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HomeMy WebLinkAbout002-1041-70-000v V~tisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety 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)]. 'ermit Holder's Name: City Village X Township VanSomeren, Richard Baldwin, Town of :ST BM Elev: Insp. BM Elev: BM Description: "" ~~ ~~~• ~ SOD- ~ 1~~ C~t~x.aw 'AAIK INFf1RM~T1f11U EL FVAT N DATA TYPE MANUFACTURER CAPACITY Septic ~p ~ U ., Dosing '~-~/~ ~~l ~ ~ / / n ~,, l't~ Aeration Holding TANK SETBACK INFORMATION TANK TO PPS WE~.L. BLDG. Vent to Air Intake ROAD Septic S 7 , ~~ / ! Dosing -Tf'G~.- Aeration ~~ Holding PUMPLSiPHON INFORMATION ~~}2;(,,t~.~(,~,r,-.. Number Head to Ft cnn nQCnOOT~nA1 CVCTCM /"1 / ~n // // county: St. Croix Sanitary Permit No 506361 0 State Plan ID No: Parcel Tax No: 002-1041-70-000 Section/Town/Range/Map No: 18.29.16.271 C STATION BS HI FS ELEV. Benchrk _ ,, / / ~V (~, ~ - A~~ v~`~ /O~~ ~OD~ U Alt. BM Bldg. Sewer SC's( yo ih~v G.~~ ~1~• ~ S Ht Inlet Cv. 3 2 ~' S 3 S t Outlet /_ W 7~ e~ / ~ ~~ Dt Inlet / /~ Dt Bottom ~ Header/Man. ,' 3 ~ ~ ,S Dj t Pin " ~ '7 ~ $S (e. 1 9 -az Bot. System ~ ~ I ~S ~ ~ Final Grade ~ ~ ~3 ~ ' ~ s+ over ~ r ~ ~ ~ 2 3, Z Ud ~ /oS -!t2 _ 2/ BEDITRENCH Width l Lem No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ SETBACK SYSTEM TO P/L L G WELL LAKE/STREAM LEACHING CHAMBER OR anufaflurer: h INFORMATION T e f S stem: ~ YP Y ~~ ~ l~r / , ~/~ UNIT , Mod Number: ~~~~ ~ri~u nVG~TCAII rtn i~iu .inn ~.rn.a Bader/M ifold .v•` ., . v . /,, / Length t~ Dia Distribution Pipe(s) ~ r ~ Length Dia Spacing x Hole Size ~- x Hole Spacing ~- }}~~ •1 7(J ' non f'~A\/CO n.-~_. .. 1111 w.~na nr A}_(~r~iYC \\/CTPmC ~ m1v v v.~ .........~ Depth Over ..~., ... ...i Depth Over -'- - - xx Depth of - xx Seeded/Sodded xx Mulched Bed/Trench Center ~ t Bed/Trench Edges Topsoil f Yes No m .es~ 1'es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ y / 6" !U'/" Inspection #2: / / Location: 915 Hwy 63 Baldwin, WI 54002 (S 1/2 SW 1/4 18 T29N R16W) NA Lot ~CIX~ Pa~~o: 1.8.29.16.2710 1.) Alt BM Description = ~ '# ~~ ~/ ~ ~ /1°,,,~`~/'~ 2.) Bldg sewer length = `~ r ~~~5' ,~y,~ d N^'B~~ V~t.O ZG s ~ ~vlvt.-- -amount of cover =~ 3 , ~ ~~~ ~- ~a,~~o( ~~~ .r j1.>C7~". ~J Plan revision Required? ~ Yes No /, ' f ~ S Z, i l Jse other side for additional Information. ~ V I L U ~J f-~~'_1~!~'~y'~`~'~-_ G'~"~I"v!'~-- -- --- - - - Date Insepctor's Signat re ce SBD-6710 (R.3/97) ~k~ 07` -~¢l ent Air Intake 1~c01faCL'h~P~~ Safety and Buildings Division County ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~ G /.~~ ~ ,~~~~~~ Madison, WI 53707 - 7162 tary Permit Number (to be filled in by o.) De artment of Commerce (608) 266-3151 ~.~;~ t Sanitary Permit Application State PI umb ~{ In accord with Comm 83.21, Wis. Adm. Code, personal information ou pro ~ C E I V E may be used for secondary purposes Privacy Law, s15.04(1 m) roject dd ererlt than~iling addre//s s) ~ ..~ ~ ~~, €.,,~ ti~ I. Application Information - Plesse Print All Information - O C T O 5 2 O O r i.. / ~~ _ ~.y b Property Owner's Nam i - T. CROIX COUN Parcel Y „~, Lot # Block # ~ ~ " / ~ ~ ,~ L ~t r ~ t Property Owner's Mailing Address Location // G~ // ~i~ Section ~~ ~~ ~' City, r ~ Zip Code Phone Number • ~ v0 ..Z '/J`~ ucle ee R~E ~Z'e~N I. Type of Building (check all that apply) "' ' , "'' '~~ r-, ~. r 2 Family Dwelling -Number of Bedrooms 3 ~~ ~' ' ,,_ .. . "~ ~ Subdivision Name CSM Number ^ Public/Commercial -Describe Use ~ , , ! ; ,~..p ^ State Owned -Describe Use T; ~ T ~~City_^Vil ~wns 'p of w III, T ype of Permit: (Check only one box on line A. Complete line B if applicable) `4' ~ 'ew System a lacement S tem p ys ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner _ ; e • , 1 IV. T e of POWTS S stem: Check all that a 1 ~ [ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constricted tiVetland r ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/T'reatmentArxc Information: Design Fiow (gpd} Design Soil Application Rate(gpdsfj Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ys b ` VI, Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fr antic Gallons Gallons of Units Concrete Constructed Glass New Tanks Existing Tanks f' ~ ~ ~.r ' ' r ° S "[ , ~. '!. 7. eptic olding Tank G~G Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown ou the attached pleas. Plumbe ' Name (Print) Plumb ignature MP/MPRS Number Business Phone Number ~o ~ ` ~.~ vZ 7' iy 7 v~~7 r Plum 's Address (5tree ,City, State, Zip C ~ ^ VIII. Coun /De artment Use Onl Approved ^ Disapproved. ,,; •" Sanitary Pe t Fee (includfs Grouydwater Surchprge Fee) - ;' . Date Issued • Issuigg Agent Sign o Stamps ~~ ' ` , , ^ Owner Qiven Reason 1br I~euial i -_ ' -'~ ' ~ ~i ,', ~: ~ ` ~ _ `-. : " ~~.. IX, Conditions of Approval/Reasons for Disapproval , '` i j Y ~ SYSTEM OWNER: .. . ~ , ., . '`• *. ,:a4 .. =~!.t~ .. '~rt~.a...~ . 1: Septic taMc,_effluent filter and + i dispersal ceB must aU be servh:es /maintained ~" ' "~ ° - ` ~ ! ~ ' ' • . as per managernenf plan provided by plumber. ' 2. AN setback requirements must be mairtained as per aPP cede / ardinstices. .+...... compmce puns iw me a.ounry omyl ror me sys[em an paper no[ leas [ran avc x t [ inenes in size SBD-6398 (R. 01/03) + ,1 PLOT PLAN ` PROJECT Richard VanSomeren ADDRESS 9i5 Hv 63 Baldwin Wi. 54002 S1I2 1/a SW i/as 18 /T 29 N/R 16 w TowN Baldwin couNTY ST. CROIX MFRS Byron Bird Jr. 220527 10-05-07 BEDROOM 3 DATE CONVENTIONAL XXX fade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ~ LOAD RATE .7 ABSORPTION AREA 684 ~ of chambers 84 ,BENCHMARK V.R.P.-Basevfisiding ASSUME ELEVATION 100' ^ BOREHOLE O WELL *g,g,p, Same as BM OVent SYSTEM ELEVATION T-1=95.0 T-2=94.9 > 12" ~~l _ ____ of 10 ~i? ~`'i // ro ~ Cu ~--~ ~ L~ . ^2 per ~~ ,chamber 6' - Long 34" Elevation SCALE 1" = 40 ` Unless other wise Noted Hy 63 Driveway 3 Bed House Well 12' Steel Both Drywell and se to be pumped and fi 40 Garage 26' i 30' is ~ st _ iJ '-----~ ID ~- B2 5 sys-~ d s,' ~ ~~ D 77' 40' shed \. v'l ~.~ PLOT PLAN - PROJECT Richard VanSomeren ADDRESS 915 Hv 63 Baldwin Wi. 54002 S1/2 1/4 SW 1/4S 18 /T 29 N/R 16 W TOWN Baldwin COUNTY ST. CROIX MFRS Byron Bird Jr. 220527 DATE 10-05-07 BEDROOM 3 CONVENTIONAL XXX rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ~ LOAD RATE .7 ,BENCHMARK V.R.P. Base of siding ^ BOREHOLE O WELL *g,g,p, Same as BM Vent SYSTEM ELEVATION T-1=95.0 T-2=94.9 >12" Cove to ~2 p~~.-~ ~~f~o ~ Q~~ ~( chamber ~v ~~ 6„ Long 34" Elevation SCALE 1" - ~ ~ TTn~PCC flthPr W7CP NAtPrl Well .~ ABSORPTION AREA 684 # of chambers 34 ASSUME ELEVATION 100' I-IV (~~ . ~' wlsconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County , Attach complete site plan on paper not less than 81/2 x 11 inches in siz an must include, but not limited to: vertical and horizontal reference point (BM), on parcel I.D. percent slope, scale or dimensions, north arrow, and location and distan t d. Please print all info Revie~ed by Personal infortnatton you provide may be used for second purpo~Et)~i#~ 1) ( ). Property Owner Property L . 'on f r ~ T 0 5 .Lot va f~ ~. Property er's Mailing Address Lot # BI # Subd. Name or I r ~ ~ ST. CROIX C UNTY Page of ' - CrO~~ ~" ~ ]0_~~ Date , ~T,~9'N R ~~ E(o~ Cdy ~ S e ZP Code Phone umber. Villagg [}Town ~ Nearest Road ^ New Construction User Residential / Number of bedrooms ~ Code cierivec. ,..:sign flow rate ~ S d GPD replacement ^ PubGc or commercial -Describe: Parent material ~~~ c ~ ti ~~_~~~~! Flood Plain elevation if applicable ff. General oommeMs and recommendations: ~-r _ / _ / S~ ~ 6 ~ a r~- ~ ` 9~. ~ 3y Boring # ~ Boring ~~ S,/ pit Ground surface elev. ff. Depth to limiting factor , 7 /G in. Soil ication Rale Horizon Oepth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/tl: in. Munseli Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 `EfY#2 a - , ~ - ~. ~ ~ ~ ;., r, 0 1 ~ U( '; a..~ ~ Boring t Q ~ ~zgi~QO~ S ~ ~L d t~ ®Boring # q ~ ^ Pit Ground surface elev. ~_ ff. Depth to limiting factor~,Z .~~~ in. it So hcaUon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/It? in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2 ~~ 1 R Y .. - trrruem ~~ = t~vu > 30 < 2Z0 mg/L and T55 >30 < 150 mglL ` Effluent #2 = BOD < 30 mgfL and TSS < 30 mglL CST Name ase Print) ~ .,~ Signature CST Number Add ate Evaluation Conducted Telephone Number ~~~ /~~ , yy-P~ ,std l~S~ ~/~0~6'~7~/ t~Tn 1~'~'~I~ T/V'IM/~\ J• Property Owner f/~~ ~"~~'~L~"~ ~~~~ C~Parcel ID # _ 1 6 1 Boring # ~eoring ~~/ ~ _ S 3/ Page of 1 1 U Plt aJlVUi~u aunaac aznsv.~~a. ~ a+cNu~ w nu ua~~y ~aawv~ i ~ w n~. Soil lication Rate Horizon Depth Dominant Color Redox Description 'Texture Structure Consistence Boundary Roots GP DlfI? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 /~' G"'G~ ~~ s ~ D ~~ - ~ f Boring # ^ Boring ^ p~ Ground surface elev. tt. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Cobr Redox Descr~tion Texture Structure Consistence Boundary Roots GP D/fl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eif#1 `Eff#2 n Boring # ~ Boring 1-1 _ l3rn~~nr1 c~vfsrb alav A fleMla to P..a:Hnn hw~n. u rn _ -- Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/It= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `EB#1 'Eff#2 • Effluent #1 = BODS > 30 _< 220 mglL and TSS >30 < 150 mglL ' Efliuent ~ = BOD, < 30 mglL and TSS < 30 mglL 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. sao~es3o nt.o~rool Property Owner ~~ ~'"~'`'c~G~"~ ,/~~?~~ C~Parcel ID # Page of 3 Boring # Boring C/ ^ pit Ground surface elev. /. ft. .Depth to limiting factor ~ %~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DIfP in. Munsell Qu. Sz. Cont. Cobr" Gr. Sz. Sh. 'Eff#1 'Eff#2 -/e~ f ~ /r ~, ~ , ~ ~ /C S fr---tom /~ ,F , D ~~- - r ~3 '~t ' Boring # ^ Boring ^ pit Ground surface elev. ft: Depth to limiting factor in . Sod ication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP Di'IP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2 ^ Boring Boring # ^ Prt Ground surtace elev. ft. Depth to limiting factor in. Sod Rate Horizon Depth Dominant Color Redox Descxiptbn Texture Structure Consistence Boundary Roots GP D/IF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~~ *E 'Effluent #1 =RODS > 30 < 220 mglL and TSS >30 < 150 mglL ` Effluent #2 = GODS < 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-6330 (R07N0) Soil Test Plot Plan Project Name Richard VanSomeren Byron ird Jr. Address g15 Hy 63 Baldwin Wi. 54002 c CS #220527 Lot Subdivision Date 10/5/2007 CountyST. CROIX S1/21/4SW 1/4S 18 T 29 N/R16 W TownshipBaldwin Boring ~ Well PL Property Line# Alt. BM ,BM or VRP Assume Elevation 100 ft.Base of siding SystemEly T-1=95.0 T-2=94.9 H.R.P. Same as BM SCALE 1" - ~ ` TTnlPee nrhr~r wier~ Nntwrl Well -~~ Nv Fib ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer //~. l1i a .~~/ /%G(s'~ SoJ~'T~/' ~ h Mailing Address ~ /,5/ /~ r, ~i ~~ Property Address Oj~G ~l/ic>/ d1 ~/ , ~ ,jrZf ~~ ~ (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification NumberOQo.~ /O ~/-- ~d ` ~2-''?y LEGAL DESCRIPT/I/ON Property Location ~,!~ '/4 , ~~'/4 ,Sec. ~, T ~N R~W, Town of ~K ~~/~~ __ Subdivision ,Lot # Certified Survey Map # ,Volume ,Page # Warranty Deed # t~ ~ ,~ ~ 7 ~` ,Volume ~ Q ,Page # Spec house yesE./ Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. N ber of bedrooms ,~ v~iJ/ SIGNATURE OF APPLICANT(S) 6 ~/~~ ! DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION i Owner ~ ` ~ r~G/ ~~1 O~Yt-[' Permit # nocv_~u oeReax~Rc Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) '~ al/day Design flow (peak!, (Estimated x 1.5) dZ~gal/day Soil Application Rate al/da /ft2 Standard Influent/Effluent Quality Monthly average Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS} 5150 mg/L Pretreated Effluent Qual"itY Monthly average Biochemical Oxygen Demand (RODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA "'Values typical for domestic wastewater and septic tank effluent. ,..,~x.^ ~oc~rcrr•ervnuc .77.7~GRI V ~ ~~ Septic Tank Capacity O gat ^ NA Septic Tank Manufacturer ~ ~ ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Finer Model ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ^ Np` Pretreatment Unit ^ NA ^ Sand/Gravel Filter ^ Peat Fker ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal Ce(lls) ^ NA ~In-Ground (grav'~ty) ~ ^ ImGround !pressurized) ^ At-Grade D Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency ^ monthls) (Maximum 3 years? ^ NA Inspect condition of tankls) At least once every: ^ ear(s) Pump out contents of tankls- When combined sludge and sc equals one-third IY3) of tank volume ^ NA ^ month(s1 !Maximum 3 years) ^ NA Inspect dispersal cell(s) At least once every: p yearls) ^ month(s) ^ NA Clean effluent filter At least once every: ^ year(s) ^ monthls} p NA Inspect pump, pump controls & alarm At least once every: ^ year(s} ^ monthls) ^ NA Flush laterals and pressure test At least once every: ^yearls} Other: At least once every: D monthls) ^yearls! ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observartwn pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a cert~ed POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completwn of any service event. GMW !4/01 } Page of START UP AND OP9iAT10N Far new consttictiarr, prior to use of the POYVTS check tnmcrr>ent tank{sl for the presence of painting products a other chemicals ffiat may tl-e treatment process and/or damage the dispersal ceUis1• R ~ are detected have the contains of the tarok;s) removed by a si~tage senriceig opera[or prior to use. System start up shah not occau when soi corditions are frozen at the infiltrative surface. Owing pourer ouRages pump tardcs may fi above normal highwater levels. When power is restored the excess wastewater will be dise~iarged to the dispersal ceNs) it are large dose, overloading the cegls) and may result in tfie backup a axface discharge of effkamt. To avoid this situaRion have the Caltent5 of the pump t~ik removed by a Septaige Servicing Operator prior to restoring power to the effluent panp a contact a Plumber or POWTS Mauritainer to assist in manually operating the pump controls to restore normal lev+als within the purrs tank. Do not drive or park vet ova tanks and dispersal cis. Do not drive or park over, or otherwise disturb or compact, the area within ) 5 feet down slope of arty moinid ~ at-grade sob absorption area. Reduction or elmiinatiori of the foflOwirog from the wastewater stream may improve the perfom>ence and probng the Gfe of the POWTS: ant~atics; baby wipes; cigarette butts; cxxidans; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain ;sump pumpl water, fruit and vegetable peelings; gasoline: 9rease: herb ides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taker out of service the folbwing steps shall be taken to insure that the system is properly and safely abandoned in o~riptiance with chapter Comm 83.33, Wiscaiskr Administrative Code: • Aq piping to tanks and pits shall be disconnected and the ab~doned pipe openings sealed. • The contents of a8 tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, aN taroks and pits shall be excavated and removed or thew covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fads and caruiot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ^ A suitat>ie replacement area has bear evaluated and may be uti"hzed fa the bcation of a replacement soil absorption system. The replacement area should be protected from distiubance and compaction and should not be infringed upon by requb'ed setbacks from existing and proposed structure, lot lines and weNs. Fa~ure to protect the replacement area will result at the need for a new soil and site evaluation to establish a suitable replacertient area. Replacement systems must comply with the rules kr 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 insta8ed as a last resort to replace the Bled POWTS. ,~ The site has not been evaluated to identify a suitable r~iacem~it area. Upon failure of the POWTS a soil and site eva~ation must be perfom~ied to ktcate a suitable replacement area. If no replacement area is ava~able a holding tank may be installed as a last resort to replxe the failed POWTS. ^ Mound and at-made soil absorption systems may be reconstructed 'm place following removal of the biomat at the infiltrative. surface. Reconstructions of such systems must compN with the rules in effect at that time. < <WARNDKi> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENT'S POWTS INSTALLER Name ' t r~G )^• Phone _ ~ ~ 76 ~~ onuvrc ueriurenu~u ...,. . Name , ~ ~j u ~" !(h ~ltr~c Phone ,6 ~~ -- ~Do~ SEPTAGE SERYICWG TOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ©(,~~° i'~ Phone Name f_ r ~ GrJ o~~ ~ Phone ~ This document was drafted in compliance with chapter Comm 83.221211b1111td1&Ifl and 83.54111, (21 & (31, Wisconsin Administrative Code. Page of START UP AND OPERATION For new consd~uction, prior m use of the POWTS check treatment tank(s) for the ~esence of paint~g products or other chemicals that may knpexle the treatment process and/or damage the dispersal cellis). U higfi concentrations are detected have tfie contents of the tankls) removed by a septage seavicing operator prime to use. System start up shall rwt octxe when sod conditions are #rozen at the aifiltrtra&ve surface. During power outages pump tanks may #~ above nom~al highwater letireis_ When power is restored the excess wastewater will be dise~arged to the dispersal cefl{s) ~ one large dose, overbad'aeg the ceUls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump ~ contact a Plumber or POWTS Manntaimer to assist in manuaity operatmg the pump controls to restore normal levels within the pump tank_ Do not drive or park vehicles over t~ks and dispersal ce11s. Do not drive or park over, or otherwise disturb or compact; the area within 15 fleet down slope ofi any mound or at-grade sod absorption area. Reduction or elimttration of the fiobowmg from the wastewater stream may improve the performance and prolong the life of the POWTS: antbiotics; 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; meat scraps; mexlications; 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 ar~d safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shalt be disconnected and the abandoned pipe openings sealed. • The contents of atl 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 artiother pert Wed material. CONTINGENCY PLAN If the POWTS flails and c~uiot be repa~ed the foAowing measures have been, or must be taken, to provide a code compliant replacement system: ^ A suitable replacement area has been evaluates and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance aril compaction and shooks not be infringed upon by required setbacks from existaog and proposed structure, bt Tmes and we;Hs. Failure to protect the replacement area will resuh in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules ~ effect at that time. ^ A suitable replacement area is not available due to setback and/w soil limitations. Barring advances in POWTS technology a hold'mg tank may be stalled as a last resort to replace the failed POWTS. ,~ The site has not been evaluated to identify a suitable replacement yea. Upon failure of the POWTS a soil and site evaluatwn must be performed to locate a suiitable replacement area. !f no replacement area is available a holding tank may be installed as a last resort to replace the Bled POWTS. ^ Mound and at-grade sot! absorption systems may be r~econsKructed in place following removal of ts~e biomat at the infiltrative surface. Reconstructions of such systems must wrnplY wiifi the rules in effect at chat time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMEI~IT' TANKS MAY CONTAIN LEi'HAL GASSES ANO/OR INSUFFICIENT OXYGEN. 00 NOT ENTER A SEP1iC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DlFFlCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~ rL Phone ~~' ]~ ~~ anuurc rurerrur~-INESt Name u ~" !(h ~'C~r~c Ph~e ,6 ~~ - ~vv? SEPTAGE SERVICING O TOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ©~~ r Phone Name ~ r. ~ d~+i n Phone ~~ This document was drafted in compliance with chapter Comm 83.22(2)(b1t1)(d)&(fl and 83.54(1), (2) & (3!, Wisconsin Administrative Code. { ~~~~(rp STaT~ $A4 OF !n'ISCOFVSfti FOR?N1 3 - 19b2 C9 QLi1T CLAIAi UEEU COCJtsEtVT S*#O. Richard Alien VanSomeren, a/k/a Richard A. VanSomeren and Carol VanSomeren, a/ik/a -, Carol ~'. VanSOmiren, husband and s+ife quaatlatins to Richard A. ~;anSomeren and Carol E.~ - 'ifanSosteren, husband acid wife, haldinc3 as s4rYivorship Marital pr'opEr_ t~ _ ttte fo7irn~inL, d~nbed nil estate tr. 3 t . C r 6 7. X_ t ;ettntp, State of \Yisconsan: Starting at t?'!e StO~th[3°St corner O` SOt1ttS Ha? f Of Soarthwest Fractional Qt:artsr (S~ of SWa) of Section Eighteen {' Et } , `i\ovnsi-tiia Twenty-nine { 29) 1~5ort3i, Renge Sixtetart (i6) Ffesc . tFtence South 20 feet . thet-.ce East 2~ feet, theitcQ irtort3-t 20 feet to the ~larth lint of sai~ So~ttY'! Edalf Of Sout2't~+ie5t Fractional (p,~arter (S~ of 54da) ; thence West 'S0 feet along said iR.^dt:: line to Fala.ce of t+eginnit-Ig. a7113 v -- ft„ REGIST~:2'~ t3~`EIeE S r b CRCJbX C(~.. WI hiAR 2 S 199$ 9 : 3 0 .A ~,2q Rs tYr of De3~i TFttS SPACE FLScRJEU F0 = RECGRDIlIG OAiw Igq/.tc n1p~+~D~tgEyltylRN wD44E55 ~!/~ ~+~ it ~VYt@LY~ ~s ~L'Sii7~l:6i~~L €.•~;~ f~~ ~iir~ ~l~•aarin, iY1 ~~Q~ 002-1041-70 ARCi~ t*~EN71Fff-At<O~ RetFUBEp Sta_+-tiny! z0 feet South of the iV~rthk2st corner of South Ha~.f of Sot2thw?st Fractional Qtaa.rt~er (S'4 of S5f q) of Se^t ion Eis3hteen (28) , Township Ttae7tt}(-nirse (29) North, Flame Sixteen t16) West, thence South 150 feet, thence East 290 feet, th,en,ce Nort!•t 150 feet, thence t+Fast 2S^0 feet to place of beginning_ ~.~~~~~~ This i8 hainesleaai property. i~s\ (`• Dated this ~` ~~ day of ~.L[ ~~1~ . A.D., i9~_. -' _ Richard A. yaLLnSo~m7er~ - - i (3EAt_) x . i i.S 1 C~ /~ Di~~ CSE:~.U Carol E. VanSoineren AUT"IiENT1CAT10N +tgr taro re(s) authrmicated thts _ day o! TlTL[. NIEMDEk 5TnTC BAR OF ~b'ISCI'lN`itPi authorixc b}• §706.116, w'ts titats. Ac:KN0~4/LEUGiY[EF7T State of Wflsconsin, ss. St. Crofx _C.oun~. ~~ i9 ~ etsona came before me this __ ``-_ day of /~~0~2.. ' in?° ,the ~bovc named ---- kichard Alien VanSo~rterE.t~, a/'6:/a ___ Richard A, Van~oit>eren and Carol VanScmeren, aj{cfa Carol E. VanSvrttei°ef to me the fo. -suing Ti-tIS 2NSTRUMENT N/AS ORAFTEO BY -~` ; ~ 's- ~ - ` .: -- 'Thomas A _McCortnactc _ _ • ~- ~'' ~ .~' J~O--- -- Baldwin, t\TI 54002 Na:ar\- P~ffiliu' r ~ . - 0:cyunt}: v\'Is _ (Stgnaluns may br authenucatcd or ac'.noudct:ged _ _ ti'-.. . [Seth are not \1r romirttssl~yt4.- ' (,. .a' n, state expiration date necrssarvl ~. ~~,.r.. -.dr;tY• ~_ }9----' ~:a¢r . -~. - ~~ mrg ,r re ...+,,,:.ay ymo Jd M Typed .x p;mle d htlow they. <~Rrv.vres ~~° 5'rATh SAR OF \YISCU.~SI~ W:S~onsn ;o6al fiaan+• Cc Inc c21~1 ( C.1 .\I\i ni:LU t-nrm No. 1 - t?A2 I.W.aoced. vJ.s :~.: Y~ 2~a5 Real Estate Property Tax Receipt 44183opoMs Tax DisMct: TOWN OF BALDWIN Property Address: 915 HWY 63 County; ST. CROIX COUNTY Section/TownlRange: 18-29N-16W VolumelPage: 1309/ 031 1307 / 4 90 Parcel*: 002-1041-70-000 Acres: 1.000 Alt. Parcel#: 18.29.16.2710 Plat: NIA-Nt}T AVAILABLE Biock/Condo Bldg; Legal Descripton: SEC 18 T29N R16W PT S 1/2 SW FRL 1/4 COM 20 FT S OF NW COR OF S 1/2 SW FRL 1/4, TH S 150 FT, E 290 FT, N 150 FT, W 290 FT TO POB & INC COM NW COR OF S 1/2 SW FRL; TH S 20FT; TH E 290FT; TH N 20FT; TH W 290FT TO POB Bill #: 86938 Total Land Total improve 6, 000 88, 600 Payment Date Paid: 07/18/2006 Receipt #: 3 9216 Gen. Property Tax: 1, 18 5.81 Special Assessment: 0.00 Special Charges: 0 , 00 Delinquent Utility Charges: 0.0 0 Private Forest Crop Taxes: 0.00 Woodland Tax Law Taxes: 0.00 Managed Forest land Taxes: 0.00 interest: JUL 2006 0.00 Penalty: JUL 2006 0.00 Other Charges: 0.00 Totat Amount Paid: 1, 18 5.81 Overpayment: 0.0 0 Iota! Value Ratio Est. Fair Market Value 94,600 0.6421 147,300 Payment Note: VAN SOMEREN Balance Prior Tax Balance: Tax Amount Paid: New Tax Balance: Interest: JUL 2 00 6 Penalty: JUL 2006 New Balance Due: If Paid By Check, Tax Receipt Is Not Valid Until Check Has Cleared All Banks. RECEIVED BY: ST. CROIX COUNTY TREASURER ATTN: CHERYL A. SLIND 1101 CARMICHAEL ROAR HUDSON WI 54016 3~ 7~y ~~~ °2°a~ i''~ RICHARD & CAROL VAN SOMEREN 915 HWY 63 BALDWIN WI 54002 1,185.81 1,185.81 0.40 0.00 o.oc 0.00