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002-1010-70-000
Wi°consin DetyartmentofCommerce PRIVATE SEWAGE SYSTEM Saft'ety and Building Division 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 X Township Place, Gordon & Maxine Baldwin, Town of CST BM Elev: Insp. BM Elev: ` BM Description: ~ /J ~ ~~ /3 X 97, o a G - TANK INFORMATION n ELEVATION DATA TYPE MANUFACTURER ~~ CAPACITY Septic ~ (it~i GS~.~. '~ ~ SUO Dosing / l~v Aeration Holding TANK SETBACK INFORMATION TANK TO n~/L ) WELL BLDG. Vent to Air Intake ROAD Septic ~~ ~ D / /p ..- Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH L Friction Loss System Head Ft Forcemain th Di Dist. to well SOIL ABSORPTION SYSTEM County: St. Croix Sanitary Permit No: 514951 0 State Plan ID No: Parcel Tax No: 002-1010-70-000 Section/Town/Range/Map No: 05.29.16.758 STATION BS HI FS ELEV. Benchmark Ait. B,___ ~ . ~ ~~• y Bldg. Sewer 1~Z.3 S z~ 97. o$ SUHt Inlet ~~ , .l ~f ~, ~~ SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover ~ ~ G ~ Q + I ~A L/ ~j ~ 7 BED/TRENCH Width Length No. Of Trenches PIT D ide Dia. Liquid Depth DIMENSIONS SETS SYSTEM TO P/L BL WELL E/STREAM LEACHING Manufacturer: INFOR TION CHAMBER OR Type Of System: DISTRIBUTION SYSTEM Hole Spacing IVent to Length Dia ength Dia Spacing SOIL COVER x Pressure Svstems Ontv xz Mound Or At-Grade Svstems Onlv Depth Over \ Depth Over xx Depth of xx Seeded/So Mulched Bed/Trench Center edlTrench Edges Topsoil ~ Yes 0 No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ Location: 1121 220th Street Baldwin, WI 54002 (SW 1/4 SW 1/4 5 T29N R16W)/metes & bounds Lot Parcel No: 05.29.16.758 1.) Alt BM Description = ~ (,~ ~~~ ~' f~'~~ d~_ 2.) Bldg sewer length = -amount of cover = ~ J (` //~ Q /~ ~ +"' C~GJ,~ k7ldG ~t~..t..~_ ~eiJP~ (fir Plan revision Required? 0 Yes ~'IQo ~ ~ ~ f Use other side for additional information. ~__ SBD-6710 (R.3/97) Date Insepcto Signatur ~-~. ~.t1J.~~J ~~ Cert. No. cpfrtmer~e.wi,gpv Safety and Buildi 'vision County , t ~ ~ ~, 201 W. Washington Ave., .0. x 7162 r ~ ~"'~ ~ ~ v Madison, W 370 Sanitary Permit Number (to be filled in by Co.) departmen t of Commerce S~ ys~ Sanitary Permit Application StateTransCac~tionN/umber ~ ~ In accordance with s. Comm. 8321(2), Wis. Adm. Code, submission of this form to the appropriate emmental ~/ lO / unit is required prior to obtaining a sanitary permit. Note: Appl S are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal informatio you p~lv~'e~i l 3r. ~~>~se~or sec ndary ur ses in accordance with the Privac Law, s. 15.04(1 m), Stats. ~ p I. A lication Information -Please Print All Information ~ ~ V Property Owner's Name ^, rrl~jQj AUG G G LGuv Parcel# ~ ' . 002 -/O/O -'70 - DOU ~ ~ ®y„ Property Owner's Mailing Address " S T. Cr OlX COUNTY Properly Location (~ 7SB~ ~~0 ~ ~ ZONING OFFICE cJ ~ Govt. Lot City, State ~ ~ Zip Code Phone Number SGt] ,/a ,~''~ ~ /<, Section / T ~ ~ N R ~ ~ II. Type of Building (che all that apply) ~ Lot # ; j ~ Subdivision Name 1 or 2 Family Dwelling -Number of Bedrooms J ~ ~ ~ Bl k # ~ ~~ oc ^ Public/Commercial -Describe Use ~~ ^ City of ^ State Owned -Describe Use CSM Number ~(~~/ ^ Village of t Town of ~ Q/ LCD 1 jtii . III. Type of Permit: (Check only one box online A. Complete line B if applicable) A' ^ New S stem y Re lacement S stem p y ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and ate s ed ~ /r r Before Expiration Owner h~ %l~~ ~ I. V ~t P IV. T e of POWTS S stem/Com onent/Device: Check all that a 1 ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment Device (explain) V. Dis ersal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ~ ~.Q~_ ~"ZA ~~ i VI. Tank Info Capacity in Tota # of Manufacturer o Gallons Gallons Units ~ Q ~ U == o New T k tin T E i k ~ ~ ~ ~ R an s g x an s s o w U a; ~ ~n ~ r7r i1. C7 R. Septic or Holding Tank Ljl~l ~~/7O D W G~' :---~. l~Q© e, Dosing Chamber. VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) ~" a l ~ ~-mo Plu 's Signature ~ MP/MPRS Number Z~oBs~3 Business Phone Number 7~s =~~ 337 . , o ~c, ~ ~o ~ - Plumber's Address (Street,~C/it)y~Sftate, Zip Code) , ~) ~~ VIIL nt /De artment Use Onl pproved ^ Disapproved Permit Fee $ ` ~ Date ssu d suing Age Signat ,a ~~ 5 ' I ~ ~ ~ ~ ',/,,- ~ r`~1~ caner Giv n Reason for Denial e a I~entafilter aria for Disapproval A~c~~~yt~ ,N't S/ ~ GU4,( (/`r ep is ank° ~ ~ ~~~ , - oG~in ~~~ dispersal cell must all be serviced /maintained ~ 7 ~~ t as per manaaPmPnt nlan r,rn yid d by plumber ~- /d ~"~"t~" ~ ~~ 2. All setback requirements must be tnaintalned Q /~ /D/ ~~Q ~ Y~ ~ ~ as per applicable code/ordinances. (/ ""` Attach to complete plans for the system and submit to the County only on par not less than S 112 x 11 inches in size ~~ ~`S~~ `tPt~~ " ~e - d~o~ 197d~ ~~m-w~ ~~B-~ (~f~~ ~ d ,~~~~• ._ SBD-6398 (R. 01/07) Valid thru 0]/09 G21y~, ~ k2;tt~~ .f~ZS~'~ s~/i1Jf ~G~~ ~1~~l~ri ~y- t~ °~~ ,~ -,ate .ro~c.~ ~~~ ~~~ . .. commerce.wi.gov ^ iscons~n Department of Commerce Safety and Buildings 3824 N CREEKSIDE LA HOLMEN WI 54636 TDD #: (608) 264-8777 www.commerce.wi. goy/sb/ www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary July 10, 2008 CUST ID No. 220853 DALE E HUDSON BOLDT'S PLUMBING & HEATING, INC. 820 MAIN ST PO BOX 78 BALDWIN WI 54002 ATTN.' POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/10/2010 Identification Numbers Transaction ID No. 1556319 SITE: Site ID No. 739617 Gordon Place Please refer to both identification numbers, 1121 220TH St above, in all corres ondence with the a enc . Town of Baldwin St Croix County SW1/4, SWl/4, S5, T29N, R16W FOR: Description: Holding Tank /Replacement construction Object Type: POWTS Component Manual Regulated Object ID No.: 1190201 Maintenance required; 450 GPD Flow rate; System: Holding Tank Component Manual, SBD-10571-P (R.6/99) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state mless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD-10571-P (R.6/99). • A sanitary permit must be obtained from the county where his project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • The activities relating to evaluation and monitoring POWTS components after the initial installation of the POWTS in accordance with an approved management plan shall be conducted by a person who holds a registration issued by the department as a registered POWTS maintainer. • The existing POWTS shall be properly abandoned per Comm 83.33, Wis. Adm. Code. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • Comm 83.22(7) - A cony of the approved plans, specifications and this letter shall be on-site durine construction and open to inspection byauthorized representatives of the Departrrpnt, which may include local ins ecp tors' Owner Responsibilities: The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy ofthe appropriate ~~iS. maintenance manual and/or owner's manual for the POWTS described in this approval. Clt 1?C11tiOllQjl17 PR4~'~D ~~o.~~.._.._ __ __________ DALE E HUDSON Page 2 7/10/2008 • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS .occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • In the event this POWTS or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely!,' ~~ _ Gerard M Swim POWTS Plan Reviewer, Integrated Services (608)789-7892,1VIon -Fri, 7:15 am - 4:00 pm j erry. swim@wisconsin. gov Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. CONCRETE HOLDING TANK DESIGN Single Tank Option INDEX AND TITLE SHEET vj ® a ? p Project Gordon Place 3-bedroom residential Holding Tank s°v ,~,~ c ~ Owner Gordon Place ~ ~ ~ ~ ~ ~ Address 1121 220th Street Q Baldwin, WI 54002 Site Address: Same Legal Description SW1/4 SW1/4, Sec. 5, T.29N., R.16W. Township Baldwin County St. Croix Subdivision Name Na Lot No. Na Parcel ID Number 002-1010-70-000 Plan Transaction ID Number Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Soil evaluation report Page 5 Designer Dale udson ~ ~ ,,,,/`~ ~ Signature Gam- ~ ~~~Gl Phone No. (715) 684-3378 License Number 220853 Date 06/04/08 pesigned pursuant to: Holding Tank Component Manual For POWTS SBD-10571-P (8.6/99) version a.o (oa/o3) Page 1 of 5 OIVIS+ON SAFETY ANi7 6UILi)INGS SEE CGRR PONDENCE HOLDING TANK SPECIFICATIONS 3 Number of bedrooms 0.0 Non-residential estimated flow (gpd) 2000.0 Minimum holding tank volume required (gal) i 3034.8 Proposed holding tank capacity (gal) Wieser Goncrete Tank Manufacturer WLP1800/1100 Tank model number JH Rhombus Alarm manufacturer SJE 10111421 Alarm model number Tank Dimensions and Data X for round tank 45.0 Liquid depth below inlet invert (in) 4.0 Maximum d th of soil cover (ft) 60.8 Height (in) Outside 184.0 Length (in) Dimensions 102.0 Width (in) Only HOLDING TANK CROSS SECTION junction box conduit blind plug to seal outlet Tank Anchor Calculations 24350 Ibs Weight of tank and cover 1.50 Safety factor 37408 Ibs Weight of anchor required 30.0 in Soil cover req. for anchor or 9.2 yds Concrete counter weight manhole Cover with ~- locking device and finished warning label grade ~4" min. -~^ 24 in. ~~~ " Manhole and vent locations • may be reversed. ~~,;~ _~ 12.0 in. alarm on A~ Electrical as per 33.0 in NEC 300 and Comm 16 Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with Comm 84. vent cap I 12" min. vent pipe 18" min. building sewer inlet 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Gordon Place 3-bedroom residential Holding Tank Transaction Number: Page 2 of 5 G S' al ~ r ~ r ~ I r r t d r r r ~ r i r ) ~ r ~i. ~ ~ / o ~ i ~ BS i ~ ~ ~ ~,l 6 2 ~ , i ~ j i r , ~ ~ ~ ~ ~ r ~ ,~ ~ ~ ' Q / ~' / asp ,i / / ~ / h N y6ro ~ ~ If. b~~rl : T o reu ~ i~ b ~ ~..ZD - ~ Slab. Elev,~ = 9734: c SG V s `~ st11 c'~ . '~ °uz~~ yard l,~/~E-~. ~~ _ ._. _~- 6.1,r/ -df' ~`• _ ' ~~~ cJL,P /BG~/~/OV com 5, ~ a~Fi'm, ~. ~o~r,5'-~ 6.e u se d cts ~Ewo , C- o,ti f a+ EM enf ko,br'n g ~ . t<o„ X : v , y~ %i` .r ~ ~o I Cantrc~c q a~a~e GL~ofPYl v .4 ~ i CX~~ff~ ~9 ,PcS. dance Assu..~ncd elG~.` _/~.~~ r r i ~- M V d~~ So;/ ed~ctct,~,?n-r 6ybQC~'LteP~,E 5a/ e,va.P. 6y ha-n d/0. ~ ale/a~~ o•-. - -- /~joi~/aY• /ecat~ior, of 6 cc.-; t,( ca.I2 : / = s~0' ,Pad' ~ /9.~s~ lvor'do.+ ~/a ee ~c~•-oho. a~./ ud{` ~ ; Bak-/~a%1 /. oo acre~~/ /ocnftd,'q Sc.JYySu~ ~.c.5; T. 29 ~1.,~. /6 cJ.~ Tn, o ~ 3a./oG.Ji n~ Jtr • C/piC Vic. cJ(. fop of~h~ld; n~ -rL~.„~/ ;~l~t = 4~. ~, E s t~; .na-~ d a !¢ rta,-E; ~~, ~ 9z. ~' ~/ -~o bG al6oc~don e~ 4 s~r Cie, ~~ .,3 °F s HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWYS) has been designed, and is to be installed and maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10571-P 6/11/1999), and the St. Croix County Sanitary Ordinance. 1. This POWYS is designed to accommodate an estimated domestic wastewater flow of 607.0 gpd. 2. The owner of this POWYS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code. 5. All service events or inspections of this POWYS shall be reported to the county within 10 business days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWYS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWYS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWYS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with Comm 83.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons should be contacted: a. Installer ............................. Dale Hudson Phone: (715) 6843378 b. Service Provider .................. Johnson Sanitation Phone: (715) 273-5811 c. Co. Zoning or Health Dept. St. Croix County Zoning Dept. Phone: (715) 386-4680 11. Project: Gordon Place 3-bedroom residential Holding Tank Transaction Number: Page 4 of 5 FOLDING TANK SERVICING CONTRACT G~»L t'i ,2G0 Y This contt~act is made between the Holding Tank Owner(s) Name{s} and Pumpet's Name tank{s} on 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(1}(c}l. Wis. Adm. Code and the approved Holding Tank Component Manual This agreemeat will also be filed with the $t. Croix County Zoning Department. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantces to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit that has signed the pumping agrcement and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper fiuther agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tanl~ c. The location of the property on which the holding tank is installed; d: The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volume in gallons of the contents pumped from the holding tank for each servicing; g. Tbe disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with local govemmental unit and the County named above within ten (10) business days from the date of change to this service contract. /-~ Owners} Name(s) (Print) Owner's Signature(s) Subscri ed and sworn todme on this date: t~ e n / ,,,~~ oday~ irate Pumper's Name (Print} umper's Signature ary Public Signature ~g ~ ~~~ ©~rz3 20// Pumper's Registration Number Commission Expiration RECEIVED JUL 0 1 2008 SAFETY & BUILDINGS Document Number Title St. Croix County Holding Tank Agreement State Plan Transaction Number - f o/~pbn ~laee, Name - (Owner) Typed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume 99? Page 3,~/ Document Numbery9f~~9 St. Croix County Register of Deeds Office; A parcel of land located in theme %, of the ~'/4 of Section S , T ~-9 N - R /(, W, Town of ~/a(rc~in , St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or detailed legal description): ~~ ~~ Name and Return Address Go~c~o n ~~4 /iz/ ,2,za'~s,~. S~O~Z UCJ.G - /U/U - 7CJ Agreement Date: C~/1Clv.~~ Parcel Identification Num We acknowledge that application is being made (or the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. Comm 83, Wis. Adm. Code, or Ch. 145, Wis. Stats. As an inducement to the county to issue a sanitary permit for the above-described property, we agree to do the following: 1 . Owner agrees to conform to all applicable requirements of Ch. Comm 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats., the governmental tihit (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, pursuant to s. Comm 83.54 (2), and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be Installed by a plumber authorized by the Department of Commerce to make such installations, with said installation complying with State re{tulations and manufacturers specifications. Ttie owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water mater, and agrees to allow the governmehtal unit or the Department of Commerce to enter the above-described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner, agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within tan (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a~person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being prope~-iy maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment sysiems certifes that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm 83, Wis. Adm. Code. 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 submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. i Owner(s) Name(s) -Please Print sc ' ed and sworn to before me on this date; i i I NG[an7e~j (~\'~ner5 S!QnBtnretS) I nfani P ihlir ¢ ~~ ls/ Governmental Unit Official Name, Title -Please Print Commission Expires II Govemmental Un Official Signature Drafted by: you provide may be used for secondary purpcsas (Privacy Law s. 15.04('!)(m)] "THIS PAGE IS PART OF THIS LEGAL DOCUMENT- DO NOT REMC?VG" This inlormaUon must be completed by submitter: document title, name & return address. and ~lN (i/required). Other in/ormation such as the granting clauses, leagal description, etc. maybe placed on this first page of the document or may be placed on additional pages o(the document. Note: Use of this cover page adds one page to your document and $2.00 to the racordlnc~ee• Wisconsin Statutes, 59.517. 1 1934 ' , oQ SORT D of Canxr~ ~ f '~t~"'~ • ' i Page t of 3 A.C.E. Sod & Site Evan /~ ~ , n Waoorrs pivi:aon d Sadly and Bum in acca C~~,~~~ " COU~y St Crobc 4~~' Attach ~ f~ on l~ ~ ~ than 8'/s I D ~ ~, rat Umrted ~. vet ~ ~~ ' .. 002-101 o-7o-OOo i„d„ , ~ percent stape, sc~e a dxnernsions, R . " ts aii ~ i Dde ~ . / E ~7 % ;,, ~r n pieasg pr ~'W f . y~ j ~L~ ~~"~ uee° .._ ......aeon Property Owner Govt. Lot SW 1!4 SW 1kt S 5 T 29 N R 16 W Gordon Place ~ # Block # Subd. Name or CSM# Property Owner's ~~ Add Na 1121 220th St. ~ ."' ~ ~ City ~ YiNage ~ Town Nearest Road Z~ ~~~!~ 1121 220Th Street ~ g~dwin B~dwin ~ Wl GPD a~ 450 fbw r Code derived design 3 ,' New Corgi Use: ~ Residential / Numkrer of bedroerns r , /-~ ~ cr ~°' J J ~'~-~~~`... ~y1T na Food plain elevation, if apP Parent mderial Giacc~al ~ be suitable for mound with A+tY~ interprative evaluation. mrnerrts ma it y Ppw(g S e Ger>e~ co S#e untie1~ tld and recamrrr ~? -g--~- ~i:'~ZC~ ~ ,~J.,.t/~ ' ~n~ ,, vn-i-~~v G ~_ ~ ~S~ -{~ ~ ~ ~ ~' G~-~ ~ BOrR>g # ~ l Ground surface elev. 9_ 3.4$ _ tt. Deptl~ to limitin9~ 16" ar. Sof Appl~atan Rate ~ Gpp!(tz Roots Stnicture Texxhue 'Eti#1 'E~ Horizon Depth Dominant Color Redox Desaiptia+ ~n~ Gr. Sz Sh. l]u. Sz. Cait. Cobr ~ 2c 0.6 0.8 3fm . rtrlfr sil 2fcr , ~ none 1 0-11 132 mv~ ~ 2fm,1c 0.4 0.6 none sii lthtnpl 2 11-16 10yr5/4 2fm 0.4 0.6 t"Lf 7.5yr518 s~ 1 msbk mvtr 3 16-20 1 pyr5/4 cv+r 6 4 0 0 12d 7.5yr416 sid 2msbk ~ 4 20-29 1 pyr4l6 . . cvv 2f,1 m _ 0.2 0.6 f3f 7.5yr4A6 sl Om ~ 5 29_g4 7.5yr3/4 - Boring # --~ ~~ Ground S~ce elev g2.p1 ft. Depth to limiting factor <8" _in. Soo Appfiption Rate GPD/f~ ~ ~ Structure ~+~ rizot- pepth Dominant Cda ~ Texture Gr. Sz_ Sh. H ~~ Rom 'Eff#2 'Eff#1 o in. Mur>seq mvfr ~ ~,f 0.6 0.8 ~~ 1 ~ 10yr32 none 1f 0.4 0.6 2vF mip7.lyr5~~ sil 1thinpl mvFr , cw 10yr5/4 2 8-16 mmzzdd ~Y~~O ~ m1~p7~.5 /tip ~ 1fsbk 6/2 416 ( ~ ~ 1vf 0.2 0.3 m } m2d 1 3 16-21 10yr 0 2 0.6 y r 46~ ~ Om mfi d 10 416 ~ _ . yr n2 r 4 21-38 7.5yr ' Ef'~nt #t = BOD ~ 3d < 220 m Land TSS >30 CST Name (P~ Ptirtt) Sim James tC Thompson f Address A.C.E. Sod & Site Eva~ations , ~ ~ 340 Paulson Lake t.~e ~ uent #2 = BOD < 30 mglL and TSS <~0 mglL CST Number ~_____ 3602 Date Evaluation Concluded' Teleptia>e Number 7182005 715-248-7767 ~' ~' ' _ _ _ _ Pending __ ~ Computer# 002-1010-70-000 - , Lot CSM: - _ Current Owner I i S 5 7/R T29N R16W _ - - J - Parcel # 05.29 16.75B _ 1/4 1/4 SW 1J4 SW 1/4 Flagged Zoned Ag-residential Baldwin Town of Municipality Address ' 1121 220th Street I~j Overlay Zoning Unknown Subdiv/Plat metes & bounds City/State Baldwin, WI 54002 857 Priority High Staff Assgn. Pam Quinn Notification First 03/06/2008; Third -- - Second Final Resolved _ Contact Hold-off FoAow-up _ - Letter _ _ - _ _ tank and the line that is discharging to e _ _ „ < _ ~_ __ _ _ - - - - - - along 220th Street -needs to be replaced ASAP. Send letter to owner ~ Trarkinn Shaat~ Print Nnta~ Arid NPw Prnhlem~ _ _ _ _ Problem Septic Failure Code Section 1 ~12.1F4.d. (2005 Sanitary).- _ _ Code Section 2 12.1F4.e. (2005 Sanitary)- i Ordinance Subject Sanitary Ordinance Ch. 12 (2005). Code Enforc. !] File # ' _ - _ _ - _-_- - Origin _ ' Inspection _ # Citations 0 Owner: Comments __ _--- - _ _ - _ - -- _ - - - - 2005 soil report documents an existing house with septic th road ditch ~~ _ , li IC DOCUMENT NQ. II STATEEAR UP' 11V1SUUN3iIV 1~Vltiri 3-ia~&;c •••~' °•^`-° ^°°°^°°'° ~"" nr•-°"~o~N~ owvw ii L~~Jf I~ {:LAI~1 %lt~t°3 _ 43L~~-~----__11_--_-_~(AL_ X77<~PAG~41._ --- __, ~ ~ r2 S'f~fi~'S O~~FIC~ ^--'-- ....___ ~•+....., si~i a..~a..r n_ oiA~o ~i~i~ „ ST.CROIXCO.,i,Vl ._____C.iCT[:CiC221._Ltl~lO.[IC.___. ~-J_A lt~1__A[ _.C_Y-_.YYI_4!Y!!__!_ ___S_1_~Y", ___J__ ~ "` Gn~+.l ., Dl ar• '"- ^ s---------- ;j R8C'Cf ?OY K2C0'C7 -----•v,,,_~p__..,---v~e._~~~-Max, nP Verne ce P1 ace, a/k/a Maxi nP ~~ ~' ---- ~l.--P1 ace, -a(k/a MaXlne pl ace, husband and wife _ _ ~ F~~ ~ 1993 qu;t elr~„nK ro Gordon D ._ ni awe -and Maxi ne V _ Place , _ - ~; pat 9:00 A~. (y{ . -__--_husband•-and, wife,,-col-d jn~__as--survivorship, maritai._ _-_:-_ i~ ~° ~? ~ ~ ---- -property.---- ------- --- _ -- ------ - ---- - - - ------- ---•-- -- ., - •- -•-•-- ----- ~' Register of Deeds ,' _ _ _ ti ~-.ra:r;--s -.:;~_-r,t,cd __aa _..____ ... .__._~t _•-f:r~~-~ -- --- ----- ------•---- ---- ------- ~~ __~- Stste of wiscun_ir• : , i~ ~flETU RN "IO ~ --- --~ :I A. Tax Parcel No : ---_-. ••_.----•-••-----.•-•-- Part of the Southwest Quarter of the Southwest Quarter 1 (SW~ of SW~j of Section Five (5), Township Twenty-nine ~ (29) North, Flange Sixteen (16) West, described as ~ __ follows: Commencing_at the Northwest corner of said f Southwest Quarter of Southwest Quarter (SW4 of SW~r); ±hence East 2 rods to the point of beginning; thence .South 16 rods; thence East 10 rods; thence North 16 cl^t= n new ... ..-... - - - 1 rnAc. +M.+ ~.~.. ..~ In .. .i .. +.. ~. tom.. _-i -r ~_ _ _:- i:,/ I #EXEifiP'~' This ...._.... ~ S ............... property. homestead (is) ~CifiX~)C > Dated this .........................~.~..-------- day o£ _. ~~/.Q!Y--- --....-----•--------......-- ---•-••---------= ls-_93... -•----• .. ..........:...•---------- .... .(SEAL) </-•-- ..~1!~-~va.Q..~--(SEAL) ' ..---_-- * --..'Ga~r-dan._Quane.._Pl.a~a ...... ........_.._...._ _ ......................(SEAL) -- - ~`'F`~ ,^'-t^1-`.`-4~-s.~-.(SEAL) ,, * ~axine Vernice P1 acv AUTHENTICATION ACKNOWLEDGMENT Signature(s) _____________ __..._..________________ STATE OF WISCONSIN i -------------------------------------------------------------------- •---------- auth-anticated this _____.__day of_ _ _ I9 ss. St . Croi x ---------------- Courtv. -- lt '~ ~ 1 _ ___________________ ______ ____ ersona y came before me this ___ M __day of 93 td ~ 1 I ~ --------------- --- - ---------------------- i -------------•------------------- . - _ . .. ............ _ - . __---------= 9_ _----_ tho ahocp n. Qrt Gordon ~arie Place, a.~k/a Gordon 0. 1~~'ace, I ! -"` ------ - --------------- ~/~%a rar,fa.,, oia.-e _a Y uIa € `~errzce'---- TITLE: MEMBER STATE SAR OF WISCONSIN Pl ace, a/fc/a P~id?~,7pe ~ ~ ace, a/k/a - ~ (If noz -•---•------- ------- ------- I ~ Maxi nz Place ~;r K k -- -.__......_ - - - ` + -------- ------- ` - ~ ~ autl;orized by § ?OS.06, Wts. Starts) TFIS INSTRUMENT `NAS ORA FTECt 8Y ' __.. ;° ~ r 3, r to me known to.LeaChe.nersanr,5,-,=---1-Qyh.~ ~ as tha _ foregoing i uE~n~~ij//7ti.>Ar~k~l~`e t:ne m ~ , ~•$ - - Thomas A. McCormack Baldwin WT 5400? - ~ -- - --- ----- ----- - • ~.---- ----•~- - - -- -•- ~ ~ U~ ~~.~,. p *----•---~",f1~lyte~ ~~ `pu- .._ _ (~ -- -- ---- ---------------•--- --•---•---...-- --- -------------- --•------ (Signatures may be ~utFenticate~l or acknowledged. Both Nott>ry Public _._L'L4.~.r~^_4i°-?. ~-~--r~ --- - > Wis. Mc Cmnmis?ion is pry erteMltl~tt£.tio`... stateCeex iration I` nre not neceaaary.) •-v=.:~..t+' z date- -- ----------------- > _. _.°---•---------> 19--------•) Ii - __- , y,•.. II it _. __ - _ =-- --_ - .. _ . _.._ ____-_ QV7T CLATM.DEL-D STATF: nAn OF w;crn±ccly .r•=-..,sn T,~:a7 R7w n ~ L+e, commerce.wi.gov isconsin A ~ -® Department of Commerce ~~ n Safet and Buildings Division Instructions For Property Owners: ~ You may apply for a grant award for up to three years fter you v ~ 'v determination of failure and after you have obtained a anitar~ t to Pa A of this form, attach evidence of your annual income expla ose items to the sanitation or health department office in the county where the property is located. PART A. TO BE COMPLETED BY THE PROPERTY OWNER PIP_aca mint Wisconsin Fund - Private Onsite Wastewater Treatment System Replacement or Rehabilitation Financial Assistance Program BE COMPLETED BY COMMER(; Ow _er"` I _ Owner - --- - r • . -~O7 ~ . Owner t ~Y +~~ ~~ l ~ 1atc~~,vE V- ~~ Owner Owner Owner Address U r~ City, State, Zip Code JZ ~ ~-~' i 2- ~a l~-w~ r- Zv~s, 5~(v oa. Telephone Number t`7~s~ ~~y -a °~~ "Grant awards will be issued in the name and address of this If there are additional o ow wners, attach documentation listing all ner. owners. 1. Is this application for a principal residence or a small commercial establishment? Principal Residence (Complete both if applicable.) Small Commercial Establishment If applying as a principal residence, do you occupy this residence 51 % of the year? Yes No NA If l app ying as a small commercial establishment, do you own and occupy the small commeraal establishment? es No NA 2. If applying as a small commercial establishment , what is the name of the small commercial establishment? Description of Small Commercial Establishment (farm, restaurant, etc.): 3. Has there been a change in ownership of the principal residence or small commercial establishment served by the failing system within the last three years? Yes No If es, lease ex lain: 4. As the owner, are you a licensed plumber or contractor engaged in the business of installing private onsite wastewater treatment systems? Yes No 5. Will a portion of the replacement system be funded by another program? Ye s o If ss, ex lain: 6. How did you hear about the Wisconsin Fund-Private Onsite Wastewater Treatment System Replacement or Rehabilitation Program? S1` ~G ~ ~`~~ ~dt~~~i~~ Y,~,, 7. Evidence of income. if you are applying as a principal residence, attach a copy of your federal income tax return for the year of or prior to the determination of failure. If you were married and filed separate forms, you must also include your spouse's return for the same year. You must include evidence of income for each owner and for each owner's spouse. If you are applying as a small commercial establishment, submit a copy of your federal profit and loss form for the year of or prior to the order or determination of failure . If you or any owner listed above did not file an income tax return, contact your governmental unit for further instructions. Evidence of income will be ke ton file at the ovemmentat unit and is sub'ect to verification b the De artment of Commerce . Property Owner's Certification. I certify that, to the best of my knowledge and belief, the information I have provided on this form and all attachments are true and correct. Owner's Signature Date Signed Co-Owner's Signature Date Signed ~~~ ! V' ~~ ~ i~-U~CC_.. ~d V ' ~~ Parsnnal infnrmaBnn vn~ ~ .,~.,.a.ae ..,.,., ~.,....,, ,a c.._ -___--'-- - ._ ..~ . _ _ .... - r w ~~~+ ~~~ ao~.~~~ua~y purposes trnvacy yaw, S. pb.U4(l)(m)l. SBD-9163 (R. 02/2005) PART B. TO BE COMPLETED BY THE GOVERNMENTAL UNiT 1. VERIFICATION OF OWNERSHIP On the document used to verify ownership, do the names match those on Part A of this application? If no, please attach additional documentation explaining. Yes No If the applicant answered yes to question 3 on Part A of this application, did the applicant(s) own the property when the order or verification of failure was issued or the system installed Yes No and incur the cost of replacement? n ~ Document or Page 2GdG Document used to verify ownership: i Number: {!~ Q 2. Is a public sewer available to this property? Yes o 3. Has a previous grant been awarded for this property under this program? Yes o L (~ 4. Principal Residence evidence of income. Please indicate applicable annual family income: $ Z 5 ~ / Z Z Federal income tax form ~0~6 Line ~y 0. ,Year ~~ OR Affidavit of ,Year Small Commercial Establishment e~~idence of income. Please indicate applicable annual gross revenue: $ Profit & loss form used: ,Line ,Year Q 5. Date of the Order or Determination of Failure: ~~ y. 1 I ~ Z~ When was the existing failing system installed? Prio - - 12-1-1969 to 7-1-1978 Vertical distance from the bottom of the existing infiltrative surface to a limiting condition: 0 to Less than 24' 24 to Less than 36" Equal to or greater than 36" 6. Private onsite wastewater treatment system failure caused by discharge of sewage to (check all that apply): Surface water or groundwater ............................................................................................................... Category 1 A zone of saturation .......................................................................................................................... A rain a or zone of bedrock .............................................................................................................. Category 2 The surface of the ground ..................................................................................................................... Category 3 Back-up of sewage into the structure served ....................................................................................... 7. This request is for what type of replacement system: At-grade Conventional If this request is for a system not listed at the right, please explain: Experimental olding Tank In-grown ressure Mound G o 8. Un'rform Sanitary Permit Number / ~ ~ ~ 5 ~ Date Issued D •' $ ~- 6~ Plan Approval Number ~ 55 t03~ ! Date Approved ~~ ~6 '" d 0 Ex eriment A royal Number Date roved 9. After reviewing this application, I have determined the applicant to be: Eligible ne igi e If ineli ible, reason ineli ible: 10. Governmental Unit Representative's Certification. 1 certify that I have reviewed and verified all information provided on this fom~- a chments and that the are true and correct to the best of m knowled a and belief. Signa a of Auth ' ed Gove al Unit Representative Title Date Signed L,u~yw,- G ~ ~~~ I I /~ ~d~. commerce.wi.gov Wisconsin Fund - i sco n s i n Grant Private Onsite Wastewater Treatment System Department of Commerce Worksheet Replacement or Rehabilitation Safe and Buildin Division Financial Assistance Program Owner's Name: Governmental Unit: ~~~~o~ P14~ ~a-. c~©; X ~~ PART 1. GRANT FUNDING TABLES In Sections B-F, the number of bedrooms determines the grant award. To use the grant funding tables for small commercial establishments divide the , estimated dail wastewater flow rate in allons er da b 150, round off to the next hi hest whole number, and use the result for the number of bedrooms. A. Site evaluation and soil testin Grant amount $250. $ 'z~Jd B. Installation of a replacement anaerobic treatment component. Number of Bedrooms Grant Amount ..............................................................................................................................$500 3 ...............................................................................................................................550 4 ............................................................................................................................... 650 5 ............................................................................................................................... 725 6 ............................................................................................................................... 750 7 ................................................................................................................................875 8 or more ............................................................................................................................950 C $ J S C. Installation of a dosing component, lift pump or siphon: Number of Bedrooms Grant Amount 1 or 2 ............................................................................................................................$1,100 3 or 4 ..............................................................................................................................1,200 5 or more ......................................................................................................................1,250 $ /(, p- D. Installation of anon-pressurized and in-ground pressure POWTS treatment or dispersal component. Percolation Rate Design Loading When Properly Filed Rate in Gallons with the Governmental Per Square Each Additional Unit Before 7-2-94 Foot Per Day 1 2 3 4 5 Bedroom: Minutes Per Inch 0 to less than 10 0.7 or more $ 1,400 $1,450 $1,925 $2,100 $2,100 $250 10 to less than 30 0.60 to 0.69 1,475 1,475 2,100 2,200 2,250 250 30 to less than 45 0.50 to 0.59 1,475 1,475 2,100 2,400 2,450 300 45 to less than 60 0.49 or less 1,475 1,550 2,325 2,725 2,750 300 /- $ Nf4 E. Installation of an at-grade or mound POWTS treatment or dispersal component. Each Additional Type of Design 1 2 3 4 5 Bedroom: At-Grade $2,050 $2,350 $2,600 $3,200 $3,800 $275 High Groundwater Mound 2,550 3,500 4,100 4,750 4,775 300 High Bedrock Mound 4,000 4,600 4,675 4,775 4,775 350 "Slowly Permeable Mound 3,250 3,600 4,400 4,750 4,750 375 Mound with less than 24" of suitable Soil or reaterthan12%slo e. 3,050 4,175 4,400 4,775 4,775 375 $ ~~. *A slowly permeable mound may be designed using percolation test results property filed with the county before 7/2/94. A slowly permeable mound is defined in s. Comm 83.23(1)(b) as having a percolation rate of greater than 60 minutes per inch and less than or equal to 120 minutes per inch, or having a soil loadin rate of 0.3 or less. F. Installation of a POWTS Holding Component. Each Additional 1, 2 or 3 4 5 6 7 8 Bedroom: Grant Amount: $2,800 3,200 3,850 4,400 4,775 4,775 $400 $ Z ~ ~d ~,,.. r..,..,.,..~~ay ..~ u.,~. ~.,~ aawn~a~y NuiNuscs trnvacy yaw, s. ia.uvl ~)(m1L SBD-9167 (R. 10/08) PART 1. GRANT FUNDING TABLES continued G. Installation of a Replacement Exterior Grease Interceptor by Gallon Capacity. Gallons: Up to 1,249 1,250-1,499 1,500-1,749 1,750-1,999 2,000 or more ,, I f~ Grant Amount: $550 $650 $750 $800 $900 $ Amount Requested H. Installation of an Experimental System. For Installation: If you are requesting funding for an experimental system, please submit a copy of the Wisconsin Fund $ ~~ pre-approval letter along with a copy of the plan approval letter and experimental approval letter containing corresponding identification numbers. Amount Requested For Monitoring: List the total cost of the experimental system and monitoring that is being requested separately at the $ ri ht. Co ies of aid invoices must be submitted with this re uest. I. Installations not Covered by the Grant Funding Tables. The Department on acase-by-case basis reviews installations not covered by the Grant Funding Tables. If you are requesting funding for an installation not covered by the grant funding tables or listed in Sections A-H, please explain your request here, attach a copy of the paid invoice showing the cost of the item, and request 60% of the cost of the installation at the right. ~i~ $ TOTAL PART 1. $ 3 ~D~ PART 2. GRANT AMOUNT CALCULATIONS ~~~ A. Enter the total from Part 1. $ B. Is the applicant a licensed plumber or contractor that installs private onsite wastewater treatment systems? If yes, enter 2/3 of the amount from section A in this section or $4,667, whichever amount p A is less. If the a licant is not an installer, ca the amount forward from Section A to Section B. $ ~ C. If this application is for a small commercial establishment and the annual gross income of the business that owns the small commercial establishment is less than $36~-560, the amount listed in Section B is the total grant award. Carry the amount in Section B forward to Section F. If this application is for a principal residence and the annual family income of the owner(s) is less than $32,001, the amount listed in Section B is the total grant award. Carry the amount in Section B forward to Section F. If this application is for a principal residence and the annual family income of the owner(s) is _) between $32,001 and $44,999, list the amount in Section B here and o on to Section D. $ /`~ D. Calculate 30% of the amount by which the applicant's annual family income exceeds $32,000 here and then continue to Section E. Annual Family Income Subtract - 32 000 Subtotal X .30 = $ /V ~ E. Subtract section D from section C. This is the maximum grant amount for this applicant. ^ ~ Car this amount forward to section F. $ / ~!- F. Total grant award requested for this applicant up to the maximum of $7,000. (The amount in this section must be at least $100 for the applicant to be eligible for a grant award. Z 1 ,,~~//~~ 3' If the amount calculated is less than $100, the a licant is not eli ible. $ c.~V May 19, 2008 Gordon Place . 1121 220th Street Baldwin, WI 54002 RE: Failing sanitary system at 1121 220th Street Further described as the SW/SW'/4 of Section 5, T29N R 16W, Town of Baldwin -Parcel # 002-1010-70-000 -Computer #05.29.16.758 Code Administration 715-386-4680 Dear Mr. Place: Land Information ~ Planning The St. Croix Count Plannin and Zonin De artment, as the " overnmental unit for 715-386-4674 y 9 g p g the regulation of private sewage systems" pursuant to Wis. Stats. 145.20(1)(a), shall RealPropeny investigate violations of the private sewage system ordinance and shall issue orders to 715-386-4677 abate the violations per Wis. Stats. 145.20(2)(f). Recycling This office has a Soil Evaluation Report on fife concerning the Private On-site 715-386-4675 Wastewater Treatment System (POWYS) that services your residence at the above- mentioned property. This report, completed by Jim Thompson, Certified Soil Tester # 3602 on July 8, 2005, indicated that the existing POWYS is discharging to 220th Street road ditch. This has been identified as a Category 1 failing system pursuant to Wisconsin Administrative Code Comm. 81.01 (92) and Section 145.245(4)(b) Wis. Stats., which includes discharges to surface water and/or zones of saturation. The existing system is also considered a human health hazard as defined in Wisconsin Administrative Code COMM 81.01(128) and Section 254.01(2) Wisconsin Statutes. Pursuant to the St. Croix County Code of Ordinances, Chapter 12 Sanitary Ordinance, subchapter 12.1 (F)(4)(d) when a failing POWYS is identified it shall be brought into compliance with Wisconsin Statutes and Wisconsin Administrative Code and 12.1(F)(4)(e) the discharge of domestic wastewater or effluent to the waters of the State or to the ground surface is prohibited. This letter constitutes an order to abate the above-referenced violation. Any plumbing work required for compliance by replacing or repairing the failing system shall be performed by a plumber who is licensed in the State of Wisconsin. A list of plumbers can be provided at your request. You will need to have a plumber complete a design for a replacement POWYS within 30 days of receipt of this letter The design must be submitted to the Dept of Commerce for review and approval A sanitary permit application must be submitted to the Planning & Zoning Dept within 2 weeks after state plan approval has been issued St. Croix County participates in the Wisconsin Fund Grant Program, which is a financial assistance program that may provide funds to property owners by reimbursing a portion of the cost of replacing or rehabilitating failing private sewage systems. All work, however, must be completed before applications can be submitted to the Department of Commerce. If you are successful in receiving a grant through this program, an administrative fee is due and payable to this office at the time you receive your grant ST. CRO/X COUNTY GOVERNMENT CENTER 1 101 CARMICHAEL ROAD, HUDSON, W/ 54016 715.386-4686 FAX .,-,.,.-„ ~~,.,r,-~,,,,, ,.,, ,,.- award check. A brochure outlining the general program is enclosed. Failure to comply with this order and with the provisions of the St. Croix County Code of Ordinances, Chapter 12 Sanitary Ordinance, or any order issued in accordance with this ordinance shall be subject to a penalty as provided in Section 12.8 (B) (2) (a). Penalties include forfeitures of not less than $10 per violation or more than $1000 per violation as/or be subject to injunctive relief. Each day a violation exists is a separate violation. Pursuant to Section 12.8(B)(3)(b) of the Sanitary Ordinance, "Any person, company, partnership, corporation or government unit aggrieved by a written administrative decision made by the Zoning Administrator, or his/her designee, or the Committee may appeal the decision to the Board of Adjustment. An appeal of a decision shall be in writing and shall be made on a form provided by the Planning and Zoning Department and shall be filed with the Planning and Zoning Department within 30 days of the date of that administrative action. Other substantiating evidence will be accepted." espec ully, _ ~~ • Pamela Qu nn Zoning Specialist Cc: Town of Baldwin Dan Sitz, Code Enforcement Enclosures: Wisconsin Fund Grant Program Application form ST. CROIX COUNTY GOVERNMENT CENTER 1 101 CARMICHAEL ROAD, HUDSON, Wr 540 ~ 6 715-386,4686 Fax :_._ S.~rving You for 50 Years Boldt's Plumbing & Heating, In X820 Main Street, PO Box 78 'Baldwin, WI 54002 Phone: 715-684-3378 Fax: 715-684-3144 04 ~ d - GORDON PLACE 1121 220TH ST BALDWIN, WI 54002 ~~ INVOICE r`~f1~~~1 d ' e 9/11/2008 0000012484 0004649 - • ~, INSTALLATION OF HOLDING TANK EXTRA -REPLACE PIPING COD 1.00 2.00 1.00 1.00 1.00 1.00 2.00 1.00 1.00 2.00 1.00 10.00 4.00 INSTALLATION OF HOLDING TANK PER CONTRACT. CONTRACT REPLACEb CAST IRON PIPING IN HOUSE EXTRA -NOT PART OF CONTRACT 4" WYES 4" CLEAN OUT FITTING CLOSET FLANGE CLOSET BOLTS (SET) WAX RING 4" X 2" WYE 4" FERNCO 4" 45 2" ST 45 1-1/2" UNION TRAP 4" PVC PIPING (PER FOOT) LABOR PIPING REPLACEMENT -TERRY ~~~ ~~~ ~ o ~ Q OCR m rt~ ?pp8 SUBTOTAL TAX TOTAL 9111 8,300.00 8,300.00 20.66 41.32 12.47 12.47 3.92 3.92 7.80 7.80 2.10 2.10 12.43 24.86 10.94 10.94 9.49 9.49 1.94 3.88 5.77 5.77 4.56 45.60 70.00 280.00 $8,748.15 $24.65 $8,772.80