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HomeMy WebLinkAbout042-1046-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building revision INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 506218 0 GENERAL INFORMATION 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: Rousso oulos, Andrew Warren, Town of 042 - 1046 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: �:::f. ���; ; • -' ., 17.29.18.2610 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER j 1 CAPACITY STATION BS HI FS ELEV. Septic , '+ Benchmark } y t It w.t t ♦�•k4 ('^i ";•,f•..1 y �:. .. ♦d.^ �i~i ./ /. w Dosing Alt, BM , AefeMbn Bldg. Sewer ` Holding r1� ,„, '. St/Ht Inlet r ,,. s .?` �.. ..: _ �• < I . , i0, i ";� - St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet r1n...tJ Septic ' e Dt Bottom f`'"i � F�;,�; .. - ( ✓,tic � � .. Dosing t , , Header /Man. Aeration Dist. Pipe Holding Bcati- Slott° PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Coves i Ir GPM Model Number 13. 1 - 77 , TDH Lift,._, -. Friction Loss System Head TDH Ft j,� i.� Forcemain Lengtp f Dia. Dist. to Well , SOIL ABSORPTION SYSTEM BED/TRENCH 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 Manufacturer: INFORMATION - CHAMBER OR �c 7 z�' ' • ` -' ' Type Of System UNIT M odel Number. . i - M �4 ( DISTRIBUTION SYSTEM Header /Manifold 04 Distribution x Hole Size x Hole Spacing Ven Air I ke Y . `^ Pipe(s) �a ,.. Length /r Dia Length Dia Spacing VL- C'� - <_% :- e7 SOIL COV x Pressure Systems Only xx Mound Or At - Grade Systems Only +'l.:., c . 0.1 Depth Over l Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center r . Bed/Trench Edges Topsoil Yes E] No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location:, 1045 100th Ave Roberts, WI 54023 (NE 114 NW 114 17 T29N R18W) metes & bounds Lot Parcel No: 17.29.18.261C 1.) Alt BM Description = �, " • _.. �a� :�� ca,w. tJ ► C i 2.) Bldg sewer length amount of cover- Plan revision Required? ❑ Yes . No r Use other side for additional information.' SBD -6710 (R.3/97) Date t Insepctor's Signature Cart. No. co1111'tmef'Ce.wl gov Safety an County / /� 201 W. Washington P.O. 7162 J'T C�19I Rm V V V „ Madison, WI 537 62 Sanitary Permit Number (to be fill d in by Co.) Department of Commerce 06 Sanitary Permit Applie 10 DECEIVED State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this orm to the appropriate governmental 0 1A unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Addro s (if different than mailing address) submitted to the Department of Commerce. Personal information you I rovide uNbe(tf To Pondary u ses in accordance with the Privacy Law, s. 15.04(1)(m ), Slats. J UlV V 1. Application Information -Please Print All Information Property Owner's Name ST. CROIX COUNTY Parcel # s© 4 `f 2 — lD4,6 °;Z-O — oA ,0 Property Owner's Mailing Address Property Location D Y S D /�.0 Govt. Lot City, State Zip Code Phone Number y Al P !r � I/J /a, Section rQ`�s �r �KD/Z� __2 g �3 circle one If. Type of Building (check all that apply) Lot # T _�_ N; R E of 1 A N �l I or 2 Family Dwelling -Number of Bedrooms l ' Subdivision Name Block # ❑ Public /Commercial - Describe Use 11 City of ❑State Owned - Describe Use CSM Number ❑ Village of yy] t jj ` S El Town of (.yO WI- 0// 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. 11 Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner / y 76 W yk y� Y --� -Z-1 V. kpe of POWTS S stem /Com ponen t/Device: Check all that a Non - Pressurized In- Ground ❑Pressurized In- Ground ❑ t -Grade ❑ Mo om ' e 24 o�fsuitable soil Mound <24 in. of suitable sod F] H Holding Tank ❑Other Dispersal Component (explain ��� V t %ement Device (explain) V. Dispersal/Treat ent Area Information: Ap &LSki 6l Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (st) System Elevation 3 � vo t 7 V gs7 970 T V .Tank Info Capacity in Total # of Manufacturerit Gallons Gallons Units 1 8 U New Tanks Existing Tanks n Septic or Holding Tank N Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum 's Signature MP/MPRS Number Business Phone Number tV u X279 Plumber's A dress (Street, Ci State, Zip Code) VIII. ount /De artmMt Use O pproved Disapproved Permit Fee Date Issued Is 'ng Agent ignature ❑ y Cfu -7 y� El Owner Given Reason for Denial $ / 6711 / J' 7 G � C17 IX. Conditions of Approval/Reasons for Disapproval / _ � 3 a 7 3 SYGTFAn ntn/�ico f L ,�� �7'C �`' ?Llc 3 r ,QJrxZjf . 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained ��- ` I n44 , f LWWrn and submit to the County o ly on paper not less than 8 1/2 x 11 inches in size 2. A'itse� must be maintained as per applicable co SBD -6398 (R. 01/07)' Valid thru 01/09 r - � F i �w 000 g { j � ` , R1 NO OrA tN 6 "L1 vin i �Nr ` BOXY JUNCTION 80X. APPROVED LOCKING 4" C.I. VENT PIPE MANHOLE COVER AND WARNING LABEL 25' FROM DOOR 12" MIN. WINDOW OR FRESH GRADE GRADE AIR INTAKE I 4" MIN. 43. ELEV. - - -- . IB "MIN." - -- — : Ct'NDUIT - -- - =- Is MIN. ` : t .• ELEVATION ``�� PROVIDE l ; AIRTIGHT SEAL 1 APPROVED JOINTS A i ill °•= WITH C.I. PIPE APPROVED •JOINT ALARM :.' EXTENDING 3' WITH C.I. PIPE s,' B , ONTO SOLID_ SOIL EXTENDING 3 l 1 ON ONTO SOLID SOIL C PUMP 1 ELEV. 7h ?SFT. OFF • t i• D :• C':CRETE BLOCK TANK BEDDING ELEV. 9'a. 15' - it RISER EXIT PERMITTED ONLY 1P TANK MANUFACTURER HAS SUCH APPROVAL DOSE TANK o MANUFACTURER UAA-N NUMBER OF DOSES PER DAY .� TANK SIZE ( G ) 1 50 c.,b L v , DOSE VOLUME ALARM INCLUDING BACKFLOW GAL MANUFACTURER 5 ;rE �.�J� -+-. CAPACITIES MODEL NUMBER i f+/3 a _a tom A ;Zq_ INCHES OR 38 6 • S GAL SWITCH TYPE t� - B A PUMP C / 12,. MANUFACTURER D _ I " d1 !Y.5 MODEL NUMBER 18 N 5-3 NOTE* Pump and alarm are to be SNITCH TYPE — f --- installed on separate •circuits. MINIMUM DISCHARGE E 1# GPM VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET + MINIMUM NETWORK SUPPLY PRESSURE F£ER'" A4 R + 56 FEET OF FORCE MAIN X V..58 FT /100 FT /,$ FRICTION FACTOR FEET TOTAL DYNAMIC HEAD 1. '15 FEET TANK SPECS: EACH 1 INCH OF DEPTH EQUALS I���� GAL INTERNAL DIMENSIONS OF TANK:' LENGTH WIDTH �$.- ti LIQUID DEPTH Y7 PUMP CHAMBER CROSS SECTION A ND SPECIFICATIONS V , N UJ w HEAD C ITY CURVE U_ MODELS(53)55-57-59 Model "53/55/57/59" 25 Ft. Meters Gal. Ltrs. 6 20 5 1.52 43 163 w 10 3.05 34 129 15 15 4.57 19 72 Z 4 Lock Valve: 19.25 ft. (5.9m) 0 1p 0 ~ 3 15/16- --6 5/32 2 5 —.-I 4 5/8 1 1/2 —11 1/2 NPT 0 3 15/16 U.S. GALLONS 10 20 30 40 50 _ i LITERS 0 80 160 4 1/16 FLOW PER MINUTE OD9897 I CONSUL7 FAC70ORY FOR SPECIAL APPLIC AT MNS • Variable level Float Switches available. • Variable level long cycle systems available. • Available with special cord lengths of 15', 25', Wand 50'. 1 _ • Alarm systems available. 10 1 /16 -- • Duplex systems available. 3 3/32 SK858 Single Seal Control Selection Listings 1. Integral float operated mechanical switch, no external control required. Model volts - ph Mode Amps Simplex Duplex CSA UL 2. Single piggyback variable level float switch or double piggyback variable level M53/55 & M57159 115 1 Auto 8.0 1 or 1 & 7 — Y ryy float switch, Refer to FM0477. N53/55 & N57159 115 1 Non 8.0 _ _ or 2 _ &6 -- S - or 4 _ &5 Y 3. Mechanical alternator "M -Pak" 10 -0072 or 10 -0075. ' BN53 115 1 Auto 8.0 ' — Y 4. See FM0712 for correct model of Electrical Altemator. BN57 115 1 Auto 8.0 — N 5. Variable level control switch 10 -0225 used as a control activator, with Electrical BE53/57 230 1 Auto 4.0 ' — Y Alternator (3) or (4) float system. D53/55 & D57/59 230 1 Auto 4.0 1 or 1 & 7 — Y 6. Four (4) hole J -Pak, junction box, for watertight connection or wired -in simplex or E53/55 & E57/59 230 1 Non 4.0 2 or 2 & 6 3 or E 4& 5 Y Y 2 pump operation, P/N 10 -0002. • Single piggyback switch included. 7. Two (2) hole J -Pak, junction box for watertight connection or splice, P/N 10 -0003. For information on additional Zoeller products referto catalog on Piggyback Variable Level Float Switches, FM0477; Ali installation of ..o,uo prctec:,c^ cerces r ^c Electrical Alternator, FM0486; Mechanical Alternator, FM0495;Sump/Sewage Basins, FM0487; and Single Phase iicensedeiectrician .Ai ' es•ct >ica'a^ sz` co: Simplex Pump ControUAlarm Systems, FM0732. recent National Eiec' = RESERVE ?Oo��RE O 22592 ti For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX 16347 Z Louisville, KY 40256-0347 Manufacturers of. . O SHIP TO: 3649 Cane Run Road qp ® Louisville, KY 40211 -1961 QgWIT PUMPS SNOT IN (502) 7 http.lAvww.zoeller.com PUMP �0 FAX (502) 7740 8 -PUMP 3624 © Copyright 1998 Zoeller Co. All rights reserved. t Ull A - m 4;j\ 3) >b w o 0 0 � o o_ a lip� _ to (n 17 s N Nt Nj � L V ,, c A r 6 o` o g W g � h but not Ne S wi mmkiaeperamt of co,r, a RECEIVED SO AE VAL ATION REPORT Page 4 y � JU1� cde o �y Avtach oompieoe aft plan on not less than a V2 x 11 irrchrde. tted t o: i .. lam ��. o y z /oy& • 2 0• 000 pennant ebpe. erne a forth amp , MW lor Pease print ail infomaSon. Reviewed by Date POMMOwo,Stl4 Prapertyownw per, mWertym ' i9 1V DR �GJ t C� 9 �y <�i� �DUSSd�D��Oi Gmt. Lot /" 114" - 9/4 s17 T�9 N R f! E(or)W Propertyownees Ma&g Address tot # Bbdc subd Name a 16Ll /dD Av.2 . �y9 39*3 �" N/ r- � Et'T S R 0U 0 05 State Zip Gods Plane Number ❑ cky ❑ vgage Iii Tam Nearest Road Ro WRTSo Gil• S yoZ3 Glz ygtJ •S3az LvAR RED /oo tj�- 4 ve . ❑ New Corctlruction use: ❑ ResideFdiar 1 Mm*w of berhooms - caode derived desion flow rate O O Gm sIMMUNt // mr� ❑ Pubic or oonercU - oesaibe: rent Pa nuteriai /4 ES f Ov .S 1 ? 07 4 lU Flood Plain etevaWn 9appkmWe /� fL General cumnurrts MW Afea,�_ Spot Tested std IW a convendonal inground system (P.O.W.M) Boft / IZI B°BMW Pli Gramdsurfaoeelev. 0 a • � z- R. Depth tD Nmi ft factor t0 :L sd Applcadm Rate Hmbm Depth Dominant Cakir Redorc Oesodpeon Texture Stiuc xe Cormbtance Boundary Roots GPM fit Munseil Cm 8z Cont. Color or. SL Sh. I'M `EM2 o- f /O /? 31 2.." shk oL 5 w 3 /o YK S/ L HO5' r2% FR w Z f Co 3 •37 �.SYR — SL ft - cw ! 55 7S R Z•S d X cS • 7 /Co • 5 SS- 7•5 Y12 s - 5 0 S �o dd•ale a � Q Pit G *WW surface etev. I R MPM 10 mov factor > sr _ sw AX&aftn Rate Hod= Dap4h Dorrinect Cokx Redw Desaipfion Tome sbustme Genoa Boundary Roofs GPM in. Mur16e1 Qu. Sz Cont. Cobr cm Sm Sh. 'E1 *em o• l 0 2 3 SL Z av+ S z V zz /o ---- lL 2,f ,5bx R w Z f . 4 j 2• . S 2 S SL- S �+^^ �Q c f • 7 s ,s' p S l• • Et>Mrerrt #1= BM :0 ms 220 aglL and TSS 3"W 1511 nglL ' Bbm t d2 s BOP 130 m9L and TSS <_ 30 nglL csr R� .0 L Q (� i G T-- sienaevre z z c�sT�r� Address Date Ev®Maaion Conducted Telephone Number /tM 3 — O '715 UlbnCht & Associ Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 2 i i © ■ / , / .1 .1 0 R-A M ��W 1 ' t �' 0 1jOr ro 9. \ VA CD �DWN ��... • Y° o / Ln 0 o m , 4 CD 4 r« W 0 - c, off_ A lb E w C N v' - _ N G m OQ ° - 0 o O N -o M , r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer O Q p I Mailing Address -� y 5 zo f yL ��,� 65 Property Address (Verification required from Planning & Zoning Department for new construction.) City /State 6Q4ke,.A(5 WJ C Parcel Identification Number 4 'f L LEGAL DESCRIPTION /�t � 61 e 1 Property Location � 1 /4 , �� C.t1 '/a , Sec. � , T ,�N R of UJr, K Subdivision � et Aly $ , Lot # Certified Survey Map # rr , Volume , Page # Warranty Deed # -79,7q a S 5 , Volume ,;� �s� , Page # Z �6 ss .qz„ Spec house yes Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SI GNATURE OF APPLICANT(S) DATE * ** * ** An information that is misrepresented may result in the sanitary permit being revoked by the Planning &Zoning Department. Y P Y arY P Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Wisconsin Department_ of Health and Social Services Plb. #67 Division of Health 4 � y PERMIT APPLICATION . for PRIVATE DOMESTIC SEWAGE SYSTEMS 75 -7 SK ac•�, ray A. OWNER OF PROPERTY TYPE OR USE BLACK INK Name Address (Street, City, Zip Code) County B. LOCATION OF PROPERTY WHE SYSTEM WI LL BE CONSTRUCTED, ALTERED OR EXTENDED Check Otte: VILLAGE LEGAL DES.RIPTIONt �t TOWNSHIP C. IS LOCAL PERMIT" REQUIRED FOR THIS WORK? C/ }fES NO / � / D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete y Poured in Place Steel Other NLtMER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check Onet One or Two Family Residence C ommercial Industrial other Specify Number of Persons to be Accommodated F. APPLIANCES, ETC= Food Waste Grinder YES - NO Automatic Clothes Washer -�' YES NO Dishwasher YES Z.- NO Automatic Potato Peeler YES T " NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length Width Depth Tile/Size No. Lines / Seepage Pits Inside diameter Liquid Depth l P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes Number Inches Thiolmess '_n Inches Since Hole in Hole Internal Second to Next to • Last To Fall 1st Wetted Overni ht in Miwtes Last Period Last Periol Period One Inch Example ; P- 0 36 To Soil 10" Clay 26t 25 es or no 30 1/2 '1 2 1/2 60 RECORD DATA FROM MINIMUM OF 3 TEST HOLES C ompute size of absorption area in acoord with H 62.20 Wis. Administrative Code. f S O I L B 0 R I N G S- Minimum 36 Below Prop osod Absorption System B oring Total Depth Depth to Ground Water Cepth to Eedrook umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches xample 0 72" 72 Black Top Soil 12 18 Sand 1811• Gre.vel 241 RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDS _ w I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter . H 62.20 (3), Wisconsin Administrative Code, and that the data -reoorded and location of test holes are correct to the best of my knowledge and belief. , NAME A l 0 , 11: A �� n, l K/ TITLE Type or Print REGISTRATION NO. or MASTER PLUMBER LICENSE No. / l i ADDRESS �, C i•' Z" * ! C `- - „r w DATE (S �`-• ii SIGNATUAi l MASTER PLUMBER MAKING APPLICATION , 1 MP t' ,Signatures t::,,t L' =.• `t1'� :� !'r "� License Numbers MP RSW (To be )) Completed by Issuing Agent) Date of Application �' ". 9 ! / Fee Paid t T Permit Issued (date)( f �v / ,Z l: �' Permit Number / Agent (name) (c�, t n,` `!,!'��� { :�, ' Fors > /•/ 1_x:1 r�L' (. Town, Village, City, County, eta. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below — FOR DEPARTMENT USE ONLY DATE RECEIVED ACCEPTED BY L' RETURNED (Initials) � (Date) (See Corres. M RECEIVED VALID. NO. � � , Pf3dIIT N0. �� 6 Yes or No) REVIEWED BY APPROVED DATE (Initials) Yes or No) COMMENTS: • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ' of 2 FILE INFOR TION /? / SYSTEM SPECIFICATIONS Owner �� ar� Septic Tank Capacity . '�Z) C gal ❑ NA Permit # SQ & a Septic Tank Manufacturer 4_'e� ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units A Pump Tank Capacity 7 , _ D gal ❑ NA Estimated flow laverage) (f U gal /day Pump Tank Manufacturer ' l - ❑ NA Design flow (peak), (Estimated x 1.5) 60 gal /day Pump Manufacturer ❑ NA Soil Application -hate gal /day /ftz Pump Model 7 1 ❑ NA S ndard Influent /Effluent Quality Monthly avers e* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) :_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODO :5220 ) (NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids _ TSSJ ' "`5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :_30 mg /L NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size 'I in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA p, Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 2 3 � (Maximum M years) axi 3 ears) ❑ NA ar {s) Clean effluent filter At least once ever onth(s) ❑ NA S /) y' j ❑ year(s) Inspect um ❑ month(s) NA p pump, pump controls &alarm At least once every: .w_.. __....__.,..__ ....5.5.55 ___.._.w.._. Q�ar(s) Flush laterals and pressure test st once every: " ❑ month(s) A ❑ year(s) Other: At least once every: ❑ month(s) A ❑ year(s) Other: 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 (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :_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. Page 21 of y START UP AND OPERATION 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; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS 'i's and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replaceme ystem: 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. 1" T aluat 3103. if nu oeptamrrent med is avaiMM a o ing tank be ' e ai a ?9D}{15 rre'S 9 R– A/6V%J CaNS7 UCT% o ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone S - 7 L lq— 3 ZZ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name Name ST. c , 1W l 0u Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. U 2658P 471, 774685 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., MI This Deed, made between Michael A. Peterson, a single person RECEIVED FOR RECORD Grantor, 89/20/2004 08:00AN and Andrew J Roussop2ulos and Carrie A Roussoaoulos husband and WARRANTY DEED wife Grantee. EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of REC FEE: 13.00 Wisconsin (if more space is needed, please attach addendum): COPYSFEE: 648.00 See Attached Exhibit "A" CC FEE: PAGES: 2 Recording Area RETURN TO: METRO LEGAL SERVICES, INC. 330 SOUTH 2ND AVENUE, SUITE 150 MINNEAPOLIS, MN 55401 - 2217 Metro Legal Services EDIRET 445034 A 395264 WT) 315135 042- 1046 -20-000 Parcel Identification Number (PIN) This is homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this CD � day of Aueust ' 2004 * * Micha A. Pet erson - - - - - - * * AUTEW2MCATION ACKNOWLEDGMENT Signature(s) - -_ _ — __ -- — -- STATE OF ) ss. - - - -- ------------------------------- ,�'� County ) authenticated this - . _day of _- _ -- _ _ _ _ _- . � ._ O Personally came before me this 0 day of pAM• t , 2004 the above named g � N �p,M1N i ael A. Peter a single person - * TITLE: MEMBER STATE BAR OF WISCONSIN s (If not _ _ _ i qrE OF W� me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) — Ituutttu instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY "IYI Attorney Kristina Ogland Hudson WI 54016 Notary Public, State of Wisconsin —�� My Commission is permanent. (If not, state expiration date: (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. Information Professionals Co., Ford du La., WI STATE BAR OF WISCONSIN 800- 6Mi2021 WARRANTY DEED FORM No. 2-19" • �' U 2658P 472 EXHIBIT "A" A, parcel of land located in the Northeast % of Northwest '' /< of Section 17, Township 29 North, Range 18 West, St. Croix County, Wisconsin described as follows: Commencing at the center of said Section 17; thence North 0 degrees 38 minutes 00 seconds � ors s West 22 � 07.67 feet along the East line of the Northwest /< of said Section 17 to the point of beginning; thence South 89 degrees 22 minutes 00 seconds West 300.00 feet; thence North 00 degrees 38 minutes 00 seconds West 302.35 feet; thence North 71 degrees 18 minutes 00 seconds East 314.88 feet to a point on the East line of Northwest % of said Section 17; thence South 00 degrees 38 minutes 00 seconds East 400.00 feet to the point of begiming, St. Croix County, Wisconsin. CC O) �1. U) 3 Z 2 v Z O N< < �l A • ? 7 a O C M 7 d y y W �r7 � � 01 ? r�� n N �- 0 in g� CD 3 cab O o m O I � c U) Z D 3 a (O p N O. rn 0 to I to 0 � r CA 4 0 o N 3 c Z 000 lr• 3 to to ca m m N y N d cl I Z .r i y N °; D m o O o CD y • H N C � m w a a 3 7 Z CD �{ N 7 � CL j' (Z 7 7 w m�-4 a`D �Z C w Z 3 w Z N CD CD CD D a D :3 n j -o cn Z a CL y a fi O o C A N � A n E 7 A ' N O V Q O W d0 00 46 O ° o a, b I` Parcel #: 042 - 1046 -20 -000 01/18/2007 03:43 PM PAGE 1 OF 1 Alt. Parcel M 17.29.18.261C 042 - TOWN OF WARREN Current X_ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner ANDREW J & CARRIE A ROUSSOPOULOS O - ROUSSOPOULOS, ANDREW J & CARRIE A 1045 100TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 1045 100TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.410 Plat: N/A -NOT AVAILABLE SEC 17 T29N R18W 2.41 A IN NE NW COM Block/Condo Bldg: 2207.67 FT N OF CEN SEC 17, TH W 300 FT, N 302.35 FT, TH N 71 DEG E 314.88 FT TO Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) E LN, TH S 400 FT TO POB 17- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 09/20/2004 774685 2658/471 WD 07/21/1999 607241 1443/442 WD 111 07/23/1997 5/46 7 WD 07/23/1997 759/304 more 2006 SUMMARY Bill M Fair Market Value: Assessed with: 149339 211,900 Valuations: Last Changed: 05/31/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.410 39,500 115,100 154,600 NO Totals for 2006: General Property 2.410 39,500 115,100 154,600 Woodland 0.000 0 0 Totals for 2005: General Property 2.410 39,500 112,200 151,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 I