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HomeMy WebLinkAbout042-1086-20-040 r Wisconsin Department of Commerce County: Safety and Building Division PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT Sanitary Permit No: 479360 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)]. k Permit Holder's Name: City Village X Township Parcel Tax No: Delta Construction Warren, Town of 042- 1086 -20 -040 CST BM Elev: ] 77Wv7BM Descri Section/Town/Range/Map No: 4L 31.29.18.482A4 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER J wtS CAPACITY STATION BS HI FS ELEV. Septic _r1 2 Ben mark W; ese�� Fad �. s 1 7— q;: o1-c... Cbwe.. D . 9 166 34 &LI) g Alt. BM �• �� 1b ?t- SZS .i �.. Ce 3.1 '17 Aeration Sewer ��lwc.a~r 5 .$ 97 •.73 Holding St/Ht inl t TANK SETBACK INFORMATION St/ Outlet k. L . `��.. TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 Z 5 $ Z4 i ZZ'{ Dt Bottom Dosing Header /Man. Aeration Dist. Pipe 1q, Y•d� �.4 Holding Bot. System � l) PUMP /SIPHON INFORMATION Final Grade �`�li✓ �• V Manufacturer Demand St Cc • I 6641,12A. PM JW �. 4• A4 -63 . 11 Model Number h' TDH Lift Friction Loss y I a 111 d TDH Ft ' IZ • W Forcemain Leng Dia. I Dist. to Well A) . 9G SOIL ABSORPTION SYSTEM co ga., fX� BED/TRENCH Width Length jNo.Of Trenches ( PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 i 6 3 ) i SETBACK SYSTEM TO J' /L BLDG WELL LAKE /STREAM LEACHING Manufacture INFORMATION CHAMBER OR .f—^4t Type Of System: / A ,+ UNIT Model Number. v DISTRIBUTION SYSTEM ( ,v 1 � 46 tlS = Header/Mani fr // Distribution ` x Hole Siz� x Hole S ci Vent to !� Pipe(s) \ \ zw,:jptakee + a Length \D Dia_ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only - j Depth Over I Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center 3 • "� Bed/Trench Edges Topsoil es l No Yes Q No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / (O / Inspection #2: / / t Location: 906 Alex Lane Roberts, WI 54023 (SW 1/4 NW 1/4 31 T 29N R 18W ) NA Lot 8 At Parcel No: 3).29.18.482A4 •— •' 6 �ts,,ra..`, G�n,al,ns a �. ,..�- �j,1� � /2Q C �h(.i2 u,%; � cct- I � It BM Description 1.) A p � I u "�1,�� IM S�LUC ���tG•»v��'n� 2.) Bldg sewer length = 2 7I ? � ��1,(,d1Z S� � I (; � - amount of cover = 7 y 11 I Y / Gu x 14 4,o. l �to llrvt,(1 I Plan revision Required? s No Use other side for additio I inf mation. 2 J Date InsepC rs Sign re Cert. No. SBD -6710 (R.3197) l _ • W commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 s e Q n s i n Madison, WI 5370 3 162 Sanitary Permit Number (to be filled in by Co.) i of commerce i s 7 o Sanitary Permit Application s`a`e Tran ti °n qu In accordance with s. Comm. 83.21(2) Wis. Adm. Code, submission of this form to the appropr ovemme N unit is required prior to obtaining a sanitary permit. Note: Application forms for state-ownedP54US are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal informatio IF sec p urposes in accordance with the Privacy Law, s. 15. t)(m), Stats. 1. Application Information — Please Print All Information Property Owner's Name Parcel # Property Owner's Mailing Address Property Location ST CROIX . GOi_iN ?Y cro -- ST N1NG OFFICE Govt. Lot City, State zip Code a um r� y, y., Section p (circle one T � N; R ZO E II. Type of Building (check all that apply) Lot # rC�r2FamilvDwellinsa NumherofBedrn ms , O Subdivision Name /\ Block # ' O-Al 1 1t/ ❑ Public /Commercial - Describe Use k ` ❑ City of CS M Num r ❑ Village of E] State Owned - Describe Use +' 1 Town of lt/If/L'A6d Ill. Type of Permit: (Check only one box on line A. Complete tine B if applicable) 4 lew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal 0 Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Numbe�las Before Expiration Owner IV ` T a of POWTS System/Component/Device: Check all that a i "n-Pressurized in -Ground ❑ Pressurized In -Ground ❑At- Grade C1 Mound > 24 in. of citable soil ❑ Mound < 24 in. of suitable soil El Holding Tank ❑ Other Dispersal Component (explain) /-ja c h Yl Pretreatment D i ) V. Dispersal/Treatment Area Information: c--,e4- 4ko- Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) s rsal At& Proposed (st) System Elevation C — I Vt. Tank Info Capacity in Total # of kManufactureT 3 Y, Gallons Gallons Units v _ U New Tanks ti Existing Tanks , /0 k 5�J "! ti U 65 rn w V A Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of tke POWTS shown on the attached plans. Plumber's Name (Print) Plu is Si MP /MPRS Number Business Phone Number Plumber's Address (Street, City, S te, zip code) a 3 A0 -& /G tom" A0 S VII oun /De artment Use Onl Approved ❑, Disapproved Permit Fee Date Issued uing Agent a 7� $ 8 j� 1 D ❑ Owner Given Reason for Denial ( P" - 1 7 -- � IX. Conditions �ofApproval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 I inches in size SBD -6398 (R. 01/07) Valid thlu 01/09 sss -moo - i 4 r f j (Cd� 27 • 93.0 u y 3 d l�r s �•�• jr� � s.y: nrtvl�SvL� csw�R, ��d.o � C�wy �� ��- '"'ho " cpd , I 9- 9p• 3 Ott pf, x -3 " --2 C%o 2413 iM �� 4W7OW 1 t I 4 1 r r d (A -9 ,cs 60' roc® } X70 .0 X3 xs' y 14 ,v d +�! - ��l, �'�� � r -T- nsf- �v�►v� tav�/� , �od•o ' �°�°'Tr� 6+! $il��vtl� z : 9 ( 99• 3 St1 s Tr� E[.cc X^ I 94.0 ► X �� 3 x -s may ,/ 441 60 _3 rf,7 A-3 " --2 _.._. - - - - - -- - -- - - ----- t4 • ,\ r ►.t Ct •-c : `: •.•- _ \.�� _ (gyp cr cl o QQ = t fr 1 1 0 t7 4 `� \ p 'MI 0 0 o"D a v fD .� M Z, w tss n ( tO 3 N o 3 �. C1 p. a n L - a Iv N 1 t ' y� Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of -3 Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Code \ minty X` Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but not limited to: vertical and hodzontat 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. R i "red b Date Personal intormation you provide rnay be used for secondary purposes (may law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot f w 114 VjCA U4 S T j N R E property Owner's Maifrug trot # Block # Subd. Name or CSM# �` d City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road (ErNew Construction Use: l7 Residential / Number-of be4hxxm Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: _ Parent material Flood Plain ft. General oanments L cFLG S 6d r and recommendations: OCT 0 9 /008 STL CROIX COUNTY ❑ Boring ❑ Bori # © Pit Ground surface elev. R Depth to lurdting factor > 97 in. Pate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots - GPDW in. Mur>sell Qu. Sz. Cont. Color Gr. Sz Sh. •81#1 •Eff#2 0- a 3 s .t , 7 /. L ..3 s Boring ❑ # X 2 U Pit Ground surface elev. 3 ft. Depth to grunting War > O�V X in. Sol tion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence B=Wary Roots GPDff in. Munsel Qu. Sz Cont. Color Gr. Sz. Sh. •0101 •Eff#2 m s s .7 .G Effluent #1= BOD > 3o _< 720 rnWL and TSS >30 ,150 mglL #2 = BOD <_ 30 m9k and TSS 130 mglL CST Name (Please Print) CST Number p S y�0/ Date Evaluation Conducted Telephone Number Ro C-ra W = yl6 00,00 - - � ': u. x ��:; ; prop" Owner Parcel ID # ®� � r� = Page Z of - o eo# ❑ BorbV ®p Ground surface elev. o . L_ ft. Depth to 6mi" factor � in. �q i2ate Horizon Depth Dw*w t Color Redox Description Texture Structure Consistence Boundary Roots GPD/fE in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "F_ff#t "Eff#2 - LS !1t es 2 7 . G Z L r 5 .v 3 _ — •� fac F1 B oring # Depth ❑Boring © Pit Ground surface elev. ft. m fxniting tor r ication Rate Horizon 1 Depth DominantColor Redox Description Texture Shuci re Consistence Boundary Roots GPDJf1= in. Munsetl Qu, Sz. Cont. Color Gr. Sz- Sh. "Eff#1 "Eff#2 Q ❑ Mwft ❑Pit Ground surface eW- 1t Depth b lirnitin9 factor in Sol Application Rate Horizon Depth Dominant Color Redox Description. Textae Structure Consistence Boundary Roots GPDIIF in. Munsd Ou. Sz. Copt color Gr. Sz. Sh. "Etpl1 `Eft#2 Effluent #1= BOD, > 30 <_ 220 mg& and TSS >30 150 ffQ& ' Effluent #2 SOD, < 30 mg1L and TSS 130 mgiL 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. SMM330(f-6M) facer► PLumw4G 4221180 2473 Roft G+ R oad 7004 a t i J G Ts� <bK/s7 B�>Y�v I t i YD R L 60 i O A t �tj l�l zs Go' FK orK 770 OA-4 - 27 ; D � #,a � ,}ta" !j rs7 j Td� t'F s . T ��/Mz►LZ` GBV,sR, /�. 3 �r�tET� r/tE S zoAE tL �C.c V ,` X - E 9p• 3 X - .3 7 _ N V Isconsin 2(11 W. Washington Ave., P. 7162 e f Madison, Pmit Number ( •' saeioary Permi be fined I„ by Co.) 4:9 360 .Department of Commerce Sari �` s `ar Permit •o ti 910 sate Plan LD. Number In accord with Course 8321, Wit. Adm. Code, ` proride GG Vr1SY may be used for y pis Pricey GR G GoF \GE Address Cif different than mailing address) I. Applicatioa Information - Pka4e Print AN Information property Owner's Na me i Lot i Mock i Property Owna'a M ailing Addttxs Property LoaLOn I � • / Z ST _ M. 40-W 'W,Section City, State Zip Code Pbome Nttmigie:r ' p (c ircle one) ` ) H. Type of B (check all that apply) S� T =-� N, R 'Sob�rpw eeiimw M Number to 2 Family Dwelling - Number of Bedrooms ( ►r I$�p Qg) ❑ Public/Commercial - Describe Use G D 2 2 A ❑ State Owned - Describe Use OCity ❑Village Wfcbwnship of Grr M. Type of Permit: (Check enly one box on line A. ComVVeHqeBffapprIcabIe) A. VNew System ❑ Replacemet System ❑ T Tandy Replacement ky Modifiatbn System Ilernik B. ❑ Permit Renewal ❑ Permit Revision ❑ Gunge of ❑Permit Trarnsfer to Date Issued Before E.Viration Plumber IV. Type of POW'IS : (Check all that ) `c 2 ) + ¢x R'Non - Pressurized In-Ground 0 Mated > 24 in. of suilabie sort ❑ Motrailf 24 in. of suitable soil 0 At -Grade ❑ Single Pass Sand Filter 0 Constructed Widand 0 Pressuraod In-Ground ❑ MOM Tank 0 Pest ❑ Aerobic Treatment Unit ❑ Rech=laung Sand Finer 0 Recirculating Synthetic Media Filter 0 Lach®g Chamber ❑ Drip Line ❑ vet -less Pipe ❑ Omer (explain) V. DispersaVrreatment Area Information: OW fA g kee 2 dal ' rE Area Required (st) Area Proposed (so S Design Flow (gpd) Design Sort ApPlitxaon Raoto�$ D�tersal �md F3 7. z VI. Tank Info Capacity in Tool fliumber Mawfacduer Prefab Site Sled Faber Plastic Gallons Gallons r "of Units Concrete Constructed Glass New Exismg Tams Tool. 2 Sew or Holding Tank Aerobic Treatment Unit' ? Dosing Chamber VII. Responsibility SWeme ut - L the asatinre - for of the PORRS shown on the anatbed plans. Plumber's Na me (Print) 's Si gaamre - bHO&PRS Number Business Phone Number b� Feprt7t Piumbbw .� — 3 — 9 ,(0 Plum G ge l Mate, zip x Spooner, WI 54801 Art v v.; - 06 c VIII. C - 7,9-/,737 6 Approved ❑ �Y Permit Fee (hrJudes Groundwater Dam Issued Agent Signature (No StamPs) Surcbarge El Denial Fee) _ 5 �_- �� zm IX. Conditions pprova SYSTEM R: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided -by plumber. 2. 'All setback requirements must be maintained as per applicable code /ordinances. Attack ao -t>Me puns (a the Coot? sow fat* me System oo PWW tat bw than SM x 11 Whes in she rogeny riumcing #221180 28288 McKenzie Rd. Spooner, Wi 54801 (715) 635.9609 ��trr� ce.�'T• Xo7' x -'saexwA • = f+I LsT cp/tMWf— Fr�f jkA o = 1200 � wf Fr LTE/z W � ALL yr � fJ:/ ' I /Soft over �P �•w� - ""r 7 '/�m rogeny riumoing #221180 28283 McKenzie Rd. Spccner, WI 54801 (715) 635 -9609 (sT ' X . re >s o • = lwlmo LOT cag Vg f- Frrfk D = /20 4*4 T• w/ FrL rE/Z 53w x6cd C- (A) C— IL fA�/' l�! YV *Oro: vsrAU F� .rev o�r�4�•�.syr.Hl /' �dcC 7+ BE FS�ii .) ,FS w.9 •�v �cEv. _ -or SG L S/Gif• - TS • I�i�Ci1'�� ALE!/• .�, of 91: � ' z /So/t DoT DrcCP ,ivoct �ht �L Nt x —1 z (.qtr. ,,c�� _ y � 1 i \ �r JA, AM Ir r r ` v jr- `Niscohsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Crn 'I SL Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information. R awed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). \ jw6 .05 1 Property Owner L Property Location k \C�a( - 8 Govt Lot 5 1144W 114 S 31 T 2 r N R/ E (or)16� Property Owners Mailing Address _ Lot # Block # Subd. Name or CSM# C' State Zip Code Phone Number ❑ City ❑ Village &) Town Nearest Road k k l 1Sqo It 1 ( IS) - 59 - 73/ a r V1 4 New Construction User Residential/ Number of bedrooms J — Code derived design flow rate _ �60> 0— _ —_ GPD ❑ Replacement ❑ Public or commercial - Describe: _ ----- - - - - -- S ri? a ilc - - -- ft. Parent material _— T � - - - -- 1 ..f��"'�'���'o : " PP � able _— _-- -_ —��— General comments / V / phi and recommendations: I q e. Boring � a Boring # �r--yy (} - 3-Pit Ground surface elev. _ _ ft. Depth to limiting factor _ in. Z� - Soil Appfication Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDiff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Z [q -4D 10 c l 2>ri5.bk m r c — l� 3 0-00 J i e qZ . Boring # Boring pit Ground surface eiev. Z ft. Depth to limiting factor y in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I 'Eff.#2 f -q /e) rJ2 :51 Zryi k mfr c- s 9 vT 5 •8 , 3 - 4g o 3 S r- 1 rY)' I c L4 & o r iA -5 s _ 7 1.2 � 4z •�o o •`fo Effluent #1 = BODS > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg1L CST Name (Please Print) Sig CST Number z�33 Address Date Evaluation Conducted Telephone Nu bar v , to 4 y Page __ of — S Property Owner Parcel ID - - -- . ❑ in. ❑ Boring Boring # _ ft, Depth to rrmftirtg factor _ -L-- -- Sod A ication Rate ®•-Pit Ground surface elev. ' GPDtW Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary ROOD , Eff #1 'Eff#2 au- Sz. Cont Color Gr. Sz Sh. II in. Munsetl �1 2 ('V� S k e S l v f ' o r_3 5 c. .3m5 IJ rY� i C w — • `f 1� 3 -7 �3(� S D m 1 Z l0 a Boring # Boring ___ ft. Depth to limiting factor __ in. Soil A lication Rate E] p Ground surface elev. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fP 11u. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff #2 in. Munsell i Boring # Boring Ground surface elev. - - - - -- ft. Depth to limiting factor _ —_ -- in• Soil A lication Rate ❑ Pit Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots -Ef GPDIft�Eff#2 in. Munsell j Ou. Sz. Con! CO'Ar Gr. Sz- Sh. 1 I 1 Effluent #1 = 300 > 3C < 220 mg1L and TSS >30 < 150 mg'L Eti uent c = BCD < 3 m� and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. I f you need assistance to access services or need material in an alternate forma please contact the department at 609 or TTY 603 -264 -8777. SDD -8330 (R.07100 i J i PAGE;� 3 # LEGAL DESCRIPTION:�c , ]A 4�✓1/4,S T ,N,R, E(or)� NAME: S �v y } LOT _ — SCALE: I"= �,.nl ELEVATION: Od , C -I- V BM 1 DESCRIPTION: C PK BM 2 ELEVATION: BM 2 DESCRIPTION: a SYSTEM ELEVATION: SYSTEM TYPE: �r� 1 �� ✓t �ti y /ta v r d� SIGNA"IDUR DATE: S '� o —o cj/ L °`hZ O a ; n q aJ rA _ Go ♦ i - ° �` t.• \ ' 1 C', CA OQ cap SD IV IL CD a a . �.` ` i fir• 19 0 ca '' _ . - _ ►_ • \ \ mss OD OQ SD • i G. CO) N O 00 on m O V ag e Z w R FILE MIFORMAMON SYSTEM SPE(3HCATO —W Owner Septic Tank Capacity 1637 ❑ NA Permit 6 Gl. 3 Septic Tank Manufacturer .� ❑ NA I Effluent Filter Marwfacturei ❑ NA DESIGN PARAMETERS ❑ NA Number of Bedrooms ❑ NA Effluent Fier Model p Number of Public Facility Units : )t_NA nPunV nk Capac+tVnk Manufacturer Q NA Estimated flow leverage) Design flow (peak), (Estimated x 1.5) aUday anufacturer J �' Soil Application Rate __ 7 aUday/ftz Pump Model i7 .MA Standard Influent/Effluent Quality Monthly average` F)Dq nt Unit NA Fats, Oil & Grease (FOG) 530 m9� avel Filter ❑Peat Fiber - Biochemical Oxygen Demand (BODS) <1" 20 mg/L ❑ NA ical Aerator+ ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L tion [I Other: Monthly ag e Cell(s) ❑ NA Pretreated Effluent Quality y O In- Ground (pressurized) Biochemical Oxygen Demand (BOD :S30 mg/L nd (gravity) Total Suspended Solids (TSSi 530 mJn ❑ NA e ❑Mound Fecal Colform (geometric nuea<t) < -10' cfu/100mi O D rip -Vie ❑Other: Other: ❑ NA Maximum Effluent Particle Size Xa in die. ❑ NA Other: ❑ NA Other ❑ NA Other: ❑ NA "Values typical for dwwshc wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service � ❑ month(s) lMa 3 years) 0 NA Inspect condition of tank(s) At least once every: FIyear(s) Pump out contents of tank(s) When combined sludge and scum equals one-th %) of tank volume ❑ NA ❑ rnonth(s) tM 3 yam ❑ NA VInspect dispersal cents) At least once every: 3 years) a rrnonth(s) El NA t, fluent filter At least once every: years) R ❑ manth(s) - Cj,MA pump. pip control s & alarm At least once every. (3 yearts) 01 month(s) Q NA Rush laterals and pressure test At least once every: [3 yearls) ❑ rnonth(s) _ nNA Other:- At least once every: ❑ year(s) QNA finer. MAI TE11ANCE INSTRUCTIONS one of the foNowing lOenses ur ceutificat'": Inspections of tanks and d cells shall be_made by an kWr..idual cog g Operator. Tank Master Plumber; Master Plumber any Sewer; POWTS lrrspintor: �WTS Mamtairner; Septa9e any cracks ex leaks, Of the tank(s) to identify any missing or broken hardware, idmtfifl/ inspections must include a visual inspection back up p of effluent on the ground surface. measure the volume of combkwd sludge and scum to check for any and to check for any P°nding The dispersal Mills) shall be visually inspected to check the effluent levels in the observatim► p and requires the of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition immediate notification of the local regulatory authority- When the combined accumulation of sludge and scum in any tank equals d�isp sed r � °$e dan�e a pt the 3e c of the tank shall be removed by a Septage Servicing operato Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent fibers, 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 days of completion of any service event. ^HT UP AND OPERAAON oducts or other chemicals For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting pr that may' impede the treatment process and /or darrive the dispersal cell(s). R high concentrations we detected have the contents of'the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when sod 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 Serving Operator prior to restoring power to the effluent pump or contact a Plumb" or POWTS Maintainer to assist in manually operadng the Pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and d'uspersall ce)1q. 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, mean 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 acode compliant replacement system: area has been evaluated and s may be ut ili ze d for the location of a r u�rrn eplae<nt soil absorption su it a bl e replacement and compectien and should not be infringed upon by systemm. . The replacement area should be protected from disturbance required setbacks from existing and proposed structure. lot Ines and wells. Faiilure to �e systems willl result in the need for a new soul and site evaluation to establish a suitable replacement _ m ust 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. Q, 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> > Tn. NOT SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL AND/OR INS l MAY RESULT RESCUE OF A ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMST PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ' - e #221180 c enzle ' SDOC uun >±ds>�t (715) 635 - 9609 j POWTS INSTALLER Name I �t L Name Phone `7'�S �3 g v9 Phone f - 7959-L Silk SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name � 1 0m oc C —TY �1- Name ` Phone -its- -� b" phone C�'� - This document was drafted in compliance with chapter Comm 83.22(2)(b)l1)(d)WO and 83- 54(1), (2) & (3), Waconsin Adininistrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �j-►� Mailing Address Property Address Qd ( N e g 1 X) m ✓ (Verification required from Planning Depa6ment for new construction) c— City /State Parcel Identification Number D 72-& _CW LEGAL DESCRIPTION ( 4) Property Location 5-4 f y,,' L ""W y4, Sec. —1-L, T 2 7 N_R I Z V Town of 416 Subdivision c Lot # Certified Survey Map # 2 ?Q ZAC' Volume IV' , Page # Y,!�*d Warranty Deed # _ ?q 7 /g Volume 2Q� , Page # Spec house Kyes ❑ no Lot lines identifiable b yes ❑ no SYSTEM MAI 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 g 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, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification Zdaysf t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 e three ye ir ation date. j F APPLICANT DATE O ER CERTIF I (we) certif that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the roperty d scri d above, by vi a of a warranty deed recorded in Register of Deeds Office. J SIGNA14JR OF 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 warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 19 F 4 5 2 REGISTER OF DEEDS ST. CROIX CO., WI STATE BAR OF WISCONSIN FORM 2- 20W RECEIVED FOR RECORD Document Number WARRANTY DEED 06/09/2005 12 :15PM WARRANTY DEED THIS DEED, made between Jay P. Urban and Rebecca L. Urban, EOPT husband and wife, Grantor, and D elta Construction Inc., Grantee. REC FEE.- 1 1.00 Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 273.00 the following described real estate in St. Croix County, State of Wisconsin: COPY FEE: CC FEE: Located in part of the SW l l4 of the NW 'l of Section 31, T29N, R18W, PAGES: 1 Town of Warren, St. Croix County, Wisconsin, more folly described as: of _ o Certified Survey Map recorded July 29, 2004, in the St. Croix n Register of Deeds Office in Vol. 18, page 4798, as Document No. 770226. --' Recording Area Name and Return Address: Edina Realty Title, Inc. 400 S. 2 St. — Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights -of -way of record, if any. 470258 042- 1086 -20 -040 Parcel Identification Number (PIN) This is not homestead property. Dated this 7th day of June, 2005. 1 �i.j d ' * Urban Rebecca L. 16an , AUTHENTICATION ACKNOWLEDGMENT Signature(s) e — fl - r0 VV STATE OF WISCONSIN ) �� tn ST. CROIX COUNTY. ) ss. authenticated this 7th day of June, 2005 t — �� Personally came before me this June 7, 2005 the above named Jay P. Urban and Rebecca L. Urban, husband and wife to me known to be the person(s) who executed the foregoing TITLE: MEMBER STATE BAR OF WISCONSIN instrument and ;,�owleed the same. (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY *Cheri Arown Notary Public, State of Wisconsin Peterson, Frain & Bergman – Steven H. Bruns My commission is permanent. (If not, state expiration date: 50 East Fifth Street, St. Paul, MN 55101 3/11/2007 ) (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 WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000 I 77��2 VOL PAGE 4798 KATBCEW U. WALSH REGISTER OF DEEDS ST. CROIX CO. III RECEIVED FOR hECORD Sc 07/2912964 0233OPS c y CW �F SM� MAP Fn Z PAGES: 2 3 N Ic J � Z ° s a BEARINGS ARE REFERENCED TO THE WEST LINE OF THE Nwl /4 OF SECTION $ 31. ASSUMED TO BEAR NO196'38'W E LT 46 t cn N01 16 26 O LO F COTTONWOOD ` LOT_ 30 i LOT 29 -- - - - - - -- RIDGE COTTONWOOD RIDGE i - - - - -- 1 i WEST Lim OF THE NW1 /4 • i 1481.67 7 03.09 ' 1 1 _ AE � 1 13SI i 13 o .� � it j R� 8 > m S rn 0 N on to .°�. i� iC/1 ;� v �� •_ z� YCf m 1 a - - - - — � S01'16 36 E 435.81 i z g8gg•• i� i 1 ca --1 W 01 4 b i C - , O ' ■`• 1 O ct _g id's r " ,p ti Sp1'16 3WE 435.61 ti- ...... S033S'48'W 318.42' Q+ � CA UNPLATTED LANDS I n v _---- - - ---- - - -- - - - - - -- v n �V oo : m m :3 O J IS z o > -. SOO'56 " N 213.06' g If S ZE O SHEET 1 OF 2 SHEETS Vol 18 Page 4798