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040-1279-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 574301 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: Schulz, Michael A. &Christine I Troy, Town of 040-1279-40-000 CST BM Elev: Insp.BM Elev: BM Description: t,•� Section/Town/Range/Map No: l 17.28.19.1566 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � 5 J Z/ Benchmark �r t1Z .1t A� • c0 Dosing Alt. BM le, co �� � e o.y l Aeration / d S Bldg.Sewer C.�i, • f Holding �".6 � St/Ht Inlet w D!'e TANK SETBACK INFORMATION St/Ht Outlet�,� TANK TO P/L� WELL BLDG. Vent to it Ip� ROAD e_l �• c�� •5/ Septic / 1 Ll Dt Bott N ,1 ti Dosing 7 Header/Man. Iz ,S /C/$(7['• Aeration Dist. Pipe TWI Holding Bot. System �3• �� Final Grade -7, PUMP/SIPHON INFORMATION Manufacturer Demand St Cover g GPM 4 lGn Model Number TDH Li Friction Loss System Head TDH Ft Forcemain nth Dist.to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS _�- SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture. , INFORMATION CHAMBER OR x.."'6 � v Type Of System: r / / / UNIT Model Number: fG Go 4 0 w*1L'L DISTRIBUTION SYSTEM �Z- Header/Manifold/ JI Distributions \ x Hole Size x Hole Spacing Ven_t tgAAiiirInta a /a Pipes) � Length_Dia I Length Dia Spacing ��-— SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth f xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No 4,L5 Z, I COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 491 Omaha Road Hudson,WI 54016(NE 1/4 NE 1/4 17 T28N R19W) Eagle Bluff Lot 34 Parcel No: 17.28.19.166 1.)Alt BM Description 44., 'e I 2.)Bldg sewer length= 5 6t& -amount of cover -- / Plan revision Required? n Yes No Use other side for additional information. ! 'rinsepctoe,#Sigpa Date Cert.No. SBD-6710(R.3/97) SITE PLAN NE,NE,S 17T28N/Rl 9W Troy township St. Croix county W�� p LEGEND 1 B_M: 100.0' top of manhole cos er _ - pits w/backhoe ® - grade elevations - contour No DSPS 383 setback problemsX :s`' Scale 1"- 30' except where indicated PbSSSi'b le- 4 h o .. 10 20 30 V Vl Gf7 Nr, r System Elev. 86.9' thru 14dt-e _ 87.8' 2cells 3ft.by 80ft. i r Lot 34 of Eagle Bluff v _ �r��s F�s't;_k ;70,1 r.r C1)1q 1 _ is- W9 g� _ O ,mow project: SCHULZ ,_ L/" 1 a page 8 of 8 oo 0 o0 h o 0 O d v 0. 0 0 °? m o m N O Q Cn cc O L C C O) N m O O m N O — N m C C N C m a c c o ��a vc, m 3 N NO ao_ oo ooroc c E Co Yogi L mm $ �o'v U O>>m o (D 0)..'O N._>Q O 7 3 N N 01 V d 3 V C M C.4p) C 20 N C O N N O X U z C T�Co c z c� ci c N'y�Na � ci o Qoco O ;.N O aci a vcm om v 0(D'oc E Q Q ° cm o m Q N m NY I i CL v m z E rn w 00 :+ O Z = O z 4) 4) d co w a m a m n CN z I I O Z v .' c co c aUi Z v o Y ° c E rn d m m N L cc Y O N N O co m m (n N C7 N L a Q I a m O c O c (n o w < N cozaQ Z s C O ++ N .. m O) o a o o. �g m Y o a` a I °v 'o o a` 2 fA fn lA Y N N N j) w m CL = a z o 9 • a a a o a a a CL cr iw E `7 N 2 C'4 M m N 7 O W O O V O O m V) J U rn N O } .O O O .- M z N N ITV d' N z }� N C'4 z `� m 0 0 0 0 co _ t � ._ o E N co O Mn O m m •- O p m �. ti p M •� L m Q CO f71 m (D f0 Q n u) v — Q n c/ m °o Q y c V o E O O M O o o c c chi m m 0 d _ C m a s C -O N N N N N O n N N C N m C m N a) C—D O O C co ~ c°) d a v , w N c c C N co co m • o 1- in u o z !N d z v o z (� ; IL el CL 76 2 `�1 A c°� a2 0 vi0 0U) 0 X75`' canv -k /50 `s fs hf . D County Wisconsin T-- ,J c G Safety and Buildings Division St. Croix 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) Department Safety Ma Professional Services 0 Q Q14 l PAID �I 30 State Sannnit�,,AA, "��rfi'�MA ptilon State Plan I.D.turpber A In accord with SPS 383.21(2�QMV Code submission of this form to the appropriate governmental Project Address(if different than mailing address unit is required prior to obtaining a sanitary permit. Note application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,sI5.04(1)m, Stats I. Application Information-Please Print All Information —Seo h� Property Owner's Name Parcel# Michael & Christine Schulz 040-1279-40-000 Property Owner's Mailing Address Property Location 491 Omaha Road Govt. Lot City,State Zip Code Phone Number NE '/4, NE '/4, Section 17 Hudson, WI 54016 612/730-4323 T 28 N/R 19W II.Type of Building(check all that apply) Lot# 34 Subdivision Name X 1 or 2 Family Dwelling-Number of Bedrooms Four Eagle Bluff Block# Public/Commercial-Describe Use city CSM Number Village of State Owned-Describe Use X Town of Troy III.Type of Permit: (Check o line A. Complete line B if applicable) A. New System Re lacement S ste p y ❑Treatment/Holding Tank Replacement Only Other Modificat' n to E fisting System i t7 B. El Permit Renewal 11 Permit Revision _Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner �( �� �(J 5 -7-7 - Z 7�e IV.Type of POWTS System: Check all that apply) X Non-Pressurized In-Ground Pressurized In-Ground. _At-Grade Mound>2��4��in of suitable soil _Mound<24in of suitable soil Holding Tank Other Dispersal Component(explain) ` Gil� l r"'u 2�atlfient Device(explain) White Knight V.Dis ersal/Treatment Area Information: {tiGCv Design Flow(gpd) Design Soil Application Rate(gpdsf) Di ersAArea Required(sf) Dispersal a Proposed(sf) System Elevation — nu) ,� 600 1.0 �/1 600.osq.f 800.0 sq.ft. 86. t ru .8' n. VI.Tank Info Capacity in Total 44umber Manufacturer Prefab Site Steel Fiber Plasti Gallons Gallons of Units %y Concrete Constructed Glass New Existing llatZ Tanks Tanks or Holding 1260 1260 1 Wieser Concrete X Tank Dosing Chamber > 1 WK-40 model ©- y X VII.Responsibility Statement- I,the undersigneOssumsresponsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plu er's gnatur MP/MPRS Number Business Phone Number Kent Hoke 1�-- MP224199 715/962-4155 Plumber's Address(Street,City,State,Z p ode) 200 Bremer Ave., Suite , Colfax, WI 54730 VII Coun /De artment Use Only Approved El Disapproved Permit Fee Dpte sued Issuing Agent 'gnature ❑ Owner Given Reason for Denial $ 6� 2 G,",/��y, IX.Conditions of Approval/Reasons for Disapprova / -- ' .` SYSTEM OWNER: � I�� L 1.Septic tank,effluent filter and yy1 a,, dispersal cell must bje srviced/maintained �J as per management plan provided by plumber. �� G,�� f ojr�k/ 2.All setback requirements must be maintained � C�Cf.G'Z�r(,Si't,c!.Gl�y►� /47V q as era applicable c Attach complete plans(to the County only�or the .,system p on er not lest n 81/2 x 11 inches in size Z���tr�ui r I HRH PLUMBING, LLC 200 Bremer Avenue,Suite D PO Box 10 Colfax,WI 54730 Ph.(715)962-4155 Fax(715)962-4156 Email:handhplumbing.colfaxwi @gmail.com June 23, 2014 TO: Ryan Yarrington—St. Croix County Zoning FROM: Kent(Sid) Hoke, MP#224199 RE: Michael & Christine Shulz 491 Omaha Rd, Hudson WI 54016 Ryan, Please accept this letter as a Contract Agreement for H&H Plumbing, LLC to provide Two (2) years of Service Inspection for the new White Knight Treatment System. Inspection dates of July 1, 2015 & July 1, 2016. Any questions, feel free to contact me at 715-556-7621. Sincerely, Kent Hoke Owner/Partner PRIVATE ON-SITE WASTEWATER TREATMENT SYSTEM(POWTS) Index and Title Sheet PROJECT NAME AND SYSTEM TYPE: SC14ULZ / Conventional system by gravity OWNER: Michael&Christine Schulz LOCATION: Street Address 491 Omaha Rd, Lot 34 of Eagle Bluff Legal Description NE1/4,NE1/4,S17T28N/R19W Township/County Troy township, St. Croix county CONTENTS: page 1 title page page 2 owner's manual page 3 operations page 4 reports page 5 White Knight information 3dgj, � page 6 White Knight details �O:', • ' page 7 cross section �� 'b► as^ �� page 8 site plan *''••., .•''Q �� Attachment. soil test to county's plans PLUMBER: H&H Plumbing,LLC SIGNED: Kent Hoke CREDENTIAL#: MP 224199 DA June 16,2014 OPERATION The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or wastes froi&*04er softeners,ni vn removal units,.other clear water moment devices and foundation drains should be discharged to the ground surface whenever possible. Note: This does not include laundry waste,showers,dishwater,etc. This system is designed to handle domestic strength wastewater,however the disposal of food based greases and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non-biodegradable items such as baby wipes,tampons,sanitary napkin,condoms,cigarette butts, should not enter the system. Chemicals such as petroleum products, paints, disinfectants, pesticides,etc. should not be flushed into the system as they can seriously damage your POWTS system. Maintain a regular steady flaw by spreading laundry washing throughout the week. Avoid traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septic tank pumper. Septic tank component inspection must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks,measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any defects shall be promptly corrected. Exposed openings>8" in diameter shall be secured with an effective locking device. When the combination of sludge and scum in any tank exceeds 1/3 or more of the tank volume,the entire contents of the tank shall be removed by septic tank pumper. White Knight Treatment Component inspection must include a test of all electrical equipment. A visual check must be made for,missing or broken devices and other hardware and the condition of the filter. Any services needs or repairs shall be promptly taken care of Alarms should be tested on a regular basis by the homeowner. If an alarm sounds,contact and individual licensed to service POWTS,There is normally 1 day reserve under regular operating conditions,however water should be conserved until the system is corrected to prevent back-up of sewage into the dwelling or surfacing. Septic Tank Filter inspect at least once a year. Remove filter from canister. Clean as needed.Filer cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. I In-Ground Gravity Component Dispersal Cells inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding at depths>75%of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. project: SCHULZ page 3 of 8 POWTS OWNER'S MANUAL MANAGEMENT PLAN FOR SEPTIC SYSTEM POWTS MAINTAINER: H&H Plumbing LLC ph. 715/962-4155 LOCAL REGULATORY AUTHORITY: St. Croix Zoning ph. 715/386-4680 DESIGN PARAMETERS Influentleffluent quality(values typical for domestic(non-commercial wastewater and septic tank effluent)fats,oil and greases(FOG)<30mg/L,Biochemical Oxygen Demand(BOD)<220mn/L,total suspended solids (TSS)<250mg/L, SYSTEM SPECIFICATIONS FOR REPLACEMENT SEPTIC Four bedroom(600-GPD)single family residence Existing 1260gal Weiser Concrete septic tank w/Zabel A100 filter Proposing a White Knight treatment system Existing two distribution cells,3ft.X 87ft. of infiltrators Proposing two distribution cells,31 X 80ft. of ARC 36 infiltrators soil application rate 1.Ogpd/ft2,area required 600.Osq.ft. absorption area credit 25.0 per 5ft.chamber proposed area 800sq.ft. Proposing a gravity 4-way valve (components must comply w/Department Safety and Professional Services Comm 384 and be installed per manufacturers specifications) DESIGN CRITERIA SBD-10705-P(N.01/01)"In Ground soil absorption component manual"Version 2.0 MAINTENANCE MONITORING SCHEDULE Inspect condition of tanks at least once every year(maximum 3yrs.) Pump out contents of tank when combined sludge and scum equals 1/3 of tank volume Alternate drain fields at least once every 5years Inspect dispersal cells at least once every year Clean septic filter at least once every year Check alarm at least once every year Change White Knight chemical bag every 6 months first 3 years project: SCHULZ page 2 of 8 U Fitt 11 TAHU r17FUH--� 11 .`, SEPTIC SYSTEMS White Knight rato ffm SYSTEMS THE ISSUE PROACTIVE PREVENTION is is cg en P-rc i�/ ec t ne-v —SidGr i a i 3yinstalling tie kik/hite Knight i,PGTU1,as a lDreve-r-itive,measure,it eliminate's systerns a lir�� 6'1-171eC-tF:,C',.i of 1 :0 20 d 3', a"!Ac&,aclincl 0,,nd conv��rts t!to imc itio.,i2l sepiic system into a-biolorlically ,,eai-s. One !'�e �,-,c- :,o i e, c a e s-i D t;c V sys'--,m� i clooainc i e ��s o r ti o t 1l5!nceci ireatment sN stem.\/Mfl-t prolDer rliRiritenande one can i s""stern. claar�,,-:1!--a ffio"Di a:SelDiic systern alMOSL il-Idef sv using the p@[ented -500," rnedia,sl--e cialized aerol)ic hacLeria are Solu'lon ;S *e CS :ed m,,ci releEseci, f6SU1ti11CI in P!-,',,''!If�Uevt ti-i-at is cleaner and oxxien of i"-,)1;le abso'-,-4ion.system fhesp 1:)ac.!�-na con- ;o cri r) even;ing,lioiogicalcioriciing between naitura:drain ap the soil. White Knight MIG TM ---- - ------- Building Occupants ------- In Treatment System 2 3 4 4 Effluent Inlet pipe from building 2 6 J -�w pump (n-z-vity on 4— Septic tank 5 3 _V64M KNWW- T" Outlet pipe to distribution-box 4 Distribution box Leach field 6 - -Z Leath field 7 piping BENEFITS What is biological clogging? 2 3 low I Y�s X L r 7; 3 F;U 2 3 an"! 7 C 4 L REPORTS Reports for maintenance, inspections and monitoring shall be submitted in accordance with Safety and Professional Services Division 383 of Wisconsin Safety and Building. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with DSPS 383.33,Wisconsin Administrative Code. l.) All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. 2.) The contents of all tanks and pits shall be removed and properly disposed of by a servicing operator. 3.) After pumping,all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,gravel or other 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: { } 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 are will result in the need for a new soil and site evaluation to establish a suitable replacement area. { } suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank maybe installed as a last resort. { x} 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 located a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort. { } mound and at-grade soil absorption systems maybe reconstructed in place following removal of the biomat at the infiltrative surface. Reconstruction of such systems must comply with the rules in effect at that time. WARNING SEPTIC,PUMP AND OTHER TREATMENT TANKS MAY CONTIAN 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 PERSONFROM THE INTERIOR OF A TANK MAYBE DIFFICULT OR IMPOSSIBLE.. project: SCHULZ page 4 of 8 CROSS SECTION - not to scale All two cells identical observation pipe Finish grade all cells 90.0' or vent pipe (12" above grade) Jma f fill ed ial I y 3tt of Natural soil System Elev. 86.9'thru 87.8' >3ft of suitable soil System installed using ARC 6 infiitraLDrs TOP VIEW not to scale front of cell 4" header area Sch 3034 vent at end of-cell 5' ARC 36 end of cell observation (Per Cell) 16 chambers X 25 credit=400.Osq.ft. 400.Osq.ft. X 2celis = 800.0sgft proposed 800.Osgft. 600sq.ft. required Two cells (identical) 3ft. by 80ft. project: SCHULZ page 7 of 8 1W for Residential Applications White Knight"m WK-40 Specifications The 1Nhite Knight NIJG` is an advanc.rod for OIISite vmstevfater LreatnienL systems and may also he.used to enhance, the of othcr eatrn-2111 Tile ul-J: Is il Size aild III fl,"s or-,ound i i iflg septic S";slann -0 t Sn! -)ns.710 tent:; .Tae'.,VK-4?;1 lF-s e�-, spacli i CaE%',-,,iesigi I e'd V" u�i�iz-n Me i-a�a i i iec _50()7,� h.�C,C�j al ni,�Idx frnni international 01 bacteria matrix is introduced into tMlhin ilic"SOPLiG 02',lik. EfflUeni ieov--,s the septic tank along`%Iith the t:cj Consume 'a-posited organic compounds, res:oring sci; particle t L pore space and natura; drairinge White Knight Microbial Inoculator Generator"I US Patent Nufnber 7658851 Model Numbers and Typical Applications lh'i 'd 0 '-�'es;de,nJFi IC&S TREATMENT UNIT SPECIFICATIONS A WK-40 4 500 1 16"x 27.5" 1/2" 5 --- 1 WK-78 6 1000 2 16"x 27.5" 8 2 11 r WK-1xx varies 1000 varies 16 x 44" varies !va varies Is AIR SUPPLY SPECIFICATIONS WK-40 1.58 38 0.9 J 1101120 6.83"x 8.09"x 7.79" j13"Hx24"Lx16"W WK-78 3.2 92 2.1 1101120 8.94"x7.05-x8.59- 13-H x 24-L x 16-W WK-1xx Call for Specifications CONTROLLER SPECIFICATIONS a Normal/Silence only visual float Vsual 7andAudible Normal e drop+/Or t oat V oat 7, t varies Normal/Silence only wum W WK-40 110/120 8 Pressure drop+/or float al and Audible 8 W WK-78 110/120 8 Pressure drop+/or float al and Audible -8 Silence only +/or float Visual and Audible WK-40 xx 110/120 varies Pressure drop+/or float --------r7l 1-1— 11 2 3 4 4 r. 6 Knight Treatment Systems,Inc.•281 Co.Rt.51A,Oswego,New York, 13126 1-800-560-2454•www.knighttreatmentsystems.com•info@knighttreatmentsystems.com Headquartered in Oswego,NY,Knight Treatment Systems.Inc.is the national supplier of the White Knight Microbial Inoculator Generator'0•a patented emergent technology utilized for the enhanced biological treatment of wastewater and the recovery of organically clogged absorption systems.The White Knight MIG�is available through and serviced by a network of factory authorized X1-01) SITE PLAN NE,NE,S17T28N/Rl9W Troy township St. Croix county LEGEND 11311: 100.0' top of manhole cover X— pits w/backhoe • grade elevations contour No DSPS 383 set back problems Scale I"— 30' except where indicated Po s--Yi b le- t, "-h '0 10 Z-O 30' System Elev. 86.9' thru 87.8' 2cells 3ft. by 80ft. Lot 34 of Eagle Bluff fie" q V c 1-0 —4a o c 2-c-p- ------------------------- project: SCHULZ page 8 of 8 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner uyer � h Mailing Address L m 0.111 o� nc , d �, ) 1 5,4 01 G Property Address ors c��oc,y (Verification required from Planning&Zoning Department for new construction.) City/State �kAA Sr,y\ T Parcel Identification Number C L+p - I z- Q 4 6 - O()C-) LEGAL DESCRIPTION Property Location tJ L '/4, iJ E '/4, Sec. I ) , T 2-c� N R l W, Town of l n a Subdivision Plat. FE a c,\ e. 1 U y� Lot# 3� . Certified Survey Map# Volume ,Page# Warranty Deed# 2 4 (before 2007)Vblum��� ,Page# Spec house dyes no Lot lines identifiable�yesQno 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§SPS.383.52(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. 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 Safety And Professional Services 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 Q /J 6 1201 . SIGNATURE O PPLICANT(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.04112) St. Croix,County AEROBIC TREATMENT UNIT (ATU) IIIIIIII�IIIIII IIIIIIIIIIIIIII SERVICING AGREEMENT 8 2 3 8 0 4 8 Tx:4194821 fate Plan Transaction Number J. 997481 BETH PABST REGISTER OF DEEDS Name—(Owner)Typed or printed ST. CROIX CO., WI Being duly sworn,states,under oath,that. RRCEIVED FOR RECORD 1. He/she is the owner/part owner of the following parcel of land 06/20/2014 10:03 AM loct►ted in St.Croix County,Wisco in.recorded in Volume EXEMPT #: REC FEE: Page Document Number g/�t.Croix County Register of Deeds Office: PAGES:: 1 1 A parcel of land located in the ML *'/4 of the tJL '/4 Of SectiOR Mane and Repun Addruss ii 17 ,T 28 N—R �_W,Town of oY r-9, �� SA I2. TR o St.Croix County,Wisconsin,being W T l Dr1/>s 4 icci i duly describe as follows(include lot no.and subdivision/CSM or w' detailed legal description): O - ►Z—i o-00c) Parcel Werhtltcattorh Number(PM) AgreementDatr. ���W( As an inducement to the county to Issas a sahidary permit for a POWTS equipped with an Aerobic Treatment Unit on the above-described property, we agree to do the following. 1. Owner agrees to conform to at appkabte requkements of Comm 93,Wis.Adm.Code relating to Aerobic Treatment Units(ATU)and the mai merence taquiremerda for the proposed POWTS(Private Onsfte Wastewater Treatment System)technology: It are owner fails to have the POWTS and ATU properly serviced in response to orders issued by the governmental unit or the Department of commerce to prevent or abets a human health hazard as described In s.254.69.Stals the govemmr l colt(Town)may enter Wan the property and service the tank or cause to have the tank to be seivtoad and charge the owner by placing the chargers an the tact but as a special assessment for current services rendered. The charges will be assessed as pmesatbed by a.69.0703.stets. 2. The owner agrees to malroln a amfrad wgh a flainsed POWfS maintainer for the tfe of the System.The POWTS maintainer wig perform pe kKk hmpec6omt and malrftwce as required by the nu nhdea rar and the oupounera.including,but not Ilmted hoc the blower.electrical corhbads,and treatmerd unit operaton and sludge depth.These bwpscdons we to be scheduled every 6 moms for the that two years of operation and yearly thereener. 3. The owner agrees to contact#w POWTS rhheintelrher hrert iy upon any malfirnctiorh of the treatment urrl and to rrhaattaln the unit so as to not aerate a human health hn>zerd as described in s.254.59.Stets. 4. The owner recogrriass that the county,Department of Comnarce,or POWTS maintainer may make pertodic Ihspeatoes of the components to complete performance monitwtng of the uniL S. The owner or the owners agent agrees to report to the deparbneM or designated agent at 616 completion of each Inspection,maintenance or servicing ehrerd It a mariner sped6ed by the departmerd or designated attend witdn 10 business days from the date of Inspection, nhsfrdanance or sewift. 6 TMs agmacrat wig ranaht in elfed a*urt61 the county since rosponsbte for the regufaton of POWFS certifies that the aerobic treatment unit no forger serves no property. M addition,Ids agreement may be certWW by exeatng and ncordahg said oerlIllicatlon with reference to this agreement in such manner which will permft the eoddence of do caftallm to be deteradned by reference to me property. i 7. This agreement shag be Wading upon the owner.the hales of the owner,and aaslgneae of the owmr. The owner ah is Its Regleter cf Oeed9.and On avesmard'shah be mcordsd in a mwow tint wit permit tins erdstenos ci fire reference to the property when the Aerobic Treatment lints is Idled. .--NOTARY Owrher(s)Name(s)-Please Print and warn to before me an thhla C Mr<.1`^��hael Mhos Chr �Gf1.f Notar¢ed Ownees Signat n"O Notary Public 144.r",4 Und Otldal N to-Pleas�f lirtl /J Mt► ��.!�'✓ i �L' cw► r.�Pn'-�b' cro:�- t3eve Drafted by: P at in may be used for se purposes(Privacy Law a 15.04(1 XMN St. Croix County 997481 Page 1 of I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 14q I 0+m c h :J�oG ,� located at: N '/4, N E '/4, Section i , Town 2 8 N, Range it Town of i a o si , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service z I , z 1 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons N 1 minutes Tank Capacity: 1 Z 1.c) k Construction: Prefab Concrete Steel Other Manufacturer (if known): W r Age of Tank(if known): Permit number(if in ) j-1 �© E, � •-� yen H e. (L cen d P er Signature) (Print Name) (Title) (License Number MPIMPRS (Date) Form to be completed by licensed plumber(Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 tti Property Owner Parcel ID# Page of F-1 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. =ff#1 02 71 Boring# F1 Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. _fI#1 ' ff#2 Boring ❑ Boring# Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. :ff#1 ff#2 'Effluent#1 =BOD 5>30<220 mg/L and TSS>30<150 mg/L "Effluent#2=BOD 5<30 mg/L and TSS<30 mg/L The Dept.of Safety and Professional Services'is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay. SBD-N33n(R l 11) , Wis.Dept.of Safety and Professional Services SOIL EVALUATION REPORT Page of-2 Division of Safety and Buildings I accordance with SPS 385,Wis. Adm. Code County , � � Attach compi I han 8 112 x 11 inches in size.Plan must include,but n ntal reference point(BM),direction and Parcel I.D. percent slope, a or dimensions,north arrow,and location and distance to nearest road. 0 4n-- Please print all information. Reviewed b Date Loca Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner Property tion c � t ' M hr Govt.Lot NL 114 NE1/4 S T Z N R Pr(or Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# �a 3� --- �-C \ a;uS City State Zip Code Phone Number C_bt L ❑City ❑Village Town Nearest Road bye t ( (p 12 ) 730 4/3x3 �re OmhoL RA ❑ New Construction use: Residential/Number of bedrooms �"�- Code derived design flow rate e0lo ) GPD Replacement ❑ Public or commercial-Describe: Parent material_* o4h.)-� Flood Plain elenvation if plicable �� fL General comments I�ee�,.�mw.d c� me b e�rta+ny e and r ommendations; 3 b , Boring# Fj Boring 7-1 Pit Ground surface elev._�ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft ' in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 * ff#2 t. • 0 l 0 31 L r Qs d I ►o--I&q 3/3 s4 a"4. iDIR ' 6 c S N R* �S 0 0 • s9- $B 7 S RY 4 Fc')] Boring# Boring Q 8 Pit Ground surface elev. V ' ft. Depth to limiting factor O�_in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 01 ff#2 1° 0-(0 1 C) -3a I�ri R r S i-lrv. 1 '4A, crr -5' -A R 4/4 cv- \vC <I _ I. *Effluent#1=BOD r,>30:s 220 mg/L and TSS>30 5 150 mg/L *Effluent#2=BOD <30 mg/L and TSS<30 mg/L CST Name(Please Print) Sign re CST Number L-^1 A. a b• !22-Y-5 Address Date Evaluation Conducted Telephone Number Meno c ie 1n)I. y u 24 J0/ '115/161.4-8119 4 SBD-8330(Rl I/I 1) i Soil and Site Evaluation Report page 2 of 2 NE'/4,NE'/4,S 17T28N/R19W 6 AA Troy township " St. Croix county �T J J Loretta Larrabee CSTM 224580 U acd LEGEND l{o Lk C. K—back hoe pits O-grade elevation No SPS 383 set back problems B.M. Scale 1"— 30' except where indicated Eagle Bluff Lot 34. - 1 b ...._. �, I ark o ��°� ®92•I ( '� W ©G Ae- Ll 1411 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO.. WI STATE BAR OF WISCONSIN FORM 2-2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 07/03/2006 03:30PH WARRANTY DEED THIS DEED, made between Colin A. Sultan and Mir am A. Sultan, EXE1141T # husband and wife,Grantor,and Michael A. Schulz and Christine D.Schulz, husband and wife,as Survivorship Marital Property,Grantee. REC FEE: 11.00 Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 1935.00 the following described real estate in St.Croix County,State of Wisconsin: CC FEE: PAGES: 1 Lot 34, Plat of Eagle Bluff in the Town of Troy, St. Croix County, Wisconsin. Metro Legal Services EDIRET 5111224 A 589727 1VD 417003 Recording Area Name and Retum Ad TURN TO: Edina Realty T' , nc.METRO LEGAL SERVICES INC. 400 S.2"d .—Suite 1130 SOl1 T k 2(il:+{!'`Pi'{F 50 Exceptions to warranties: Hud ,WI 54016 �gJlvS EppOLfS,MN 55101 ��1'I Easements,restrictions and rights-of-way of record,if any. 224 040-1279-40-000 Parcel identification Number(PIN) This is homestead property. i Dated this 16th day of June,2006. olin A.Sultan * am A.S 1 * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST.CROIX COUNTY. )ss. authenticated this 16th day of June,2006 Personally came before me this June 16, 2006 the above * named Colin A. Sultan and Mir am A. Sultan, husband and wife to me brown to : the TITLE:MEMBER STATE BAR OF WISCONSIN foregoing instnune tan a.! �S e (If not, NOTARY BUC authorized by§ 706.06,Wis. Stats.) ISCONSIN Tr THIS INSTRUMENT WAS DRAFTED BY *Pamela J Goulet Notary Public,State of Wisconsin Peterson,Fran&Bergman—Steven Bruns My commission is permanent. (If not,state expiration date: 50 East Fifth Street,St.Paul,MN 55100 1 10/11/2009 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity must be typed or printed below their signature 1of1 WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420577 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: Renton Homes I Troy Township 040 - 1279 -40 -000 CST BM Elev: 1 Insp. BM Elev: I BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be chmark OOQ Dosing Alt q'��• 98 Aeration Bldg. Sewer 2-42. WS Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION 3.9(, 3• �1 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' ZS f r 5 f _ Dt Bottom Dosing Header /Man. Aeration Dist. Pipe 3 S Holding Bot. System L 12 - 14o 4 J3S• 12 .90 Final Grade PUMP /SIPHON INFORMATION w ! Wrw,, g to q 37. W Manufacturer D St Cover q GPM Q. 0 l a. S Model Numbe T Lift I ' n Loss System Head TDH Z Ft Forc In Length Dia. to well SOIL ABSORPTION SYSTEM @fiWR NCH Width Length o. Of Tr ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME ONS 3 f •S� 1 SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufa r r. INFORMATION Type Of System: CHAMBER OR y _ UNIT r v • 1S (+ Q 5 1 0 1 Model Number: ( 11 DISTRIBUTION SYSTEM -V 4 6x0- Q• L Header /Manifold tt Fistribution Size x Hole Spacing Vent to Air Intake Lengt ipe �� Dia ength Dia Spacing 10 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 A � Yes [W No F Yes ❑ No COMMENTS: (Include code discrepancies persons present, etc.) Inspection #1:11A ZZ 1240 1 inspection #2: Location: 491 Omaha , Road Hudson, WI 54016 (NE 1/4 NE 1/417 T28N R1 9W) EAGLE BLUFF Lot 34 Parcel No: 17.28.19.1566 1.) Alt BM Description = 4 &v , 1 s' 2.) Bldg sewer length = (S i - amount of cover = i t- c. cs> +. -log ,¢� 4-c,w .`t- ►�.Ir. �et� . w• . `4� Dbs+uv. -�- PI n revision Required? Yes No a Z Use other side for additional information. SBD -6710 (R.a/97) Date Insepctor's Signature Cert. No. l I c t s� S as -- ) S � � Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 N VIsconsin Madison, WI 53707 - 7162 Site Address Department of Commerce )I- LL.-QZ Sanitary Permit 'A' p --- plicatio Sarti Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal informati you gravid$ e qZ D 5 q-fi ma be used for secondary purposes Privac Law, s15. m ❑ C eck if Revision I. Application Information - Please Print All Information , 2 0 State Vlan I.D. Numbe Property Owner's Name ( ' 0 1 1 f Parcel umber S� t,s l) Property Owner's Mailifig Mail' Address Property Location G - 7 0t lA) P& AL- '1(/ Alt S T Z N. R City, State Zip Code Phone Number Lot Number Block Number 5 � � � Subdivision Name CSM Number H. Type of Building (check all that apply) a g •wi ❑City %I or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ownship ❑ State Owned Nearest Road ( 2) - 3 t K al-s 41uJA III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. For County use. 1 3KNew 2 ❑Replacement System 3 ❑ Replacement of 6 ❑ Addition to Sys m Tank Only Existing System B • ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply) (numbering scheme is for internal use)-? - Fr-tc"V Er 44 )(Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 Cl Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispersal/Treatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate Istem Elevation Final Grade Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) ,gyp 2 S r� _ ? 3.�,'i�Z Elevation m q 39, l�r (J U ,/� t�1 F ri �-a� 4 j� 93 6-,,o J' 39' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing A- /" Tanks Tanks Septic or Holding Tank Za Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume ponsibility for installation of the POWTS shown on the attached plans. PI T's Name (Print) I PI 's Signature MP/1 Pff Number Business Phone Number Plumber's Address (Street, City, State, Zip C e) VIII. Co un /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse. Determination EK. Conditions of Approval/Reasons for D' royal n A � —= U U At= complete to a onnty a Aft not Was tan 81a M Inchts to size SBD -6398 (R. 05(01) ke , e�moel /, o 4- l SoyLE j "% �/vr !�9 a s +. x ZA B LA/ g �� 1 ^ .- Imo- C�3 9-- 9 b'> cl 3 5 . �Fz- r 1 �� u- ( 9 So of o o' T;vAZ =Tip r Iv c `,�yo tix ® LL b 7A ljjfk B �V ct35-'° Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _� of A- Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County :5T, CAqo�x Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). QJ.1a w 1 1(27. /OZ Property Owner Property Location CRA PIR ; s, COO Ne 1/4 NE 1/4 s ('7 T ZS( N R I t Property Owner's Mailing Address Lot # I Block # I Subd. Name or CSM# 117 Q6 A a✓ r 4 sr N Su.1114E 100 34 — lr--raGt4-- J�y City State Zip Code Phone Number ❑ City ❑ Village (X,Town Nearest Road (.A IAJ F- I AA 1,55 4 10,63) 757- 96 C, 9 TK01 I TO W AM V AUL>EY RAr New Construction Use Residential / Number of bedrooms tom- _ Code derived design flow rate �� q �-�- GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material 5AMLgM 1 f 1 E _ Flood Plain elevation it applicable General comments Z T121✓NCi I R S and recommendations: 5y5TeM ELr'Vft 7 1 Ci3q� 4 z r �►` t �� 7 ST �GUNTy F-A] Boring # a pit rig — _ j�ZONING OFFICE (� J � Ground surface elev. ft. Depth to limiting factor in. f`� Soil o ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary G in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 "Eff#2 I o-Z 1oy _ 5i1 cc5 � 3v� o.s o, 2 2 -q 10 Y 3�3 _ 2 GR C kl 3 v�- O, S p. 3 .4 -Zy 10 41061 — 511 I rn 512 K rn J aw 2,f f-m o Z 0,3 z4 -37 woe 5 16 1 I m 51b K V� 0. 1,7- 37 - 7:5vR 51 (r, 5h t rn J 2 4 Q , q o b „ q/ s 0 m I ab Zvf m 0, 1, z 5i- IL 7.sYa 5]q v r \ \); i -m 0.-7 1.2 k BoriM ng Boring -�� El Pit Ground surface elev. 9. 4z ft. Depth to limiting factor ? �d�_ in. Soil Application Rate Horizon De th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft: iri Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 g � 7-5 Y -- 5 C) S Q W �-m 0 -'l 1.2 1011R 5 A . — S 4 s — b. - 7 1.2. [ Q UIEt_ Lfp Effluent #1'= BOD > 30 220 mg/L and TSS >30 < 150 mg /L " Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si ature CST Number LAM 10 Rou-\-!NTER ZZ48 5 Z Address Date Evaluation Conducted Telephone Number Lkn975 LR N dJE K%UER FADS 5ti-o2z LDT 3LI Property Owner CO W. C Ha►� 5 Parcel ID # Page Z of Boring # E] Boring A pit Ground surface elev. — ft. Depth to limiting factor `� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-4 z i s _,,� ds s �f o.5 a.® 2 0-12 3 2 ( (,-&,5b d5 � O.Ll O.6 3 12-- tO V 5 ►) ZF'atb Ih1r CS Zd m 0 5 0.8 1 - 1 -24, y 3 St ( 3-FaLW 0-5 24 rh 0.5 0.$ 5 Zb -4p 3 M TY Z 'j f - 0, 112- 40 -4 q 100 -- 31 I ms rf\NJ Iv - o,ti 0.6 7 YS -$J 7.5`1 5 ms b MJff Boring Boring Fo-1 &QMj-. tR pit Ground surface elev. G3(o. SO ft. Depth to limiting factor 7 � i Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 8 57 -(o5 7,5 1 m 0,-7 I. Z q 105. k5 .5 Y -3 S -- 0. I, z Fc-1 Boring Boring # Ground surface elev. 364 Z- ft. Depth to limiting factor 1 �$ in. ® pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 f 0 V IZ `� 1 ( I f-r✓t s 3� F O A 0 2- - "0 3 5t1 I'V C' d sh S l -m 01 Z- 0.3 3 10 -zo io 3 Si ` Z bK C-5 0.9 4 -30 10 %W --2 S � Z -m S C 5 24� -m 6 N GS ZJS- 0r) I.Z 4Z -5 7. 3 15' r dl 1 �_ 0. 1.Z 52-161 7f5 V4 Is 4 r g 7Z -104 (OVZ 5 0 . - t I. Z ' 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 (RAW) Lit' 3Y4 S Property Owner COOK GNkie-Les Parcel ID# Page 3 of _ 1 -6 1 N Boring # - F] Boring pit Ground surface elev. _ 4, L ft. Depth to limiting factor 7 00 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary . Roots . GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 - Eff#2 m ds es 3 vf o.s o. 4-11 3g — st1 vF h ;�, o,S o. - 1 1-24 d sl CS b,z o.3 H 2 0 -3 iov.2 — 1 s I ds c� I,z S '3 7.5 Y 3 �4 s l m Bbl s 0 0 1.2 S3 ID — S — 0 i, Z soar acv L t zt)n! qs s F -1 Boring # El El � El Pit Ground surface elev. ft. factor in. Soil Application 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 •Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 30 mg/L and TSS q < 30 mg/L I 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 -6330 (R.6/00) ,s wz I E pOprp1Y Offim ` coo K f �1 v .E5 L - CArNV: 11 QT-I-j LE Q�uP! �tiw�rte �Of�D 13M� - 0 0 AIL 11,1 LATt1E T LWATEp IAI I E o f a 9FAca . (m#Z- o 1% EC TzgN, R I W WA) 0 TROY P E Ml TIeMM 1'7"4 6 ou v i s vc "'Ty W 0- 501L 13Of;IN6 W/ I3ACKNM su.,tF+cE NO COMM 65 %VCK KOUM5 B 4 , Q VI � y3b.4z n a � E• fAJ� b - Rn. T o OF 516W C5r • ZZ4 PATE; I zs-ao rare J4 OFX COWTOUX, LoNes F-OK L I)J eA&LE tLu.FF SLAZID. - - - - - - - - - - - - - - - 33 \ _ - j,3 C 8-3 ------ - 6-33D - . ...... ... c + V ` 0 O c c_ 'o Y O IK t Lk LU r Q u r Q �12J3A I ~ U x h o 6 Ln Y. O i� C%4 c Z Z .� a L7 � + a 'Q p -c V z y o a /�A h W c \� c s 8 � 1 � 0 X 0 N N LL 1,"©- 4 � � 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 Number of Bedrooms Desi n Flow - Peak (gpd) Estimated Flow - Average (gpd) Septic Tank Capacity (gal) 2 a Soil Absorption Component Size (ft) 9 4 r Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 2 g=b .$ 43 ,, , Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 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 utlet filte s hall be cleaned as necessary to ensure roper operatio 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 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 u e s d 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. p ced. 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 p erson from the interior p of the tank may be difficult or impossible. Y p 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 � p Table 2. The longevity of a soil absorption compon 9 Y p p ent depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices b all occupants and the installation of Y p o 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 ondin , if any, P 9 y, 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 inter months. The 9 compaction or removal of snow cover over the component may lead p Y 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 s 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. PL�e , i �CC5- o iJ --� ►J k S� co Aj c 2 + 715 b 7 2 3 c�or� COZo�r�'C� .715-r39b+c,'�6�o l� �✓r�� 7th z73 6 74K7 3 - i - ST C ROIK COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer &,n , C Mailing Address 7Q T Property Address 3v (Verification required from Planning Department for new construction) city/state 7` h2A2 19P Ze - 0 4 Parcel Identification Number ' IF -[`AL DESCRIPTION Pmperty Location (N� %s, AJE %, Sec. _�, T� �1 -R W, Town of e QZ Subdivision v Lot Certified Survey Map # -- Volume _, ,Page # Warraaty Deed # z . Volume Z ° . Page # S� 3 Spec house A yes a no Lot lines identifiable 0 yes O no WT EM MAINTEhIAMM use and maintemnceof our tic tem could result in its premature failure to handle wastes. Proper maintopan ce .Improper Y �P � put into du system eoosiits of pumping out the septic tank Query three years or sooner, if needed by a licensed pumper. What can affect the function of the septic tank as a treatment stage in the waste disposal system. The owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a ProPertY tewater system ve ' that 1 the ou -sitc was dispose yst mastorplumber, journeynsa�nPlusaber, restr'iat�edplumber or a li pumper nfying ( ) after inspection and if nomssary), the septic tank is less than 1/3 full of sludge is is proper operating condition and/or (2 ) pumping ( Uwe, the undersigned have read the above requirements tad agree to m=tam the private sewage disposal system with the standards set forth, herein, ss set by the Department of Commerce tad the Department of Natural Resources, State of Wisconsin. Cerdficadon stating that your septic system has been maintained must be completed and returned to the SL Croix County Zoning Office within 30 days of three year expiration date. II / lllOa GNATURk 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($) of the pro 'bed above. by virtue of a warranty deed recorded in Register of Deeds Office. 11 /�, IQNATURE OF APPLICANT DATE « «««.« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.' « «, « � application: a st ampe d warrant deed from the Re gister of Deeds office Include with this applica Lampe ty a copy of the certified survey map if reference is made in the warranty deed U 2 0 5 5 P 5 6 3 699402 STATE BAR OF WISCONSIN FORM 1 - 1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI Document Number RECEIVED FOR RECORD 11121/20®2 11:88A![ This Deed, made between _Troy Development Corporation, a ?4innesota C ort�oration EXEMPT # Grantor. REC FEE: 11.08 -TRANS FEE: 269.70 and RENTON, INC., A WISCONSIN �'.ORpnRATTnN- COPY FEE: _._ CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following de at estate In St. Croix County, State of Wisconsin lir:�.rdmq Awa ert Name and peturn Addreae Lot 34 of the Plat of Eagle Bluff in the Town o f Renton Homes, Inc St. Croix County, Wisconsin. PO Box 932 Subject to Declarations of Covenants, Conditions and Hudson, WI 54016 Restrictions for Eagle Bluff, recorded in Vol. 1589_ page_ 516 , as Doc. No. 6 as appearing in the office of the Register of Heeds for St. Croix County, Wisconsin, and such other easements, ✓ 040- 1279-40 -000 restrictions and reservations of record, or in use, Parcel Identikation Number (PIN) and the "Buyer" obligations contained in the is not Purchase Agreement for this lot. This homestead property. (is) (Is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 19th day of November 2002 41illi0Z FRI 09:55 NAL 715 786 1687 REGISTER OF DBFDS Cp�oo2 STATE BAR OF WISCONSIN FORM I - 1998 9MLM A. yam WARRANTY DUD ��'. >< or Dow oa.aeaeaMw+. awgivo FOR Rum Thb Dead. Bedeeaeean � /20ft laae"N D�e14Deent a on, . nneevta �or�oratlan _ Ezm # f rrntar 'TUNS 11.90 and - JLV;cw.. IWC.. A WISCONSIN COEZaReXLM 'TUN gFEPnQ 2!9.70 COPY p CM 1 7 COPY pm.. Cneeka. Crmm*. for a mAeab)e cmw1d.rµloft awwas to Ganbe nr a uarinj daawlteN rod ow" In 'S.LOi7L eminee Sane et Wt®ewn lot 3 4 of tra plot o Man Ent hawm soave >� Hinff i the ztnrn of Renton NolllRS, Inc w , St. Craii Country, Mismimin. agWen to D_ smm Ums of Caueams. Canditicew and PO Box 932 Romiciaef leer Fagle Bluff, reacrasd in Hudson, WI 54016 . as Doe. M. §3M _, as appwrIM is W=n of o 'o! an Aeointar at naeas for f. Croix County, vfiscaoeina and mm% oeleez its' 040 - 1279 - 40-000 reulrimions told reams wtiaele of re�dr or. in use. MM tae MPJPW oltiigwms Cwtai"d it tba fern FM pwraft sa Agre"wat for eDis ]et. Thm is not noffAw .a W°Pany- (a1 A+ nofl Ta$Ww wah all a#pmereant rW&6 Oda wd 1Maaeta r.mor waernda tmj the Wk to Dee Pmpnv is rod. lnddVmdAr M fm eBop6 o.d Dee and elan of bmemdn oma "I Dded that 19tlI �� NotemDer 2002 CRAU Trar . ChaFies s. f:oole, Ptveidemt Dmuqftmb auvwatlon DBaW OBA{d • AUTHENTICATION AeM OWLBDGM ENT �,,,.y) Alfnnesosa Sea of 1lA"ena4sr. . �-- . • w g r rp fp salt ow dw day of A pe�aw� 1 k R liar flp Ihjs 19 e1 QN if 9� dm aho.e naeaad Clrerlas s. Cook. Praesid e 42yl� eson®nt Go -rani •oat Tn7.M MFMM S SM CAR OF W)SCONSlM m prna, — — - -- env kennn b be dw puaan who .sKvud a* re ■edo&w audeoetad aw $1oam. WI& 3w") 111mmrd and aet+ewkd same. r TM elellR MVIT was 01N110 V TM neVxio�n ea eeraei�an Rion Soh o n Non? Puwr. Sear —A I - Aff so C*Mt . Him. Charleee S. 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