HomeMy WebLinkAbout040-1291-80-000 Wisconsiry Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
'Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
514817 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:
Jerome, Darcy Troy, Town of 040- 1291 -80 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No.
QS• �p M C 24.28.20.1665
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 3 0 01 Benchmark
wee,6 q C
5 lot-A, /Z(.00 5'�F �/ dn s S
Alt. BM 3. T? 3.T%
Aeration Bldg. Sewer S, 39 q7 1 . 11
Holding St/Ht Inlet
7, IZ �$ . S(P
TANK SETBACK INFORMATION St/Ht Outlet 7. 4
TANK TO P/L WE BLDG. Vent to Air Intake ROAD Dt Inlet
fir! j4rlp�!
Septic 7 Z7 / 7 ) -6 — Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System , I S9 Ck
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM Vil - C✓ J ' T? 3 .a O
Model N tuber
TDH Lift Friction Loss S m Head ITD Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS D Z I r,,liQ
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: l� I mo`
INFORMATION CHAMBER OR '
Type Of System: '77 AJ4 UNIT
t1 � Model Number: QUA `� 4 w
o��e
DISTRIBUTION SYSTEM Ste- NZ, •.!S Z Z +- Z Z fe./ VLeq- -Q_
Header /Manifold, �� Distribution ` x Hole Size x Hole Spacing Vent to Air
Pipes) \ �. �i
Length S Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over �// Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed /Trench Center Lip 3 Bed /Trench Edges \ Topsoil \ - No kYes No
_ // L_.
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:/ / Inspection #2: / /
Location: 317 Lindsay Rd Hudson, WI 54016 (SE 1/4 SE 1/4 24 T28N R20W) Troy Village 5th Addition Lot 137 Parcel No: 24.28.20.1665
L.�,1 e.� C O J �c. L` Cep e�
1.) Alt BM Description = J 4$, Z
2.) Bldg sewer length = P #11
- amount of cover = a�
Plan revision Required? "Yes _ No 1 `—I f> ir _ �l /_{�� 7.e Use other side for additional information. /
SBD -6710 (R.3/97) Date s 4Sjgture Cert. No.
commerce.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 _ ti ✓
4t ht s Madison, WI 07 — 2 Sanitary Permit Numbber (to be filled in by Co.)
nt of Commerce ✓ 14 p 1 7
Sanitary Permit Applicatio - - _ -- State Transactiop Pumber
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental / r F
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
p urposes in accordance with the Privacy Law, s. 15.04 1 m , Stats.
I. Application Information — Please P ' Information D
Property Owner's Name / REC Parcel #
Zak
Property Owner's Mailing Address P Location
._._ roperty � 1&&5
Govt. Lot
City, State Zip Code p �t ,�� y., Section
ZONING OFFICE (circle one).
T R Eor
II. - Type of Building (check all that apply) Lot #
1 or 2 Family Dwelling Number of Bedrooms Subdivision Name
1 4 V%
❑ Public /Commercial — Describe Use
' ❑ City of
❑ State Owned — Describe Use CSM Number ❑ Village of
N 16T �✓ ZZ 7�?/c. t�q / � Town of � y
III. Type of Permit: (Check only one box online A. Complete line Bit applicable)
A. New System ❑ Replacement System g Replacement y g Y (explain)
❑ Treatment/Holding Tank R lacement Onl El Modification to Existin System ex lain )
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS S stem /Com onent/Device: Chee Z 7 `
Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other ispersal Component (explain) ' ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Vol
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (s f) Dispersal Area Proposed f f) System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units .2
New Tanks Existing Tanks c d i M CC3
Septic or Holding Tank / ^
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume respo sibility for installation of the POWTS shown on the attached plans.
Plumb is amc (P - t) Plumber's igniAwre MP/MPRS Number Business Phone Number
Plum er's A (fdress .Strcet, City, Stat , Zip Code)
��VII��I. County /De artment Use Onl
.�sAppro�cd d Permit FFee Date Is ed Issuing gent Signatu
cr Given R for Denial S #✓ Oa 1 "01/Q
Z 07
IX. Conditiff$ � /�easons fo sapproval
1. Septic tank, effluent filter pnd
dispersal cell must all be services /
as per management plan provided by plumber.
2. All setback requirements must be maintained
Attach to complete plans for the system and submit to the County only on paper not less than 81/2x 11 inches in size
SBD -6398 (R. 01/07) Valid thru 01/09
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Wisoonsin Dapartmsnt of c«nmerre SOIL EVALUATION REPORT Pege _-L or-�
owion of Safety and Buildings
In accordance with Comm 95, Wis. Adm. Code
C" Attach compete site plan on paper not lets than B 1f2 x 11 Inches In size. Plan must
ST, cRo+
Include, but not Nmlted to: vertical and horizontal reference point (BM), direction and Pascal 1. D.
percent slope, scats or dimensions, north arrow, and location and distance to nearest road. d L40 I Lq /- q - NO
Please print all information. e e oats
Personal Information you provide may be used for secondary purposes (Prlvaey Lew, a. 1 &04 (r) (m)). Jl
property owner Property location
CO���rINtiN'� l `�£�t D���T ���' ,� 1f4-� 114 Sz14 T 2:9 N R �G W
Property Owners Mailing Address lot 0 Block 0 Sutxf. Noma or CSMM
C) f3 A�� 5,. >�. Sv l"1t ion 13'7 — (Z vl�cAcc- FIF1N PD
C2ty State a Number City ❑ Village MTown Ne cad
p 4\imiL w4 j bS 1 #4'9l(74,5) 75 - 7- -)562 `TRO I LIMM
Now Construction User Residential / Number of bedrooms derive design flow rate � 0� �._� .._ GPD
Replacement
El or commercial - De - - -
Parent matwtsl �t flood Plain eleva if applicable
General comments
and recommendations: COA1vE.rs1j6MAL - rt2En1GH 5 OCA
1 4 2002
S1 G� NG pFFVGE
n Boring # ❑ Boring
❑ pit Ground surface slew. _$ . r:� ft. Depth to limiting factor 74� In. SpU A Rate
izon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD/f?
Hor
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •ER#1 'Etflr2
sb d4 c.
Z (, -1'L Ip�K (I C d CA0
.3 iz -IQ SGT rn Mj; Q.5 lv� 0.(0 O•IJ
MS (�S m� 1,Z
5 zi -40 tow �3��0 a ,11 a m CL O,O o •D
q0 L-
�Fz~ SIDr3�5 " ► tzor b HA
13d ) Bo" ❑ sotto
Pit Ground surlece elev. g4Z' S it. Depth to HmlUng factor __ In. Soil Applicallion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Miff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Effg1 *E17#2
1 D - to YI 1 I, Z t✓o-bl \I�r 0 , m 0,75 04
Z _GJ 4K.' -`- L _ l 0- rr) r C 5 Ok 6
3 -17 Ia YK` �' G L
$ ZZ -Z �SVR�� I
C s d I
:I V3 0 Effluent 01 ■ BOD > 30 S 220 ,,, A- and 50 mgft ' Effluent #2 = BOD _< 30 mgA. and TSS <_ 30 mglL
CST Name (Please Print) ature CST Number
S Zz4$-V—
Address
Date Evaluation Conducted Telephone Number
W98TS togO AdE, Rt�E T- uS WI ,54022 09-oz-oz� �1S Nzb 75
- »
,
(UT
Property Owner SON I tN l_ Parcel ID # ()L40- I Z4 — $ Q - 0� D Pape Z or
(�� ❑ Boring - q �{
U Ong # Pit Ground surface Slay. _ 4 � Q ft. Depth to limiting factor - In. licadon Rate
Horizon Depth Dom Co
Dominant Color Redox Description Texture Structure nsist Roots GPDI ence Boundary •ER#t •Eff #2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
1 D -S f a 12 z
2 - 5 -1 S y k .
3 15 NW, S US rr vJ - 0 .
y
i
a Boring # ❑ Boring
Ground surface elev. _ h. Depth to IlmiUng factor in. Sop 1 D/1'r Rate
C) Pit
Roots GPDIfC
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary •Eff#1 •Eff #2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
a O # ❑ Boeing Ground surface elev. —._— h• Depth to Iimillng factor In. Appl ication Rate
❑
pit
Roofs GPD/ff
Horizon Depth Dorrtinant Col Redox Description Texture Structure Consistence Boundary ,E1 •Eff#2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Effluent #1 = BOO > 30 220 mg/L and TSS >30 1150 mglL ' Effluent #2 = BOD 130 mgA and TSS _< 30 rrVL
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 depaAmet t at 608 266.3151 or'ITY 608 - 264 - 8777.
320.1330IR -WW)
" PL PLAN
IttY 0w1�R: I n1 A L �J PILO -
13 / i
NO Comm 85 SEiii a PRO eM5
T�SGvwzR lhlTn ��i4� d
' 135A /,
Ste / aa 13E0
i
,(37/130
1.7 138
0 13 A 1370 137
,g / / 925
P //(37 ,
egos,
V MA
d9iA
35/13e 136
e 9.
* Sec.
SIGNED Of
2zyggz
x
vu,u�ie�•► a.J/ DATE: 01- 0 7 02
-
Labor, Hu
nd Human a � One man Relationlations In dustry ,
labor SOIL AND SITE EVALUATION REPORT Page I of 3
a
Division 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 i�'6ae.: Plarrmust include, but
sT • ��z-o �k
not limited to vertical and horizontal reference point (BM), directiontand % of slope, scale or PARCEL I.D. # i-jp L,V G
dimensioned, north arrow, and location and distance to nearest road:
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION y ]� EVIEWED BY _ DATE
PROPERTY OWNER: PROPER'LCATTON `
0-b '-3 - R N TJc�L h1 T C�1Z -(� , S FZ 1 /4; e E 1 /4,SZ4 T ZF6 Z 0 E( W
PROPERTY OWNER':S MAILING ADDRESS • T # BLOCIf # ` .BUBD. NAME OR CSM #
L b. ! TRO `•t V 11.1.ftGE �L PtD
CITY, STATE ZIP CODE PHONE NUMBER CITY ❑VILLAGE (MOWN ' NEAREST ROAD
TQ-O`l ��tiOS'Pr�l l�•UPn7
[XI New Construction Use [ aq Residential / Number of bedrooms u [ J _ AdditiQn to existi building
(] Replacement [ ] Public or commercial describe
Code derived daily flow boO gpd Recommended design loading rate - bed, p2
9 9 gpd/ft 8 trench, gpd/ft
Absorption area required I M bed, ft - 1-SO trench, ft Maximum design loading rate •-) bed, gpd /ft - 8 -t ench, gpd/ft
Recommended infiltration surface elevation(s) EL 3e q . 0 'OBON ft (as referred to site plan benchmark)
Additional design/ site considerations S NOit I ti sTmuLsR O ry vsl' G e 3
Parent material L_o ez�S CUM - Gt tu ft-. Ov*Tw" >) Flood plain elevation, if applicable W R ft
I S = Suitable for system F CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN RLL I HOLDING TANK
U = Unsuitable fors stem I 9S ❑ U (3S ❑ U ®•S ❑ U I ®S ❑ U ®S ❑ U ❑ S [Ru
SOIL DESCRIPTION REPORT
Born # Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Bouxlary Roots Bed Twit in. Munsell Qu. Sz. Cont Sh
Color Gr. Sz. .
lwAbt cis ct,S
Z Q -ly
'-/ 31y 1
0 59 CS
Ground 3 )\4 -S `12 3L y S E. Gti, 1 .
elev.
8 86.9 ft -t(2 • 10 '1 PL Mlle '�S O S9 Yh ] CS • S . b
r �t g to S 41_10 1
S `12 3! Sa 61- d S9 In 1 — •� •8
factor
Remarks:
trn
_ b t u�lrZ 3 ! z s'► I lwt 51�� aCS o - S
- —
�-
6-1W3 �.-SLIP- 31Y S�t o Sg ti,•t 1 -� € ,�
Ground
elev.
It
Depth to
limiting
factor
Remarks:
CST Name:— Please Print Phone:
Arthur L. We erer 715- 425 -0165
egerer Soil Testing & Design Service -P.O. Box 74 River.Falls,WI.54022 '
Signature q' j_ Z g 7- \"L6 Date: 1 I 2.9 - 4 9 CST Number. .
220254
PROPERTY OWNER SOIL DESCRIPTION REPORT Page '?-
PARCEL I.D. # Jy G
Borin # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft
Z� in. Munsell Qu. Sz. Cont. Color Consistence Bour>dary Roots
Gr. Sz. Sh. Bed Trerxh
lZ s 1 mSbl'c
Z ►Z 31 1 u ti tz 316 G�• s\cl ZI'n S bh MT i L. tip ,S
Ground 3 31 - U I R 516 S bk
elev.
t3 y U3 -SZ 1 U `l R S f �•s� R Sly s 11 l sb4t
Depth to S S7- -119 -) •S `9 R 3 /y 1 S 6h O S 9 i
limiting
factor
l lot 4 �
I
Remarks:
Boring #
�?.Z l > , ) 0 -15 l 0`1.2 3 LZ 1,
�'•:$.:;:��� Z \s - - ►•S�� qt . _ 1 s v sg >�) dw - •� •�
Ground 3 2- -11, - 1•SLA1 3 /y - S g G►.
elev.
& 89.1 ft.
Depth to --
limiting
factor
Remarks:
Bo rriin�g #
3 l Z
17- oQ S h c — • S 3.6
Ground 3 yp -t2o �•s LifZ 31. - $ sc G►. S� _ ,.� .C&
elev.
� 9 4 • ft.
Depth to
limiting
factor
Remarks:
3oring #
fit; <;� >' •
;round
;lev.
ft.
)epth to
imiting
actor
Remarks: _
PROPERTY OWNER C-OKM .)Q- 13'td. 'Z)'l► . SOIL DESCRIPTION REPORT • 2 3
Page _ of -,
PARCEL I.D. # pb) tv G
Borin � # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft
_..� �- in. Munsell Qu. Sz. Cont. Color Consistence Boundary Roots
Gr. Sz. Sh. Bed Trench
0_ V
s t 1 l wr Sb 1-c yv► `� es . Z . 3
Z tZ 31 l u �t h- 31(o Gr s�cl Z Lin s bit`s i e� _ •`� .s
Ground 3 31 -�13 l u �! sil — s i 1m s hk Y✓t�'r es _ . z 3
elev.
t3 �( �l3 - 1 0`1R S1�, ��•SyR Slt S11 l`Nts�
Depth to S Si -119 `1 •S `72 Sly S Cih d S
limiting 9 y� �' - ; • g
factor
� 1
Remarks:
Boring #
a- S Z 3
.�:,... ,., sit 1 w►. b�
Ll P-
?i4v:2 <ti SSiij:
Ground 3 Z -tty �. S `tt2 3/y - S G� rJg ►+n 1
elev.
Depth to --
limiting t
factor
? Ilq '' 1
Remarks:
Borin # ,
W-A40 lovtt 3!6 — St I Zr►t sb>z posh c g — •s 1.6
3 yo -I 2,p -S
Ground Lift Sly
Vvl •"1 .$
elev.
P 14 . t
i
Depth to
limiting
fac tor 2
4
Remarks:
3oring #
around
Aev.
ft.
)epth to
imiling
actor
Remarks: _
PLOT PLAN Page 3 of 3
SCALE 1 "= Sp '
a'
ft-mL.
9g
0
c
� 5
cy� 1 -W PIPE
�'NVS� `IO - t3 - "PtST ZS `Fzom► : Tvz �m '2m.
3�
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11- Z.9 -4 210
(7 15 ) 425 -ni n5
CST Signature Date Signed Telephone No. CST -Amm
D � Mumma
fi#G79936 TROY VILLAGE FIFTH ADDITION
LOCATED IN THE SW 1/4 OF THE SE 1/4, THE NE 1/4 OF THE SE 1/4, AND THE SE 1/4 OF THE
SE 1/4 OF SECTION 24, T28N, R20W, AND THE NW 1/4 OF THE SW 1/4 AND THE SW 1/4 OF LOCATION MAP ��
THE SW 1/4 OF SECTION 19, T28N, R19W, TOWN OF TROY, ST, CROIR COUNTY, WISCONSIN, sm Sit rA"wl� ANM N'
BEING PART OF OUTLOT 9 OF THE PLAT OF TROY VILLAGE, adw,n. cm
NM
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l
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION W, - L s , _ � SYSTEM SPECIFICATIONS
Owner
Septic Tank Capacity �� ga l ❑ NA
Permit #
Septic Tank Manufacturer ; ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer �' _ f— ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model Y ❑ NA
Number of Public Facility Units ;9 NA Pump Tank Capacity al J$ NA
Estimated flow (average) gal/day Pump Tank Manufacturer .0 NA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer J25 NA
Soil Application Rate g al/day/ft' Pump Model -15 NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease (FOG) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD <220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) <150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD <30 mg /L Uf In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) <30 mg /L $I NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) <_10` cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size % in dia. ❑ NA Other: ❑ NA
Other.
❑ NA Other: ❑ NA
* Values es typical for domestic wastewater and septic tank effluent. ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once eve ❑ month(
ry' Z ear(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (%) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: .® ❑ month(s) (Maximum 3 ears) ❑ NA
year(s) y
Clean effluent filter At least once every: ❑ month(s) ❑ NA
JF1 year(s)
'nsioect pump, month(s)
p pump controls &alarm At least once every: ❑ year(s) NA
Fil. =k !a,e-als and pressure test At least once every: ❑ month(s) _Z1 NA
❑ year(s)
�-4
At least once every: ❑ months) ❑ year(s) !� NA
Crh
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 tank(s) 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 cell(s) 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 (% or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of <_12 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 cell(s). if high concentrations are detected have the contents
of the tank(s) 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, overloading the cell(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; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; hgrbicides; 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:
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 lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or, soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< < WARNING > >
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 INSTALLE POWTS MAINTAINER
Name _ Name
Phone �, Phone
SEPTAGE SERVICING OPERATOR !PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
0
This document was draLet `- a-. _ :: ,h chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
11/30/2007 10:59 FAX 1 715 247 3038 BELISLE EXCAVATING lih 002
f ..
f
- ST, CROIX COUNTY
- SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owne,-li3uyer -� �te -O�� ,
Mai1ilig Address as
Property Address
( 4'ertlic,ftiun t'ctluiretl liu,ii 11,11111 &Zoning Dopanntcnt for tiew constructiuu,)
City /State Sa'V Parcel Identification Number O a — �d 6
LEG LL DESCRIPTION
Property Location y + ,s ,� !�N , Sec. ,� !i' , 'L' a�' N R 20 W, Town of
Subdivision Lot #
Certified Survey Map # , Volume , Page # _
Warrauty Deed # -- Volume
Spec house nu Lot lines identifiable yes uo
SYSTEM MAINTENANCE AND OWNER CERTIFI ATYON
Improper use and uaiiiitemltice of your septic system could result in its promrsue failure to lmndle wastes. Proper
maintenance consists ofpultipiug out die septic Lank every du yuars or sooner, if needed, by a licensed pumper. What you put i,itu
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner rliaint
responsibilities are specified in §Comm 83.52(!) and is Chapter 12. St. Croix County Sanitary Ordinance.
The property owner agrees to submit to st. Croix County Planning & Zoning Department a certification farm, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the ou -site
wastewater disposal system is in proper operating cundi.tion and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 lull 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, asset by the Department of Co mme rce and the Depsrtrnent of Natural Resources, State of Wisconsin, t
Certification stating that your septic system has been maintained must be completed and retumod to thv St, Croix Cotmty Planning & r
Zoning Department within 30 days of the dirt a year expiralion date.
1; wu certify that all slatcmvnts n 0) -N 10"m art: trut; Ito lilt best ofniy /uur knowledge. 1 /we andllm die owner(s) of die
P ribed above, by virtue of a ac, anty deed rccurtivd in Register of Deeds Office.
Number of b oms
NA
7'URE OF A LICA (S) DATE
'Any information that is misreo esente ma ' r lilt in the sanitary permit being revolted by the Planning & Zoning `
b sing Department. • »*
Include with this applicatibn a r o w an ad from the Register of Deeds Of6de and a copy of the ramified ravey mgp ii
reference is made in the warran deed. j
(REV, 08/05)
I
I � i+
STATE BAR OF WISCONSIN FORM 2 - 1998 6 L:a 4E3B 1
WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIR CO., WI
Document Number _
- RECEIVED FOR RECORD
This Deed made between Troy Development C,Qrporation 01/19/2007 10: 15AN
' WARRANTY DEED
EXEMPT #
Grantor,
an d Darcy Jerome REC FEE: 11.00
TRANS FEE: 584.70
COPY FEE:
CC FEE:
Grantee. PAGES : 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Cro ix County, State of Wisconsin:
Recaraing Area
Lot 137 of the Plat of Troy Village 5th Addition in the Town
of Troy, St. Croix County, Wisconsin, Name and Return Address
Darcy Jerome
:804 Spruce Drive
Subject to the Declaration of Covenants, Conditions and Restrictions ;'Hudson, WI 54016
for Troy Village, recorded in Vol. 1241, Page 256, as Doc. No. 559964,
and the Declaration of Golf Course Covenants, Conditions and Easements,
recorded in Vol. 1241, Page 301, as Doc. No. 559969, all as appearing
in the office of the Register of Deeds for St. Croix County, Wisconsin, " — and such other easements, restrictions and reservations of record, 000
PanelId 291 000
8- -
or in use, and the "Buyer" obligations and conditions contained in 040 - 1 rcMM
the Purchase Agreement for this lot and any addendum thereto between
Grantor and Grantee herein, which includes, without limitation, This i s not homestead property.
requirements for approval of plans by an Architectural Review (is) (is not)
Camlittee, approval of home builder by Grantor, compliance with
Grantor's approved builder requirements, payment of the Developer
Service Fee and cannencerent of construction deadlines together with
related rights of redemption, all of which shall survive closing and
conveyance of this property and shall be binding upon Grantee, and
his /her /their successors and assigns.
ii
k�
Exceptions to warranties:
Dated this 16th day of January 2007
�€
(SEAL) (SEAL)
* i chard Hal uptZ , " President
Troy Development Corporation
(SEAL) (SEAL)
f�
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Minnesota
State of)111fDIDdt>m 9SX,
ss. �
Af10ICa County. �!
authenticated this day of Personally came before me this 16th day
January , 2007 the above named
Richard Haluptzok, Vice President
Troy Development Corporation
*
TITLE: MEMBER STATE BAR OF WISCONSIN to !'
(If not, me known to be the person who executed the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same.
p � ii
THIS INSTRUMENT WAS DRAFTED BY
Troy Deve Corporation * David Lamers
Notary Public, State of VVSKYWYO K Minnesota
Charles S. COOK, President My commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not January 31 -.2o ) I
necessary.)
* Names of persons signing In any capacity must be typed or printed below their signature. 0AVV F. LAMER$
1 o4ARRANTY DEED STA FORM No, WI'C� 11 Com b" P E*k M im.31.2 cousin LeQLegalNwa kae, Wis.
Yy COgibbll E;Y.Na. 31.2009