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EAST LINE OF THE
SE1 /4
THIS INSTRUMENT DRAFTED BY: JOSEPH W. GRANBERG SHEET 1 OF
\ /nl 1 Z D.•.n Z7r1G
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
399457
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: -----------T
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:
Albri ht, Dennis Warren Township 042 - 1053 -20 -200
CST BM Elev: 1 Insp. BM Elev: BM Description:
OD-b �o.c1' Nis � = csr Qwt� I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION B HI FS ELEV.
p O Benchmark �/ Is c t
Se pt ic co", I Z (� 2 I * �
Dosing V Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet • r / l 9 8 -1 0 ,
• I
St/Ht Outlet ��� cy }. � 1
T K SETBACK INFORMATION l
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' 31 Dt Bottom
Dosing Header /Man. Z,2
Aeration Dist. Pipe
Holding Bot. System
Final Grade � 1
PUMP /SIPHON INFORMATION "- J
Manufacturer Demand St Cover 2,30 I f] ( ct9
GPM
Model Number
I T DH Ift Tin Loss System Head TDH Ft
orcemain L . I Dist. to Well
SOIL SORPTION SYSTEM(
RE C Widf Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
aAffT- DI S 3 1 116 t�
SETBACK SYSTEM TO P/L JBLDG WELL LAKEISTREAM LEACHING Manu u r:: — S�
INFORMATION CHAMBER OR
Type Of Systenj: 1 ` UNIT Model Number: w
DISTRIBUTION SYSTEM ( - / V
Header /fold It Distribution x Hole Size x Hole Spacing Vent to Air Intake
�p Pip ) °JS
Length rN Dia 1 1-eng Dia
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of x xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ® Yes [] No j] Yes ❑ No
COMMENTS: (Include code discrepancies persons present, etc.) Inspection #1: -1 / OL / al Inspection #2: /
Location: 988 83rd Avenue Roberts, WI 54023 (NE 1/4 SE 1/419 T29N R1 8W) NA Lot 2 Parcel No: 19.29.18.30120
1.) Alt BM Description = — flq
2.) Bldg sewer length = 1
- amount of cover = 3(o
3) b4ek-A —tZ
Plan revision Required? [a] Yes No
Use other side for additional information 3 I Z 2�..
Date Insepctor's Signature Cart. No.
SBD -6710 (R.3/97)
f
er U Ave . 64 as
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
ISCOnSin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
state owned.)
Attach complete plans (to the county copy only) for the , n,paPer not less than 8 -1/2 x 11 inches in size.
County sta anitary Permit Number ❑ C ck ' ioision to previous application State Plan I. D. Numb r
I. Application Information - Please Print all Information i Location:
Property Owner Name ✓ O Property Location
/ A C P 5 i C 1/4 5 C1 /4, S T , R (or
Prope Owner's Mailing Address _ GORY j Lot Number / ock Number
/ 1
- H A(n
City, State Zip Code pf f e / Subdi Nam,` 13 umber
8 0 60 c .-' s O /Jj i)�i C Dhwf
II. Type of Building: (check one) ❑ city
03 1 or 2 Family Dwelling -No. of Bedrooms : ❑ Village C4#1 2 l �2 1 q (
❑Public /Commercial (describe use):_
19 Town of 3 �J
• State -Owned
Nearest Road
BOTH UE'
Parcel Tax Number(s)
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) q 0 7 q / 3 O
A) 1. N New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
19 Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
�9Q11{y ��� wiA�lit�
V. Dispe al/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals1 ay /s ) (Min. /inch) 9 7 6 PO 11 1,6 Elevation
1 0 0 I � J /N�/ G , q c5 , d L 0,0 /&1/, 00
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks, Con- Con- glass
New Existing crete structed
Tanks Tanks
7 1C AX 15 SO EE `
VIII. Responsibility Statement
I, the undersigned, assum responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (print) PI is Signature (nos RS Business Phone Number
�. 7 T 4 - 1 — j —
Plumber's Address (Street, City, State, Zip Code)
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued g Agent Signature (No stamps)
pproved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination l6da D
X. Conditions of Approval /Reasons for Disapproval:
1. Effluent filter to be installed and maintained per manufacturer's recommendations.
2. All setbacks to system and residential structure must meet applicable code requirements.
3. This system was designed in accordance with the in- ground soil absorption component manual (version 2.0).
4. Well setbacks to be maintained per NR 811 & 812.
5. Floodplain mapping = Zone "C"
SBD -6398 (R. 07/00)
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Wiscor�osin Department of Commerce SOIL AND SITE EVALUATION
Division of Safdty and Buildings Page of
Qureau of Integrated Services in accordance with s. ILHR 83.099,Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si :.P{an mus ^' ! �� County
include, but not limited to: vertical and horizontal reference point (Bltion and .
percent slope, scale or dimensions, north arrow, and location and d' W� d to ar rqa
APPLICANT INFORMATION - Please print all info g s. 5.` Cj by Date
I I Personal information you provide maybe used for secondary purposes (Priv , 04c(1) l,aiX ') I � l � G
Pro erty owner / Prq"16cation
/i7j'/ , ``• �3 �Eb /,�. `' f 1 /4,S 9 T ,N,R /JT 4 =(ar)®
Property Owner's Mailing Address ; : - Lpt P.- - tBlock4f Subd Name or CSM#
s
Ci State Zip Code Phone Number Nearest Road
_ ❑City ❑Village ® Town
S GJ Z Sy6,3 (7TS — ) 7 3.7/ r � /¢d+°
New Construction Use: NResidential / Number of bedrooms - Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: �7
Code derived daily flow _ gpd Recommended design loading rate . / bed, gpd /ft trench, gpd/ft
Absorption area required KV2 bed, ft Y0 trench, ft Maximum design loading rate bed, gpd /ft 2 __A:!� - trench, gpd/ft
Recommended infiltration surface elevation(s) Se � r d at�p 3 f (as referred to site plan benchmark)
'.
Additional design /site considerations a Se .0
/ ' 4_renn c, e s & 1. 9 -5/0Pe
Parent material 1AX_ i 4 40" Ac) e, Flood plain elevation, if applicable
[ED SUnsuitable uitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
for system WS ❑ U RI S ❑ U (? S❑ U ®'S ❑ U ®'S ❑ U ❑ S 9u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
L CS _5H
Ground SC ,n.. S,4 t
elev
/eft. 0 4 0 , r ,e /Y S L o s 6,�
Depth to 0[W IO S
O�
limiting
factor '
/pJ4 I 1 4. Could
Remarks:
Boring #
PL C
.,..:.. 3 - 2 7 7M VI L S Y , w sZ 7
Ground -l68 Q 5
^ elev.
:1
Depth to
limiting
factor
10IL4in. Remarks:
CST Name (Please Print) / Signature Telephone No.
, 4onr4 .
Address / l/ / Date CST Number
J re lJ c / 1 4 r7 r 5d" e 7 �f -22 2
PROPERTY OWNER /r"! b SOIL DESCRIPTION REPORT Page 0 of 0
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
cs / C
Ground Y- S,
elev. Q S Q
Depth to
limiting `a
factor 1
1O6* -in.
Remarks:
Boring #
Ground / �J D (1,,e s- A/
elev. r
�tadL '
Depth to
limiting
factor
/ in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # f c34 Mae 313
love S
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5 Ayj 10We b
Depth to T-1
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oo n.
/ - � i Remarks:
Boring #
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Ground
elev.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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POWTS OWNER MANUAL r""' °
+ FILE INFORMATION SYSTEM SPECIFICATIONS
Owner �@,y�� S ��brti Septic Tank Capacity t•I:� al ❑ NA
Permit # 1597 5::�_ Septic Tank Manufa w ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 13 NA
Number of Bedrooms
❑ NA. Effluent Filter Model A (0 ❑ NA
Number of Commercial Units A NA Pump Tank Capacity gal
Estimated flow (average) gal /day Pump Tank Manufacturer RNA
Design flow (peak), (Estimated X 1.5) gal /day Pump Manufacturer 014A
Soil Application Rate t ; . -:� gaVday /ft Pump Model 0NA
* Pretreatment Unit .21VA
Monthly average
Influent/Effluent Quality ❑ Sand /Gravel Filter ❑ Peat Filter
Fats, Oil 8t Grease (FOG) :530 mg/L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BON :5220 mg /L ❑ Disinfection ❑ Other:
Total Suspended Solids ( TSS) I <_ 150 mg /L Manufacturer
Pretreated Effluent Quality ' ❑ NA Monthly average* * Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) :530 mg/L Aff"16ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) :530 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean)
:510 cfu /100m1 ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size A inch diameter * Values typical for domestic (non-commercial) wastewater and septi
tank effluent.
* * values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Frequency
Service Event
Inspect condition of tank(s) At least once every I ❑ months ,"year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Ys) of tank volume
At least once every ( ❑months �ear(s) (Maximum 3 yrs.)
Inspect dispersal cell(s)
❑ months year(s)
Clean effluent filter At least once every (
[3 months ❑ year(s) ,f T
Inspect pump, pump controls 8x.alarm At least
once eve
❑ months ❑ year(s) A
Flush laterals and pressure test At least once every
Other: At least once every ❑ months ❑ year(s) 2rNA
Other: At least once every ❑ months ❑ year(s) j-NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shat[ be made by an individual carrying one of the following licenses or certifications: Ma:
Maintainer; Septage S
Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Servicing Operator. Tank i s
easur i
must include a visual inspection of the tank(s) to identify any missing or broken hardware, Ide ntify
the ground surface ddispersal' ponding
of e ffluen t volume of combined sludge and scum and to chec k for any back up o r
cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent or
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 (A) or more of the tank volume, the en tire contents of the tank shall be removed by a Septage Servicing
Operator and disposed of in accordance with ch. NR 1 13, scot
Administrative Code.
S tom onenu, pretreatement components, and any other
mechanical or pressurized PO p
effluent filters meth WT p
The servicing of efflu m d bWTS Maintainer.
maintenance or monitoring at intervals of 12
months or less shall be p erfor e y a certified PO
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION of painting products or other cherr
For new construction, prior to us t he
and damage dispersal a cell(s). o If high o centrations are detected have the con
that may impede the treatment proce
nr tka ranlr(.t1 ramovp b a S entape servicing opera prior to use.
• Page — of
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(%) in one large dose, overloading the cell(%) 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 restorinv
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore ncrmal 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 swats; degreasers; dental Ross; diapers; disinfectants; tat;
foundation drain (sump pump) water; fruit and vegetable peetingsl gasoline; grease; herbicides; meat scraps; medications; oil;
painting eroducts: pesticides: sanitary naokins: tamoonsi and water softener brine.
ARAN DON EM ENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to Insure that the system is
proper(y and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Adminlstrative Code:
• All piping to tanks and plu shall be disconnected and the abandoned pipe openings sealed.
• The contenu of all tanks and plu shall be removed and property disposed of by a Septage Servicing Operator.
After pumPine, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, grave( or another Inert solid materlal.
CONTINGENCY PLAN
ores have been or must be taken, to provide a code compliant
1 nn be repaired the following me ,
f alls and ca of g ss
1f the POWTS a p .
replace ent system:
�A suitable replacement area has been evaluated and may be utilized for the location of a replacement soft 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 strucwre, lot lines and wells Failure to protect the replacement area will
result in the need for a new soli and site evaluation to establish a sultable replacement area. Replacement systems must
comply with the rules in effect at that dme.
O 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.
0 The site has not been evaluated to Identify a sultable replacement area. Upon failure of the POWTS a soli and site
evaluadon must be performed to locate a suitable replacement area. if no replacement area h available a holding tank may
be Installed as a last resort w replace the failed POWTS.
O Mound and at-grade soil absorption systems may be reconstructed in p!ace following removal of the bionnat at the
Inflltrative surface. Reconstructiotu 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.
E INTERIOR OF A TANK MAY BE DIFFICULT O
T •R
DEATH MAY RESULT, RESCUE OF A PERSON FROM K
IMPMURl F.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name ame
Phone - 71 — Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Agency 19 . Cro I - JL-
Phone I fbon
09/22/00 FRI 14:46 FAX 715 386 4686 ST CRX CO ZONING 0001
ST CROIX COTJM
SEPTIC TANK MAINTENANCE AORBBMENf
AND
OWNER MW CWTIFICATION FORM
OwnerA3" ar , S 1C , a
Moiling Address (' k a L"e-
Property Address a g e3 h d ►
(yWo wou se pked !bm Ptaw ft D"atmeat for acw comewtiw
City/state Parcel Ideadfication Number C) - 0 " " A D
SAL DEMBUMN
property Location . V., ACV, Sot. T a `1 N R_aW, Town of
Subdivision W S Lot # / 0-_.
Certliriie+d Survey MAP # �I�2-� . Volume . - , . Page # J�
Wfarnnty Deed # 5 �5 . Volume ,L.l _,.., Pap #
Spec house 0 yes % no -� Lot liars identifiable Yes E3 no
Lmprarpa ase sad maomtmanoeof You+' septic system coWd result in its pramattue failture t bsuadk waster. Props mtintenanoe
G= k% of pumping out tha septic tank ovary three years or so="* if nmdod by a Itoensad Ptmtpar. What You put moo the system
cwt atTect thu: function of the septic task as a tteatmeat stage in ft waste disposal sysawst.
rw Property owner agrees to submit to St. Croix Zoning Department a certiticatiou form. signed by lira owns sad by a
a attsiarphuaba. jw aeymaap =*a. nskw odplumba w a Item pumpar ver4ft that (I) the on-she wasew+ttow4uposal system
is in peeper operating 'lion (2) after in�tion and pumping (if swe"IFY). the septic tank is kas rhea 113 fitil of shtdge.
=read the aad a to maintain the privato sewage disposal system with Ate sttmdatds
Uwe. the � re9uiramems f;�
aot bilk herei% as set by dW DRNK of Commerce and 60 Depuuoaa� ofNswurad Resoot"s, Sate of Wbcondm �
tbuN your system bas iron mast ba coanplated and rettaaed w the St. Croix Cooaty Zoning Office widdn 30
t Are three year
T ftft
DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form ase uw to ft beat of my (0w) knowledge. I (w0) am (m) the owtia(s) of
the AWscnlmd above, by vW a of a warranty deed reauded in Register of Deeds Office.
D
SIGNATURE OF APPLICANT 0 DATE
0 Any b the ♦••s••
Aay infgmatioa that is mi: raprea�ted may result is the unitary Petmtt being Y �i� �'
ee Mdads with this aprp icatioa: a stamped warranty deed from the Reofstm of Deeds off=
a 9W of dw certified smvey mV if rdbrcaw is made in the warranty deed
STATE BAR OF WISCONSIN FORM 1 - 1998 656554
WARRANTY DEED : <.it C ;il_cEN H. WALSH
EC OF DEEDS
Document Number vc - i .f 1 7 1 1S PAGE C N 7 1 A 'CU. :li
( PE WE
D On :RECORD
This Deed, made between - &6 – r 11 I
l `1 1L/�d ra J. T j- , :;t �u-0 9:30 AM
-- —. - -- — - -__- _ WARRANTY DEED
— Grantor,
and (� d ucx:i COPY FEE:
'
— _. – _ _ CJH r c:
i _- TRANSFER FEE: 30.00
, :Cu!,DisG FEE: 11.00
Grantee.
Grantor, for a valuable cons deratign, conveys to Grantee the following
described real estate in County. State of Wisconsin
(the Property "): i
Name and Return Address
L rfi fled a V Llq blar � i 1 � �'
� tI
s� ff
'' I a l v ea f ed /n -�- M �
lo� �/} /1 C r Parcel Identification Number (PIN)
a nd 1 } e, J / �" 4 �f �! � e This homestead property .
f orolx (�+C�� �•��,
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 thi day of
(SEAL) (SEAL)
T-Aie L A IM �h _
(SEAL) (SEAL)
ayxIra
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State l / oP JIL Wisconsin,
Count.
authenticated this day of Personally came be cii me [his day of
_ , g Qb0 I , the above named
- - -- g . .--
TITLE. MEMBER STATE BAR OF WISCONSIN 5C at. & _ ._..
to
(If not, me known to be the person ,. who executed the foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. ...
THIS INSTRUMENT WAS DRAFTED BY
/
—�� — -- Not ublic, S of Wisconsin C � O J O
My comml sion is pertna [,nt. r 3tr'te exbtiatlon'cate:
(Signatures may be authenticated or acknowledged. Both are not
necessary)
'Names of persolu signing in any <apadty must be typed nr printed below their signuoue.
STATE BAR OF WISCONSIN Wisconsv. Legal 51dnk C.- Inc
WARRANTY DEED FORM No. 1 - 1998 Milwaukee. Wis.
r�
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FILEp
0� OCT o 5 1999 ► h
KATHLEEN H. WALSFI G J-15'7'7
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OCT 4 5 1999 a Z o ti i ° $Q
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approval date approval shat
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1,321.37
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THIS INSTRUMENT DRAFTED BY: JOSEPH W. GRANBERG SHEET 1 OF 3
nl 1 Z P.:. 374E