HomeMy WebLinkAbout040-1222-20-000 Wiscontin Department of Commerce PRIVATE SEWAGE SYSTEM y
Safety and Buildings Division Count St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitn4� "r No.:
Personal information you provice may be used for secondary purposes [Privacy Law, S 5.04 (1)(m)).
Permit Holder's Name: ❑ City ❑ v' ` e T f State Plan ID No.:
Larson, Gary T'r`oy �o"i�ip .---
CST BM Elev. Insp. BM Elev.: SM Description: Parcel V461
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic t Benchmark �o , (}� _ a
Alt. Bm
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet �• .S - '
� Z
TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet
In
2S
Septic Se ' r NA Dt Bottom --_
� p + �
Dosing NA Header / Man. -7 . 99.3 /
Aeration NA Dist. Pipe 3V
-qtr 9�•
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade C_
F
Manu cturer mand cover o , `fo
Mo Nu er PM
TDH L . ction System TDH Ft
H ead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM 4444
BED /TRENCH Width r L n , No. f Tr nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Man a urer:
SETBACK _ -
INFORMATION TypeO Co" 5 , + 5� � _ CHAMBER M e Number: -
System: OR UNIT – u
DISTRIBUTION SYSTEM
Header />!lanifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length lim Dia. ength Dia. pacing ? b�
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over N Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center S A- I Bed/ Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 0 Inspection #2: ' --f - '
i
Location: 360 Southern Pacific Road, Hudson, Wl 54016 (SE 1/4 NW 1/4 16 T28N R19W) - 1628191080 Glover Station
Addn. III - Lot 47
1.) Alt BM Description = " how
2.) Bldg sewer length = —s8
- amount of cover = 1'
WO CCQOAQ4
Plat revision required. ❑ Yes No
Use other side for additional information. 05- o$ o I N H-�
SBD -6710 (R.3197) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
1
r E
F
� r
i
F
j F I
N
f
E
O G
a Safety & Buildings Division
anitary Permit Application 201 W. Washington Ave.
In accord with Comm 83.21, Wis. Adm. Code PO Box 7302
V M5 See reverse side for instructions for completing this application Madison, WI 53707 - 7302
O Personal information you provide may be used for secondary purposes (Submit completed form to county if not
oepdrrment of!Commerce [Privacy Law, s. 15.04(1)(m)) state owned.
Attach complete plans to the coup co only) for the stem, on paper not less than 8 -1/2 x 11 inches in size.
State Sanitary Permit Number ❑ Check if revision to previous application State Plan 1. D. Number
County C `
I. Application Information - Please Print all nformation Location:
Pro rty Owner Name Property Location -��y
�� 1/4 11- /4 S TS , Numbers
Lot Number v
Property O cr's Mailing Address nn
City, State Zip Code Phone Number Subdivision Name or CSM Number
r
❑ City
11. Type of 13 ilding: (check one) ❑ village /
1 or 2 Family Dwelling - No. of Bedrooms : 6 Town of e/
6uUlic/Cornntercial (describe use):_
bra
❑ Sfatc -Owned _ _ - I Nearest Road
A Par (Tax �r
III. T e of Permit: Check only one box online A. Ch k btax on li a ' licable ', - 5 - 6, O Addition to
A) 1. New 2. ❑ Replacement 3. ❑ ReplaceFrtctt�f= oltTVG ��C� �` Existing System
stem S stem Tank Only _ Datc Issued
B) Permit
❑ A Sanita Permit was previously issued 1
IV. Type of POWT System: (Check all that apply) ❑ Sand Filter ❑ Constructed Wetland
Non - pressurized In- ground ❑ Mound
• Pressurized In -ground ❑ Holding Tank ❑Single Pass ❑Drip Line
• At- de ❑ Aerobic Treatment Unit ❑ Recirculatin — 0 Qthcr:
V. Dis ersal/Treatment AreaInformation: ���
I. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil App ication 5. Per ation ate 6. System Elevation Elevation on G rade
Acquired Proposed Rau (GaJslday/ q�t� �.inJinch) o po
/() -
-7 .�
Tank Capacity in Total # of acturcr Prefab Site Steel Fi
VII: ass Plastic
Gallons Gallons Tanks M u Con- Con- g
Information crete strutted
New Existing
Tanks Tanks ` ❑ ❑ ❑ ❑ Za
t 1000 t VC9` - of
VIII. Responsibility Statement
1, the undersigned, assume res onsibili for installation of the POWTS shown on the attached tans. Business Phone Number
Plumbers Name (pri Plumber's Signat no stamps): PRS No.
e
7
4r..4es Address (Street, City, State, Zip Code)
,� t S 0 t
IX. County /Department Use Only
Sanita Permit Fee (Includes Groundwater
Approved ❑ Owner Given Initial Adverse Surc Date Issued mg event Signature (No stamps)
❑ Disapproved ry, /I`E.eN'^-
harge Fee) �� S��oa �7 D!7
Determination
f Approval /Re g son for Disapproval: 5 - p E, �,,�aPA,tct�- i�✓°
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DERRICK CONSTRUCTION Fax:715- 246 -4948 Nov 17 '00 1:48 P.02f02
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DERRICK CONSTRUCTION Fax:715- 246 -4948 Nov 17 '00 1:48 P.01/02
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FAX TRANSMISSION
DATE: 1— 1 — c7 <Zk TIME • 4Z
PLEASE DELIVER TO: F-00
) E R R I C K COMP �1-134-x
ONSTRUCTION�
FAX NUMBER:
THESE PAGES ARE FROM:
Residential
Commercial TOTAL # OF PAGES INCLUDING COVER SHEET:
Remodeling
IF YOU DO NOT RECEIVE ALL OF THESE PAGES, PLEASE
CALL (715)246 -2320 AS SOON AS POSSIBLE. THANK "YOU!
1505 Hwy. 65
P.O. Box A ADDITIONAL NOTES: P- CS • 4'cg%� i�x-
lew Richmond, WI 54017
(715) 246 -2320 b -� 'T ' tC -
FAX: (715) 146.4948
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page )I of
L�tior a'! Human Relations
Dnns�on of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
• COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but . #
G� 1 dC
not limited to vertical and horizontal reference point (8M), direction and % of slope, scale or PAACELI.D #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
C - m • B`! E b��N 1 S SCE{ U LT Z GOVT. LOT SE 1/4 MW 1 /4,S /b T - Z-FS ,N,R 19 E (011
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
L Q) 9T - q 6666 Svikl 1J 3 1 " 4 i'�D rp 0th
CITY, STATE _ ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
NLJshj�
[)d New Construction Use D< Residential / Number of bedrooms [ ] Addition to existing building
I ] Replacement [ ] Public or commercial describe
Code derived daily flow u o gpd Recommended design loading rate 0 • bed, gpd/ft trench, gpd/ft
Absorption area required S `b bed, ft 1 SO trench, ft Maximum design loading rate o - bed, gpd/ft 0 - `� trench, gpd/fl
Recommended infiltration surface elevation(s) 0 )8.0 It (as referred to site plan benchmark)
Additional design /site considerations 'S e. ry 0 E 016 P+tG E 3
Parent material S'M 1 W1 MT OLML I G "U Lst Flood plain elevation, if applicable ft
S = Suitable for System CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL I HOLDING TANK
U= Unsuitable for Stem (a S❑ U ®S ❑ U 0S El U [R S❑ U Q S [I U I ❑ S MU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure CortslSWM Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Cola Gr. Sz. Sh. Bed Tmnch
wc: )I k3 -116 2 - 1Z _ S �, Z. `�5bVt 0-S 0•
2 16 -3$ X0`1 LZ 31 L S i Z'F S l bk Y>7 'Ft- e S ] vj u- S 0.6
Ground 3 3$ -SI L0 -1 R- Y!6 — S o S� vn C S o•l 0.8
elev. �l C 1 Q _ /� yy� 1 u
1, 3 ft. 1 53 - 0 1u`t2 V/9' V S� .1.1 _ de f 0.v
Depth to
limiting
factor
3 �,
Remarks:
Boring # ;
t o - tZ )01-IQ 31 - s Z`F 0 tin of lr e S z v 0.5 o. 6
�Z _
Z N Z -30 IV H.2 3/ lei o• ta•6
3 3o -Sty IQl (-I 2 �-j16 — S o sq wt 1 es — 7 n•8'
Ground
elev. y so -fib toLitt V/r 0,� u.
1 019 ft
li mitin g D e pth
IaC 8 6
Remarks:
TName: Please Print Arthur L. We erer one 715 - 425 -0165
egerer Soil Testing & Desig Service -P.O. Box 74 River Falls,WI 54022
SgnaUrre: L �. r �� J 3_4 Date: S -3 - `� CST Num ber:
0 0 5 7 6
PROPERTYOWNER B`'l� - Set{yL SOIL DESCRIPTION REPORT Page `7,6f-v-
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP.D /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Z `F S bk ,Pry S u-
3 :tz.
<:< Z $ -qD d -t 1Z 31
Ground 3 L4 L-3 t %j S S Al c S � �• � �• 8
elev.
�o -S ft. y sb -89 L� �tR �[! — S O sue, � 1 - o•� n -8
Depth to
limiting
factor
Remarks:
Boring # _
-\Z lw R 31 Z _ g 1 Z `� c�- vv) Q �°- 5 zu � o -S i C,
4}��...`)._`' Z �Z._`f� �o�Q �!!b - S o S9 wt � c S - o � o•8
Ground
3 YJ - 5 1 y 2 Y/ — S O S
elev.
1 0)-o ft.
Depth to
limiting
facto�r
Remarks:
Boring #
6- ►O 1 1 tt 3 1 Z VA U` I, A. S 2 u `� b• S o . 6
gg \:
S f -Z f - L _ , q g to -IR Vl( - S o sg ri1 1 cS - o•� �•
Ground
elev.
Nob` ft.
Depth to
limiting
factor
Remarks:
Boring # 1 04 `p 31a
'" 2 5 -39 io�t�316
�: 6 ��� — S 1 � 2`FS alt �'►'�1r c 5 � n.b
3 39 -S3 13 `1R Y!6 - S S
Ground
elev. 53_85 10M2 Y/y — S O S ►'►�) — o -� 'U•�
10� ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
PRgPERjYOWNER ' -SCH -UL'rz SOIL DESCRIPTION REPORT Page 3 of
.PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Bax�y Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Try
Z 0 S V
M -7
13 -3o Io 3 )'"i`��. c I o f u• S v•
Ground 3 3o -y I - ). S`1 2 Y14 — GH S yn V 1r LS 4 �/ 0 • S
elev.
�o�ft. III -60 Icon Y/6 S O cs o•� n .$
Depth to 1 60 I to`i R w — S O S yvt o , � • &
limiting
factor
? l ZA
Remarks:
Boring # -
`
W1 U `�lr C4 , s Zvi
Cj • S O
4r' r.�.t. p
} ci 8 O.S 1o'-I. Y16 -- S o S g Y►1 cS - o.� :o•�`
3 S Yz) yR Y/Y S p S 'YVN \ — o-- a•
Ground
elev.
ft.
Depth to
limiting
factor
7 80
Remarks:
Boring #
Ground
elev. -
ft.
Depth to
limiting
factor
Remarks:
Boring #
Jo :r
Ground
elev.
ft.
Depth to
limiting
factor F-T
Remarks:
SBD- 8330(8.05/92)
` PLOT PLAN Page 'q of ,
Wl
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w /FOvclz7 `.7
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Nsconsin Department of industry SOIL AND SITE EVALUATION REPORT Page ) of
Labor and Human Relations
Division of Safety & Buildngs in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S � C ' 1 X
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, 4nd location and distance to nearest road.
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
0-. M- 4t 1J� � S S C�{ U L Z GOVT. LOT SE 1/4 U W 1 /4,S //6 T 2 8 . ,N,R k 9 E (mow
PROPERTY OWNER' :S MAILING ADDRESS LOT BLOCK# SUBD. NAME OR CSM #
N3. M j}t" 9T - 4_1 I'D CA Ki
CITY, STATE ZIP CODE PHONE NUMBER []CITY (]VILLAGE NrOWN INEARESTROAD
ij2ZUeR. 1_�Ls w 1 5 414z.Z (715) 4Z3 1 1 Soo Lana: RAN
[� New Construction Use pQ Residential / Number of bedrooms y [) Addi*n to existing building
j) Replacement [ ] Public or commercial describe
Code derived daffy flow gpd Recommended design loading rah 0. 1 bed, gpdV trench, gpdAt
A b s o r p ti o n a r e a r e g t * e d S S 1 6 bed, ft 2 1 S O trench, 0 Madam design l o a d i n g r a t e o- -) bed, 9Pdlf °' b trench, 9WR
Recommended titliiltration surface elevation(s) q8 O It (as referred b site plan benchmark)
Additional design /she considerations - SEE - tv OTe oty PitS E 3
Parent material GLi%t. Such I G tutu C-t- Flood plain elevation, if applicable N - A - It
r S W tab le for system CONVENTIONAL MOU14O N-( fD PRESSURE 7 [RS GRADE SYST9tt IN F LL Hq DNVG TAW Unstatfable for. 9 S ❑ U [US D U C�! S❑ U
0 U 0S o U I ❑ S klu
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color k1oftles Texture Structure Co,§sIence Bou,d3y Roots GPD /ft
in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed TRY&
ti 3 -16 2 b -S 0-6
16 -3$ tU`Z 2 31 L _ S j ,f- S6k Yn JH e S 1 v Q 'S 0.6
Ground 3 38 -S3 Lo 42 Y/4 S c S 0S 0.8
elev.
w0 ft y 5343 lull? 4/! _ S O Sig Y�1 - 0.-1 ` o
Depth to
limitin
factor
a3�
Remarks:
Boring #
o- �Z % 31 Z m U c S z v o 5 A. 6
E tz -30 I%*.)4 Z 316 - s1 ZjAh +^"'F1 ag l�f o -S o•6
Ground
3 -�Sb 10 H 2 V A S o S9 wt I e S - �� �•8'
` elev. y so -% t CS i tic Y/f s g 0.7 1 ;3..r
ft
O to
tirttiling
tam 6 1
Remarks:
TName: Please Print Arthur L. We erer 715 -425 -0165
eg rer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022
Signature: a R. / Date: CST Ntunber:
�•�i q3 -L{y 5 -3 -°r3 M00576
PROPERTY OWNER B`'I� - Se1}uLTZ SOIL DESCRIPTION REPORT Pageof
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP.D /ft
in.. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
*,Sbk kn
1$ -�10 Vo �i (z 316 _" S 1 Z '� Sbh l►7'Fh CS lv'� o. 5 u
Ground 3 yo -S6 ► o - 19 - ki S o S All C S n• �� $
elev. s9 1+11 - �•� ; n•8
\ \.S ft. y 56-89 to '-t ft S[� -- S
Depth to
limiting
fa � ,
Remarks:
Boring # ,
-1Z toti% 311 Zu •S o•
YA. — S o S9 1►'1 cS 0.8
>rt
Ground - A Y$ -95 1r-� 4 2 WV C5 S 5
elev. I
1 0�.o ft
Depth to
limiting ;
factor s `
i
Remarks:
Boring #
...: • < , 1 -1Z t0'1 Q 3 12 S Z 41� C'�, vn U - 2, o • S o , b
' S Z. 11_x($ 10`1 IL V1(. S O Sg , cs — o•'� v•
at. s?vbay.�3. >4
Ground
elev. I
lob ` ft.
i
Depth to _
limiting `
factor �
� 99
Remarks:
Boring #
1 O`I2 3 -S
R ,
4 •\ \y ivi
7-is Ic -�1 C S ��� o• o.b
3
Ground 3g -S3 1 3`1 It VA. -- S O S5 � � eS — 0.7 jo•$
elev. �_qs to`t2 y/y
10 z.,l tt.
Depth to
limiting
factor
i
Remarks:
SBD•8330(R.05/92)
I
PROPERTYQWNER kfU1-TI SOIL DESCRIPTION REPORT Page 3 of
PARCEL I.D. # LOT 1
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Ba.r>day Roots
_ in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mr>m
1 0 _\ 3 \ 3!Z mi Z `'F- $ b1z y.1`{ -�. �S 2- f 0 S V•6
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PLOT PLAN Page L) of ,
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Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 37 0 32 3
Number of Bedrooms 3
Design Flow - Peak (gpd) 0_
Estimated Flow - Average (gpd)
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) [Coo
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
F__ EEI
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
R
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
TA G
3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer LA Qxj
Mailing Address /L!u SS i i r
Property Address
(Verification required from Planning Department for new construction)
City /State /JV t4 f LET Parcel Identification Number 64Q - /2 7 - ' ZO - ` O
LEGAL DESCRIPTION
Property Location 5 C '/4, "" �/., Sec. / , T 24' N -R /q W, Town of
Subdivision &LoyC -tL -'o A m r ®s4 Lot # 7
Certified Survey Map # Volume . Page #
Warranty Deed # q 922 2- L / , Volume 139Y . Page # ddb-
Spec house ❑ yes)Kno Lot lines identifiable ye s El no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and' by a
master plumber, journeymanpllimber, restrictedplumberor a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
SIGNAttW OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
C; C . LA-d A"A 1( ///0
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.******
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
Oct 07 00 02:15p C 6 G Software Design 16511 674 -2387 p.4
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VOL 94 P*M?
59;`324
Warranty Deed REGIST H. DEEDS
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between ALEXANDER A. ALEXAMORO, 01 - 08 -1997 9:30 AM
JR., A SINGLE PERSON, Grantor(,) W)RRMTY DEED
and GARY L. LARSDNA CATHERINE A. LARSON EXEMPT M
HU ND WIFE Graniee(s), COPY FFEEEEII FEE:
TRAMM FEES 201.00
REMIM FEE: 10.00
WITNESSETH, That the raid Grantor(s), for a valuable PAGES: t
consideration conveys to Grantx(s) the following described
real esta THIS SPACE RESERVED FOR RECORDING UAI A
t T CROIX County, State of Wisconsin:
R"- AND RETURN ADORERS
LOT 47, STATION THIRD ADDITION IN THE p4;7
TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN
PARCEL IDENTIFICATION NLUM
This is not homestead property.
Together with all and singular the hetWitamc nts and appurtenances thereunto belonging;
And above named grantors warrant that the titic is good, indefeasible is fee simple and five and clear of
encumbrances except any easeruents, restrictions and reservations of record, municipal and zoning ordinances,
and will warrant and defend same.
Dated: JANUARY 7, 1999
3 " (SEAL) (SF.AI.)
ALEXANDER A. ALEXAN S RO, JR.
(S AL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Si�mW tx(y) auWeatiueled: .
6YMC OlWLcoml::, )
1 sS.
ST CROM Ci.ety. )
Trill: MEMBER 1rVXrY. BAR OF W ISCO -NIMN Pamally came before me at , rtte abaw named ALEXANDER
A. ALEXANDRO, JR., A SINGLE PERSON to be lawm to be
Ow peaat(s) who mxvtd UW tarCpft isommmt end
THTR TNR'1'Rl IR41?'VT W A.4 T)R.4FTR1> AY:
rl::/ (type nr prim)
BARRY C LUNDEEN NOWYPt"4 5T CROIX CO ,ty, WilIMIWL
My ,ermmimion ie petrmmant (If mt, stele wpuetiun dale:
MUDGE, PORTER, LUNDEEN &SEGUIN
HUDSON, WI 54016
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