision fzz, CC,. , Lot # �.
Certified Survey Map , Volume , Page #
Warranty Deed # �oX (4PJ 2:� — , Volume . #
Spec house El yes ❑ no Lot lines identifiable J� yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
IGNA 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 prope described above, by virtue of a warranty deed recorded in Register of Deeds Office.
/.
I ATURE 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 1944 P 522 tk
STATE BAR OF WISCONSIN FORM 2.1999 6 6 6 5 2 2
WARRANTY DEED KATHLEEN H. WALSH
Document Number REGISTER OF DEEDS
ST. CROIR CO., VI
This Deed, made between Lakes and Hills, Inc., a Minnesota RECEIVED FOR RECORD
Corporation,
-- 08 -09 -2002 11:30 AM
-- — NRRRON DEED
Grantor, and Jeffer A. J acobs EXEWT #
— - REC FEE: 11.00
TRAMS FEE: 52.50
COPY FEE:
Grantee. - CERT COPY FEE:
Grantor, for a valuable consideration, conveys to Grantee the PAGES: 1
following described real estate in St. Croix _ - _ County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
of Plat of Pine Acres, Town of Star Prairie, St. Croix County, Name and Return Address
Wisconsin.
0 38 - 1194 -80 -000
Parcel Identification Number (PIN)
This is not homestead property.
0i) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this icy' day of August 2002
Lakes and Hills, Inc.
• • By: Richard S. Nelson, Presid
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
-- - - - - -- ) ss.
St. Croix County )
authenticated this day'of !
Personally came before me this cp//k� day of
REVERS August 2002 the above named
n = Lakes and Hills, Inc., by Richard S. Nelson, its President,
It OF
TITLE: MEMBER STATE BAR & WISCONSIN
(If not, to me kn to be hp n(s) who executed the foregoing
--------- - - - - -- ins". d ac u _d ed the s ms e•
authorized by § 706.06. Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY s ( C
Atto Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 - -_ M or mission is perm ent. (If not, state expiration te:
(Signatures may be authenticated or acknowledged. Both are not necessary.) )
*Names of persons signing in any capacity must be typed or printed below their sig re. trtamefion Pmfesslmals compwy, Fa+d du tae, wi
STATE BAR OF VA9CONSIN 800-655.2021
WARRANTY DEED FORM No. 2.1999
S00 17" W 335.s9 1
470.24' _
32800 109.24 12
—43Z24- �\ \
W 70,634 sq.ft. \
14 s 1.62 acres
65,600 sq.ft. g N so.
o�
1.51 acres
13
6 7,544 sq. ft.
q
F
1.55 acres
328.00'
N00'53'1 7
G
15 '" F
76,424 sq. ft.
1.75 acres 2
M 1 8 NI
68,652
lie ° w 8 a' lti 1.58 c
32aoo' 70,766 sq. ft. -
N00 7 ;c 1.62 I �ccr TO
16 g
74,128 sq.ft. N
1.70 acres �,�� y''r'o
3
20 �$
32800'
93,346 sq. ft.
N00W.17'E ! g 2.14 acres
19
1 93,110 sq. ft.
66,730 sq. ft. 2.14 acres
1.53 acres
- 0 1 Drainage &
•- O II— Ponding Easement
o I 100YR HY& 987.3
—127Z43- 01 i
i
32803' 307.81' 250.83' ,
T 4 ,We st 1310. imas 12 line if NE 1/4 of NW 1/4 - -' 8 50 E
of Sec. 13, T31N, R18W y� ` 1310.45'(rec.)
I I
,+ PRAIRIE _ RICH
-------------
GILLE TRUCKING & EXCAVATING, INC.
Septic System Installation Perc Tests Basements • Black Dirt • Driveways Waterways • Gravel • Site Prep
DENNIS GILLE
372140th Street Telephone /Fax: 715 - 268 -6637
Amery, WI 54001 MPRS - CSTM
Z6 Y 221471
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