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HomeMy WebLinkAbout040-1207-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488169 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: Lien, Michael & Jennifer Troy, Town of 040 - 1207 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section ( fown /Range /Map No: 6M L c 7 16.28.19.983 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , I f Benchmark * �� It6 it /ez-7) QQSing n Alt. BM �, $ •�, 47•{p5 F; v pb c7,c. 6 Z S Lj.,AK 000r /, Z`1 9 tv •.3 �o Aeration Bldg. Sewer W. � lo.z( H olding St /Ht Inlet 2.sL 5.� 92•c�� TANK SETBACK INFORMATION S t /Ht O Lc( 92 3 Iv v ent to Air in ROAD Dt I n l e t S ep tic Bottom e ng is ion >50 8 7 , A3 ' > 56 g osi Header/M /6 ,53 7 tb'l era is . Pipe �067 ?.a o ing Bo t. system 11. $ (o • Z ina PUMP /SIPHON INFORMATION ra e ( cf /. 3Z m anufacturer Demand st Cover GPM M ociel Number nc ion LOSS 1 systern ea orcemam eng j uia. SOIL ABSURPTIUN SYSTEM or-L)l I mr-M,171 MUM rullym U. ul I lellcne5 U1M=N1_jivr4S Plits 111*11.1a ul.. ula Uepirl DIMENSIONS 2 r e,14- \ . INFORMATION CHAMBER OR C EL � 7b Z:S ype 01 SyStell Lie UNIT DISTIR113UTIO SYSTEM t^JQ.a+ z� JA nUIC 011a naducl, viol III— / L4 Pipes) S� Ger Length to Dia Length Dia Spacing \ 1 d- x Pressure Systems Only xx Mound Or At - Grade Systems Only Bed /Trench Center 5 � 'T 6` , / Bed /Trench Edges \ Topsoil Yes No Yes No J COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 373 Milwaukee Road Hudson, WI 54016 (SW 1/4 1/4 NW 1/4 16 T28N� Glover Station Lot 2 . 9 / L Parcel No: 16.28.19.983 1.) Alt BM Description = Lj,. (c O V\ 5 " ` ` �-Vva� l�•.S 7 ✓� 2.) Bldg sewer length = 30 / - amount of cover = / Plan revision Required? ;Yes No Use other side for additional informati 610 —Insap gnature - -- - -- - -Cert. No SBD -6710 (R.3/97) Safety and Buildings Division County n 201 W. Washington Ave., P.O. Box 7162 \. Nvia wnson Madison, WI 537 [ovi Sanitary Permit Number (to be filled in by Co.) Department of commerce (608) 266&-3 RECE 4� (09 Sanitary Permit Application State Plan 1. Nu beer In accord with Comm 83.21, Wis. Adm. Code, personal information you deM AY 0 may be used for secondary purposes Privacy Law, sl5.04(l xm) rolect Add (if diff ft than mailing address) I. Application Information — Please Print All Information i I 7 ,' Property Owner's Name Parcel # 1.t# Block # _ b Property Owner's Mailing Address Pro Location Y., Section Ci State Zip ode Phone Number S� %. 1 l / . 7 T� N; H. Type of Building (chec a tat apply) v Name 0.5 ScJ(or+� . ?l or 2 Family Dwelling - Number of Bedrooms ^F- rl p, }•,�� r (7 � .� Subdivision Name CSM Number 0V A ❑ Public/Commercial- Describe Use a ❑ State Owned - c ' Use ❑City _❑Villagelfownship of cc) III. Type of Permit: (Check only one box on line A. Compide 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 POWT'S System: Check all that a pply) X Non - Pr In- Gro und ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized hi-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line vet -less Pipe ❑ Other (explain) V. Dispe rsalfrreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation / VI. ank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units n L Concrete Constructed Glass New Existing G✓ ro/ 16k_ PL 5 t Tanks Tanks y� Septic [iohimg Tank 5 �S .Q t^� /l Aerobic Treatment Unit Dosing Chamber VII. Responsibili Statement - 4 the andersiga , assume nsibility for hs n the POWTS shown on the attached plans P ber's Name ( T Pjagtb�' Si awre RS umber Business Phone Number �4s L � 715 S Plumbers Address (Street, City, State, Zip Code E L) N r 1 VIII. Coon apartment Use Onl Approved ❑ D ppro Sanitary Permit Fee (includes Groundwater Date Issued Issuin gent Signaw Starr Surcharge Fee) �60 5 q ❑ O rvep Reason for Denial / IX. Conditions of Ap for Disapproval SYSTEM OWNER: 1. Septic tank, affluent filter and dispersal cell must all he services / maintained as per management plan provided by plumber. 2. All aefack requirements must be maintained n per applicable code / ordinancea. Attach complete plans (to the County only) for the system on paper not less than 81/2 x I1 inches in size SBD -6398 (R. 01/03) I A314wc) M3T2Y2 r fir{ +q1 1rt9t!n1g .,r{l1&� ".�i� r -. ` t "� Ens —2 .. ." �fi t't:!t .•r^ �.l;.:tyU$'t� �;911tf,`•"rf:rt. -±(: ; ;j; r; ,?try: rv'3,.. , i %`:tl '^J6�++2 s�'1 d3JlSE�r�tilU'i'![�!';; °l17B�3�QC{$ l� I II — tot -� Qlf or I ao 9 0 o n 3 3 -7t PJL, kit & CM 1 _..�.. 1 35 V Wisconsin Depcirtment of Commerce MAY ( b�I 0 6AL TION REPORT Page 1 of 3 Division of Safety and Buitdi �Fq�111OaQbM flfiYWis. m. Code County ST. CROIX Attach complete site plan on paper not le n must include, but not limited to: vertical ndzLmtal reference point (BM), direction and Parcel I.D. 040 - 1207 - 90 - 000 percent slope, sca or imensions, north arrow, and location and distance to nearest road. Please print all information. Revie Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location --�� MICHAEL & JENNIFER LEIN Govt. Lot ---- SW 1/4 NE 1/4 S 1 T 28 rr N R 19 E Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 29 -- Glover Station City Stat& Zip Code Phone Number flY ffvllage ET own Nearest Road AJ 1 5 to tk. ( t5 ) 53 L 165 $ T -rou Milwaukee Road E] New Construction Usei] Residential ! Number of bedrooms 4 Code derived design flow rate 6 00 GPD Replacement Public or commercial - Describe: Parent material outwash Flood Plain elevation if applicable NA ft. 6@n @rgl @ @Ri fl@fltti C6nventio nl In- gf6una trviehen =- 0.5 loading tate __ pumping may he mquirttl fbt mplaceffient Uea and recommendations: To be designed by Roger Nelson Boring # 0 Boring El Pit Ground surface elev. 89.40 ft. Depth to limiting factor 90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I 'Eff#2 1 0 -4 10YR3 /2 1 3fgr mvfr cs 3vf -co 0.6 0.8 2 4 -8 10YR3/2 - ) 2f -msbk mvfr a b 2vf -co 0.6 0.8 3 8 -31 10YR3/4 - sl 2f -msbk mfr cs 2vf -co 0.6 1.0 4 31 -60 7.5YR4/4 ifs lmsbk mvfr cs lvf -co 0.5 1.0 5 60 -90 10YR3 /6 -- fs Osg ml -- -- 0.5 1.0 Some gr < 1% 1 1 M 2 Boring # ❑ Boring 99.00 94 ❑ Q Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I 'Eff#2 1 04 10YR2 /1 1 3fgr mvfr cs 3vf -co 0.6 0.8 2 4 -11 10YR2/1 - 1 3fsbk mvfr cs 2vf -co 0.6 0.8 3 11 -24 10YR3 /4 sil 3fabk mfr cw 2vf -co 0.6 0.8 4 24 -56 10YR3/4 ifs lmsbk mvfr cw lvf -m 0.5 1.0 5 56 -94 10YR3 /6 fs Osg ml -- -- 0.5 1.0 * Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L * Effluent #2 = B013 30 mg/L and TSS < 30 mg/L GST Narm (Plf m PdM gign@tllr@ 66T N@mb@r M&F J6 Hollister c -SL 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 04-03-06 (715) 426 - 1775 4 Property Owner LEIN, Michael & Jennifer Parcel ID # 040 - 1207 - 90 - 000 Page 2 of 3 L awng ❑ Pit droound surface elev. �: ® ft. Depth to knili g facts in. Sol Avlicadon Rate Horizon Depth Dominant color Redox Description Texture Structure Consistences Boundary Roots t,PD/if in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 '0111 1 0-4 IOYR2 /1 — sl 2fgr mvfr cs 3vf-co 0.6 1.0 2 4-11 IOYR2 /I — sl 2f-msbk mvfr ai 2vf-co 0.6 1.0 3 11 -17 10yR3/2 — ifs Imsbk mvfr ai 2vf-co 0.5 1.0 4 17-60 10yR3 /6 — S Osg ml cs lvf-m 0.7 1.6 5 60-100 1OYR4/4 — 1 s Osg ml — — 0.7 1.6 Z - 11 1 --1 'tw ----t 4] Boring # Bourg ■ Pit Ground surface elev. NA ft. Depth to lirru6ng factor 86 in. Soil Application Rafe �Honzon Depth Dominant Redox Description Texture Structure Consistence Bound" Roots GPD/fP - -- Myrad Qu: f: oft ®f: 1k ah: • 1 1 0-5 IOYR3/2 — 1 2f-msbk mvfr cb 3vf-co 0.6 0.8 2 5 -12 _ 1 2fabk mvfr ab 2vf-co 0.6 0.8 3 12 -24 1 IOYR3 /4 -- sil If-msbk mfr gs 2vf-co 0.4c 0.6 4 24-70 7.5YR4/4 — Ifs l msbk mvfr cb 1 vf-co 0.5 1.0 5 70-86 IOYR3 /6 — fs Osg ml — — 0.5 1.0 ❑ Bonrrg Pit Ground surface elev. ft. Depth to lin Wm factor m• Soi Rate Horizon Depth Dominant Color Redox Description Texture Structure C insisterce Boundary Roans GPnff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Effluent #1 = BOD, > 30 220 ngll- and TSS >30 150 mglL ` Eff luent ;N2 = BOR < 30 mgA and TSS 5 30 ng/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 altemate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. 98134330Ted(R07M) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property Owner L.EW , K le-'Mrd- � I "NXFef- l " =.50ft Legal Description rM z 6c.Vbe SvPn I oa (except where noted) S W y4 of -Mle McYy .56C. 16 , - r2RJ#J 3 RIt w , TO O = Backhoe pit oF - CROV. St. CaouX coi,►ATrV� t�nsc�Ns�N. I� = pets Not vs� y North s� �o Z, s` ACULS x 4 DES r .c• =EAU s�.FtIC D� 0 0 5 8 R �y4Q; O O N Site Location: y SEC. U. FF EZ'1203H . f . .::: ' 4 •�` .: •' ,� lip esevve♦ � vvvsvvs VWW ve. eve . ^'.L °r i; , '..r . '� • `�'�` v,e 12 24 vvv er VTV 4.625" v v v v eev V.' V " 1/2 Cjrc. = 18.84" vve vev evv Wee o vv V vvvvoee v V, VV wove vevo�e Vvvvvve vvvvvvvv WV WvV W V• vvvvWev vevvevvvavvvvv VWTVVVe ,.�..__ 24 11 • Bottom 36" VOW Volume 12 -I /2" DIA. (typ.) So il Interface Area 11L 141s, Ft Void Coefficient in Aggregate given at 57.4 %. Sidewall (2 Sidewalls) 2 * 18.84in — O.D. of 4" 12in 3.14 pipe = 4.625 inches 3125;a Void volume per linear ft. - 3.14 • 2. ltt = 0. 117 fN Bottom lft om 2.00 12inlft ) O.D. of center cylinder = TZ.S inches Total Soil Interface Area 5.14 SQ.FT Void volume in a 6.25in _ Z 3125i ggregate of tenor cylinder = 3.14 • 3.14 *( -' 574 = .422 fl? ( �12in/ft) 12in /ft O.D. of outside cylinders= 12 inches Projected Trench Area Void volume in outside cylinders - 2.3.1 6m 2 574 - .901 ft, Sidewall Height = 12 in. 0 2 = 2.00 Sq.Ft. l 12ht / tt J •' Bottom = 36 in. = 3.00 Sq.Ft. Void volume at bottom between cylinders m 24in • bin l l 3.1 6p, 1 ( } , 12in /ft 12inift) — ( �12inlft )� =0.215 ft Projected Trench Area S.00Sq.Ft. Void volume at outside bottom comers (1/2 of void volume between cylinders) 0,215 12 —0.108 fe Total void volume — 0.1 17 + 0,422 + 0.901 + 0.215 * 0.108 = 1.763 cubic ft f ft Gallons per ft — 1.763 X 7.48 - 13.2 ealions per linear ft. X (� — EPS Aggregate Trench System E Z1203H EZ�ZU1� Rint3-lndustrial Group 65 Industrial Park Rd. Oakland, TM 38060 SCALE FXE NAME, EZS2t)3H -vat SHEET: t of 1 11-27 -01 �,II POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION Owner SYSTEM SPECMATIONS Permit # Septic Tank Capacity a l ❑ NA Septic Tank Manufacturer �c ❑ NA OEStt3N PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model Capacity ❑ NA Number of Public Facility Units ❑ NA Pump Tank C al ❑ NA Estimated flow (average) O aUda Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) Pump Manufacturer al /da ❑ NA Soil Application Rate s Pum Mode( r gal/day/ft p 0 NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) 5 /L 30 m ❑ NA g ❑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 CeN(s) ❑ NA Biochemical Oxygen Demand (SOD 530 mg /L In- Ground (gravity) 11 In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At - Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other; Maximum Effluent Particle Size Y in dia. 0 NA Other: 0 NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE EE Serplce Event service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maxknurn 3 years 0 NA earls) Pump out contents of tanks) When combined sludge acrd scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cells) At least once every: 13 month(s) (Maxlrnum 3 yearls) years) ❑ NA Clean effluent fiber At least once every: months) ❑ NA * year(s) Inspect pump, pump controls & alarm At (east once every: ❑ month(s) ❑ yesr(s) ❑ NA Flush laterals and pressure test At least once every. ❑ month(s) Other. ❑ year(s) ❑ NA At least once every: O months) her: ❑ yeor(w 0 NA Ot ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks) to identify any missing or broken hardware, identify any cracks or leaks, 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 cells) 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 Coda. All other services, including but not limited to the servicing of effluent fitters, 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. START UP AND OPERATION Page of 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 co ft). if high concentrations are detected have the contents of the tanks) 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, overfoading the call(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; degrees; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system. /4) A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption ll 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 fines and wells. Failure to protect the replacement area will result in the need for a new loll 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 MAp11TAlNER Name Name Phone (S S 3-S— Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Nine Name s C VL Phone Phone 7 S - I 1 This document was drafted in compliance with chapter Comm 83.22(2)(bl(1)(d) &(f) and 83.54111, (2) & (3). Wisconsin Administrative Code. START UP AND OPERATION Page _ of For new construction, Prior to use of the POWTS check treatment tank(3) for the presence of painting prod may impede the tre cts or other chemicals altment process and /or damage the dispersal ceti(s). if high concentration are detected have the contents of the tanklsi removed by a septage king 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 es power nt. 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 fife of the POWTS: antibiotics; baby w i p es; ciga rett e butts; Y Pen tts• coed bl9 ems; cotton degreasers; Teasers• � � � dental floss; drapers, disinfectants, fat;. foundation drain (sump Pumpi 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 63.33, Wisconsin Administrative Code: e All piping to tanks and pits shall be disconnected and the abandoned Pe i P openings o enin s sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot tines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL. BASSES 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 DFFiCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name c Name Phone (5 5 S Phone SfPTA(iE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY' Name Name < < V Phone Phone '7 L This document was dratted in compliance with charter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1 (2) & (3), iWisconsin Administrative Code. i _ ST. ,CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ ! "i rl.+4Et— A*i & Ji "1 -Lt f= ,,, t t 1lj Mailing Address ` ' S A1 IGArl(= O N X 1K / Property Address Vi ttz- � AC,t k -E �'J `� 71" / (Ve ication required from Planning & Zoning Department for new construction.) City /State /7�0 S -ad,( If 60 T Parcel Identification Number LEGAL DESCRIPTION Property Location S/ 1 /a , % a , Sec. LSO , T N R /q W, Town of Subdivision _ (VL'G V % TT , Lot # Certified Survey Map # Volume , Page # Warranty Deed # W l -7q , Volume , Page # Spec house yes no Lot lines identifiable yes 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. 1 83.52 and in Chapter 12 - St. Croix County Sanitary () P t3' 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number edro '/ 4 - © �o SIG ATURE 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) Trial And Road Map For Glover Station .. » r 9 8 7 6 5 4 10 3 a N RDAD 2 11 19 20 21 22 23 1 12 24 's 25 13 18 17 30" 31 26 16 27 25 29 � 32 14 15 35 40 41 43 39 38 37 36 33 34 42 44 47 got Y 48 to 50 59 52 53 55 45 88 49 60 87 57 58 92 69 58 70 62 61 91 _ i56 71 63 64 89 72 65 as 87 74 73 ae 93 SCALE MV FEET 78 OD : :75 85 �{ . 95., 0 200 400 800 84 76 77 78 LE 81 63 96 97 y6 1aM}MatoMnmr 19JOEATtd1 ...........» MMN xo�O 82 r�aTrANOOQ+► aarE ..�...��� Civil [18BFS 1k LtUla StJt�YlyyOrs 101 20'-- ICM Ibl J1r1 10 0. Ndtd St. Rww Fd% TA SMOrIt !00 99 3 #� (Its) 425 -71 103 102 ».... �. »... » .» ;Vltuo r tZ- C.Y. BIB MO OIAE L. WE WMIS R. S+CIMU AND SANDRA C. SOWTZ DATE 5-30-W P.O. 8000 167 • 711 25 1!2 AVOW RIVER FAtt&, V"SOMiN SMO22 QIYBER I M. Wimm S1N 54M 99 -,2380 .7.7 GJC7 '� 74 KATHLEEN H. WALSH WARRANTY DEED Sr. Ri o X G O . , W1 DOCUMENT NO, RECEIV FOR RSCORh @4/83/2006 18:156[ NTY This Deed made between John L. Moen and WAKED Suzanne E. Moen, husband and wife, and each in their own REC Fig 11. right, Grantors and Michael T. Lien and Jennifer L. Lien, HAAS F &: 345.88 husband and wife, as survivorship marital property, CO FEE.- Grantees, PAGES-. 1 Witnesseth, That the said Grantors convey to Grantees the following described real estate in St. Croix S & C BANK County, State of Wisconsin(: RETURN TO: 100 Mill St Lot 29 PO Box 10 Glover Station Subdivision L Balsam Lake, N 5481"010 Town, of Troy Tax M# 040- 1207 -90 -000 This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; and John L. Moen and Susanne E. Moen warrant that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations, if any, of record. I Dated this day of M A.vLti , 2006. / (SEAL) `• (SEAL) Joh4nL. 1 Vloen Su74ne E. Moen ALUHE NTICATION ACKNOWLEDGMENT Signatures of John L. Moen and Surtnne E. Moen authenticated this STATE OF WISCONSIN ) ' day of 2006. ) SS COUNTY OF ST. CROIX ) TITLE: MEMBER STATE BAR OF WISCONSIN ��tt +t' + + +� Both arc Personally came boforc me this t���F 2006, (Signatures may ha authenticared or acknowledged. Bo nor the above named John L. Moon 8. Jmown to nocesm ry ) be the Persons who exoeuted th Q)ing ecrcnowledgcrl eseme. ` j `�O i-m r THIS INSTRUMENT DRAFTED BY: D. Peter Seguin MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. Notary Public, state of wisco i 10 Second Street, Post Office Box 469 My Commission (eupires); U �S Hudson, Wisconsin 54016 ����� t+h1iiit���`� Parcel #: 040 - 1207 -90 -000 05/02/2006 12:10 PM PAGE 1 OF 1 #: `16.28.19.983 040 - TOWN OF TROY Alt. Parce Current U 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 JOHN L & SUZANNE E MOEN O - MOEN, JOHN L & SUZANNE E 373 MILWAUKEE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary ' Type Dist # DescriptionMILWAUKEE RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.560 Plat: 1993 - GLOVER STATION SEC 16 T28N R19W 2.56A GLOVER STATION Block/Condo Bldg: LOT 29 LOT 29 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 16- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 764/39 07/23/1997 659/600 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/22/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.560 90,000 0 90,000 NO Totals for 2006: General Property 2.560 90,000 0 90,000 Woodland 0.000 0 0 Totals for 2005: General Property 2.560 90,000 0 90,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i