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�/C1 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
,� In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
O ff
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
0 (Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016 -7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper no 8- x 1 1&jQches in size.
County Sanitary Permit # ❑ Check if revisi revious ap
1. Application Information - Please Print all Information Locatiion;
Property Owner Name RECEIVED 'JC 1/4 W1 /4, Sec
Vl T 3� N, R E (or
Property Owner's Mailing Address Lot Number Block Number
JUL 2 3 2008 S
City, State Zip Code hone f%avVROIX COUNTY ubdivision Name or CSM Number
OF / C
� r
II Type of Building: (check one) o l� ® ❑City ❑ Village .Town of
1 or 2 Family Dwelling - No. of Bedrooms:
Public /Commercial (describe use):
❑ State -owned Nearest Road
11. Type of Permit: (Check oa heck box on line B if applicable)
Parcel Tax Number(s)
A) [0 Repair 2 c.❑ on plumbing 4. ❑ Rejuvenation
Sanitation
B) Permit Number Date Issu d
State Sanitary Permit was previously issued Sot f �p 4 ; 0 e9l
IV. Type of POWT System: (Check all that apply) � — `
Non - pressurized In- ground ❑ Mound ? 24 in. suitable soilM❑ �� My ound <_ 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating 6,J /
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min.Anch) Elevation
-too N4
1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
Segkc K 0bQ O Le- C_ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
Ii. Responsibility Statement
I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A
license is not required fort ralift rep k or the installation of non - plumbing sanitation system.
Plumber's Name (print) lumber's Signature (no stamps): MP/ PRS No. Business Phone Number
Plumber's A (Street, City, ate, Zip Code) ��� 3 / - / / VZ/
I c 1 t
VIII. County Use Only
Disapproved Sanitary Permit Fee Date Issued I ing Agel Signatur (N s)
pproved Owner Given Initial Adverse S f
Determination
IX. Conditions of Approval /Reasons for Disapproval:
STEM OWNER: —'� /� �� G( A V U�
an , and
dispersal erviced / maintaine �� 06_7 y as per mapr ovided by plumb v must be maintai k per ap Inances.
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
395296
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:
Gibson, Thomas Star Prairie Township 038- 1195 -50 -000
CST BM Elev: Insp. BM Elew BM Description:
TANK I FORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septi Benchmark /
,9D 02.40 l��o
Alt. BM
-. W � om
Aeration Bldg. Sewer
Holding St/Ht Inlet
/ � o /� 9 Q s � q Sz
St/Ht Outlet Ir cf r ( !
TANK SETBACK INFORMATION 26 1.( t
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet r
1• �•
Septic z D t "S -() f Dt Bottom I I• ci/. 5 ,
�' I
Dosing > Zo t Header /Man. q /
Aeration Dist. Pipe 1 2. D 90, CM
Bot. System 'Z g8' 66 1
Gr ��, 3��' /
PUMP /SIPHON INFORMATION Final ad °j �. S S
Manufa er and I St Cover Z) 1 9. 30
9 (00
GPM J
Model Num � p_ � Z �� 6D
TDH Lift tion Loss System Head TDH Ft
Forcem ' Length Dia.
SOIL ABSORPTION SYSTEM Z
BEDITRENCH Width Length t`h
I No. Of Trenches IT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3� (3i -St 1
SETBACK SYSTEM TO P/L / BLDG WELL LAKE /STREAM LEACHIN Manufa tyrgr: [
INFORMATION CHAMB R 1 ` rs�1W y
Type Of System: i I , NIT Model umber:
�. t J, �� "' � k - C& au
DISTRIBUTION SYSTEM y„ Plc- c..w &.A 6 w� - 'svus.a JL.
Header /Ma ' Id �� Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
L Dia Length Dia Spacing J
SOIL COVER x Pressure Systems Only xx Moun 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 [W No [m Yes [M No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: _ / t 5' / 2-� 0 7- - Inspection #2: — + — f
Location: 1327 218th Avenue Star Prairie, W - 5402 (SE 114 NW 1/4 13 T31 N RI 8W) Pine Acres Lo Parcel No: 13.31.18.1020
1.) Alt BM Description = S iI l �
2.) Bldg sewer length = 3$� Dtw�vv�519�/
- amount of cover =
`� AS �� i l� • O1 r- ' ��
A - `10D 6 +v
Plan revision Required? ® Yes X No}
Use other side for additional information. ZZ ,
Date Insepctor's Signature Cert. No
SBD -6710 (R.3197)
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Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 716'1' •
l Visconsin Madiso 53707 - 7162 Site Address P I g h v e_
De aftment of Commerce ^ S Permit Number
Sanitary Permit Application �ti
In accord with Comm 83.21, Wis, Adm. Code, personal information yo p v e O _ C1 lip
may be used for seco ses Privacy Law, s15. I ` p� Number
I. Application Information - Please Print All Information \� ,
Property Owner's Name o \ arji Num r /
CG G
4Prortyl Mailing Address
�, Pro tiob 38 - 1196' - So - o
f� ?� ti
_T _ -A Alld -A; S LZ N. R
City, State Zip Code Phone Number t ber Block Number
✓ ,---
Subdivision Name CSM Number
II. Type of Building (check all that apply) ❑City
JQ 1 or 2 Family Dwelling - Number of Bedrooms ^ , V v'v ❑Village
❑ Public/Commercial - Describe Use OTownship
❑ State Owned Nearest Road
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if app cable)
A. For County use
1 0 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addidon to
stem Tank Onl E:tis ' S sum
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) i�A f �•i�F .t �k.wttl
44 D& Non - Pressurized Inn-Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Lim Ir
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 Recircula ' 30 ❑ Other
V. D' ersaU'h�eatment Area Information: -
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate ystem Elevation Final Grade
Required Proposed Rate(Gal JDays/Sq.Ft.) (Min./Inc Elevation
a ✓
VI. Tank Info CapaciQinNumber Manufacturer Prefab Site Steel Fiber Plastic
Galloof Tanks Concrete Constructed Glass
New Tanks Septic or Holding Tank Dosing Chamber
VII. Responsibility Statement- I, the undersized, as5trme responsibility for tion of the POWTS shown on the attached plans.
P='se ), Plumbe9 Si MP/MPRS Number Business Phone Number l/
Plumber's Address (Street, City, State, Zip e)
xQ
VIII. Cotmt /De artment Use Onl
pproved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
❑ Owner Given Initial Adverse �'fa
Determination
IX�R ndit' ns of �Vproy �VReasons for Disapproval
uentilter to nstalle an maintained per manufacturer's recommendations.
All setbacks to system and residential structure must meet applicable code requirements.
Property is zoned Ag- residential - only one principal dwelling is allowed on this property.
Floodplain mapping = Zone "C"
Ausa complde plans (to the County only) for the system on paper not less than 31/2 x 11 lnchea In size
SBD -6398 (R . 05101
I
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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 ^s
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.
Please print all information. Revi we by Date
R I®
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 6
Property Owner Property Location
Govt. Lot 114 1/4 S Z T N R E (or&
Property 'Owner's Mailing Address Lot # lock Subd. Name or CSM#
x
City Stat Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
New Construction Use: Residential / Number of bedrooms ��,_ Code derived design flow rate 1 > GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments G
and recommendations: S �' b S "" '"' ► .
r 71 IV Boring # ❑ Boring
Pit Ground surface elev. ft. Depth to limiting factor V in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring #
❑ Boring
pit Ground surface elev. ft. Depth to limiting factor: z� 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
An
4 le 5
G J i
3
* E uent #1 = BOD > 30 < 220 mg /Land TSS >30 < 150 mg /L *Effluent #2 = B5 < 30 mg /L and TSS < 30 mg /L
CST Na a lease ri Si atur CST Number
,S
Address Date Evaluation Conducted Telephone Number
4��!. jq /
SBD -8330 (R07 /00)
Property Owner Parcel ID # �,_51S ^.��$�5'-�� Page of
Boring #
❑ Boring
Pit Ground surface elev. 5 ft. Depth to limiting facto 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
/
� J
❑ 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 /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.
El Pit
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
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.07 /00)
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- 564 - - - -- -- -
ws - Igo
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION - Page 1 of -�
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference {8,p�, direction and
percent slope, scale or dimensions, north arrow , a nt 0dr diitait" to nearest road.
% l Parcel I.D.#
APPLICANT INFORMATION - Pi , an �ilrf ail in _ Pendin g
Personal information you provide may be used for se pur ( Law, s. 15.04 (1) (m)). Re V
Da Q A
Property Owner ,.�1, Proper Location
Lakes & Hills Development :` Govt. I of f /4_NW 1/4,S 13 T 31 ,N,R 18 ( W )
Property Ow is Mailing Address Lot # ' Block # �TSubd. Name or CSM#
7- L -- ❑ Pine Acres
ity Sta a Zip C `PhotleXuhiW �" I :City lage XTown Nearest Road
11
le-0 S�S��'j ?�kL , 218 TH. Ave.
_❑ New Construction Use: N Residentiali•1a16[ 6r Qf bedrooms 3 ❑Addition to existing building
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate -7 bed, gpd/ftz 8 trench, gpolftz
Absorption area required 643 bed, ftz 562 trench, fts Maximum design loading rate .7 bed, ,gpd/ftz 8 t rench.: gpd/ft
Recommended infiltration surface elevation(s) 94.2 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material- - - - - -- Flood plain elevation, if applicable ----- ft
S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ U ®S ❑ U ❑ s ❑ U ®s ❑ U ❑ S ®u ❑ S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPDR
in. Munsell
Boring# Horizon Texture IConsistenc Boundary Roots Bed Trench
Qu. Sz. Cont. Color Gr. Sz. Sh.
1 1 0 -10 10YR3/3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5
2 10 -24 10YR4/4 ------------ - - - - -- 1 lmsbk mvfr gw 1vf 4 .5
Ground --- - - - - -- �-
3 24 -56 7.5YR4/4 ----- - - - - - cs osg n l gw - - -- .7 .8
elev 1 — --
98.9 ft. 4 56 -96 20YR4/6 --- --------- - - - - -- s ❑ osg ml - - -- I - - -- .7 .8
Depth to —
limiting
factor
>96
Remarks:
1 0 -11 10YR3/3 -- ------- -- --- --- - 1 lm sbk mvfr as if .4 .5
2 – -- - - -- - - - - - --
2 11 -25 10YR4/4 ------------ - - - - -- I lmsbk mvfr gw lvf .4 .5
Ground 3 25 -50 7.5YR4/4 ------------ - - - - -- cs osg m1 gw - - -- .7
8
elev
98.2 ft. 4 50 -94 10YR4 /6 ------------ - - - - -- s osg ml - - -- - - -- 7 .8
Depth to
limiting
fac >
Remarks:
CST Name (Please Print) Signature: Telephone No.
Jacque Hawkins _ C,,, . __ V'7 Z P V V
Address / Date CST Number Ref #
1 a U wh Gv �C u c' y 4/9/00 L z 397
PROPERTY OWNER: Lakes & Hilts Development SOIL DESCRIPTION REPORT Page 2 of �
PARCEL LDA Pending
Depth Dominant Color Mottles Structure GPD/ftz
Horizon in Munseil Qu. Sz. Cont Color Texture Gr. Sz. Sh. onsistence Boundary Roots
Red i Trench
3 1 0 -11 10YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as if 4 .5
2 11 -26 l 0YR4 /4 ------------ - - - - -- l 1 msbk mvfr gw 1 of .4 .5
Ground
elev 3 26 -52 7.5YR4/6 ------------ - - - - -- cs osg ml gw - - -- .7 .8
98.7 ft. 4 52 -94 10YR4 /6 s osg ml - - -- - - -- 7 8
Depth to
limiting -
factor
>94 - -- - - - -- —
Remarks:
4
1 0 -11 10YR3 /3 - 1 lmsbk mvfr as if
- 2 11 -26 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw ivf .4 .5
Ground
elev 3 26 -49 7. SYR4 /4 ----------- - - - - -- cs osg ml gw - - -- .7 .8
- --
-- 98 - .2 ft. 4 49 -89 10YR4 /6 ------------ - - - - -- s osg ml - - -- 7 8
Depth to
limiting
factor
>89"
ELL
Remarks:
5 1 0 -11 10YR3 /3 -------- - - - - -- 1 1 msbk mvfr as if 4 .5
- 2 11 -25 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground —
elev
3 25 -52 7.5YR4/4 ------------ - - - - -- cs os g ml gw - - -- .7 .8
98.9 ft- 4 52 -96 10YR4 /6 ------------ - - - - -- cs osg ml - - -- - - -- .7 .8
Depth to
limiting -- — - —
factor
>96"
Remarks:
Ground - -
elev
ft.
Depth to
limiting - - -- — - -- - --
factor
Remarks:
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POWTS OWNER'S MANUAL 81: MANAGEMENT PLAN Page of _
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner r _ - Septic Tank Capacity ga l ❑ NF,
Permit # Septic Tank Manufacturer - ,16 ❑ NA
Effluent Filter Manufacturer ❑ NA
DESIGN PARAMETERS ❑ NP.
Number of Bedrooms O NA, Effluent Filter Model
gal C,�NF
Number of Commercial Units
,�'NA Pump Tank Capacity
Estimated flow (average) gal /day Pump Tank Manufacturer NP
Design flow (peak), (Estimated x 1.5) g
al /day Pump Manufacturer O.-NP.
O
Soil Application Rate Z gal/day/ft" Pump Model NF
Monthly average* Pretreatment Unit NF
Influent/Effluent Quality ❑ Sand /Gravel Filter ❑ Peat Filter
Fats, Oil 8z Grease (FOG) s30 mg/L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) 5_220 mg /L ❑ Disinfection ❑ Other:
Total Susp Solids (TSS) 15150 mg/L Manufacturer
Pretreated Effluent Quality ❑ NA Monthly average * Dispersal Cell(s)
530 mg/L f4 In- ground (gravity) ❑ In- ground (pressurized)
Biochemical Oxygen Demand (BODs) ❑ At -grade ❑Mound
Total Suspended Solids (TSS) 5530 mg/L
Fecal Colifor n (geometric mean) 5_ 10' cfu/ 100m1 1 ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size �6 inch diameter
* Values typical for domestic (non -commercial) wastewater and sepu
tank effluent.
* * Values typical for pretreated wascewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
onths years) (Maximum 3 yrs.)
Inspect condition of tank(s) At least once every ❑m
Pump out contents of tank(s) When combined sludge and scum equals one -third (A) of tank volume
Inspect dispersal cell(s) At least once every ❑ months year(s) (Maximum 3 yrs. )
Clean effluent filter At least once every ❑months Dr
Inspect pump, pump controls 8z:alarm At least once every ❑ months ❑ year(s) JZ NA
Flush laterals and pressure test At least once every El months [3 year(s)
Rf NA
Other: At least once every ❑ months ❑ years) NA
Other At least once every ❑ months ❑ year(s) NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or cerdflcadons: Mast
Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspection
must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure d
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) s hall be
and su visually inspected to rface. The pond ng o f effluent on ground surface o
ay Indicate l a faili tco check dition requires the immediate
n
the ground su
notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Ys) 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 ch. NR 113, Wiscons
Administrative Code. ent components, and
The servicing of effluent filters, mechanical � or pressurized
orleuOs POWTS be performed by a�certified POWTS Maintainer. ny other
maintenance or monitoring at Intervals
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
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 chemic::
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content
of the tank(s) removed by a sentage servicing operator Prior to use,
ll
Page — of
System start up shall not occur when soil condlt)Qm art frozen at the Infltrative surface,
During power outages pump tanks may fill above normal hlghwater levels, When power Is restored the excess wastewater will tje
discharged to the dispersal cell(s) In one large dose, overloading the cell(s) and may result In the backup or surface discharge o►
effluent. To avoid this situation have the contents of the pump tank removed by a Sepup Servking Operator prior to restorint
power to the effluent pump or contact a Plumber or POWTS Malntalner to assist In manually operating the pump controls to
restore ncrmai levels within the pump tank,
Do not drive or park vehicles over tanks and dispersal cells. Do not dtive or park over, or otherwise diswrb 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 strearn 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 petiings; ,gasoline; grease; herbicides; meat scraps; medicatiuns; oil;
painting croduco; pesticides; sanitary naokins: tamponsi and water softener brine,
ASANDONEMENT
When the POWTS fails and /or Is pemranenciy taken out of service the foliowlnj steps shall be taken to Insure that the system is
3. 3 Wisconsin Adminlstradve Codes
r erl and safe) abandoned In compliance 3 ,
P op Y Y pl lance with ch, Comm 8
• All piping to links and plu shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property disposed of by a Sepuge 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 falls and cannot be repalmd the following measures have been, or must be taken, to provide a code compliant
replacement system;
19 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 b;
required setbacks from exiscing 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 sultaWe replacement area. Replacement systems must
comply with the rules In effect at that time.
O A suitable replacement area Is not avalWle due to setback and /or soli limitations. Barring advances In POWTS technology
a holding tank may be InsuAed 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 ma;
be installed as a last resort to replace the failed POWTS.
C Mound and at-grade soil absorption systems may be reconstructed In place following removal of the biomat at the
lntjivaOve surface. Reconsvvctlon3 of such systems miva,comply with the rules In effect at that time.
< < WARN ING> >
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 TKE INTERIOR Of A TANK MAY 6E DIFFICULT OR
IMPMURI F.
ADDITIONAL COMMENTS
POWTS I $T.A ER POWTS MAINT 1 R
Name / Na me
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Apricy '
Phnnv fhont _
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer JLttit� >�tr / �Qti oewa -� v-- 1_
Mailing Address , S" �j r- , ��'� 1 J` 4Pa-6
Property Address
(Verification required from Planning Department for new construction)
City /State - -ySPa, /Jj ,��L Parcel Identification Number
LE GAL DESCRIPTION
Property Location ' /n, ' /4, Sec. T�N -R_A5 W, Town of
Subdivision l ; r �y S Lot # J'!�
Certified Survey Map # — ,Volume , Page #
Warranty Deed # ��' , Volume /�'�� , Page
Spec house O yes J no Lot lines identifiable l yes O 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 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 Office within 30
d s of the three year expiration date.
slot
GNA F APPLICAN DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are pe to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty de e recorded in Register of Deeds Office.
XWfla.—'1 cgz4 OC
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
**s *s*
** 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
VOL VW //�� +fir
PAGE51z 654255
STATE BAR OF WISCONSIN FORM 2. 1999 K ATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Lak and Hills, Inc., a Minnesota _ RECEIVED FOR RECORD
Corporation,
• -- 08 -20 -2001 10:00 AM
WARRANTY DEED
Grantor, and Thomas A. Gibson and Jennifer L Maypark EXEMPT 8
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 83.70
RECORDING FEE: 10.00
Grantee. _ __....._._. PAGES: 1
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 25, Pine Acres, Town of Star Prairie, St. Croix County, Wisconsin. Name and Return Address
I �V13
X3 01 Ces. lc s 'et se }
Pt 038- 1054 -90 -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 14 4-4 day of August 2001
Lakes sa H Inc
/
• �_ + By: Richard S. N elson, President -
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix _ County )
authenticated this day of ,
Personally came before me this l` _ t4 day of
August 2001 the above named
L akes and Hills, Inc., by Richard S. Nelson, its Preside
TITLE: MEMBER STATE BAR OF WISCONfIN
(If not, pry U n me kno to be the persons) who executed the foregoin
authorized by § 706.06, Wis. Stats.) S,ya> V. �•'yC0 nstrur nd c o le d the s
THIS INSTRUMENT WAS DRAFTED BY + / Ca
Attorney Kristina Ogland Notary Public, State of Wisconsi —
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) _ -b os
* Names of persons signing in any capacity must be typed or printed below their signature. Bdmmelim Profna"Is company. Food du Lao, wl
STATE BAR OF WISCONSIN eoorss -zozr
WARRANTY DEED FORM No. 2. 1"9
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