HomeMy WebLinkAbout018-2019-56-000Wisconsin Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)],
Permit Holder's Name:
City Village Township
C&J BUILDERS
TOWN OF HAMMOND
CST BM Elev:
Insp. BM Elev:
BM Description:
C04u- c�_
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
2
Dosing
� S S
�❑ l
o i
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
x �oIl
❑��
_
5
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Numbq
TDH
ift
Loss
Syst Head
TDH Ft
F rcemain
ZFrion
Dia.
Dist. to Well
SOIL AUORPTION SYSTEM
ELEVATION DATA
County: St. Croix
Sanitary Permit No:
648499
State Plan ID No:
Parcel Tax No:
018-2019-56-000
Section/Town/Range/Map No:
29.29.17.1256
STATION
BS
HI
FS
ELEV.
Benchmark
s s6A - VJV �0
Alt. BM
Bldg. Sewer
10(o$ • D9
St/Ht Inlet
. 2 �
1 0(02.9 2
St/Ht Outlet
Headeameri-
Dis
Bot. System
IG
St Cover
3 . cv�
I o0 . sl
ipc, -k s n
,22
I050(.g5
BED/TR
Width
Length
No. Of Trenches
PIT DIMENSIO.
o. O Pits
Inside Dia.
Liquid Depth
DIMENSIONS
SETBACK
SYSTEM TO
P/L „/
BLDG
WELL=TAKE/STREAM
LEAC
Manufac rer:
INFORMAT N
BER OR
UNIT
T f System-
yp y
Mod Nu er:
DISTRIBUTION SYSTEM
Header/Manifold
Distribution
Size
x paci
Vent to Air Intake
Pipe(s)
Len Dia_
Length Dia pacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
Depth Over,
d/Tre h Center
pth Over
Be ch Edges
xx Depth of
oil m
xx Sec d/Sodded
Xxlalc'h2U
Yes ❑ No
❑Yes ❑ o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:
Location: 1623 75TH AVE
1.) Alt BM Description =
2.) Bldg sewer length =?
- amount of cover =
Plan revision Required? ❑ Yes No
Use other side for additional information.
9 2Z3
Date
SBD-6710 (R.3/97)
Inspection #2:
Cert. No.
_ ' j! f / (tom U
Safety Buildings Division
County
St. Croix 5
and
201 W. Washington Ave., P.O. Box 7162
Sanitary Permit Number (to be filled in by Co.)
W_
Madison, Wl 53707-7162
* �N
_:'L, 1 1 X L C
c `� � "'' "~� Pormit Application
State Transaction NL1111hCr
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
90'75C
-
Project Address (if different than mailing address)
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.041 X m), Stats.
1623 75th Ave
1. Application Information — Please Print All Information f
Property Owner's Name
Parcel
C & J Builders
018-2019-56-000
Property Owner's Mailing Address 110 A
Property Location
316 Kamloops Place
Govt. Lot
NW 1/4, SW '/4, Section 29
City, State
Zip Code
Phone Number
River Falls,
54022
-1,29circle one)
NaNR 17 EorW
11. TYpe of Buil(fing (check all that apply)
Lot 4
4 \//
I or 2 Family Dwelling - Number of Bedrooms 1
56
Subdivision Name
Block #
Rolling Hills Farm
El Public/Commercial - Describe Use
- -----
El city of
11 State Owned - Describe Use
Village of ---
CSM Number
Town of Hammond
11111."Type of Permit: (Check only one box on line.A. ('omplete line B if applicable)
New System
El Replacement System
El Treatment/Holding Tank Replacement Only
El Other Modification to Existing System (explain)
El Permit Renewal
El Permit Revision
El Change of Plumber
El Permit Transfer to New
e� it-�j,,cMue
List Previous Permit NUMb and Da d 55'
Before Expiration
Owner
t __ _ LZ
617796 1 /2/20
IV. Type of PoN'TS.,5ystem/('()mponent/Devicc: (Check all that a
El Non -Pressurized In -Ground El Pressurized In -Ground El At -Grade Mound > 24 in. of suitable soil
El Mound < 24 in. of suitable soil
❑ I Holding Tank El Other Dispersal Component (explain)Pretreatment Device (explain) Hoot 600
V. Dispersal/Treatment Area Information:
Design Flow (gpd)
Design Soil Application Rate(gpdsf)
Dispersal Area Required (sf)
Dispersal Area Proposed (st)
System Elevation
Existing
V1. Tank Info
Capacity in
Total
4 of
Manufacturer
Gallons
Gallons
Units
a
0 73
New Tanks
Existing Tanks
C73
V)
�7.
Scptic or Holding Tank
400/921
1
Hoot 600/ Wieser
x
Dosing Chamber
V11. Responsibility Statement- 1, the undersigned, assume responsibility for in�tallation of the POWTS shown on the attached plans.
Plumber's Name (Print)
Plum r' Signature
Number
Business Phone NUmher
Keith Knudtson
648443
651-470-1737
Plumber's Address (Street, City, State, Zip Code)
927 150th St. Roberts W. 54023
VIII.Counq epartrnenttJsc0nly___,.__
N(Approved isapprov Perillit 1-'cc Date Issued Issuing Agent
Signature
7nerGiven Denia
for Lenia
IX. Conditions oQp1rova roval 3
__q - )
&,,ILAA IZ&rCm_ vV-.- .,,LVL
SYSTEM OWNER:
1. SepVc tank, effluent filter and dispersal cell �tl OL tA-94 6-a- .- 6-kr&b-v,)
a_4 4,"k M4-(L ` f) -r S
must be serviced / maintained as per k&&,ke
management by
plan provided plumber.
2. All setback requirements must be rna'�ntained A T, mi4dl 6e t CIO -.1 4:gary COX _1J
A.Ar OL
as per appJc,�tie code I ordinances.
OW- 1i4A&Q01kq_ At
Attach to complete plans for the system and submit to -the County - onh? orbpaper nAi-less -than 8 to x 11 inches in �e
r
C &L cal� CL/Ico
0- —A-
SBD-6398 R. 11/11) t ka meozi UJA�
Art Ct 141 1eAV-1* V-'e L&rAgP bkl��23 3, c&t�
75TH AVENUE
COPY ARC LENGTH
72. 99' 12.19'
•i w4
PROPOSED
DRIVE WA Y
PORCH
20.11 8.7 ni 3.3 23
i
C3�
14.0 13.0
C!
1a0
I
c
to
lei
N
LOT 55
21,7M sca r.
I
%A in
85. r8*
SGLLE: 1INC" = 30 FEET
-;p!T ------MNMMNW
0 30 60
VERTICAL CONTROL DATUM: NAVD 198a
PROPERTY ADDRESS:
1623 75TH AVENUE
H MOND,IM 54015
�� � NORTH �? '�-7
auaiMuM suuaNG sETsnucs:
FRONT 35 FEET
I SIDE 10 FEET
REAR lOfEET
DIMENSIONS ARE SHOWN FROM
LOT UNE TO EXTERIOR FOUNDATION WALL
LEGEND
• FOUND IRON PIPE PER PLAT OR AS NOTED
0 WOOD HUB SET AT 10' OFfSET OR
ON BUILDING LINE EXTENSION
T.O.H. TOP OF HUB ELEVATION
`O T.O.P. TOP OF IRON PIPE ELEVATION
N — — — — — UTILITY g DRAINAGE EASEMENT
— - — — DRAINAGE EASEMENT
02, 61ec>x-% %-�
COPY
U)60-,�t /,:" w 12
,., dam. eapP.
d0
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Hoot lot 56
Owners Name: C & J Builders
Owners Address: 316 Kamloops Place
River Falls , W i. 54022
Legal Description: NW 1 /4 SW 1 /4 S 29 T 29 R 17 W
Township:
Hammond
County:
St. Croix
Subdivision Name:
Rolling Hills Farm
Lot Number:
56
Parcel ID Number:
018-2019-56-000
Page I
Index and title
Page 2
Plot Plan
Page 3
S tern Sizing & Cross -Section
Page 4
Filter Specs
Page 5
Maintenance information
Page 6
Management Plan
Page 7
St. Croix Cty Septic Tank Maintenance Form
Page 8
Warranty Deed
Page 9
CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber.
Keith Knudtson
License Number. 648443
Date:
06/05/2023
Phone Number (651) 470-1737
Signature
Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
H ,y
T TREATMENT SYSTEMfN1TIAL SERVICE POLICY
(Oi�j HOOT Aerobic Systems, Inc.
2885 Highway 14 East Lake Charles, Louisiana 70607
(337) 474-2804 phone (337) 477-7904 fax
Our ornpany, / &�.
��4 4 & a(- -WJ V intain the Hoot Aerobic System located
at L-Ao T 10--fz- •- . Aerate and mal
5,6- *044#1 HIMS F4rl% *'
Permit # (legal description only)
for the period of 2 years beginning and endin
This contract will provide for all required inspectiorLs, testing and service of your HOOT Aerobic Treatment Systern. The
policy will include the following:
inspections a year/service calls (at least one every __6p months), for a total of 4V over the two-year
Period including inspection, adjustment and servicing ofthe mechanical, electrical and other al�p_�Iicab�le component parts
to ensure proper function. This includes inspecting control panel, air pumps, air filters, diffuser operation, and replacing
or repairing any component not found to be functioning correctly.
2. An effluent quality inspection consisting of a visual check for color, turbidity, scum overflow and examination for odors.
A test for chlorine rtsidual and pH will be taken and reported as necessary.
I If any improper operation is observed, which cannot be corrected at the time of the service visit,, you will be notified
immediately in writing of the conditions and estimated date of correction.
4. The Homeowner is responsible for maintaining a chlorin residual of at least I rng/L in the treatment system. This can
be accomplished by US'Mg chlorine tablets designed for wastewater use, NOT SWIMMING POOL TABLETS. Upon
visit, if the system needs chlorine tablets the service provider will add them and charge the customer. If the customer
fails in their responsibility to add the chlorine tablets, they are in violation of law and appropriate action will be taken.
Initials of InstallerInitials of Homeowner
5. Any additional visits, inspections or sample collections required by specific Municipalities, Water/River Authorities,
County Agencies the TNRCC or any other regulatory agency in your Jurisdiction will be covered by this policy.
At the conclusion of the initial service policy, the Service Provider will make available, for purchase on an annual basis, a
continuing service policy to cover labor for normal inspection, maintenance and repair. According to state law, all owners
of aerobic systems must maintain a factory authorized service provider for the lifetime of the system.
The HOOT Homeowners Manual must be strictly followed or warranties are subject to invalidation. Pumping of sludge
0
build-up, for reasons other than due to wwantied mechanical failure, are not covered by this policy and will result in
additional charges. By signing this form, both Installer and Homeowner agree to the terms of this policy. By signing this
form, both the Installer and the Homeowner agree that the Homeowner has received a copy of the Homeowners Manual and
the Installer has made a reasonable effort to explain all pertinent information to the Homeowner.
HOOT is not responsible for service, it is the SERVICE PROVIDER indicated below.
HOME OWNER
G+3 �v�tde�s tKc.
Name
3►6Lj:9 P5 i7LAC-F,-
��v�����s,%,I J_ sr 4 o �
Ph Who..'
Si of Home nwncr-
SERVICE PROVIDER
NWnL4 of 'Smice Company Ptepre5enr*40
9�v 7—
Addr .
C'
Pfione
Zepk"c of'gc_rVrc� Provide- and Licensc- 4.
THIS BOX MUST BE COMPLETED BY THE SERVICE PROVMER
HOOT Model # Blower/Panel Serial # 1400T Mold
White Copy - Home Owner Yellow Copy - InsWler Pink Copy - HOOT GOIdCarod Copy - Rcgul story Agency
Contractor Guidelines for ATU Septic Homes
The septic system for this home will depend on the proper functioning of the Aerobic Treatment Unit
(ATU), which is designed to treat and degrade solids prior to discharge into the shared septic system. As
contractor/builder, please observe the following Construction guidelines:
As part of design and construction, arrange for water from SUMP Pumps to go to an external
disetwge. Backwash from water softeners should also be discharged externally, as doing so will
extend the life of the septic system. Note: Regulations prohibit furnace condensate from being
discharged externally-
• Garbage disposals are not recommended.
• Avoid allowing any inert construction materials such as plastic, rubber, cigarette filters, bandages,
rags, cloth and towels to enter the system. Likewise, prevent construction chemicals and toxins
such as paint and paint thinners, solvents,, etc., from entering the system.
Contact Knudtson Plumbing and Contracting prior to siting house gradc in order to confirm that
adequate fall will exist to allow gravity flow betwcen the house, the ATU and the shared septic
line (which may be as shallow as 42 Inches). Incorrect siting may require an additional pumping
station and incur significantly higher costs.
• The ATU manufacturer does not recommend tank installation in frozen ground, and it will be
done only at the contractor/builder's request and risk- Installation under these conditions will
likely also incur added costs related to requirements such as snow removal, frost ripping,, etc.
• Freeze warning: Water from furnace condensate lines or other sources, includina sinks and
toilets., entering the system during winter construction Can - cause the to and cpmpQRents to
freeze and fall., as there is no bacterial action at this stage to -generate heat- Use a salt sump to treat
this water prior to entering drain lines. Contact Knudtson Plumbing and Contracting for a
description. Builders failing to observe this precaution may be liable for system repair and/or
replacement due to freezing. Whenever possible, keep interior water lines to off during
winter until the time of occupancy.
-�P ,4e,.qje,* Tanks must be Pumped prior to homeowner occupancy.
must be contacted bythe bul
Q-ccupgacv. Contmetors f el
kl—ing-tQ-40—so will so] Y responsible for any resulting dainages!
For questions regarding these construction guidelines,, call:
Knudtson Plumbing and Contracting, 651-470-1737
I have reviewed and understpnd the above guidelines:
C4hf&tor
5
Rolling Hills Lot #
6/�/aoa3
Date
1 /�M
O�
31 �' 74it
CO
4" CAS � �d� � �� 4" CAS
L6 J
` oz
I 14�1
t 41" 1 1 40" i
4K12"A
Q ser R
isaz (t�
0 GPD QRA �?JTGw
H-w6OO A
NK- -SPEQIEI CAM
Dimmomft
W r
�Q
o it
MANHOLE: 20 & be 1,-M PLASTIC t43D
HE10 ; 70 obe
MM LID (T'P) LENQlH 10e* a,D.
WIDTHS 74 " O.D.
BELOW IN � a7* aD o
WMOHM 11,135 UM
INLET VD OU'#UM
4 CAST A --SEAL, (CAS) OWT OR EQUAL.
CO1M MIX DESIGN NO n9M
TANKS IIC DEMON FOR)
CUSTOWIrM TANKS:
FOR CUSTi TANKS OONTACT WIESER CONCRETE
) r
YP
SIDE MEW
TANKS ARE MANUFAOn= TO MEET OR EXCEED ASTM O1227 RECUREMICM .
't
DRAWINGS SUBMITTED
FOR APPROVAL
mmwm m
OPnava an:
PROWCfS MmW �Y7
(2) (:D
CW~% O�flr
H=Ser*ies Gravity Treatment System
Green Chore Applications:
Single and Multi -Family
Dwellings, light commerdal,
Churches, and other similar
Residential strength uses.
Performance:
98% Reduction CBODs
99% Reduction TSS
99% Conversion of Ammonia (NH3)
�sl
<1 �nnr� ���: C d;s:nfeCtio^
Gex,-zi
Range of Sizes:
500r 600,750 & 1000 GPD
High Performance• low cost, energy elfident tre�tntent systen�
The H-Series Gravity Treatment System provides high performance at a price comparable to most entry level ATU's
Producing effluent of less than 3 mgA- on CBODs and 2 mg/L on TSS, it far exceeds the secondary standards of 25 mg/L on
CBODs and 30 mg/L on TSS. With these results, many locations allow reductions in disposal areas between 25 and 4096.
Because the H-Series completely transforms ammonia into nitrate, it is best suited for applications with rich organic soil
content surface plant growth and depth to groundwater to prevent nitrogen pollution of the water table.
simple ins lat3on, reliable performance, low cost of ownership
This level of performance is enhanced by its simple installation, energy efficient performance and low cost long term
maintenance and ownership. The systems components are assembled at controlled manufacturing fadiities, rather than in
the field, to ensure reliable performance with local support
Enemy efficient, environnrentat protec#ion
Made of locally available and manufactured concrete, the H-Series features an energy efficient linear compressor that
uses less power than an average light bulb. Its polyethylene clarifier hopper is made of recycled milk jugs. Choose Hoot,
and you make a sensible, decision to protect the environment as you protect our most precious resource, our water.
Owaland Ve"Scal oil R�di�C ors
With gravity flow discharge, the H-Series allows you to choose your disposal application from conventional lateral lines,
leeching chambers, other alternative drainfield materials, in some areas direct discharge Is an option as well. Reductions
of vertical separations to groundwater and impermeable layers such as rock range from 1 to 2 feet
llllake the green choice for wart r ent
Your wastewater system is the most expensive and important appliance you will ever purchase. Donl settle for just any
system. Protect your family and the environment with a Hoot H-Series System.
Wieser Concrete Products hm 1-800-325-"56 ftMMwww1e&eff conc.rftexom
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Homeowner Guidelines for homes equipped with Aerobic Treatment Units
The septic system for your home depends on the proper functioning of the Aerobic Treatment
Unit (ATU), which is designed to treat and degrade solids prior to discharge into the shared
septic system. To avoid breakdowns and costly repairs, please observe the following guidelines:
• Avoid allowing any inert materials such as plastic, rubber, scouring pads, dental floss,
cigarette filters, bandages, hair, mop strings, lint, rags, cloth and towels to enter the
system. These materials can build up in the tank, resulting in system malfunction,
clogging and premature pump failure.
• Do not flush or drain chemicals and toxins into the system, as they kill the microbes
necessary for treatment. These include paint and paint thinners, solvents, drain cleaners,
automotive fluids, fuels, pesticides, herbicides, fertilizers, metals, disinfectants and
sanitizers.
• Paper products including disposable diapers, paper towels, baby wipes, facial tissues and
moist toilet paper are not designed to dissolve in your on -site treatment systems. Neither
will excessive amounts of toilet tissue decompose.
• Limit garbage disposal use to food waste that cannot be scooped and thrown in the trash.
Do not put ' fats and bones, grease, coffee grounds, citrus and melon rinds, corn
cobs, egg shells, etc. down the sink. Also avoid putting spoiled dairy products and yeasts
from baking into the system.
• Do not put medicinal materials, automatic disinfection tablets and similar items into the
system. Also, septic tank additives generally do more harm than good.
• If possible, spread laundry practices out over several days, rather than one "wash day," so
the ATU can more efficiently process the water as it enters the system. Liquid detergents
are recommended over powder; fabric softener sheets are preferred over liquid softeners.
Use bleach sparingly, at half the recommended rate.
• Clear water waste from dehumidifiers, HVAC units, gutters, whole house treatment
systems and sump pumps can increase the flow to both your on -site system and the
shared system, leading to shorter life. Both clear water and backwash from water softener
regeneration should be discharged to an alternate outlet. Talk to your contractor.
Do not disconnect power from the unit!
Your ATU is equipped with an alarm that will notify you of a malfunction. If the alarm does
sound, for diagnostics, service and repair call:
Knudtson Plumbing and Contracting
651-470-1737
S7: CRO, - UNTY SANITARY SYSTEM Rife�o ":_
I Office �only
OWNERSHIP/ADDRESS FORM CnWed21
Community Development Department will utilize this information to provide the property owner wl'th
information regarding operation and maintenance of your new or replacement Sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, Property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email. If you would like to view your i55Ued sanitary permit online, you can
do so by using theEr Filgs S�anned weblink-
OWNER/BUYER INFORMATION
Owner/Buyer C +;:y i3v r I, dcr,g im-ti C"'
Mailing Address- 3 6KAML0(>P_5 F"CIF
City/State/Zip Ktva F-ft<<S1 uz 5j(oaa
Phone Number (required) It 5 - a-a`a--�
Email Address (required) sb7 &AC�nc-,�
Parcel Identification Number 0 aOlImftb 0 0
(found on the property tax bill)
NEW SYSTEM.- LEGAL DESCRIPTION
Property Location 1/4 1/4 Sec. on CD _9L_1j T NR11W,Townof 1+A^K0&0
Subdivision Plat _ . Lot # 5
� .
Certified Survey Map # Volume Page #
Warranty Deed # -J (before 2006)Volume Page #
Number of bedrooms Spec house E3 yes )q no
Lot lines identifiable 4yes 0 no
New Property Address
(staff initials)
__ � GAS
(Verification of new address required from Community Dweeloprr;ent Department for new construction_)
Zg 24a) C?
(Date)
OFF11 USE ONLY
Axc-
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: Include with this form 0 recorded warronty deed from the Register of Deeds Office rind a copy of the certified
survey map if reference is made in the warranty deed.
715-386-4680 Community Development Department - Land Use Division
r_dd0)SCCWL'g0V 11St. Croix County Government Center
01 Carmichael Road, Hudson, W1 54016
715-245-4250 Fax
State Bar of Wisconsin Fozm 1-2003
WARRANTY DEED
DoCmwWNk=ba I Dm=wcWNamc
BY TIM DEED, VoraaDeSoto LLAC, a nesvta United liability company,
(h, ; .11fler"GranW."whedberomornuml convey and ww= to c & i Builders,
„ a whMends csrparxti,1 1
khezein� "Gramee," whetter one or more), the
folkming desmibed real estaw in SL Croix county, state of wisconsk:
Lat 56, FW of Ro@kg RM Farm in the Tomm of Hmmend, St: Croix County, Wisconsin.
Exception to qjnfips' Fase _119ts,11--t-whow and covamits of record; highway and
sued r*W of war, and Municipal and nxdng ordinanem and agrmneuu entered
under and finAer except real estate taxes acciruing in the year of this conveyance.
Did 7 /27/22
Vora LLC, a hfinnesoft kited liability company
VJ�ILS. %
* -Br. Paid Schreier, Pnmmikut
1156709
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
07/29/2022 02:58 PM
EXEMPT#:
REC FEE 30.00
TRANS FEE 120.00
PAGES: I
**The above recording information
verifies that this document has
been electronically recorded
& returned to the submitter
Recording Area
NWW and Return Address
St- Croix County Abstract & Title Co., Ine-
575 N. Knowles Ave., Suite #13
New Rkhmond, W1 54017
018-201�
-Wel 1dcgMif"i0n Number (P"
This IS NOT homestead pn4K"y.
(SJAMES S MALONE
EAL) Ariwo- q
Notary Public
State of Minnesota
My Cornmission Expires
January 3l, 2026
AUTHEIMCATIM ACKNOWLEDGMENT
STATE OF 1%
authenfic I ated on COUNTY FNAWZ15Y
Personally came before me on 7
the above -named Paul Schreier President Tfll.E- hCEMBER STATE BAR OF WISCONSIN I as of
knot VoranDeSoto LLC, a Minnesota limited liability compj!ny
authorized by W-k Star. § 706-06) to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
THIS IN LUMENT DRAFTED BY: JPWtV,,S AAA -LooOG'
St_ Croix County Absuza & ride -Co., Inc-, by Andrea S. fvka_g�.
Cmpent= at the dkeWon ofthe Cauntor. 22-S31625Z Notary P State of
My Commission (is permanent) (expires:
(Skwtwex may be autbenticoted or wAnewiledged. Both are met necessary.)
N[ T]k TMS IS A STANDARD FORM. ANY MODMICA111ONS TO THIS FORM SHOULD HE CLEARLY IDENITRED.
WARRANTYDI" 0 2003 STATE BAR OF WISCONSIN M-RM NO. 1-2003
* Typc welt below v ig. - il 1 6
St. Croix County 1156709 Page 1 of 1
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ARC LENGTH
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VERTICAL CONTROL DATUM: NAVD 198a
PROPERTY ADDRESS:
1623 75TH AVENUE
H MOND,IM 54015
�&/5/- � NORTH �? '�-7
auaiMuM suuaNG sETsnucs:
FRONT 35 FEET
I SIDE 10 FEET
REAR lOfEET
DIMENSIONS ARE SHOWN FROM
LOT UNE TO EXTERIOR FOUNDATION WALL
LEGEND
• FOUND IRON PIPE PER PLAT OR AS NOTED
0 WOOD HUB SET AT 10' OFfSET OR
ON BUILDING LINE EXTENSION
T.O.H. TOP OF HUB ELEVATION
`O T.O.P. TOP OF IRON PIPE ELEVATION
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PRIVATE SFVVAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (A I I AC H IL I.,.j PI I MI I',
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Rollinq Hills Farm 0wnei!,"; /\ssociatloru
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TANK INFORMATION
TANK SETBACK INI"ORMATION
St C roix
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617796
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TOWN OF HAMMOND 018-2019-79-000
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Document Number
Document Title
St. Croix County
AEROBIC TREATMENT UNIT (ATU)
SERVICING AGREEMENT
State Permit Number --
C & J u ilders, Inc.
Name — (Owner) Typed or printed
He/she is the legal owner of the following parcel of land located in St. Croix County,
Wisconsin, with their deed or document of ownership interest recorded as Document
Number 1156709 St. Croix Register of Deeds Office.
This Property is described as follows (include lot no. and subdivision/CSM or detailed
legal description):
Lot 56, Plat of Roiling Hills Farm in the Town of Hammond, St. Croix
County, Wisconsin
OR:
❑ See attached deed copy for legal descriptions
Agreement Date:
Doe A: 89It Jill
86336
Tx: 5 69235
1168333
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
06/ 2.8/ 202.3 09:08 AM
EXEMPT #:
REC FEE 30.00
PAGES: I
Recording Area
NAME AND RETURN ADDRESS
�� �� e
�.
018-201.9-56--000
Parcel Identification Number (PIN)
As an inducement to the county to issue a sanitary permit for a POWTS equipped with an Aerobic Treatment Unit on the above -described property, we
agree to do the following:
1. Owner agrees to conform to all applicable requirements of SPS 383, Wis. Adm. Code relating to Aerobic Treatment. Units (ATU) and the
maintenance requirements for the proposed POWTS (Private Onsite Wastewater Treatment System) technology. If the owner fails to have the
POWTS and ATU property serviced in response to orders issued by the governmental unit or the Department of Safety and Professional Services
(DSPS) to prevent or abate a human health hazard as described in s. 254.59, Stats., the governmental unit (Town) may enter upon the property
and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment
for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats.
2. The owner agrees to maintain a contract with a licensed POWTS maintainer for the life of the system. The POWTS maintainer will perform
periodic inspections and maintenance as required by the manufacturer and the Department, including, but not limited to: the blower, electrical
controls, and treatment unit operation and sludge depth. These inspections are to be scheduled every 6 months for the first two years of operation
and yearly thereafter.
3. The owner agrees to contact the POWTS maintainer immediately upon any malfunction of the treatment unit and to maintain the unit so as to not
create a human health hazard as described in s. 254.59, Stats.
4. The owner recognizes that the county, DSPS, or POWTS maintainer may make periodic inspections of the components to complete performance
monitoring of the unit.
5. The owner or the owner's agent agrees to report to the department or designated agent at the completion of each inspection, maintenance or
servicing event in a manner specified by the department or designated agent within 1 ❑ business days from the date of inspection, maintenance or
servicing.
6. This agreement will remain in effect only until the county office responsible for the regulation of POWTS certifies that the aerobic treatment unit
no longer serves the property. In addition, this agreement may be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall subrr�i ►tk� �ement to
the Register of Deeds, and the agreement shall be recorded in a manner that will permit the existence of the agreem�t � gBj3jS 'iV d by
reference to the property where the Aerobic Treatment Unit is installed. ��. Pam, . • - - • .� rf r
Owner(s) Names) - Please Print
Subscribed and sworn to before me on this date '
Notarized Own 's Signature(s)
Notary Public�:"•'1S'G�i����
Governmental Unit Official Name, Title -- Please Print
My Commission Expires
Community Development Department
�-- r--�
Gov mental Unit Official Signature
Drafted by:
AJ -L
I } Personal information you provide may be used for secondary purposes [Privacy Law s. 15.04(1)(m))
St. Croix County 1168333 Page 1 of 1
r
COUNTY
OWNER Cj.. guw� f�N'C..
SBD-06499 (RI 1/20)
...... ..........................
uE X
CHAPTER 145.135 (2) WISCONSIN STATUTES
(a) The purpose of the sanitary permit is to allow installation
of the private sewage system described in the permit.
(b) The approval of the sanitary permit is based on
regulations in force on the date of approval.
c The sanitary permit is valid and may be renewed for a
� � Y ]P Y
specified period.
(d) Changed regulations will not impair the validity of a
sanitary permit.
(e) Renewal of the sanitary permit will be based on
regulations in force at the time renewal is sought, and that
changed regulations may
impede renewal.
y
(f) The sanitary permit is transferable.
History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314
Note: 1f you wish to renew the permit, or transfer ownership of
the permit, please contact the county authority.
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