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HomeMy WebLinkAbout040-1143-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538892 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: St. Croix Holdings, LLC, c/o Richard Lindholm Troy, Town of 040-1143-20-000 CST BM Elev: , Insp BM Elev: BM Description: Section/Town/Range/Map No: 1-2. 9 2 , o 01.28.20.5738 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. _ ej /l~0, ~DIJ, p Septic Benchmark Z Dosing Alt. BM Aeration 5 ~5 Bldg. Sewer tw~ • `1< Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L _WPLL. BLDG. Vent to Air Int ke ROAD Dt Inlet Septic Q 80 Dt Bottom 3 9-13 n~ Dosing D~ eadan. 1 -7 Aeration Dist. ipe ~ 92• ss O Holding i Bot. System w~ o . PUMP/SIPHON INFORMATION Final Grade --~'V rS Manufacturer Demand C ver ? t J GPM S .7 7'w3 95. Model Number 5 r _ TDH Lift Friction Los IS-ystenffad TDH ~Y Ft Forcemain Le t to( 2 h Dia. Di . to Well l I; 7 SOIL ABSO TION SYSTEM BEDITRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of P' Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO V P/L. BLDG WELL LAKE/ LEACHING ~~r r. _ ) INFORMATION Ty Of System: CHAMBER OR W 2,I I 2ov Model Number: IBUTION SYSTEM ,S'C l ader/ a fgld Distribution I x Hole Size x Hole Spacing V~Air Int e Pipe(s) *9 f ~e ngth ~~UJJ Dia_YL Length T O Dia Spacing ~ Q SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over , Depth Over xx Depth of xx Seeded/Sodded r Mulched Bed/Trench Center N Bed/Trench Edges Topsoil Yes No 0 Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ Inspection #2: / & c/ 2 Location: 291 Riverview Drive Hudson, LWI~r5,4,0,116, ('Gov't Lot 1 1 T28 R20W) metes & bounds ~otParcel No: 01.28.20.57313 1.) Alt BM Description ~3 1_" 2.) Bldg sewer length - amount of cover >42_1,t4 N p L>'/j?cLC~%UZo~ru~ _,,le~ < Plan revision Required? 0 Yes No Use other side for additional information. t _ Y►/t"! _ L SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. commerce.wi.gov Safety and Buildings Division County M 201 W. Washington Ave., P.O. Box 7162 St. Croix ' SCO S Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department l C ary P~rml Application State Transaction Number In accordance with Comm. 83.21(2), Wig, A;. ode, sub 'ssion of this form to the appropri a ment Project Address (if different an mailing address) unit is required prio o obtaining__``~~ s ary pe t to Application forms for state-owned POW submitted to the Dep ent of'~, - ce, % ormation you provide may be used for secondary Same purpos in accordance the P -vac W,(m), Stats. 1. Application Inform ion - 11 Information Property Owner's Name \N1%1);" Parcel # 040-1143-20-000 St. Croix Holdings, LLC - Richard F. & Sheryl D. Lindstrom Property Owner's Mailing Address Property Location (5-738) 291 Riverview Dr. Govt. Lot 1 City, State Zip Code Phone Number Na '/4, Na Section 1 (circle e) Hudson, W1. 54016 715-386-5394 T 28 N; R 20 r W II. Type of Building (check all that apply) Lot # or 2 Family Dwelling - Number of Bedrooms 2 2 Subdivision Name Be w ~ f~ / ' 15TI 4- Block # Na I''ct:e O~ Y ❑ Public/Commercial - Describe Use Na ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Na Rfolwn of Troy III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A. ❑ New System Replacement System 11 Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System (explain) B• El Permit Renewal El Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/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 (e) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Informati :24 Infiltrator "Q-4" Standard Plus chambers, 4 endc s & Pol Lok PL-525 effluent filter Design Flow (gpd) Design Soil Application Kate(gpast) tspers Area egwre s Dispersal Area op em Elevation 300 gpd 0.70 gpd/sq. ft. 428.58 sq. ft. 500.40 sq. ft. 92.00' VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o d v New Tanks Existing Tanks C $ Gay- 6~ . 7 aU in y Qn w a Septic or Holding Tank 1,000 1,000 1 Wieser Concrete X Dosing Chamber 500 Na 500 Na Wieser Concrete X VII. Responsibility Statement- I, the unde igned, assu responsibility for in Ration of the POWTS shown on the attached plans. Plumber's Name (Print) lumber' ignatur MP/MPRS Number Business Phone Number James K. Thom son MPRS 30021 (715) 248-7767 Plumber's Address (Street, City, State, Zip Code 340 Paulson Lake Lane, Osceola, WI 54020 VIII. oun /De artment Use Only Approved El Disapproved Permit ~Feeee~ Date Issued /Issuing Agent,,, na~~rree ❑ Owner Given Reason for Denial $ / / " ) YZ33 11 %~i"Alf'0.proval/Reasons for Disapproval 3 S-7 310 l.Q-UA14 V 1 Septic tank, effluent filter and l-w dispersal cell must all be serviced / maintained as per management plan provided by plumber. Qy/~~ a'~ G~j LG~ 2. All setback requirements must be maintained ac to comp e e plans for the system and submit /o the County only on paper not less than 8 ! z inches in size SBD-6398 (R 02/09) Valid thru 02/11 Elcc/a-~~ ~G: Qer >`z.2.Gz .Sf. Cr0 i x o~'~~yy''S G„c Q, cJ.ard F. d Sl~Scy 1 z9/ Q;✓crr/,'~ ck: ~ 1 f~u.alsor,, c,Ji. 55~~/6 - 7. o{'~ay, bci~y 2.ct~ Gcirs U i i EYi 5~~~ ~.cJe (f 'Je wtlK , ~ ~ Tod So~~ _ raixd f lcwv~ _ _ _ s~ac~Cf%/L1!_~Jo Elula~fDpcf ~W, L I ~~,ri5~inq 5rp~ic _ 4 Pro~ax~C byte "+-.-Ch 2(o5~cr m Z Sc.~ - ~0 ct-t.7--,o trenclos@ffitr. dary to ty» d fd~ LAX// y q.d.c ce,nrt; ® s`be ,dam //a~eas~ bea6arrdrm v,Y~ E~eds~r1cncG; a5 ~c/ Cede . ¢rosoh C,Sp~ ~j~+r;E.or9rac~ F-ICu~c! oec~ I~OPGS<G(ccJ eSe~Conr/c~C ~•.y / a, Ex~st7~y c~11 s. r. /P. e. L,)/ P,/Y La ~/OZ szs o ApPrvX. /o Ga.E%on oi` Cncs~ o{ S/ope ,Q/YS ¢/r/a ~i0~ 1 nt s. Eie~ = 9rs9' R~s,c~ Dose-Conventional POWTS Index & Tilte Sheet Project Name: Rich & Sheryl Lindholm 2 bedroom Replacement Conventional POWTS Owners Name: Rich & Sheryl Lindholm Owner's adress: 291 Riverview Dr., Hudson, WI, 54016 Site address: Same Project Location: Subdivision: Na Legal Description: Gov't. lot 1, Sec. 1, T.28N., R. 20W., Town of Troy, St. Croix Co., WI. Parcel ID 040-1143-20-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions & System Cross Section Page 4 Pump Chamber Calculations/Cross section & Pump Curve Page 5 Septic Tank /Pump Chamber Detail Page 6 Filter Specifications Page 7 System Management Plan Page 8 Septic Tank Maintenance Agreement Page 9 Parcel Map Page 10 Waranty Deed Attachments: Soil Evaluation Report Mater PI ber Re 'cted Service: James K. Thompson, Dept. of Comm. Credential #30021 Sinature: Date: 7 Page 1 Of 10 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) ■ ~/eda/ua ~~o~ ~o,t • !-aco-t4~ ~7~op. S~ Sf• Go i x f/o/aG'~j' S 1-40- N~calso, c.~~. sya/6 FN &06/ /o~/ SCc 7 . o F T oy, 5~. Croix G~ o24,-6416 Elri~'~q tc.Je(( / ~ 'fie 4x1K / ~ r 0 ✓ ~ . '96'40 ' L,~SfG ToPSo,/ 1'~¢G~ - ! Aixd ~IcuW4 ' SEocJ~~i/~ rJf ~Je f(u! of five 1. ~iris6%~q Srp~.c os~ strr 6~. E.~ e-ro:5 cv mA- tvn d yccx// .Zd c tR, ■ ~i loCiw., ryy 4~p~ Ge aba,7 drnmul S`6eya a aiuAs~ ctS ')4r' Cbt~l¢ . eroSVM GSPk e~oSlun, ero5io.-;` /aq5 ~/;M;E o~'9~rtdin9~ l (0 3' _ CogqS `~e d dri✓cL44 f-~Cuf✓a! Ocd w 1, /SGD CL/tJi/7QT!'G~ i ~tL areq EJCiSO~ 4XJ~ s.u)/Pa/y Loe'/0/- s1s App/oX. A, Ca E: on o{' \ e /'eSZ, o{ S/ooc / ,0,-es aides flan one 1E . S T o rlCO-bo~t~q po 2- Wia LINDHOLM DISPERSAL CELL SIZING CALCULATIONS NOTE: System to be oversized to utilize available area and maximize system performance and life expectancy. 1. (2 bedrooms)(] 00 gallons estimated flow)(1.5 design factor) = 300.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 g_pd/sq. ft. 3. Absorption area required: 428.58 sq. ft. 4. Absorption area as proposed: 500.40 sq. ft. (24chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA 428.58 sq. ft. - (4 endcaps)(5.10) = 408.18 sq. ft. 408.18 sq. ft./20.00 = 20.41 chambers required Number of trenches: 2 @ 12 chambers per trench Trench width: 2.83' Trench length: 50.00' Trench spacing: 9.00' on center Total system area w/ 9' center spacing: 12.00'x 50.00' Soil Absorption System Cross Section 95.73 ft 4" Schedule 40 Final Grade PVC Vent Pipe V\+ith Vent Cap 68 tt Leaching / Chamber ,2. oZ tt System Elevation ?.83 ft Soil Absorption System Plan View 50 ft 2.e 3 { ~IIIlI~I11I1?lT~l1I (o,~ ft !..euci,inq Trench 1- 1 Vent Or Observation Pipe I[III~IIII[iT~ !I1 [ DII1iJ IM „ Rit e-. 4r a matn 4 Dia. Trench 2 Header Pg. 3 of 10 Lindholm 2 bedroom Dose Conventional Pump Chamber Calculations 1. Force Main: Diameter 2" Length 40' Flow rate 35.00 gal./min Friction loss 1.03' (40')(2.58 ft./ 100') = 1.032 ft. 2. Total dynamic head: Min. supply pressure 0.00' Vertical lift 7.50' (P.C. bottom = 84.50',Off float = 85.50', Header invert = 93.00') friction loss 1.03' Total dynamic head = 8.53' 3. Pump selection: Manufacturer & Model number: Zoeller BN 53 Pump will discharge approx. 36.0 gpm @ 8.53' TDH (Flow Velocity 3.67 ft./second) 4. Dose chamber: Wieser W1000/500 MR Comb. ST/PC - 51.00" @ 9.84 gal./inch (501.84 gal. actual) A) One day holding capacity: 31.00" = 305.04 gal. B) Alarm setting: 2.00" = 19.68 gal. C) Dose volume: 6.00" = 59.04 gal. (300gal.)(20%) + (.164)(95') = 66.56gal. max. dose D) Reserve storage: 12.00" = 118.08 gal. Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and 1~ Comm 16.28 WAC Disconnect 4 in. min. Tank component is properly vented E-- Alternate outlet location Forcemain diameter Wieser W1000/500M Manufacturer 1.5 in. Capacityl 501.84 Gallons Volume 9.84 gal/inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 31.00 305.06 B 2.00 19.68 C Pump off elevation (ft) C 6.00 59.03 85.5051 D _ 12.00i 118.08 D Total 51.00 501.84 i Lq 11 1 Dose tank elevation (ft) 3" Bedding under tank. 84.50 Alarm Manuafacturer ~JH Rhombus w PUMP PERFORMANCE CURVE - - Alarm Model Number Tank Alert SJE 1011421 MODELS 53155157159 Pump Manufacturer !Zoeller Pump Model Number r~N53 _ 20 - TOTAL DYNAMIC HEAD/FLOW PER MINUTE 15 EFFLUENTAND DEWATERING 10 MODEL 53/55/57/59 Feet Meters Gal. Liters 5 5 1.5 43 163 10 3.0 34 129 15 4.6 19 72 10 20 30 40 50 Shut-off Head: 19.25 ft.(5.9m) GALLONS 4W/O 691" 57" z 93" r m N w 3" t I I I ~i~` 6th.. I / D m / \ 5„ / e I I < m m D~ p A I 54" < m z z O ~ c D m A --I m n z C c N D --I n C zm D r r Z Z p nD C-) D z p ~r- W*r K(OW:N Z C O zX ~ m z Z F~ G7 C.) O(Az Dlz m~moZmD0O - ~ G~ 07 V1 A Co prN p Sn x0 2:0!5X 2;uOrcn m m m =j :r n m D V) n AZ~ ~(AC fi r - ~r0 N O O m~ m 2 m ~zm nDm -mmw8(0m m O I i can i- O co A N O N= p D Z Oo - ~ N I (A rr m (7 D m m (o (o m m ((N O N (Jn \ N- f7 V' (NTI O V7 (n < n D r W e o N . p (W TI O V) -m -u oz ° c~c~ mom ~W o 06-0 o ° Z D O z V) m z m C Z Z > tax p CD D n (A A D 1 -3 U) A O ~7 p x N-I O c'1 -a A --1 C m r -1 m 0 Z I 20 r m K:~ OOC z m O~ O v mr A A A F O m m m m O O 0 r O N A A m m A m m Z r Z m ~ ~ Lf) \ O = W1000 500-MR MIESER COOCAETE SCALE:1/4" = 1' REV NO. DATE: m DRAWN BY:SWT Z SEPTIC MANUAL W3716 US HWY10. MAIDEN ROCK, WI 54750 DATE: JANUARY 2008 REV. JAN. 2008 800-325-8456 FILE: W1000 500-MR P. so~io Filters PL-.525 EFFLUENT FILTER (C Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters. The PL-525 is rated for over 10,000 GPD Alarm (gallons per day) making it one of accessibility Accepts PVC the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots Rated for over float up and temporarily shut off 10,000 GPD the system so the effluent won't leave the tank. No other filter on F . the market can make that claim! Accepts 4° & 6° SCHD. 40 Pipe «n- PL-525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional st alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank Automatic shut-off pumper or installer. ball when filter is removed 1. Locate the outlet of the U.S. Patent No# 6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4" or 6" outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. i (*W/o Dose Conventional POWTS Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10567-P (R.6/99). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. If the septic tank is fitted with an effluent filter, it shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the pump discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface within the system and will promote frost penetration during cold weather months. Cold weather installations (October- February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing biologically clogged adsorption and dispersal media and replacing said components as deemed necessary or by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to Jim Thompson at (715) 248-7767 or your County Zoning inspector. 2262 Wisconsin Xty mmerce SOIL EVALU OIEPORT Page 1 of 3 Division of an Buildings in accoance with Comm 85, Wi . dm. A.C.E. Soil & Site Evaluations site n l perpptosl fi rx" 1 inches in size. Plan must St. Croix Attach oo \Iette,, eference point (BM), direction and par I LD. include, bmited to: r percent sale ordji@[ arrow, and location and distance to nearest road. 0-1143-20-000 ~~73 , p~fprint all information. Re 'ewe Date Personal informaflafyou provide may be used for secondary purposes (Privacy Law, s.15.04 (1) (m)). Property Owner Property Location St.Croix Holdings, LLC - R. Lindholm Govt. Lot 1 1/4 1/4 S 1 T 28 N R 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 291 Riverview Dr. Na Na Na City State Zip Code Phone Number City I Village ✓1 Town Nearest Road Hudson WI 54016 715-386-5394 Troy Riverview Drive I New Construction Use: r/ Residential / Number of bedrooms 2 Code d rived design flow rate 300 GPD 1/ Replacement Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Proposed trench elevations to be 92.00'. Pump needed to reach system elevation. Boring # lei Boring ✓j Pit Ground Surface elev. 97.00 ft. Depth to limiting factor >110" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E 1 PD/f~Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-13 10yr3/2 none sil 2fgr dsh gs 2fmc 0.6 0.8 2 13-27 10yr3/3 none sil 2fsbk mfr gs 2fmc 0.6 0.8 3 27-49 10yr4/4 none sil 2fsbk dsh aw 2fm 0.6 0.8 4 49-54 10yr4/6 none Is Osg dl cw 1fm 0.7 1.6 5 54-110 10yr5/4 none s Osg dl - - 0.7 1.6 h M Boring # veI Boring in. Soil Application Rate ✓J Pit Ground Surface elev. 95.60 ft. Depth to limiting factor >94" Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E 1 PD/ftzEff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-9 10yr3/2 none sil 2fgr dsh gw 2fm,1 c 0.6 0.8 2 9-26 10yr4/4 none sl 2fsbk dsh cw 1fmc 0.6 1.0 3 26-30 7.5yr4/6 none Is Osg dl cw 1 fm 0.7 1.6 4 30-94 10yr4/6 none s Osg dl - - 0.7 1.6 "Effluent #1 = BODS> 30 < 220 mg/L nd TSS >30 < 15 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur CST Number Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 9/19/2011 - ' 72 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner er 5 411, O _ AS tCS Mailing Address - u•~5rm ~~~~6 Property Address ~,5ame (Verification required from Planning & Zoning Department for new construction.) City/State A Parcel Identification Number II J4.3 -,W -cam LEGAL DESCRIPTION u •lo~~ Property Location '/4 , 1/4 , Sec. / , T -246 N R ?'0 W, Town of rax Subdivision Plat: 4 , Lot # 44 Certified Survey Map # rta , Volume 0. , Page # Warranty Deed # yy iz3 e (before 2007)Volume .0-(99Zp , Page Spec house ❑ryuv io Lot lines identifiable ❑ yes ❑ 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 0 9 , C( 1zJ'7e_J4 SIGN T ~ OF APPLICANT(S) 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. 09/07) 7~`~~38 KATKL£EK OF DEEDS MOM O S£GISTER CD. • kI RD CROIX V 2 6 9 2 P 2 RECEIVED FOR 0 pK X04 UIT CLAIM DEED 11 IT CLAIN DEED ` DUI't 6949 # 15S 13-~ REC FFF,' = ent Number: G VsE'. FEE% Docum C/ 2 Address' & G°tl PAGES - ,osberg 0 Return an p Parsinet► Kahl Street, Suite 1100 100 South Fifth S 55402 Minneapolis, Number (PIl~; 040114320 parcell.D• ,rRUSTEE5 OF -TI-IE T U/A D LINDHOL gEVOCABLf, T . Slimited F. LIl~x~ M and 5H R ~L CCRp~HO D S5'Cr x County' state of WC14ARD L,n.TDHO real estate RICHARD h'31 1999, oll wing described dated N4arc the liability company' 7.O AND MADE APART HERO ~Jisconsin: HED HERE C DESC~TION ATTA SEE LEGS' AS EXH~IT A' RYL day of October, 2004. _HOLM and SgEST' RICHARD F' gEV OC E Dated this L O M D• OLM> -f rustee CHARD F. `TD BY: LIl HOLM, rnistee And : SHER . LIND ACS O~EDGMENT OF FLC )ss day of STATE e tHOLM Trustees !edged before m LE :Th COUNTY OF ment was acknoa d 5HERYL D• L HOLM REV©CAB L D D. LIND :rl~ The foregoing instru LINDHOL SHER `Ck31` 2004, by RICO HOLM AND Yf~12 October, Ab1RD March 3111999, Grantor. F• GOv of theT 1 gIjC dated c •(2$, TRUS _ Notary pub ~ County, Florida fI'C11 ires: _ y {KEMEYER - " pNDA pUA COnin1155i°n ekp °~m I No any Public. Stale of 26x2009 1VIY in t ,:.Page ° My comm. exD re'gA . nao. oo ..•1dCd1 cg~~ D~~ED gY: :':a'.4..)". : UMEN tlieb P , T A• TgIS INKap glanRosberg & Go §dbjec Parsinen Fifth Street 100 South tE 1100 402 the. •r-b 'Minneapolis, ~ 55 :•d1ZWd (612) 333-2111 Se ::cOft1AU722C 399 795v1 SURVEY FOR STANLEY LEA; Nov. 11, 1970 SEc.T►a~c L-►w~~ soo ~a. ; r s.~: ~ 1~6V7 A parcel of land in Govt. L #1 Section 1, T.28N., R.20W. Tr Township, St. Croix County, 9If as dese ribed in deed to Stanle Lee recorded in vol. 433, page S`614 of the deed records, and , „ FRN~,yFshowinS encroachment of new Pence near northerly property line] on \ the drawing below,,, ;`I A Paul J. Boyd ~f' 21t l Renistered Land 31}rvey~or '.3 .~f. \ • -j Ra ~ PIN M A%V KS-KS Y T L OT \'S ! c~ 3 < 9 14\c RED 44 5-P, tx7 6 . 1' x So Ps Co- ST T f f Q og tie' YY F e nom, $ M ~ncroa:r.nri . 'It f Y •y T. 11+ N" 1% 40 4= J•. ~ may,` ~~V ' fff{Y`