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HomeMy WebLinkAbout038-1116-90-000 Wisconsfn bepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 514848 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: Belisle, Roland Star Prairie, Town of 038 - 1116 -90 -000 CST BM Elev:� p Insp. B� �lev: BM Dr on: Section/Town /Range /Map No: o g $ U V 29.31.18.488K TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS G Hl 2 q FS ELEV. "e Septic n / { /� /D it /1 BenpY�iu k �. g A y 1 Z. g it l Dosing Alt. BUM ZIA sad 17V 97 S'7 Aeration ��- Bldg. Sewer 3. t/ `6 - Holding r� St/Ht Inlet 7 • � 13 St/Ht Outlet f� TANK SETBACK INFORMATION -7. Z TANK TO P/L f�" BLDG. Pntto Air Intake ROAD Dt Inlet Septic / 1 f Dt Bottom Dosing I Bader an. • 7 1 Aeration Dist. Pipe B r7 Holding Bot. System / PUMP /SIPHON INFORMATION Final Grad 5 E EO 9&7- Manufacturer Demand St Cover / P GPM Model Num Q W - G TDH Lift Friction Loss e TDH Ft Forcemai L Dia. Dist. to Well SOIL ABSORPTION SYSTEM 4- / BED /TRENCH Width Leng(J� No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 6/ SETBACK SYSTEM TO P/L BL WELL LAKE /STREAM LEA HING Manu rer: INFORMATION CHAMBER `( Ty Of System: / ` `� UNI Model Number: In 4 2- DISTRIBUTION SYSTEM Head r/M n Q1��7 Distribution x Hole Size x Hole Spy TV�entt Air Inta � Pipes ength Dia Length Dia Spacing�� 3 V SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over r Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center s 3 Bed/Trench Edges Topsoil Yes � No 0 Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /�/ Q Inspection #2: Location: 2001 Cty. Rd. C Somerset, WI ` 540�25(NW1/4 NW 1/4 29 T31 R1 8W) NA Lot 2 P /� ^ Pa, cel q�2�,31.1$.48�� _ 1.) Alt BM Description = �vn �ltt S r`�� r/ lt.+ � ick, 2.) Bldg sewer length - amount of cover = j Ai- Plan revision Required? El Yes [No I , G Use other side for additional information. A _� o J (•A _ SBD -6710 (R.3/97) Date Cart. No. Insepctors Sig ature Safety and Buildings Division County 1 *hs n cons 201 W. Washington Ave., P.O. Box 7162 t C i Madison, WI 53707-7162 Sanitary Permit Number ( o filled in by Co.) (608) 266- S� Y Department of Commerce State Plan I.D. Number Sanitary Permit Application In accord with Comm 83.21, Wis. Adm. Code, personal information you may be used for secondary purposes Privacy Law, s15.04(1 xm) Project Address (if different than mailing address) 1. Application Information — Please Print All Infor GG Pr Owner's Name F rla ar el N� 6 — � t 0 Block 8 0 Li R V 05 ope Owner's Mailing Address GO ON! Property Loca t V �7jC f ,$ l.11 /., t ZU,L ' /•, Section _ G„ City, State J Zip Cod one Number L S y0� b T � rio (circleo� II. Type of Building (check all that apply) �2�Li , ®1 or 2 Family Dwelling — Number of Bedrooms Subdivision Name ❑ Public/Commercial — Describe Use - r5 ❑ State Owned — Describe Use ❑City_ ❑Village WTownship of A iii. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. 11 Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) 6V ;<` e Non — Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ , Recirculating Synthetic Media Filter a Leaching Chamber D Np Line ❑ I -less Pipe ❑ explain V. Dispersal/Treatment Area Information: h d Gbh ZO L' Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (st) Sys�� evation Y50 `0 513 f _ IF& VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 62 Aerobic Treatnxnt Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installa ' of the POWTS shown on the attached plans. Plumber's Name (Print) PI 's Signature M PR umber Business Phone Number Plumber's Address (Street, City, State, Zip ode) 8 9 VA 1- 1-,5 % Eft: Z_X 4 l VIII. .ount v /De artment se Onl Approved ❑Disapproved Sanitary Permit Fee (inelude�Groundwater Date Issu d 1 uing Agen tgnat re o Stamps) Surcharge Fee G/v El Owner Given Reason for Denial g ) /� V n ttions of Approval /Reasons royal � Gvh� -1 f7�ulm SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as p er plum management plan provided by b 7 /� / ' 9 All s qul emenis must a maintained y /IO p as per applicable code / ordinances. r: Attach complete plans (to the County only) for the system on paper no ess than 81/2 x I1 inch in ze SBD -6398 (R. 01 /03��/ 10 W7 Wlf.,i?r�j - be 0M rn Ce 7 OY t/,r17, �� ��� t0 / Hod?iZ. r 0 V. 2- c� ,4 �l�z�h- �,, , z . _ = g - 7, 0( e , s v O f 4 T S� 6-y, Sli CA ep 43 CAW-& ri �aA 4Lr ph e A.V —A V 'e A7 7 -3 w CROSS SECTION 4 "PVC Inspection and Vent Pipe (� l Approximate Grade z' �I Approximate Grade II l r 3' M s s 4 - �' 1 .I I- > 31 J Fol ' p(-,qNr) OELI f -- t'T CSoc7 1/,Of. 7 /, loss r W� Ale * ,4 a� S %y S `-' %y SAoT3 /A,-Ri L - _. rx _ GAS BEN 13 0&0 G A2A6E � � v ' 8M [ A co 7 / 9 A1 .A 04F 56 6 IIAI- t' y rl /E 6v 7Z- 56A7e45 e i t0f S'y�2 s 'dA1 ;r CVI' - 9 a n y/ • 1 • • /'C•C� C� �siC?1Ir C�C.C� GCtrMa� ;a�r�rrrrrrr �1CRCCIF•f fA:?W".rd VI., HE k I e An ONE NON OEM ■[[[[ I/ U■ /rnrrrrI� [[[[[[[[[■ 0[[[ [ MP[[!® "®1�[[[i/[[[ /A /rrrrrrson • - .. . .0 K :�rrrrrrrrr■ 0 Fir 31.70 INERIPM no ONE 0 feFE ■rs��rr��rrn`�rrrnrrrrrrrrrrr■ - -• ■sir, VVIIMEN �r ® rrurruMEN rr��rrrrrrrrrrr0 ■ rr� ! rrrrrrrrrrrrrrl�rrrrrrrrrrrrrrrrrrr■ ■ lIMMEM No IM mom mom vim [il[[[[[[[[[[[[ oWEE I, [[E7■ / rrrr / [[r� ■ r7[[[■N M EMO [ � 7[[ [[[[[II[[[[[[.�ii ■ /I■ � • . r%ding'Jw[Ft'1n� R'[[[C:[[[[� /[[ [C�[[[[[[[[ /r'i■ go 0 a WNW T. yi1r. ��[ rJrslwl�i,1� ■i���il/[[[[[.r[[■ �1!!!!* ENE 1�ra !Gr,�r�r� ►�rr��rr�1mom [[��•.- no MEE mom No NONE MEMMEMM■ERM SOMME on no ■■ON MMMMMMMMMMMMM■■rMM so ONES SOME MEMEMMEMMOMMEM ON so on W m EROSION CONTROL PLAN CHECKLIST Q CL Check (a) appropriate boxes below, and complete the site diagram LU .? Q with necessary Information. Z Site Characteristics North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways. ❑ Location of existing drainageways, streams, rivers, lakes, wetlands or wells. . ? Location of storm sewer inlets. Location of existing and proposed buildings and paved areas. ;1 The disturbed area on the lot. Approximate gradient and direction of slopes before grading operations. Approximate gradient and direction of slopes after grading operations. Overland runoff (sheet flow) coming onto the site from adjacent areas. Erosion Control Practices ❑ Location of temporary soil storage piles. Note: Soil storage piles should be placed behind a sediment fence, a 10 foot wide vegetative strip, or should be covered with a tarp or more than 25 feet from any downslope road or drainageway. Location of access drive(s). Note: Access drive should have 2 to 3 inch aggregate stone laid at least 7 feet wide and 6 inches thick. Drives should extend from the roadway 50 feet or to the house foundation (whichever is less). ❑ Location of sediment controls (filter fabric fence, straw bale fence or 10 foot -wide vegetative strip) that will prevent eroded soil from leaving the site. ® Location of sediment barriers around on -site storm sewer inlets. ❑ Location of diversions. Note: Although not specifically required by code, it is recommended that concen- trated flow ( drainageways) be diverted (re- directed) around disturbed areas. Overland runoff (sheet flow)from adjacent areas greater than 10,000 sq. ft should also be diverted around disturbed areas. ® Location of practices that will be applied to control erosion on steep slopes (greater than << 12% grade). Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions, and re- vegetation by sodding or seeding with use of erosion control mats. ® Location of practices that will control erosion on areas of concentrated runoff flow Note: Unstabiliized drainageways, ditches , diversions and inlets should be protected =' from erosion through use of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod, and rode rip rap. When used, a A given in barrier should not receive drainage from more than two ayes of unpaved area, or one acre of paved area. in- channel practices should not be installed in perennial streams (streams with year round flow). ■ Location of other planned practices not already noted. w J m � V a Indicate management strategy by checking (V) the appropriate box_ Aj a ts .... Q o f p Management Strategies Z ® Temporary stabilization of disturbed areas. Note: It is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized by seeding (between April 1 and September 15), or by other cover, such as tarping or mulching. Permanent stabilization of site by re- vegetation or other means as soon as possible {lawn establishment). • Indicate re vegetation method: ® Seed O Sod O Other • Expected date of permanent re- vegetation: AG/G�IST • Re- vegetation responsibility of: ❑ Builder ® Owner /Buyer • Is temporary seeding or mulching planned if site is not seeded by Sept. 15 or sodded by Nov 15? g Yes ❑ No ® Use of downspout and /or sump pump outlet extensions. Note: It is recommended that flow from downspouts and sump pump outlets be routed through plastic drainage pipe to stable areas such as established sod or pavement ® Trapping sediment during de- waging operations. Note: Sediment- laden discharge water from pumping operations should be ponded behind a sediment barrier until most of the sediment settles out. ley Proper disposal of building material waste so that pollutants and debris are not carried off -site by wind or water. Maintenance of erosion control practices. 2a Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to half the height o f the barrier. • Breaks and gaps in sediment fences and barriers will be repaired imme- t diately. Decomposing straw bales will be replaced (typical bale life is three months). • All sediment that moves off site due to construction activity will be cleaned up before the end of the same workday. • All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday. • Access drives will be maintained throughout construction. • All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized. For more assistance on plan preparation, refer to the Wisconsin Uniform Dwelling Code, the DNR Wisconsin Construction Site Best Management Handbook, and UW— Extension publication Erosion Control for Home Builders. The Wisconsin Uniform Dweffing Code and the Wisconsin Construction Site Best Management Handbook are available through the State of Wisconsin Document Sales, (608) 266 -3558. Erosion Control for Hone Builders (GWQ001) can be ordered through Extension Publications, (608) 262 -3346 of the Department of Commerce, (608) 267 -4405. I X X, JUL,191990► 9 ; JAMES O'CONNELL Aegister of o 0 460622 SL CMIx Co., wi En ,.. C) �. 0 Ot = OO` 0 1-+ co co 7 0 cn v O \ h+ .Q + n 1p 10 D 1+• 1 Q a of Ln o. 'h to 0 /> = N N O F S oto 1'3 f a° to o a d a n. n /Q0 t o / Oi a me - 1 a t A i '� 1• w o -3 -3 Q i 4 1 � o � ' C o C to t N CD Ole— too -' to m c'), 0 C 0 C O i y rt c to 0 1) w r• �7[ r E % d� Q� t0 = O cr rn Lo C C.0 N14o \� =r o 06, , \ z co __ o rp C. 1 Cu ?ISM t` \s la W w c �, �B/� 8 S. 21 \ . 1 „mc S7u f 64 .181 89 4 N0002815 n NS /' ° ti Q o\' mow �12 71 - -*— 85, Sp 1 u� o N i i'r� 4i� in N00o 82 15811W 's a °O d /� � --3 c o F- ' w o Q ti o, t^ C=) o ti = y i oa to y O r co C. a) 'o D r' I to 'ZS 30 1 -.LA� I F w 00 -- "�_ 371 ` MeandeZ 328.241 n A . P P F �\ o f9. 6 9 i '✓ �m � a = :c r . c cr' r 0 n r o C"7 m 'r Z I w a = t1 a i tort d m 1+ to ' a. to m r• ^' �7 c' '�• m o to = N r a •rt+• = c •-�-� � a m Z v. 0 i "•o n cn_ N .• - c� \ o � to :3 N � 19 N a � Cl) m -+ m -°» o o. ' L7 < Q. 30.101 Wi r M N T N :U r O N rt O m O � to C e < N ~' H W o C� .-. H N01 °081 �3"W CD w c', to = m .'• Ln ' r- -n C r, east to to l in e II 20 t= ' H: d rt �, rt u tli .n ro T a o the �_ .r co to `.17 ~+, o, _ ° _ < r a. S111� Q the �ar/ -n to t'> S W} N Z o 0 'E �e _ J •yam. X rr a ' C . er d ►., O O '• T V S J H r N y o Z ry Mr C f t,•. .-• C rr b••�^ (n cn < = N O 3 o f9 I N A Z N 1 c2• O\ ••'� 1 C �H �• tJ O ' /D co rt r 1 tr 0 2 © ® ° �` s °, to r 0 C3 • Z 1 O L N N+ r C V) N C vm C `'� v I_ • q � N N `���, �,�."�•..H..a' .t .�. VOLUME 8 PAGE 22113 to o � 'TOA CD C\j 0- w iz 0 co 0 (U cz 7 C Co t o v) CD 0- 73 1�1 -! .y o U, cu 1� cl, 0 r- 0 u1i (li LO -0 [ C-7 11"Co CD 0 U :D rL �OT -O > 41 F- 0 rl Cl) Lr) lu CIJ w 0 7) c; M CL w 0 x V) 0 IV cra L C) cr 'D L 0 m 41 V) CD 0 U M C� U- 0 cu Q- CD �.O m ou , 2 (1) 0 t 0,4r) If 10 co c 30 Qj to C: C_} L-.j o J =j Oo - s T x Lo 3 .a c- C-) I I -'-- L ID 4- -c- V) 00 .5 W Lf" 0 00t" C:) eq . Qz t 0 cn 3 . 1 3 7_ 0 cn 0 i �90 tu IA3 - Cl) - un Ln - C� co o s 19 C,7 v 0 0 0 C: C, 0 CIJ M P-4 cli Co C:� o C) 00 C'i Cl) Lo Lr) Lr) -t V) m Ln al u :t Z3 "I u w m 0 = W O C-) r� , C) O 0) ol C*D Q) 0 V) VD VD n N L. :;z CL) 41 0 CL cn 4- w L: V) 0 X ro C:) 0 E= M LO 0 140 EVALUATION REPORT V #1582 Department of Commerce in accordance with Comm 85, Wis. Adm. Code / Page 1 of 4 Division of Safety and Buildings �, Schmitt Soil Testing, Inc. Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. Revie O Date C�tN Personal information you provide may (Priva Law, s. 15.04 (1) (m)). 9 A -7 Property Owner Property Location �/ Melendez, Pat Govt. Lot S , R18W 7 Property Owner's Mailing Address 17 LUU Lot # Block # Subd. Name or CSM# Up� 1C 861 Park Place Drive 2 1 1 CSM Vol 7, Page 2055 70 City State Zip QWeCR04ToWWW6rA6er City ❑ Village M Town Nearest Road Mendota Heights MN 22 Star Prairie I Cty Rd. C [� Newf&ns ruction Use: Z Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement — 1 Public or commercial - Describe Parent material Outwash Sand and Gravel Flood plain elevation, if applicable 79.35' ft. General comments and recommendations: Area is suitable for a conventional s stem with a 0.7gpd/sgft rate. Possible sysytem elevation for Area 1 is (step trenches) Hig renc 93.2', Low ren ope rs 5 %�,� ac Ohs F-11 "�i� w�l\ .a.YG Boring # Ground surface elev. 96.72 ft. Depth to limiting factor 104+ 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. *Efr#1 *Eff#2 1 0 -7 10yr3/2 none sl 2mgr mvfr Cs 2m,3vf .6 1.0 2 7 -13 10yr4 /3 none grls icsbk mfr Cs 2vf .7 1.6 3 13-42 10yr5 /6 none s osg ml Cs 2m,2f .7 1.6 4 42 -68 10yr5 /4 none vgrlcos Osg ml gw 2vf .7 1.6 5 68 -104 10yr6 /4 none grs Osg ml - - -- - - - - -- .7 1.6 oil +r ❑ Boring # El M Ground surface elev. 96.72 ft. Depth to limiting factor 110+ 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. *Efr#1 *EfW 1 0 -8 10yr3/3 none grls lmsbk mvfr Cs 3vf .7 1.6 2 8 -33 7.5yr5/6 none grlcos Osg mfr Cs - - -- .7 1.6 3 33 - 60 10yr5 /6 none s Osg ml Cs - - - - -- .7 1.6 4 60-72 10yr5/4 none grs Osg ml CS - - - -- .7 1.6 5 72 -85 10yr6/4 none s Osg ml Cs - - - - -- .7 1.6 6 85 -110 10yr6 /4 none grs Osg ml - -- - - - - -- .7 1.6 4 f * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS > 0 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signaturec /J ,,� CST Number i Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 8/24/2007 715- 247 -2941 SBD -8330 (R.07 /00) Property Owner Melendez, Pat Parcel ID # Page 2 of 4 3 Ell "� # E Ground surface elev. 9202 ft. Depth to limiting factor 100+ 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 1 0-4 10yr3/2 none sl 2fsbk mfr Cw 2m,3vf .6 1.0 2 4 -27 10yr5 /4 none vgrcos lcsbk ml Cs 1vf .7 1.6 3 27-49 10yr6/4 none grcos Osg ml Cs - ----- .7 1.6 4 49 -60 7.5yr4/6 none vgrlcos lmsbk mvfr gw - - - - -- .7 1.6 5 60-100 10yr5/4 none gricos Osg mi - - -- - - - --- .7 1.6 F-1 Boring # El [] Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ❑Boring # ❑ Ground surface elev. ft. Depth to limiting factor in. El Ground Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtW in. Munsell Qu. Sz. Cant 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) Schmitt 5011 Testing, Inc. Page 3 of 4 Conducted by: Conducted For: Schmitt Soil Testing Inc Name: Pat Melendez Thomas J. Schmitt, CST 227429 Address: 861 Park Place Drive 1595 72nd St. City, State, Zip: Mendota Heights, MN 55118 New Richmond, W1. 54017 Phone: 715- 247 -2941 Subd.Name: CSM Vol. 7 Page 2055 s;t„re_ Lot No.: 2 Doe .�Y / Legal Description: SWI/4 SWl /4 S20 T3 IN R18W Backhoe pit Township, County: Star Prairie, St. Croix County A Bench Mark EL 100. ' Top of 2" pvc pipe O Alternate Bench Mar El.87 1 .89' top of 2" pvc p' Slope= 15% .L Scale " = 40' X P ���`► 631 Uo ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer fiDL /Va J%E< < �u z— Mailing Address 72 2 11,o 7 < < iMt=/1 r.e=T 41V-- o 'j: o S� Property Address 00 / W > (Verification requ' ed from Planning & Zoning Department for new construction.) City /State LSON/EIZ E& T Uh* • Parcel Identification Number (Zg - " p 038 — /09y .Sts — 000 LEGAL DESCRIPTION lL' �J� ) j �' 1 Y - L k y- Property Location 5t 1 /4 , �t _ 1 /4 , Sec. .20 ,T 31 NR / Town of -5 '+4 P/!;�/�� Subdivision , Lot # 1_ ` — 22 N3 Certified Survey Map # 6 Z , Volume JloL 9 , Page # Warranty Deed # i �(0 1 9 Volume , Page # Spec house yes no Lot lines identifiable ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 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. 1 /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 Planning & Zoning Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 o te 1- SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page l of r y FILE INFORMATION SYSTEM SPECIFICATIONS I Owner LA N D e1ISG 1= Septic Tank Capacity a l ❑ NA .2y_ Q'I j _r Permit Septic Tank Manufacturer e ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 7 L� L ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model Sr ❑ NA Number of Public Facility Units 0 NA Pump Tank Capacity a l N NA Estimated flow (average) DO g al/day Pump Tank Manufacturer 10 NA Design flow (peak), (Estimated x 1.5) p g al/day Pump Manufacturer N NA Soil Application Rate , ' gal/day/ft' Pump Model D NA Standard Influent /Effluent Quality Monthly average' Pretreatment Unit O NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD,) 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 ® In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu /100ml ❑ 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 1 MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 0 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 ❑ NA Inspect dispersal cell(s) At least once every: ® year( ►(s) (Maximum 3 years) ❑ NA ❑ month(s) ❑ NA Clean effluent filter At least once every: ® year(s) Inspect pump, pump controls & a ❑ yeaarr((ss ) ) larm At least once every: ❑ m ) 0 N ' ❑ month(s) 0 NA_ Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ® NA At least once every: ❑ year(s) Other: ❑ NA y 'r MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator.' Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks l 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 _a 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., 4 F. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. -s S � }r Page – 1 of rAR UP AND OPERATION For new cofstruction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may iriioede 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. im start up shall not occur when soil conditions are frozen at the infiltrative surface. L, ...og power outages pump tanks may fill above normal highweter levels. When power is restored the excess wastewater will be discharged -to the dispersal call(s) in one large dose, overloading the call(s) and may result in the backup or surface discharge of affluent.' 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. Jo 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. 3ANDONMENT Nhen the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is )roperly 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. )NTINGENCY PLAN the Poytrs fails and cannot be repaired the following measures have been, or, must be taken, to provide a code compliant 3place nt system: 7A 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>> EPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT LATER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A ERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. OITIONAL COMMENTS f WTS INSTALLER POWTS MAINTAINER Name Nam© l 7/ Phone — — Phone, _ I " , E SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY me _ Name Phone Phone _ document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.. 11111111111ii1111111111111111111111111111111111111 * 8 6 2 8 6 7 1 PERSONAL REPRESENTATIVE'S 862867 KATHLEEN H. WALSH DEED DOCUMENT NO. REGISTER OF DEEDS ST. CROIX CO., WI PATRICIA H. MELENDEZ, as Personal RECEIVED FOR RECORD Representative in the Estate of DORI E. HILES 10/23/2007 10:45AM PERSONAL REPRESENTATIV ( "Decedent"), for a valuable consideration conveys, EXEMPT I without warranty, to ROLAND BELISLE, Grantee, the REC FEE: 11.00 following described real estate in St. Croix County, TRANS FEE: 300.00 State of Wisconsin (hereinafter called the "Property"): PAGES: 1 That part of the NW' /4 NW' /4 Sec.29 and part of SW SW % Sec.20 -T31 N -R1 8W described as follows: Lot 2 of Certified Survey Map recorded as Document �vol.8 Pg.2243 Number 460622. Together with and subject to a 66 foot wide access easement as shown on Certified Survey Map as Document Number 444007. Personal Representative by this Deed does convey to Return to: KRISTINA OOLAND Grantee all of the estate and interest in the Property ESTREEN & OGLAND which the Decedent had immediately prior to 304 Locust Decedent's death, and all of the estate and interest in Hudson, W154016 the Property which the Personal Representative has Tax ID# 038- 1116 - 90-000 and 038 - 1084 -50 -000 since acquired. Dated this day of Oc3 QaQty , 2007. � ' /V (SEAL) Patricia H. Melendez, Personal gepresentative ACKNOWLEDGMENT STATE OF Mvoes6A ) THIS INSTRUMENT DRAFTED BY: ) ss D. Peter Seguin COUNTY ) MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. h 110 Second Street, Post Office Sox 469 personalty came before methis (�k ob>:✓ 2007, the above day d Patricia H. Hudson, Wisconsin 54016 Melendez, to me known to be the person who executed the taregoing instrument and acknowledged the same. Pl Public, State of =mission (expires): JULIE A. WOOD Notary Public- Minnesq� My comm�lOn ExPires Jan 31, 2oto 1 Oil Parcel #: 038- 1116-90-000 04/04/2008 11:34 AM PAGE 1 OF 1 Alt. Parcel #: 29.31.18.488K 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - BELISLE, ROLAND ROLAND BELISLE 719 210TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 2.110 Plat: N/A -NOT AVAILABLE SEC 29 T31 R1 8W THAT PT NW NW SEC 29 Block/Condo Bldg: T31 N R1 8W AND PART SW SW SEC 20 T31 N R1 8W KNOWN AS LOT 2 CSM 7/2055 N /K/A LOT Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 2 CSM 8/2243 2.11AC INCLUDES P352D 29-31N-18W Notes: Parcel History: Date Doc # Vol /Page Type 10/23/2007 862867 PR 10/23/2007 862866 DM LTTR 05/05/2006 824465 QC 07/30/1990 460884 877/128 WD 2008 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/1512004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.110 57,700 600 58,300 NO Totals for 2008: General Property 2.110 57,700 600 58,300 Woodland 0.000 0 0 Totals for 2007: General Property 2.110 57,700 600 58,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I Parcel #: 038 - 1084 -50 -000 04/04/2008 11:37 AM ' PAGE 1 OF 1 Alt. Parcel #: 20.31.18.352D 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address' Owner(s): O = Current Owner, C = Current Co -Owner O - BELISLE, ROLAND ROLAND BELISLE 719 210TH AVE SOMERSET WI 54025 I Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 5432 SOMERSET SP 1700 WITC I Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE SEC 20 T31 N R1 8W PARCEL IN SE CORNER Block/Condo Bldg: LYING SLY OF HWY C R/W AS DESC IN VOL 490 P 447 EXC PT TO TOWN HWY 0.01 ACRE Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) NOW KNOWN AS PT LOT 2 CSM 8/2243 ASSESS 20- 31N -18W WITH P488K I Notes: Parcel History: Date Doc # Vol /Page Type 10/23/2007 862867 PR 10/23/2007 862866 DM LTTR 05/05/2006 824465 QC 07/30/1990 460884 877/128 WD more... 2008 SUMMARY Bill #: Fair Market Value: Assessed with: 0 038 - 1116 -90 -000 Valuations: Last Changed: 01/07/1991 Description Class Acres Land Improve Total State Reason I Totals for 2008: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2007: General Property 0.000 0 0 0 Woodland 0.000 0 0 I Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 to / a FIL £ Jut.1 s Issa► JAMES o r,oRNEU 460622 Of n O O n O q, m z A z tv o � a o ; 0 O o 0 %� o o° j a z ° •� >> 'f n' w o i � P Y A N N .e r 7n 6 t0 O ti ti �� o 0 a 0 to j -i N w o n 0 p QO 9 { Nl � 14, af S f 1g f 2 pl ` s m T m n 60 57n S ro 4 W c {, • 9a' co NSO c rn { or { o 1 ?rS7n 84.18, s o 1NSo4?, f 8000 28 , 58„ y 121 57af'r•._ 85.5 r v n e °o / a on W N o° 800028, 58 m o cb a N W A N � I is l r w • � N 0 3Z8.Z4, --_Cif = .rlJ O 1So Iv . o s " P E AP 6p, m`m \ m f s r. A w ►. W ° a A g \ m t,7 r rr a s r..r o• A opo a � w •� r '� Y a w a T a� \ .0"' 121 130, e °� c° Rol 0 08 , ?3 _ m a s i .+ a of �-• T C H er east nli Ev $ i OF line of the the SN{ SA tJ� 10 C . 3. M n / N c! O 'f - oo � !� Ac a r l� A 1s to N 0 cm VOLUME 8 PAGE 2243 W. qji6 !11111 llll(IIII(IIlII IIIII IUII IIII il(!!! !ill l(!I * 8 6 2 8 6 7 1 PERSONAL REPRESENTATIVE'S 862867 KATHLEEN H. RALSH DEED DOCUMENT NO. REGISTER OF DEEDS ST. CROIX CO., WI PATRICIA H. MELENDEZ as Personal RECEIVED FOR RECORD Representative in the Estate of DORI E. HILES 10/23/2007 10:45AM ( "Decedent "), for a valuable consideration conveys, PERSONA Ez MPPIESENTATIV without warranty, to ROLAND BELISLE, Grantee, the REC FEE: 11.00 following described real estate in St. Croix County, TRANS FEE: 300.00 State of Wisconsin (hereinafter called the "Property"): PAGES: 1 That part of the NW % NW % Sec.29 and part of SW '/. SW Y4 Sec.20 -T31 N -R18W described as follows: Lot 2 of Certified Survey Map recorded as Document vol.8 Pg.2243 Number 460622. Together with and subject to a 66 foot wide access easement as shown on Certified Survey Map as Document Number 444007. Personal Representative by this Deed does convey to Return to: KRISTINA OOLAND Grantee all of the estate and interest in the Property ESTREEN & OGLAND which the Decedent had immediately prior to 304 Locust Decedent's death, and all of the estate and interest in Hudson, W154016 the Property which the Personal Representative has Tax ID# 038 -1116 -90-000 and 038 -1084 -50-000 since acquired. Dated this ` day of , 2007. (SEAL) Patricia H. Melendez, Personal Wepresentative ACKNOWLEDGMENT STATE OF M.t�c+esbiFa THIS INSTRUMENT DRAFTED BY: ) ss D. Peter Seguin VV1nr .0n COUNTY ) MUDGE, PORTER, LUNDEEN $ SEGUIN, S.C. 110 Second Street, Post Office Box 469 Personally came before me this C h day of Hudson, Wisconsin 54016 2007, the above named Patricia H. Melendez, to me known to be the person who executed the foregoing instrument and acknowledged the same. Ndfafy Public, State of mmission (expires): :ot IE A. WOOD N I'ubllt�Minn4ta MY ow wires can s. zoto 1 of1