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HomeMy WebLinkAbout042-1059-50-600 0 ? alu / ° m A k 2 E m .. 2 _ \ — � � rr r O 0 e z ƒ( § A )0 \ - $ / 0 ms w 00 ®E \ / ( 3 § _ to O j © 9 / >£ 0. 3 \ @ > e e22 m @ k #E O CL f 0 0 a 7 A & : qftd � { 0 0 o k " ■ Oro & ° § § I < w z / q R > 0 / J ° & & — n / . § cc 2 § { E \ z 0 \ = k \ o /R 4 / / ƒ k k . « i f Co 0 z 3K§ -4 cn f # i § \ § CD 0 0 E 9 0 § / w � 2 ] \ 0 / 7 q z 2 k # % / � CIS$ /� = =— m —C�cE m m U) — , ® ® a8 O:KS CD CD (nom P ° °a) K , u a- CD � 2 R ,3,g �k , {� @�&m fE - o - U 1 0 , a kn - -3 )E == =%E 2 U)3 -2& CD 3 ¥\ n�2 mam 2$E � /k\ ( k 7Em a �ƒ7 8cn0 za) = i u CD aCL 2 \) E 0 _< § % w o § k 2 Safety and Buildings Division County ` E A 201 W. Washington Ave., P.O. Box 7162 scons><n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) ` Dep artment of Commerce (608) 266 -3151 Sanitary Permit Applica ',�s W State Ian I.D. Number In accord with Comm 83.21, Wis. Adm. Co de�persrp�al in o u p ?vide may be used for secondary pu stivacy LaW; sl S ) 'project ddress (if different than mailing address) I. Application Information - Please Print All I rmation Property O er's Name �� cel # Lot # Block # Property er's Nfitiling Address roperty //••on City, S to Zip Code Phone Number �`'��0' Section J-7- - _ 7Q ircle II. Type of Building (check all that apply) v O � T =L N; R E o(�j 1 or 2 Family Dwelling - Number of Bedrooms , S e GSM / ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use +I 2 ❑City ❑ Vil a �T wnship of 11I. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ❑ Replacement System y ep y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal � Permit Revision El Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration '�" �~ Plumber Owner 3 0L1 f IV. iype of POWTS System: Check all that apply) / 9 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Con toted Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leachin Ch ber Drip Line ❑ G vel -less Pip ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank _ Aerobic Treatment Unit �� r Dosing Chamber VII. Responsibility Statement- I, the undersigned, a tite responsibility for installation of the POWTS shown on the attached plans. Plumber' am (Print) PMP/MPRS Number Business Phone Number lu ber'sAddress (S eet, 7 Zip Code) J�' _ VII Coun /De artment Use Onl Approved El Disapproved Saga ge m) Fee inc s G rou round Date Issued Iss g Agent ignature ps) Q Owner Given Reason for Denial 66 IX. Conditions of Approval/Reasons for Disapproval cd a-t a,4— Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size SBD -6398 (R. 01/03) b �X �f i j kl I I I I I Is � i Wisconsin Department of Commerce SOIL EVALUATI ORT Page of Division of Safety and Buildings in accordance with ode Co unty Attach complete site plan on paper not less than 81/2 x 11 in es in size. Plan must include, but not limited to: vertical and horizontal reference poi t (BM), direction -art�l !�� p I.D. percent slope, scale or dimensions, north arrow, and location a d distance tit nearbst road. Please print all information. Re ' d Date Personal information you provide may be used for secondary purposes ( v ac LaW�(Qry _ Property Owner roperty Location Govt. Lot 1/4 1/4 T N R ZX E (or Property Owf9es Mailing Ad ress Lot # BI # Subd. Name or CSW City State Zip Code Phone Number Ej City ❑ Village .0 Town Nearest Road New Construction Use: f o Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement 4 Public or commercial - Describe: Parent material a , Flood Plain elevation if applicable ft. General comments and recommendations: / Gt �Q G�Pi`u�i�za� t--l� Boring # ® Boring l / I ❑ 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 I *Eff#2 e 3 ^ a y Boring # ® Boring ❑ Pit Ground surface elev. 973 ft. Depth to limiting factor 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 I *Eff#2 e - * E uent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L E uent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Na a Printl Signature CST Number Address ate Evaluation Conducted Telephone Number Property Owner p� Parcel ID # Page of 1Z Boring # J4' prig ❑ Pit Ground surface elev. - 9,< /( ' ft. Depth to limiting factor ->Z-.2Q 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 F Boring # El 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 I *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 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 (R.07 /00) v ��� ��� s� /q- sw //� - /- Tai✓- fit /Sw' KGs 9� I h I I � 1 � 8 c�. OliJet�fi� Wisconsin Del3artment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463041 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: Village X Township Parcel Tax No: Nelson, Gar City Warren Townshi CST BM Elev: Insp. BM Elev: BM D s ription: Section/Town /Range /Map No: (o v /LY). a rh � SlG�r'n 21.29.18. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmarrk� ) (-t �C.OY. 2• t o Dosing � � Alt. BM � Aeration Bldg. Sewer r e_ - Holding St/ Inlet ^ dl-�:' TANK SETBACK INFORMATION S t Outlet S 7 93 •g TANK TO P /L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ` f � Dt Both Dosing / Head Man. n 7-� r JA 2 9 Z_ 3 Aeration D ist. Pip I - 5 k-45 RZ. 3 61 Holding 77 7� Bb . ys em (� 3 PUMP /SIPHON INFORMATION 7 hE Manufacturer Demand St Cover . GPM .� Model Number Friction Loss TDH Ft (j1 VW Y Forcemain J . L A n Dia. Dist. to Well SOIL ABSORPTION SYSTEM - BED/TRENCH Width t Lengt No. Of Trenc es SIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J— SETBACK SYSTEM TO P /L, BLDG WELL LAKE /STREAM LEACHING an er: r INFORMATION CHAMBER OR I- 1 Typ (System: Z r t UNI Model Number: DISTRIBUTION SYSTEM ea /Manifold Distribution r r- x Hole Size x Hole Spacing Vent to Air Intak tr Pipe(s) �Y �� �..�, Length Dia Length 1 "' Dia _ Spacing -3 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 s Bed/Trench Center'' Bed/Trench Edges Topsoil ,a. L-l] Yes < No n Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_ C4 Inspection #2: Location: 1118 80th Avenue Roberts, WI 54023 (SW 1/4 SW 1/4 21 T29N R18W) N Lo t 7 Parcel No: 21.29 1.) Alt BM Description = /� 2. Bldg //�12���c sewer length = 4.--Y , , L G� 9 g k.eGt� S d'i.�l - amount of cover t j_ _ r " nI et d _ �Wa1� ►wTNa� f (` / r✓� Plan revision Required? ] Yes�o Use other side for additional inform ti SBD -6710 (R.3/97) Date Insepctor's Si nature Cert. No. 1* 110 i S afety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 consin Ma (6 - 1 �! Sanitary Permit Number to be filled in by Co.) Department of Commerce ! Sanitary Permit Appli -,ati P Z 004. 1 State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal it ormation you provide may be used for secondary purposes Privacy La sl5.04(1)(m) Project (if different than mailing address) ST. Cf�UIX G00N i ', 3 I. Application Informatio Please Print All Information I Property O�er's Name Parcel #, t # A Block # Property Owner3 Mailing Address rope tion Citf State Code Phone Number 1 5 1AL �1>�' /°, Section 3 (circle e) T N; R�E orW II. Type of Building (check all that apply) 5 nat A I or2 Family Dwelling - Number ofBedrooms S. N2 C M um er ❑ Public /Commercial - Describe Use / % 7 1 ❑ State Owned - Describe Use [ !City ❑vill e J ownship of III. Type of Permit: (Check only one box on line A. Complete li if applicable) A. New System y El Replacement System ❑ Treatmen Ida Tank Replacement Only ❑ er odification to Existing System B. viou ermit umber and ued ❑ Permit Renewal ❑ Permit Revision El Change ermit Transfer to New lb Before Expiration Plumber IV. Type of POWTS System: Check all that a pply) Non - Pressurized In- Ground ❑ Mound > 24 in. of suitabl oil ❑ Mound < 24 in. suitable soil El At-Grade El Single Pass Sand Filter El Constructed Wetland [I Pressurized In- Ground El Holdi Tank El Peat Filter ❑ obic Treatment Unit El Recirculating Sand Filter El Recirculating Synthetic Media Filter aching Chamb El Drip Line ❑Gravel -less P e ❑ Ot er (explai V. Dispersal/Treatment Area Information: 2 X S 3 Design Flow (gpd) Design Soil Application Rate(gp Dispersal Area Required (sf) Di ersal Area Proposed (sf) System Elevation q� -(_?0 VI. Tank Info Capacity in Total Number Manufacturer Prefab Sit Steel Fiber Plastic Gallons Gallo of Units 4- t- oncrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VIL Respopsibility Statement- I, the udersigne assume resRousibility for installation of the POW IS show %n the attached plans. Plumb 's ame ri t "lumer'sat MP/MPRS Number Business Phone Number Plum er's ddress (Street, City, State, ip ode VIII. Coun /De artment Use nl Approved ❑ Disapproved f Sanitary Permit Fee (includes Groundwater Date Issued I suing gent Signa re (No Stamps) Surcharge Fee) � El Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: ,�2:2 / 6/h & 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. p 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) I i !� i ' - ' _s�' -s c �- T 1✓l i H1: _ Y- 44 r L IA , O I I , I I ; J ' I I i � I , I ' i I : , , , r , I } - - T , , I I i !! ll I I 1 1 _ I , , 1 I I L , 4 i 1 ,515 - el s�r� s��- s cam/- T /� �i° /�rrv� y x -I ill p \ � U �,C,Gt(cE of the Southwest '14 of Section 21. Township 29 North, Range 18 West, lk' ? r• Town of Warren, St. C.'roix (:'aunty, Wisconsin, being Lot S of that x Certified Survey Map recorded in Volume 13, Page 3648 of St. Croix County Certified Survey Maps. s ': I �3 33I m g # G) '`� 8 N 00' 11'40" E 515.23' m S 482.23'— 25 ° � Ut I ! f � MST LINEIOTS rM I J .✓1 i ., N 1 �� N ,_. � �1 P 2 �S ' s 1 ! ZI a I v z °23'21" W 515.23' Co l .o ° ;4- I i ti, T• �{ 7 i� � A Q ,� 7� r 1 $� � ►/yam_ f� (J� '= i 1 0 I < �m 482.23' 432.23' nt ` ° R N 89'38'36' W S 00'23'24" W 515.23' � 86.00 FBI ST UNE I O r 6 y .228.03 50.00' 278.03' ti P� N i S 00 °23 24" W 311.03' r- 0 C c C I33' r , '`� ► I b • O Ari a �Z 1 �0� `6'i b� 4 z 1 1 � ` z � ° > � 1 r ^ y y / —1— S ()0'23'24"W g .o St :32 I i 204.20' \ l 1 � 1 � ` t m x TR /S INSTRUMENT DRAFTED BY JERALD L. LARSON SHEET 1 OF 2 JIaFl- ci - `d0 4 1b:53 FROM: QUALITY SEALCOATING (715)381_9978 TO ?494@07 0 CERTIFIED SURVEY MAP m L. Newel and Dorothy M. J"ee ramtb Tract t4car d M pwf of rAv & whwral % gf1he Southwest % and Southeast fhe SvlrlJsm, % Rf s llon 21. Tawaship 29 North, Raw i8 IWWeS1. r� Town of Warren. S. Cmix Cowry. Mmomie. being U S of/Mal Q C irl#led Survey Map recnnhd In Yvlrrne / i. Purr 3648 of Sl. C:roir C'.uusy Cerifled Swvky taps. KIN p o I Q I �� I �� Noo•�r�e etas � �� �� ! � ZI IkI.� •� I, a o C I All as ap 0 VJ ili d ill '� i; I soc•»74 ° w aim• �, -� � }� 'sw I + y L aiC2t 1� I =I 00 lr r ' : ey,�A{pLIAASGM SHEE7 fi � nw ae rrlwt+ur trurrro e n v \ l t RECEIVr o: 7 r ��Ak i i;uy 3 Wisconsin Safety Depar Bul me SOIL EVALUATION REPORT Page of Division of Safety and Buildi s S1. C[ih16 i6M9i W M C�mm 85, Wis. Adm. Code ZONING OFFICE i County �\ Attach complete site plan sIMM - M z 11' Wnches 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. Date Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). Z Property Locatio 111 X J1A111 — 16 ; " n Go . Lot J 1 114 E (oqo Property Owner's Gng ss t BI Nine XA mss' ,L - 4 Ig t City Zip Code Phone Number ❑ Village ® Town Nea 'eh I :Z M New Construction Use: Residential / Number of bedroom Code derived design flow rate - Z194 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material �a«>;,� Flood Plain elevation if applicable General comments and recommendations: ��YS� 9'lf F—/1 Bori # Boring ® pit Ground surface elev. ft. Depth to limiting fador in. Soil icadon 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 Boft 6 E l Q of © # p01 Boring 0 pit Ground surface elev. 2a .'5� ft. Depth to limiting factor in. Sop 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 C _ 4 9 R 4' • Effluero - SOD > 30 < 220 mg& and TSS >30 < 150 mgA. • E wffiW 130 mg& and TSS 1 30 mglL CST Now 0 S CST Number Address Date Evaluation Telephone Number � z n 2z _ � _ f Property Owner ^ Parcel ID # Page of orin DI Boring Pit Ground surface elev. ft. Depth to limiting factor > 1--Q0 in. Sal Appl Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDIN In. Munsell Qu. Sz qont Color Gr. Sz. Sh. •Efl#1 Min Ll a F-1 # C] Boring [] Pit Ground surface elev. ft. Depth to uniting factor in. sal ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence. Boundary Roots GPD/f! in. Munsell Qu. Sz. Court. Color Gr. Sz. Sh. MINI •Etf#2 ❑ Boring # E] Borin Ground surface elev. ft. Depth to Nrrwfing factor in. 1:1 Pit Sal Application Rate Horton Depth Dominant Color Redox Desaiption. Texture Stru clure Consistence Boundary Roots GPD/ff; In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 • Effluent #1 = SOD, > 30 1220 mg/L and TSS >30 1150 mglL • Effluent #2 = BOD, < 30 mg/L and TSS 130 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. sao43wttAWt A r4 IF I j v�D�O � •�i,.,�cs/ /I�i�P��� e � �J�y .t/,s %I (yle� /Jk�J�` -� 97,.33 --- -- i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ,�_ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al O Ni- Permit ;r ❑ N! V C) Septic Tank Manufacturer ��� � -� DESIGN PARAMETERS Effluent Filter Manufacturer ' O NA Number of Bedrooms O NA Effluent Filter Model ❑ Ni, Number of Public Facility Units C6 NA Pump Tank Capacity a l T, N_ Estimated flow (average) g al/day Pump Tank Manufacturer ONA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer f NA Soil Application Rate al /da /ft2 Pump Model O NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit Af NA Fats, Oil & Grease (FOG) 530 mg /L O Sand /Gravel Filter C] Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L O NA O Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L O Disinfection Q Other: Pretreated Effluent Quality Monthly average Dispersal Cells) O Ni Biochemical Oxygen Demand (BOO,) 530 mg /L Ad In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L O NA O At -Grade O Mound Fecal Coliform (geometric mean) 510" cfu /100m1 O Drip -Line O Other: Maximum Effluent Particle Size Y in dia. O NA Other: O NA Other: O NA Other, O Ni, "Values typical for domestic wastewater and septic tank effluent. Other: O NA , MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) O NA � ears :. Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume O NA Inspect dispersal call(s) At least once eve O month(i) (Maximum 3 ears) C7 NA �'' ear(s) y Clean effluent filter At least once every: O month(s) O NA� CE year(s) Inspect pump, pump controls & alarm At least once every: O month($) - NA Q year(s) Flush laterals and pressure test At least once every: O month(s) r: .- aNA D y ear(s) ocher: At least once every: O month(s) O NA O year(s) Other. O 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 crooks 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(a) 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 b a Se tae Servicing O perator and disposed of In acco with chapter NR 113, Wisconsin Administrative Code. y p g g r c p p old , w ap 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 512 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. OMW (4/01) i Page of 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 highwator levels. When power is restored the excess wastewater will uu discharged to the dispersal cell(s) In one large dose, overloading the collie) and may result In backup or sud000 discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator pdW 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; herbicide ;;, 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 Septago .Servioing 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 maturial, 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 POWTr, 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 CIRCUMSTANCE8. DEATH MAY.RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTAL E POWTS MAINTAINER Name Name Phone — Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(01)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTiC TANK MAINTENANCE AGREEMENT AND OWN[;161-11P CERTIFICATION FORM OwnerBuyer Mailing Address 6 O a ( 5 Vc Property Address 4 0 f ��_ (Verification required from Planning Department for new construction) City /State R0 6 E GUZ7 Parcel Identification Number LEG AL, DESCRIPTION Property Location -j7 '/4, Sec. T N -RAW, Town of � Subdivision _ , Lot # �. Certified Survey Map # `7 ( _+27 -,Volume 4 , Page # 70� — " LS S D &cam N �[ Ws +rty Deed # _ ��3 0 ,Volume 2fO ,Page # 09 / Spec house IR yes ❑ no Lot lines identifiable 9 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restncted plumber or a licensed pumper verifying that (1) the on -site wastewater disposaI system is in proper operating condition and%or (2) allcr inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of th hree year expiration date. T Y SIGNA OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are tnte to the best of my (our) knowledge. i (we) am (are) the owner(s) of the property described above, by virtue of a %,arranty deed recorded in Register of Deeds Office. �l�loY SIGNA U APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. " * *•• ** Include with this application: a stamped �karranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ,�11 77388 U' 2 6 4 7 P 0 9 y STATE BAR OF WISCONSIN FORM 7.2000 KATHLEEN H. VAL"SH REGISTER OF DEEDS TRUSTEE'S DEED ST. CROIX CO., VI ' Document Number RECEIVED FOR RECORD 08/31/2004 03:00P11 Daryl L. Jones TRUSTEES DEED as Trustee of EXElP1 # L. Newel Jones and Dorothy M. Jones Family Trust REC FEE: 11.08 TRANS FEE: 143.70 COPY FEE: CC FEE: for a valuable consideration conveys without warranty to PAGES: 1 Gary Nelson and Jillie J. Nelson, husband and wife as survivorship marital prox>erty Grantee, the following described real estate in St. groig County Recording Area St of,W4&eo (if more space is needed, please attach addendum): Name and Return Address of Seven (7) of Certified Survey Map filed August Scenic Title and Abstract, Inc. 2004 in V olume 1 8 of Certified Survey Maps, page 220 Locust Street, Suite One 481 1, as Doc t o. 771727. Located in the Hudson, Wisconsin 54016 fractional SW % of the SW 1 4 and SE 4 of SW 1 4 of Section 21, T29N, R18W, Town of Warren, St. Croix County, Wisconsin. part of 42- 1059 -50 -400 Parcel Identification Number (PIN) Dated this 31st day of_ August , 2004 * * Dgryl L. Jo s Trustee Trustee AUTHENTICATION ACKNOWLEDGMENT Signature(s) Y PC/ STATE OF WISCONSIN ) ss. St. Croix County. ) authenticated this day of I S. KAY, V. ii Personally came before me this 31st day of 1. K PALM Aucrust , 2004 the above named Daryl L. Jones * �OF WIS�.3 TITLE: MEMBER STATE BAR OF WISCONM to me known to be the person who executed (If not, the foregoing instrument and acknowledged the same. authorized by § 706.06, W -s. Stats.) �7 THIS INSTRUMENT WAS DRAFTED BY * lm Michael H. Foreeki, Attorney_ Nota Public, State of Wisconsin Eau C>sas ma y authe}sin My Commission is permanent. (If not, state expiration date.) {Signatures may be a authenticated or acknowledged. Both are December 12 , 2004 not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature. TRUSTEE'S DEED STATE BAR OF WISCONSIN FORM No. 7 -2000 Attorney Michael H Forecki 3452 Oakwood Hills Pkwy Ste 1, Eau Claire WI 54701 -7928 Phone: (715) 835 -3029 Fax: (715) 835 -4112 Title One Premier Group T7] 58455.2FX Produced with ZpForm' " by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 383 -8805 .gR ;rr1,com ? 7 1 7 2 7 VOL 4811 KAT ISTEERR H. DEEDS ST. CROIX CO. VI RECEIVED FOR ECORD 08/16/2004 09 :30A1! CERT?EIED_SURV= MAP REC FEE: 13.00 CERTIFIED SURVEY MAP CPA 3.00 L. Newel and Dorothy M. Jones Family Trust Located in part of the Southwest '/, of the Southwest '/. and Southeast '14 of the Southwest % of Section 21, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, being Lot S of that Certified Survey Map recorded in Volume 13, Page 3648 of St. Croix County Certified Survey Maps. C') Q3 331 .+ 8 m ;m,m X0 w c" ; m 1 m I 1 I N 00 °1114 82.2 515.23' 3' o '.100, UNE LOT5 Cft Coo co � Z N I a Co ;T .. I 24" W 515.23' F 4� 482.23' � Y3 - - LLIP D `fn' --i 3� CA :!I i 100 � �, RoixcoV p z ' 50.00' 482.23' - 432. ' r 2 Pl�ntd�9 Peeks Com^eo �+ q N 89 W S 00 W 515.23' - 1 $• EAST LINE LOT 5 AUG 1 6 2004 - 50.00' 228.03 - w D all I 278.03' Sd VAitAn 30 dWS of I S 00 °23'24" W 311.03' �' a ",,, approval Shah ba sppfOVal MA and Void .- .� 33 m a °m r y a c a 133' boo i7 o a o, 13 ► D• O A e2 0 it to w •• m m • - 2 I as yT nn y c C1'1 Co 2Q V T m o rn ,r N S 00 °23'24" W� ;C >e r~ 204.20' C cl rn rn I I I y m THIS INSTRUMENT DRAFTED BY JERALD L. LARSON SHEET 1 OF 2 Vol. 18 Pg 4811