HomeMy WebLinkAbout038-1195-70-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No: 408291 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:
Marek, Darin I Star Prairie Township 038 - 1195 -70 -000
CST BM Elev: Insp. BM Elev: Descri tion:
'm ` BM Ct �° ra sQa a�' 1 S, 10 -A-2—
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic MC cf Benchmark
Dosing Alt. BM ,
`f•So to °•��/
Aeration Bldg. Sewer
3.z4' 1 (.96
Holding St/Ht Inlet
5 IM•ol l
St/Ht Outlet
TANK SETBACK INFORMATION SSS`f 9`1 gyp
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic > 50 / �` , $ r Dt Bottom
Dosing Header /Man. r
to •O q�•Zl
Aeration Dist. Pipe (, — X
(o $a -�
Holding Bot. System # 3 f - o} 1?,
�•9f . 7 7.3 - 3 ,
Final Grade low
PUMP /SIPHON INFORMATION bu '
Manufacturer Demand St Cover er, euQ
GPM ark¢
Model Numb l
44 4 3 5-. as• 77
TDH Lift ion Loss System Head TD Ft
Forcemain Length Dist. to Well
SOIL ABSORPTION SYSTEM (
DIMENSIONS
JCW Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
3 `8 •� I �2
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING ManufacI rgg
INFORMATION CHAMBER OR
Type Of System: r r UNIT
—3(o 36 Model Number: 12-
DISTRIBUTION SYSTEM
Header /Manifoo, Distribution x Hole Size x Hole Spacing Vent to Air Intake
� L « Pip s) I
Length lk ,�qvv�� 4 Dia Length Dia Spacing — 41)
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of eeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil xx S
Yes � No Yes 0 No
\
Co ,) RENT S: (Inclu cede iscrepencies, pers ns present, etc.) Inspection #1: f t �J Z-T.j Inspection #2: ---- -- �—
1 ty'-"'r v�' C�v�S�•u.c�'edl '��1S�2c�t�6�. .
Coca rot n: 1339 218th Ave New Richmond, WI 54017 (SE 1/4 NW 1/4 13 T31N R18W) Pine Acres Lot 27 Parcel No: 13.31.18.1022
1.) Alt BM Description
2.) Bldg sewer length = .�-
- amount of cover
� s� ! �s� � , a�G�a�•- lo.e�s i. 5 ��2. �s►� a� �.Q� W •t6�:t o . ®��� �:Q. S � �D
Plan revision Required? M Yes No �cs-Z6
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No.
/339 . ig Ave, J
Sanitary Permit Application safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
1 *isconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of commerce [Privacy Law, s. 15.04(1)(m)) (Submit completed form to county if not
- y
�r —d z 0l9go /5 state owned.)
Attach complete plans (to the county copy only) for 4Lastem, on paper not le th an 8 -1/2 x 11 inches in size.
County State SanitagPermit Number ❑ C ck if rpm 8 I? v n State Plan I. D. Number
I. Application Information - Please Print all Information Location:
.{
Property Owner Name J U 2 J 2002 i_ Property Location
Property Owner's Mailing Address l P 'y Lot Number Block Number
/6 13 S c��
City State /f Zip Code Phone Number Subdivision Name or CS
II. Type of Building: (check one) ❑ cit
1 or 2 Family Dwelling - No. of Bedrooms: ❑Village
�
❑ p Town ublic /Commercial (describe use):_ � 5 Z5 of
❑ State - Owned
2 � /� ! � �,� ��� � ✓
Nearest Road / ?
6L ( ✓
el r y / Parcel Tax Number(s
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) /,3.3 .
L A) 1. ew ` �. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
S tem System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV Type of POWT System: �QKeck all that apply)
W Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information: 3 1. C> / - 5 e r - , f
e Aji., 7, — k a v
1. Design Flow (gpd) 2. Dispersal Area 3. Disperses "- °° 4. Soil Applicat on 5. Perco on Rate 6. System Elevation 7. Final Grade
Required Proposed t Rate (Gals. /day /sq. ft.) (Min. /inch) Tr _ Elevation
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, as sume responsibility for installation of the POWTS shown on the attached plans.
Plumb 's Name (print) Plumber' nature (no stamps): MP/MPRS No. Business Phone Number
Plum s Address (Street, City, State, Zip Code)
ew
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Is Agent Signature (No stamps)
❑ Owner Given Initial Adverse Surcharge Fee) _
pp roved Determination 0 a, ' "e o p J Q' Z `(
X. Conditions of Approval /Reasons for / Disapproval:
A lt s. 6-c-kJ ik✓s �2 ✓BP %f+lG✓ � /r� /yr �a �G /nS r cHSH^ / w�i�^ ,
L �VICG�0,^ /� Preltiq�tG9��? I"tGL✓ph'r�� .��L- /t�''�� LQG�e�Lt�
-i Fi ' �'�I K-�-� �/{tr Sha���,C ✓lt kiyl'�il�,e��p , �d ✓ l�kan.��c S glQt -ci >rl c,.,��
LoC�T� e ti �N v �L EVE` l to P/Lt D�'L d C o 4j M 4�iv ) CatirS71t0e t
SBD -6398 (R. 07/00) _ .
PLOT PLAN
PROJECT Qarin mares ADDRESS 2168 134th st NewRichmond WL 54017
SE 1/4 NW 1/4S 13 /T 31 N/R 18 W TOWN StarPrairie COUNTY ST. CROIX
7 -29 -02 BEDROOM 3
MPRS Byron Bird Jr. 22052T DATE
CONVENTIONAL XXX -Grade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 17 LOAD RATE .7 ABSORPTION AREA 642 # of chambers 22
BENCHMARK V.B.P Top of lath SE comer of PL ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL •H.R.P. same as Bm
Vent SYSTEM ELEVATION T- 1 =95.8T - =95.3
>12" Sidewinder High
Of Capacity Leaching
Cove Chamber with 17.2
6" ^2 per chamber
Long 34" Elevation t/
t 7;Ee e w�
1,75
2 3 ' B1
98' 10'
ob pipe
34th st 15'
100' > I0(
30' to P
�w� 15'
0 Garage 3 bed House
/
4 t ,
�
Drivew
X
i
- V
PLOT PLAN
PROJECT Darin marek ADDRESS 2168 134th st NewRichmond Wi. 54017
SE 1/4 NW 1 /4S 13 /T 31 N/R 18 W TOWN StarPrairie COUNTY ST. CROIX
A-- — 7 -29 -02 3
MPRS Byron Bird Jr . 220528-' DATE BEDROOM
CONVENTIONAL XXX -Grade CONVENTIONAL LIFT HOLDING TANK
i
MOUND SEPTIC TANK SIZE 1000gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE o LOAD RATE .7 ABSORPTION AREA 642 # of chambers 22
BENCHMARK V.R.P Top of lath SE corner of PL ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. same as Bm
Vent SYSTEM ELEVATION T- 1 =95.8T
AT' Sidewinder High
Capacity Leaching
Chamber with 17.2
6" ^2 per chamber Gra-- at System L/
Long 34 " Elevation
� /tom
1 QCutlti e t T��cE�� �aSaw�ew�
17.
2 3 ' B1
98' 10'
99' 15'
ob pipe
34th st 15'
100' > 10('
W✓ 1v } 30' to P
w� a 15'
0 �'' e 3 be ouse
�0 c
�0
A�
Driv X1
A '
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code /
County pl C 6
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must _
include, but not limited to: vertical and horizontal reference point (BM), direction and P rcel AEC
t ,; t °
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. l evievved by Date
W �I
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot 4 r i t (T = R E (o
Property Owner's Mailing Address Lot # Block # Subd. Na SM#
City State Zip Code Phone Number ❑ City Village ZTown Nearest Road
New Construction Use: Residential / Number of bedrooms T Code derived design flow rate ��� GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material ' C A Flood Plain elevation if applicable .,lrQ ft.
General comments
and recommendations:
B oring # E] Boring F/I � 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. I *Eff#1 I *Eff#2
0
s
Boring # ❑ Boring )—
❑ Pit Ground surface elev. 15 ft. Depth to limiting factor > _i 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 # = BOD < 30 mg /L and TSS < 30 mg /L
CST Name ease Print) Si gnat CST Number
Address Date Evaluation Conducted Telephone Number
77&2- Qa 7is vz6 0 </L
SBD -8330 (R07 /00)
I 1
I �
I
Property Owner 4a r ff �ur e 1) Parcel ID # Page of
51 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
f G i
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
F-1 Boring # ❑ Boring
El 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
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)
r -
t Soil Test Plot Plan
Project Name Da rin M Byron rd 3r.
Address 2168 134th st.
t
N Wi. 5 4 0 17 CST #220527 IPI
Lot 27 Subdivision PineAcres Date 712912002 County CROIX
S E 1/4 NW 1/45 T 31 N /R W Townshi Sta rPrairie
R Boring Q Well PL Property Line# Alt. BM -, ��m,6 / S, /"�-
,BM or VRP Assume Elevation 100 ft Top of lath SW of PL
System Ely. T- 1= 95.8T -1 =95.3 H.R.P. same BM
t� v BM
2 35' B 1
10'
99' 15'
34th st
100' > 100
3C to P
Garage 3 bed House
Drivew
WisFonsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 13
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 point (BM), direction and -5-71 �� o
percent slope, scale or dimensions, north arrow, and locati distance to nearest road.
Parcel I.D.#
w -utnd ;- Pending
APPLICANT INFORMATION - Pleas N!>4t)3k rnformad0j?. Reviewed By Date
Personal information you provide may be used for ar ' VGrposes rivacy Law, s. 1 .04 (1) (m)).
Property Owner s ` i i " 9 Property Location
Lakes & Hills Development Govt.'Lot 1/4 NW 1/4,s 13 T 31 N,R 18 W
Properly Own s Making Address �^ v' ` 1 LdF# Block # Subd. Name or CSM#
is
Q X (� ! 7 -- _ Pine Acres
Ity , Stat Z 'r de Phonel tbg ity ❑ ' ge [1�]Town Nearest Road
i �Lf�K- 218 TH. Ave.
❑ New Construction Use: Resi tilt /,Npmi>prof,be ms 3 ❑Addition to existing building 1. ❑ Replacement ❑ Public or coinn`ler ' ribe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ftz .8 trench, gpd/f?
Absorption area required 643 bed, ftz 562 trench, ftz Maximum design loading rate .7 bed, gpd/ftz .8 tr ench, gpd/ffs
Recommended infiltration surface elevation(s) 98.1 ft (as referred to site plan benchmark)
Additional design / site considerations Alternate Area Elev- 97.3
Parent material - - - - -- Flood plain elevation, if app licable ---- -- 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 M S U ❑ S® U ❑ S® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/fP
Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 1 0 -10 10YR3 /3 ------------ - - - - -- 1 imsbk mvfr as if .4 .5
2 10 -18 1 0YR4 /4 ------------ - - - - -- 1 l msbk mvfr gw 1vf .4 .5
Ground 3 18 - 38 10YR4 /6 ----- cl lmsbk mfr as - - -- 2 3
elev — - -- — —
102.4 ft. 4 38 -55 7.5YR4/4 - ----------- - - - - -- s osg ml gw - - -- .7 .8
Depth t0 5 55 -93 10YR4/6 ___ __ ___ _______ _ __ s o ml - - -- - - -- . .8
limiting
factor
>93"
Remarks:
2 1 0 -11 10YR3 /3 ----------- - - - - -- 1 imsbk mvfr as if 4 .5
2 11 -20 10YR4/4 - 1 1 msbk mvfr gw 1 of 4 .5
Ground 3 20 -34 10YR4 /6 - - - -- ------- - - - - --
cl imsbk mfr as - - -- 2 3
elev
102 4 ft. 4 34 -53 7.5YR4/6 ------------ - - - - -- s osg ml gw - - -- .7 .8
5 53 -93 10YR4 /6 -- ---------- - - - - -- s osg ml - - -- - - -- .7 .8
Depth to --
limiting
factor
>93"
Remarks: -- - -- -- - - - - -- -- - - - -- —
CST Name (Please Print) Si ature: Telephone No.
J Hawk �' _ — _ Y71 __ "Y �_
Ad ress _01 Date CST Number Ref#
I U uC �� �' yPfj 4/9/00 /_.7. 2- 399
Il
PROPERTY OWNER: Lakes & Hills Development S OIL DESCRIPTION REPORT Page 2 of
PARCEL I.D.# Pending
Depth Dominant Color Mottles Structure GPD/fls
Horizon Texture � onsistence � Boundary Roots
in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ;Trench
I
3 1 0 -9 10YR3 /3 ------------ - - - - -- I lmsbk mvfr as if .4 .5
2 9 -19 10YR4 /4 ------------ - - - - -- I l msbk mvfr gw l of .4 5
Ground —�—
elev
3 19 -37 10YR4 /6 ------------ - - - - -- Cl lmsbk mfr as - - -- 2 3
101.6 4 37 -51 7.5YR4/6 ------------ - - - - -- s osg ml gw - - -- .7
.8
Depth to 5 51 -93 10YR4 /6 ------------ - - - - -- s osg ml - - -- ---- 7 8
limiting
factor
>93" --
Remarks:
4 1 0 -10 10YR3 /3 ---- -------- - - - - -- I lmsbk mvfr as 1f 4 .5
2 10 -21 10YR4 /4 ------------ - - - - -- 1 l msbk mvfr gw l of .4 5
Ground
elev 3 21 -36 10YR4 / 6 ------------ - - - - -- Cl lm mfr as - - -- .2 .3
O1.O Ft, 4 36 -50 7.5YR4/4 ------------ - - - - -- Cs osg ml ew - - -- 7 8
Depth to 5 50 -88 10YR4 /6 ------------ - - - - -- s osg ml - - -- - - -- 7 8
limiting
factor
>88"
Remarks:
5 1 0 -10 10YR /3 ------------ - - - - -- 1 lmsbk mvfr as if .4 .5
2 10 -23 10YR4 /4 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground -
elev 3 23 -34 10YR4 / ------------ - - - - - - Cl lmsbk mfr as - - -- .2 .3
101.1 4 34 -54 7.5YR4/6 ------------ - - - - -- Cs osg ml Cw - - -- 7 8
Depth to 5 54 -86 10YR /6 ------------ - - - - -- s osg ml - - -- - - -- 7 8
limiting - - - -- -
fa cto r
>86" --
Remarks:
Ground
elev _ - -- - --
ft
Depth to
limiting - - -- -
factor
Remarks:
D, k L Z,
�. PC
1
3
x
n
s
7� w /.-) i
.a� 2 - 7 p i
r
� r
i
If_• �y _
l�
ox- C_ e l m s
3
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATIO-K SYSTEM SPECIFICATIONS
E wn �,, ( Septic Tank Capacity �� al ❑ NA
# Sep tic Tank Manufacturer 4-9—' ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 061 ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) OcD gal /day Pump Manufacturer ❑ NA
Soil Application Rate al /day /W Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD <_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) <_150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD <_30 mg /L AIn- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) <_30 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: ❑ m onth(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume 4 2 ❑ NA
Inspect dispersal cell(s) At least once every: EI month(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
❑ year(s)
Inspect pump, pump controls & alarm At least once every: ❑ mo nth ❑ yeaarr (s) (s) ) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)month(s) ❑ NA
❑ month(s) Other: At least once every: ❑ year(s) ❑ NA
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septag e Servicing Operator. tor. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
u
measure the volume of combined sludge and scum and to check for any back p or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
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 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
provide a code compliant
fit cannot repaired the following p
If the POWTS fails and c t be p g measures have been, or must be taken, top
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
lot lines and wells. Failure to protect the equired setbacks from existing and proposed structure, replacement area will P P
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 �� Name �V,
Phone ` Phone V
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name k (j h y , Name , /^O
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
• ST CROW COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State f Parcel /e �'G � Identification Number 6
LEGAL DESCRIPTION
perry . e •14, Sec. , � T�N -R�W, Town of �7 /� r �✓ �.�-�
Pro Location
-t
Subdivision I /-7 <-- �"� j' . Lot # �.
Certified Survey Map # . Volume . . Page #
Warranty Deed # a 'f C g�° , Volume Page # S 7d
Spec house yes ❑ no Lot lines identifiable od 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
maw restricted plumber or a licensed pumper verifying that (1) the on site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set f herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
sta that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
daks f the three year expirati n date.
GNATURE OF APPLICANT DATE
OW NER 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 rty described above, by Zeo w arranty deed recorded in Register of Deeds Office.
NATURE APPLI 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
• i1 19 0 1 it 5 10
_ . STATE BAR OF WISCONSIN FORM 2 -1999 6 843 4 8 6
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., YI
This Deed, made between La and Hills, Inc., a Minnesota RECEIVED FOR RECORD
Corporation,
05 -31 -2002 9:30 AN
WARRANTY DEED
Grantor, and D H. Marek EXERT 1
REC FEE: 11.00
TRANS FEE: 78.00
COPY FEE t
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
Lot 27, Pine Acres, Town of Star Prairie, St. Croix County, Wisconsin. Name ift w - ftA OGLAND
ATTORNEY AT LAW
P.Q ^,O)' 359
HUDSC,�, V-., 5ewie
03 8-1195 -70-000
Parcel Identification Number (PIN)
This is not homestead property.
(1() (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of May 2002
Lakes and Hills, Inc.
• • By: Richard (S. Nelda, President
s
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
Signaturc(s) Lakes and Hills, Inc., by Richard S. Nelson, its )
President, ) ss.
,� County )
authenticated this � ,q " day of May 2002
Personally came before me this __ day of
th
i e above named
r Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the persons) who executed the foregoing
(If not,
authorized by § 706.06, Wis. Stats.} instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY •
Att orney Kristina Ogland Notary Public, State of Wisconsin
Ruction, 1 54016 My Commission is permanent. (if not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) , _.._.._ —_ •)
• Names of persons signing in any capacity must be typed or printed below their signature. wftmawon Prof"SimNs Company, Fare du tae, WI
STATE BAR OF WISCONSIN���
WARRANTY DEED FORM No. 2 -1999
I
. • , p„ • Located in the SE 114 of the NW 114, part of the SW 114
1 and Part of the NE 1 of the NW 1 14, all in Section
F -WAY
• R18W, Town of Star Prairie, St. Croix County, Wisconsin.
��'
TM4�E EAS BE U N P L A T T E D ' � �
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A 4 1.503 acres
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65,531 sq. ft.
° 5i .31'29 0. ' 1.504 acres
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272
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205 82,146 sq. ft. X 0 6
Vtr i� c+. �` \ 1.89 acres �, ^ \ t
83,213 sq. ft. \
1.91 acres
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68,652 sq. ft. \ '�� N>' ?gip? c35� 0o. 12,
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1.58 acres 30'07 W 76,537
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