HomeMy WebLinkAbout038-1210-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
• 479364 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:
Oeverin , Ken I Star Prairie, Town of 038 - 1210 -30 -000
CST BM Elev: Insp. BM Elev: BM De ri n: \ Section/Town /Range /Map No:
-� , /°''rl.d gm. - (v CBr, (Y� �d� 13.31.18.1141
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic D �� Bench 3. '� 4 •_7
Dosing � ' / ✓ Alt. BM `�• VG 2 �Q
Aeration - -- - � 9 Bldg. Sewer J
Holding St/Ht Inlet S'�„( U-b N 6t7 S- 33
SUH utle
TANK SETBACK INFORMATION
TANK TO /L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
>
Dosing !�� v ► ader /Man. -
Aeration Dist. Pipe
Holding Bot. System 1 t7
Final Grade
PUMP/ ON INFORMATION h
Manufacturer De St Cover
Model Number OP -7. 15 C/ S
TDH Lift Friction Loss System DH Ft id ' 2 1 + ,
!✓�S
Forcemain Length Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length I No. Of Trenches PIT DIMENSIONS No. Of s Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO ` P/L BLDG WELL LAKE /STRE LEACHING Manufac �
Ty Of Syst
INFORMATION ` CHAMBER OR T O k
em: ' ! 1 N UNIT Model Number: S �
V /+f
chti(� i� J 40
qfS" IBUTION SYSTEM
Distribution x Hole Size x Hole Spacing Y�a�.n�(t
Bader/ anifolc� to Air In
f O u Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over ' Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes 1 No Yes -j No
COMMENTS: nclude code discre encies, persons present, etc.) Inspection #1: /1/ Inspection #2:
( P
Location: 1362 212th Ave ;w �ichjnd�WI 54017 (NE 1/4 SW 1/4 13 T31N R18W) orthgate II Lot 51 Parcel No: 13.31.18.1141
1.) Alt BM Description = jj��
2.) Bldg sewer length 5 >fa
amount of cover = 7 ' � N � � , J ' A iv
p T J — - - - - - -� - -- -J
Plan revision Required? es
7 -
" o 0 �J
<
Use other side for additional information. -- -_ S -
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division �
ashington Ave., P.O. Box 7162 County
,� - 7162 'tary ermit Number (to be filled in by Co.)
51 O p �$ 266 - 3 IFICEIVED y 7
'De artment of Commerce Sta Plan Number
Permit Appli n
Sanitary 201
In accord with Comm 83.21, Wis. Adm. o s N tt� y L rw s15. 1 (m)
Pr Address (if different than mailing address)
maybe used for secondary pure / `/�
llcat ionlnformation- PleaseprintAllinformation ZONING OFFICE 6 a o ! o7'W
L App Parcel If # Block #
Property Owner's Name 1Lb 36 --=
Y._4 ll" i property Locatio
Property Owner's Mailing Address ®^ %,, Section l� /
Zip Phone Number �j� trcl one)
City, S T ___L N. E W
` Subdivision Name CS Number
ype of Building (check all that apply) C`'$ G ( q • n-�
2 Family Dwelling- Number of Bedrooms ,' J D
❑ public/Commercial - Describe Use []City_[IVilla ship f
❑ State Owned - Describe Use
III. Type f Permit: (Check only one box on line A. Complete line B if applicable} ❑ Other modification to Existing System
A. S ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only
List Previous Permit Number and Date Issued
B. ermii Renewal permit Revision
hange of L] permit Transfer to New y.30�3
❑ pwner
sum er
Before Expiration
S ste
IV. a of POWT$ m: (Check all that a l ❑ si Pass Sand Filter
> 24 in. of suitable soil El mound < 24 in. of suitable soil ❑ At - G=ate gl ❑
-Pressurized Groff [] Mound _ _ Sand Filter
n
❑ H Tank El Peat Filter ❑Aerobic Treatment Unit D Recirciating
Constructed Wetland ❑Pressurized In - Gro ❑Drip Line El Gravel Pipe ❑ other (explai �
Synthetic ing Chamber Media Filter Ch
Recirculating Yn pro set (sf) S
V. Dis ersaYrreatmen s ystem Elevati o
t Area ormatio pis eral Area _POS
d Design Soil Application Rate(gpdsf) Disperse] Area
Design Flow (g , sired p
p) / L!„( 6
, - J Prefab Site S 1 Fiber Plastic
e� Total Number Manufacturer Concrete Constructed Glass
Tank Into Capacity in
Gallons Gallons of Units
New E)agting
Tanks Tanks
septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
MPM Number Business Phone Number
'VII. Responsibility Statement T, the orders' ne ,assume responsibility for installation of the POWTS shown oo the a ttached ens. /
plumb, 's Name (Print) /J
Plumb s ignature - z o-6
l
plumber's Address (Street, City, State, Zi ode
Date Iued ]ssuin gent Si o PS)
VIII. Conn /De artment Use Onl Sarinmy Permit Fee (includes Groundwater ss
Approved ❑ Di to Surcharge Fee) �b $ ' 6 b5
11 son for Denial
IX. Conditions of Approval/Reasons for Disapproval r d (� Q_ -- o
3 � � � � � � 1 uJ� OL
SYSTEM OWNER: )
1. Septic link, etMtent filter and
dispersal cell must all be services /maintained MGL{ ,Ai
as par management plan provided by plumber.
2. Ap sdback requirements must be maintained
0, D W,nQ�- t ^ t
as per apps csOde / ordinWl=-
Coon only) t
for the system on paper not less than 8112 111 inches in size
Attach complete plans (to the County ly ( P/0 ✓l. l
SBD -6398 (R. 01/03)
PLOT LAN
PROJECT Ken Oyerina RE S 838 Summer Pines Circle Hudson Wi 54016
NW - 1/4 S E 1/4S 13 /T 31 N W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 8 /2/05 BEDROOM 3
CONVENTIONAL )00( IN-GROUND - SURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chamb s 22
BENCHMARK V.R.P. Top of 1 " PVC Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑BOREHOLE O WELL - H.R.P. Same as Benchmark
SYSTEM ELEVATION 95.8/95.7' 4 below qrade
Y B '
.M.
35' 40' °t°t.'1S Y4ja ! �� P14-
251 5 , op of 1"
B -1 30'
B pipe @ 99.75' Sv V
� Plans Designed Using
B- 0' Conventional Powts
40' Manual Version 2.0
Vents
Li B -5
B -2 Property Line
2 -3' X 69' cells with >3' Well is to meet all
spacing 01 setbacks required by
WDNR
S
30'
Pro 3 dr ouse C
288' Property Line
Vent
>6„ tandar iodiffuser
of Cover ng Chamber
ith 3 1. 1 ft2 of Area
6' Lo
3 4" Grade at System Elevation
e
i lk AD
AN N
PROJECT -Ken Overina S 838 Summer Pines Circle Hudson Wi 54016
NW . 1/4 SE 1 /4S 13 /T 31 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 8/2/05 BEDROOM 3
CONVENTIONAL XXX IN- GROUND A SURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of 1" PVC Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑BOREHOLE O WELL H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.8/95.7' 4' below qrade
B.M. * Alt.B.M
. 35' 40'
25' Top of 1" pvc
10, 5 pipe @ 99.75'
B -1 30 B -4
Plans Designed Using
Conventional Powts
40' B -3 0 Manual Version 2.0
Vents
B -5
Li k
B -2 Property Line
2 -3' X 69' cells with >3' Well is to meet all
spacing 50' setbacks required by
WDNR
S
30'
Pro 3 Bedroom House
288' Property Line
Vent
ALo Standard Biodiffuser
Leaching Chamber
with 31.1 ft2 of Area
"
Grade at System Elevation
34"
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8.066 ning ¢iCge into system is not exceed those required as per Comm. 83
cy Plan
f system fails, de termine cause of failure, use alternate area and install new
sted replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
Option#3. No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715 - 246 -5148
Shaun Bird #226900
i
Safety and &nMings Division COMM
/Sf�flSl/f 20 1 W. Washitg Am, P.O. Bit 7162
Madison. wI s37o7 — 71ti2 saahary Pbramt�be fiUaa m by Co -)
Department of Commerce ( 266 -3151 ? j o 7-
Sanitary Permit Application Sin& PIM IM- Number
In accord wide Comm 83.21, wis. Atha. Co&, petsoml iofwnmfon yon
may be used for seoo>day pwpom Privacy Uw , s15.tW(Ixm) 'D Pfoject Address of aven., than mwim address)
L Application Infoimatim - Piece Print All
y "ms's Na Parcel 1 Block
Property Owner's Mailing i Property'
8 �S � -- • -�.... ._. _.....� .. /- _.w_,..a �,�_ u, Ste/ lf,seclica / t
(Sty, save zip code phone Number -- `�
moo! 7/� - .7 ( °hd
T �_ N; R
II. Type of (eLeck aII thatt S w A4 i =
101 or 2 Famit y Dwellig - Number of Subdivision Name CSM Number
n
O Public/C.ommereW - Desc ibe Use
❑ Slate Owned - Describe Use _ Ocity ❑Village Wiwnsbip of
XIWA
in. Type of Permit: (Cbmk a* bw on Mule AV-mpkft Mine ap &able)
A. p'f`teM, System ❑ Rephcement Syswm O TIqrYTkok Replacement only ❑ other ModifiMM to E=ft Symm
B. ❑ Perm Renewal ❑ Permit Revisim ❑ t ❑ Permit Tt a New List Previous Pam Number and Dace Issued
Before Eq*atan p) nmber Owner
M Type of POWTS - (Check all that ) C ✓ . S S _ S
WNon - Pressurized htGrouund ❑ Mow d > 24 in. :YCO� ❑ < 24 in. of suimw sal ❑ At -Grade t] Single Pass Sand Filter
❑ Cawed Wetland ❑Pressurized In Ground ck ❑ Faeer 7Y
❑ Aerobic emtnent unit ❑ Raarcalating scrod Falter
❑ Recirculating synthetic Media Fitts ❑ Leadwg Drip Line Grave l-le s Pipe ❑ Odw (e*bW
V. DbpersWrreatmat Area Information: -
Design Mw (t9Q Design soil Apptiation RwvC~ I Dxpeml Area Re"Ked ( Area Proposed ( t* c s - Elevation
/, o ,Z„ (ass . ( L S:
VI. info Capacity in Taal Number Maoufaqurer Prefab Sim &W Fiber Plastic
Gallons Gatlaan of Unbs / �n �' Comm Constrnaod Gfass
Toots Taolrs .EL "/
septic .at
t£ 1'
Aerobic Treatment Unit
Dosing Dumber
VII. Responsibility - I, aasame for tonstaBatlan of the POW15 on the attatrrbed plt�.
Pt nubd Mi)► 1>g 's Si RS Number Business Phone Number
#221180
99 288 MrKpn7o fi e
P'" '�� zip code
(715) 635 -9609
VIII. JIE Only
Approved ❑ DbVW4& Sanimry Permit Fee (mckrdes Grotmdwaeer Doe Emsed Agent S' (No Stamps)
)
❑ Owner Given Reason for Deaitd
IIC. Conditions of ApprovaVRessow for Disapproval
� l
�o
AUs* -= pj� On the Cmm =W br nee 3 an paper not ran am an z 11 iu bw in sine
Fogerty Plumbing
#221180
28288 McKenzie Rd.
�T s Spooner, WI 54801 f
Sc � yo � , / (715) 635 -9609
7/1/3
4 #/
c�
x x
r-y
� plyc'h
li
I I
ZX j 4.rs '
(I
fv.
Fogerty Plumbing
#221180
28288 McKenzie Rd. f
Spooner, WI 54801
S� , «= YO . / (715) 635 -9609
7f1�df 3
A #�
4
s -r _
x =5L x
1-Y
` 0
3 DA'r�
'IVC Aft
•� t / � a /Aa 6sK- �7. � fs
I
II
�I
._ ... _�_ .._.. gVis. NiVv %Vf e c e V �a.vw I wn "L rvn ��
LiOD� wRd ftrletior�s OA W
am wan of e�►f q, Suttdw+os.. in eu' ' rd with ILHR 83.05, Wis. Adm. Code
COUNTY
Aftch oompleto site plan on paper not less than S 1/2 x f 1 inches in size. Plan must include, but 124- forv%jx
nut limited I* vertices .end hadzoraai refwonce point 184, direction w%d % of slope. scats or PARCEL 1.0_ #I
dimenswnwd. nonh envw, and location and distance to nearest road. 038 •1055 -
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION REVtEWEDBY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOYi. LOT . 1r4 S 1r4,S 13 T 31 .N.R 18 J (W) W
reermood PROPERTY OWNERS MAILING ADDRESS LOT • BLOCK #t . SUBD. NAME OR CSM •
CITY, STATE ZIP CODE PHONE NUMBER " GE NEAREST ROAD
()I New C nft ciiort use (J Reeift ab 1 Number of bedrooms g t I Addition to e*tirq building
L I Replacement [) Pu blic a ooMmeatai describe
Cade derived d* fbw 600 gad Reoorrxne Ided design kWing rape _ .7 b ed, 9P� - g t
rea
A*VpliW a required . 858 bed, 0. 750 _ _ bench, g2 MelAwn design loading rate - 7 _ t>erf, go/ft 9 Irench, MXV4
Recommended inMW dab surface devadOrt(s) 95.75' ft (as referred to site plan benduna4o
Adfflb* design I bits oondderadoris na
Parent material outvi3�h .� � � - Flood plain +elevation, it appdCable na n
S =stBww bf sp *n I CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDNG TANK
u - u�saimble for slam ®s O u ® o u ® s ❑ u [2S 0 ®s o u ❑ S L2u
SOIL DESCRIPTION REPORT
Boring 4 Horizon Depth Dominant Color Motdes. Texture Structure Cons+stertoe Saxiby Roots GPD/ftz.
in. Munson Qu. Sz. Cart. Color Gr. Sz. Sh. Bed
1 •
Graxxl
stet+.
99 It
1
Depth to
hLior
+ - -
Remarks:
Boring P
,. .5
2
Ground
dev. - —4 i'1A 7. tiyr amp Ina na -A .
9 ft.
NmiOng
kldor 'i _
Remarks: J
CST N=m. -Picew Print Gary L. Steel P6ow: 715 -246 -6200
Address: 1554 200th. Ave.. New RkWmd, WI 54017
gignamn; Date: 11 --6 -98 CST Number: m02298
PROPEFITTYOWNER Greenwood Enterprise SOIL DESCRIPTION REPORT Page �2 .ofd
PARCEL I.D. # 038 - 1055 -95 i
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GOD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed jTrench
.................
?3
1 0 -11 10 r 3 none 1 2msbk mfr if .5 .6
2 11 -28 10 r 4 4 none sicl lcsbk mfr qw if .2 .3
Ground 3 28-R4
elev.
99 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -12 10 r 3 3 none 1 2msbk mfr w if .5 .6
4 2 12 -26 10 r 4/4 none sici lcsbk mfr qw if .2 .3
Ground 26-84 r none cos I 0sa ml na . na .7 .8
elev.
99.55 ft. —
Depth to -
limiting
factor
+84"
Remarks:
Boring #
1 0 -11 10 r 3/3 none 1 2msbk mf77 if .5 .6
5 11 -26 10 r 4 4 none sicl lcsbk mfr w if .2 .3
Ground 3 26 -32 10 r 5/4 none sil lcsbk mfr 9w na .2 .3
elev.
9 9.55 ft. 4 - 4 none cos os ml na na .7 ; .8
Depth to
limiting , �j
factor
+84
Remarks:
Boring #
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
f '
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of • 3
Labor and'Human Relations
Division of Safe q; & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach cdmplete 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 % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 038- 1055 -95
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: GOVT. LOT LONCANTION4 SE 1/4 13 T 31 ,N,R 18 � (or) W
Enterprises, Tnr. Greenwood
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1416 Thir
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE WN NEAREST ROAD
Hudson. WT. 54016 �15) 386-3674 Star Prairie
[ New Construction Use [ J Residential / Number of bedrooms 4 [ ] Addition to existing building
(] Replacement ( ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft : trench, gpd /ft
Recommended infiltration surface elevation(s) 95.75' ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwacs;h Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S ❑U ®S ❑U ®S [1U ISS ❑U ®S ❑U ❑S 49U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer&
..................
1 0 -12 m .5 .6
2 12 10vr 4/4 none sici lcsbk Mfr aw if .2 .3
Ground 3
elev.
9 9,3L ft.
Depth to
limiting
factor
+84
q&
Remarks:
Boring #
1 0 -12 10 r 3/3 none 1 2msbk mfr CFW if .5 .6
2 2
Ground 3
elev. _
9 9.75 ft. -
Depth to
limiting `,
factor rl
+841 I ,
Remarks: ; sr cRacx�
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 '' Z ING � - �•
Address: 1554 200th. ,Apvffl., New Richmon WI 54017
Signature: Date: 11 -6 -98 CST
STEEL'S SOIL SERVICE
Gary L. Steel Greenwood Enterprises, Inc. 1554 200th Ave.
CSTM2298 N6d4SE4 S13- T31N -R18w New Richmond, WI 54017
MPRSW -3254 town of Star Prarie (715) 246 -6200
lot #51- NorthGate
This 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 shown
as permanent lot lines were not established at the time the test was conducted.
N
1 " =40'
BM.= top of 1" pvc pipe @ el. 100'
Alt. BM.= top of 1 11 pvc pipe C el. 99.75'
Z.6
Gary L. Steel
11 -6 -98
d
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E ao c 'n �
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H
r POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of
'ME II1FoRMAnoN SYS I M SP0 1ONS
owner _ Septic Tank Capacity d D NA
Permit / 3
AW p � Septic Tank Manufacturer x D NA
DES16N PARAMETERS Effluent Fitter Manufactures - L D NA
Number of Bedrooms 3 0 NA Effluent Filter Mode( El NA
Number of Public Facility Units XNA Pump Tank Capacity g d J314A
Estimated flow leverage) 1 .) ga lld ay Pump Tank Manufacturer Q NA
Design flow (peak), (Estimated x 1.5) L1 ga Pump Manufacturer 10 NA
Sal Application Rate _ aUd /ft� Pump Model iT J�A
Standard Influent/Effluent Quality Monthly average` Pno6eatment Unit CI NA
Fats. ON & Grease (FOG) 530 mg/L 0 Sand/Gravel Fitter 0 Peat Filter
Biochemical Oxygen Demand (BOO 5220 mg/L 0 NA O Mechanical Aeration O Wetland
Total Suspended Solids (TSS) 5150 mg/L 0 Disinfection 0 Other.
Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA
Biochemical Oxygen Demand (BODJ 530 mg/L )q In- Ground (gravity) D In- Ground (pressurized)
Total Suspended Suds (TSS) 530 mg/L 0 NA 0 At -Grade 0 Mound
Fecal Cdrdorm (geometric mean) 510 cfu/1O0m1 O Drip -line 0 Other.
Maximum Effluent Particle Size )`s in dia. D NA D NA
Other: G NA Other. D NA
'Values typical for domestic wastewater and septic tmk effhrerrt Other 0 NA
MAINTENANCE SCHEDULE
Service Event Service Frinluency
Inspect condition o f tank(s) At least once every: ( hiLik k num 3 years) D NA
� s)
Pump out contents of tank(s) When combined sludge and scum equals one -third JYJ of tank volume 0 NA
Inspect dispersal cell(s) At least once every: 3 O months) 3 Yom) DNA
Yearls)
Clean effluent filter At least once every: 0 months) El NA
Z_ - year(s)
Inspect pump, pump controls & alarm At least once every: 0
month( A
Risk Literals and pressure test At least once every: D yearls) ' 0 n earls)) C2 NA
Other: At least once every: O month(s) r), NA
0 years)
Other. UNA
MANCrENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following or certifications:
Master Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWYS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tanks) to identity any massing or broken hardware. identify any cracks Or leeks,
measure the volume of combined sludge and scum and to check for any back up or pondirg of effluent on the ground surface.
The dispersal cell(s) shalt 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 pondmg 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.
I
Page L of �—
UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanklsl for the presence of painting Products or other chemicals
that may knpede the treatment Process and/or damage the dispersal COINS). If high conce ntrations are detected hales the contents
of the tank(s) removed by a septege servicing oPerator Prior to use-
S ystem start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal h ghwater levels. When power is restored the excess wastewater will be
discharged to the dispersal ceps) in one large dose. overloading the cen(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 manuapy operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal calls. 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 fife 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; gases% grease; ham: most scraps; medications: of
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
rat system:
A suitable t area has been evaluated and may be utilized for the location of a replacement sop absorption
system. The replacement area should be protected from disturbance and compaction and should not be mf6riged upon by
required setbacks from existing and proposed structure, lot Ines and wells. Failure to protect the replacement area will
result in the need for a new sal and site evaluation to establish a suitable replacement area. Reptacem>en't systems must
comply with the rules in effect at that fine.
O A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
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 tune.
< <WARNWG> > OXYGEN. DO NOT
SEPTIC, PUMP AND OTHER TREATMHIIT TANKS MAY CONTAIN LETHAL GASSES AND/OR ppStl
.- ENTER A SEPTIC. PUMP OR OTHER TREATMENT TANK UNOER ANY CIRCUMSTANCES- DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTEF" OF A TANK MAY BE DFRCULT OR O E-
*221180
SflOOi.°r wr r�n�fn=
(715) 63
POWTS INSTALLER POWTS MAMIT
Name I 1 v Name
Phone — 3bs� Phone — O
SEPTAGE SERVICIING OPERATOR (PUMPER) LOCAL tRECU, LATORY AUTHOW7 Y 22�'
Name Name �"l l , Caw, C6,JWTy T�
Phone � 1O1e l ` r r 2
This document was dratted in com pUnce with ch%r Comm 83.2242 (U1MM &(fl and 83.54(1), (2) & (3). Waco A*nkdsV&tWe fie.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OVMERSHIP CERTIFICATION FORM
Z e� 4 & OwnerBuyer ,l
.M ailing Address ��� UGi�tr��� Y /�S �r� A
Property Address 3 z ,- tov -
(Verification required from Planning Department for new constructi on)
City/ tate Parcel Identification Number 0& lzd r.-, - &w
LEGAL DESCRIPTION
Property Location '/4, r oe e /4, Sec. /I . T 3L N -R W, Town of Ai �
Subdivision &Id/tTiSc Cr: Lot #
Certified Survey Map # _ _ . Volume . Page # -
Warranty Deed # - 719J YZ . Volume Page #
Spec house ER O no Lot lines identifiable [ayes O no
SYSTEM MAINTENANCE
Imprapause. andmeeafyoursepticsystemeesldies�� tispttaoaUarefieRiseb haseIlewastes. Proper�tenance
comists of pmnping out the wptic tank emy three years or moor, if needod by a ficessed puibper. What you put into the system
can affect the function of the septic talc as a u aftunt stage is dre waste &sposal system.
The propeaty awns ap= to sdwait to St. Crone 7 Wing Depuiment a eextifieatim form, signed by the owner and by a
miwivrPluwber. rest&ftd -1 . L U beror a licensedpt!msparvenfying that (I) the on4te wasievate rdispoW system
rs m proper operatmag oondltion asdRor (� afia iaspaxian and pang Cif necessary), do septic fast is less than W hill of sludge.
Uwe, the mod have read the abort requranents and agree to maintain the private sewage disposal system with the standards
set font, herein, as sd by the De jaarimea I of Cooamecoe and the Department of l&mral Resources, State of Wisconsin. Certification
static the systemm has been mefinimod must be ca®pI and retamod to the St Croix County Zoning Office within 30
Sys czpamna date.
SIGNATURE OF APPLI DATE
OWNER CERTIFICATION
I (we) certify that all I an this tome are true to the best of my (our) lmowledge. I (we) am (arc) the owner(s) of
the de ' by vatue of a warranty deed rex�oided in Register of Deeds Office.
-� /2-V 03
SIGN&URE OF APPLI DATE-
Any information that is mis- represented may result is the sanitary permit being revoked by the Zoning Department.
** Include with this application; a stamped wumq deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
• 2 2 2 t 1 i 2 0 2 7 1 9392 ' y
• jI STATE BAR OF WISCONSIN FORM 1 - 1998 ii HATHLEEN N. WALSH
1 WARRANTY DEED REGISTER OF DEEDS
i
ST. CROIX CO., MI
Document Number
RECEIVED FOR RECORD
U
This Deed made between Greenwood Enterprises, Inc., I 09130/2003 09:15AN
a Wi sc-nnsi n Corporati nn __ WARRANTY DEED
-- -- -- - -. — -- -- EXEMPT #
Grantor. 'i, REC FEE: 11.00
and __,_- — -- - -- --- TRANS FEE: 69.90
COPY FEE: 2.00
CC FEE:
a north T i v
PAGES: 1
Gl !' i 0 L Crantee. j
Grantor Liable consideration, conveys to Grantee the following
described real estate in S t craim County, State of Wisconsin
(the Property "): !� Recording Ar
_
r Name and Return Address
Tiff-'
!! Lot 5 of the Plat Of ? orthGat =,: I, recorded in the I
I ice of the Register of Deeds for St. Croix County, 4W SGwi tl w
Wisconsin, on June 20, 2001, in Volume 8 of Plats, at
Page 55, as Document Number 648882 gj4-r
i
038- 1210 -30 -000
Parcel Identification Number (PIN)
This i S nnf homestead property.
+� (is) (is not)
I j
I
l i!
i!.
Together with all appurtenant rights, title and interests.
if
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
I
I easements, restrictions, and reservations, if any, of record.
= Dated this — day of A 20033
D , I
(SEAL) / (SEAL)
; .James E. Rusch, President
(SEAL) (SEAL) I
jl
ii
AUTHENTICATION ACKNOWLEDGMENT
I
Signature(s) h
State of Wisconsin,
J
St. Croix � County. ,
authenticated this day of Personally came before me thi day of
i
_ 1_ , the above named
.TATpc F Ritcrrh, its P gidPS1t, anri Mares
- JL Rusch, its
I
TITLE: MEMBER STATE BAR OF WISCONSIN """ "` to
(If not, _ me known to be the person g w)tt a elot@ going
authorized by §706.06, Wls. Stats.) instru ent and acknowledge the
V. u
THIS INSTRUMENT WAS DRAFTED BY /� ^-
Mary R. Rusch Sandra Gehrke
Notary Public. State of Wisconsin j C
New Richmond, WI 54017 My commission is permanent. (If fto %'�y�aie sx4i{k�t�p date'
(Signatures rnay be authenticated or acknowledged. Both are not CH "��a )
necessary)
--- - Septemberfi 4 - , - 2064 -- ` -
Names of l )er%ons signing in any capacity must I* typed or printed below the,r ,ignatu-
STATE BAR OF WISCONSIN Wisconsin Legal Biank Co., inc.
WARRANTY DEED FORM No. 1- 1998 Milwaukee. Wls. ...
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