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HomeMy WebLinkAbout032-2167-35-000 . commercewi. v 2 jo ri Bu Wo Ave. ildings i s nsz CounLy Sit' CiZD► gS R01~CUUN WI 53707-7162 Sanitary Permit Number (to be fined m by Co.) Deparbnent of 1 ~,~CINING State ort Numb" Sanitary Permit Application Transacti In accordance with s Comm. 8321(2), VAs. Adm. Code, submission of ft form to the w)red are Pro Unit is re*W Prior to obtaining a sanitary Permit. -Note: A fams for statt ject Address (if dffnat than mating address) submitted to the Dcparttment of Commerce. Personal info yon pravidc lic'umd br secondary d~~ ' pwPoses in accordance with the Privacy Law, s. 15. 1 m 5tats. L Application Information -Please Print All Information Property owner's Name Parcel # MCr f L ftverty ownees Mailing Address Property Location ~ J'{ 15 -731 -Govt Lot City. State /f ZiP~C/od/e Phone Number yy Y., N~ Ys, Section 247 tIU~S~ ~V 1 / l.~l~ Tf N; R (1Vm$il 11 Type of Building (check all that apply) Lot # l / if, or 2 Family Dwtlhi g-N>mmbcr of Bedrooms 64 7~ 3 Subdivision Name 4k As t PI P6 U I FF ❑ PubWCommexciai - Describe Use ❑ City of A4 646$V) ❑ State owned- Describe Use CM Number 0 Village S O IIA 2 Z III. Type of Permit: (Check dialy one box on line A. Complete Mine B if applicable) A. New System ❑ Repiacemdrt System ❑ Trea#menWddmg Ta& ReplacementOnly ❑ Other Modifimition to Existing S at= (explain) 44 B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Majed Before EiTiration Owner a IV. 4;We of POWTS m nent/Device: Cheek all that a Non-pr mi Tn Cnoemd ❑ pres~ized In-Ground ❑ At-Grade ❑ Mormd? 24 in. of suable soil ❑ Momrd X24 in. ofsuitabk soil (ezglain) ❑ Holding Tank ❑ other Dispersal Compor>ent (exPlam) Prtent Device V. Dispe rsaVTrea ent Area Information: Design (gpd) Design SoilApplxanon Dispersal Am Dispersal 7 Am ' e6 Iff 'T VL Tank Info Capacity in Twat # of blantrfacuuer 0 a Gallons Gallons Units 0 hh ~ ~ v 8 F ' New Tanks F Tanks !~J ~ . V ~~V 8 C = `a9 y ~ v ~ W as t^; 'S a Septic or HoldmgTank Dosing Ctmmber VII. Responsibility Statement- is the undersigned, assume nsibilitty for tion of the POWTS shown on the attached pleas. 's Si Brame. Pao Number Plumber's Name (Print) 2 ZyZ ~15~ IS5 -Z y~I OFF Fo-f,. 01 q V ( Plumber's Address (Street, Cit)G State, Zip Code) 90, go)( 5L~: DR vUl' ~~/OD~ VIII. un /D apartment Use On Approved ❑ PetmitFee Issued Issuing Si /Ofirt ❑ Reasoner X75 7- IX. Condi fAp Reasons for Disapproval 1. Septic tank, effluent fitter and 3) .4Jb L.+ " t A, Wd e• dispersal cell must all be servtces / maintained 5 t A- , q't as per management plan provided by plub. aF Potsese ~.(.I e• v 2. Al setback tequiretitets n must be L 1 as" Ulaimboxb1owilluft"n 4.(-.0. 15 6I' ff1~ . L I a Attach to complete plans for the system and submit to dbe County only on paper not less than a in z 11 inches in sae CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: MkC +kZWA Q Owners Name: fIk)~a1 PJF Pf\M6~-K Owner's Address: Pt1. B-t, `k PQ L7_Sn KJ _ Vll0 ~~IQI Legal Description: 5VJ ~I I 90k 5 24, 731 AJJR 19 1/V Township: S N\F-1;~SOT- County: 5'( C Col X- Subdivision Name: 61J I' Lot Number. 3S Parcel ID Number. Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. C~ F r- FO x. License Number. Date: I I zo I/,?- Phone Number Signature / l1 Designed pursuant to the In-Ground Soil Absorption Component Manual for Powys Version 20 SBD-10705-P (N.01/01). Page 1 lr~ PIIJw-U fF 4mkr-p s S vN'~y NC- ijy S 2 L -i 31 I g 1,1 &,,,L "731 LAA 35 t~f IJEL~I i ~-~U D cIJ , Lcl FF 5 N01(o So t n,Lasc-i -Tvi s? ,r a Im, i4c.4LDi OL- Sc 113M K 1 i Z ` (SAL -iA i4- A Ede A A -RCOLMAQ IL41 -i LIt DF I ~r STEC L P t ht' = 100 A SCI.Y1 iMAILIL42 10P OF 1 , 5-f(. PIPE ~L = 10523 t3 -SOIL RLR W6 Soil Absorption System Cross Section 16H,86 ft 4° Schedule 40 - Final Grade PVC Vent Pipe M n E ft Vent Cap 7O Leaching Chamber v System Elevation 3 ft >3 ft Soil Absorption System Plan View 88 ft 3 ft } ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4' Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model i NOLTRK-100. Odle-V-4 EISA Rating 20 sq ftper chamber Soil Application Rate x7 gpd/so ft lv gpd Design Flow = e-7 Soil Application Rate ~ZC EISA = ~3 Chambers 2 rows of 22 chambers each. I Page of W P U. d cc) C.4 C., pa O W ~ o 0 o CO LL- Ll- LL. U cr_ - - F- I-- .L co d olio C6 LL 30fe m J s s 0 START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > 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 COMMENTS POWTS INSTALLER POWTS MAINTAINER Name -EV F Name Phone 26- 15 2 q 6, Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY 1 Name Name 5-r bll' L~ T-f 20l"I Li+ Phone Phone -'7 (5- 2 CQ) r, ` L9D This document was drafted in compliance with chapter Comm 83.22(21(b)(1)(d)&(f) and 83.54(1), (2) & 13), Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS F P11J0-U PF -PFV S Septic Tank Capacity 12~ 0 al ❑ NA # Septic Tank Manufacturer WCC 4S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ge5"r ❑ NA Number of Bedrooms "1 ❑ NA Effluent Filter Model 4-8 ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) J950 gal/day Pump Manufacturer ❑ NA Soil Application Rate . 7 al/day/fits Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) S30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) :220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODE) 530 mg/L P( In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other. ❑ NA Other: ❑ NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 0 meonnthM (Maximum 3 years) ❑ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 1% year(s) Clean effluentlifter At least once every: ' 9' q month (s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) 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 tank(s) 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 observation 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 (Y3) 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 _<12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyerj~F(IsIF Yi~~7.UL'~9 Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State =aL~ N C-'V' WI Parcel Identification Number LEGAL DESCRIPTION Property Location n\Nr 1/4 , NE 1/4 , Sec. 2 , T3 1 N R I q W, Town of -510 M EAZS && T / K)C- C-0 Fl- - , Lot # . Subdivision Certified Survey Map # , Volume , Page # Warranty Deed # Volume , Page # Spec house yes o 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. Number f bedrooms t"- - /AK/-~QL SIGNATURE 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. 08/05) U 2 9 2 2 P 9 2 8 7.4.17sa i KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM I - 1999 REGISTER OF DEEDS ST. CROIX Co., WI Document Number WARRANTY DEED RECEIVED FOR RECORD This Deed, made between Stan D. Falkenhagen and Laura L. 09/29/2003 12: 45PM Falkenhagen, husband and wife WARRANTY DEED EXERT tt Grantor, and Pinee iff Partnership, LLC REC FEE: 11.00 TRANS FEE: 450.00 • COPY FEE: CC FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Part of the Northwest Quarter of the Southwest Quarter (NW 114 of SW 1/4) Recording Area and part of the Southwest Quarter of the Southwest Quarter (SW 1 /4 of Name and Return Address SW 1/4) of Section Twenty-six (26), Township Thirty-one (31) North of Range Nineteen (19) West; St. Croix County, Wisconsin described as The Riverl32nk follows: Lot 1 of Certified Survey Map filed May 29, 2002 in Volume 16, P. O. Box 188 page 4308, DocumentNo. 680290. Osceola, WI 54020 Together with the right of ingress and egress over Outlot 1 of said Certified Survey Map. part of 032-1073-40 and 042-1073-60-200 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is not home<etead Ixaperty. 4W (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and ordinances of record and will warrant and defend the same Dated this / D 141 day of September 200 + +.5ta en e + * ra L. Fa enhag n AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. Polk County ) authenticated this day of Personally came before me this 16141 _ day of September 1 2003 the above named + Stan D. Falkenhagen and Laura L. Falkenhagen TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing i strument and dgecth same. authorized by § 706.06, Wis. 5tats.) THIS INSTRUMENT WAS DRAFTED BY ' ~1 Ct-r i Priscilla R. Dorn Cutler. Attorneys at Law Notary Publi of $visa Osceola, Wisco;xIn $4020 My Commies' rtlt t:'' , state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) • tstanes of pcrsoars signing in any capacity -in be typed or printed bdow their signature. ' armslim Prorasalonals Company. Fong du Lac. WI eoaess2oz+ WARRANTY DEED STATE BAR OF WISCONSIN FORM No. I -1999 I Ig t < 1 i Lot W ,es'ce~~ ~ ~ • . . CD I I zN ~vsee~.aasob1 os ui V- I~ I I o ~3 oTA O ~ z m o U I , ,89•~svnnsa,te~~a5 ' V i ~ ~ 1 _ ~ X O 12°°= -a1 I 1 ~ 5g,05 = I ~ 1 N Cn I p ~ S 1 l1J l ( • cr_ go 100 / V N1 O w U_ U) OZ I $ ^ / Z ct) OO 31" 41e,osv &Ckmoos ,ee~ze~ nh.e~,soooos rr I I Z ~ I ©I Cs i I w I I .tv'~. cn I I ( z C4 0 X101 I ~ I ~ I ~a'esv nn.e~,saoos ~ ~ Wisconsin Department of Commerce SOIL EVALUATION REPORT Page r of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I. . percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. R Mvied Date Personal information you provide may be used fqr secondary puroses (Privacy Law, s. 15.04 (1) (m)). ~p Z Prope Owner roperty Location 11f/1 e1pi r' 1T ~Cc 7 /l try ' ovt. Lot 1/4 N~ 1/4 S < 6 T 3 N R f (or)1N Prop(ertyQ Owner's Mailing Address i 6) € of # Block # Subd. Name or CSM# d1 er 7~JV r ff2lfnecfrr city State Zip Code Phone Nufter , r ❑ City ❑ Village [RTown Nearest Road [ New Construction Use: [ Residential / Number of bedrooms Code derived design flow rate 16 OCR GPD Replacement ❑ Public or fcommercial - Describe: ,r Parent material 5C Ci'6 / J-t"- - 0 rfflood Plain elevation if applicable General comments yS f cr, i L , q 9, so~r 4jr C~ i e ~z and recommendations: F-1 Boring # ❑ Boring pit Ground surface elev. L-35-ft. Depth to limiting factor 176 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I ff#1 'E Z 12- ro '~7/v a j Z Q, S E 7,5 -Yt ~ SL Z s~ k C w lam, 0. S ® . y y 3~Sy 757% L e ~I-A 0, 7 1.,,2 S SY44 7s % A Cob f L - - -0,-7 J d Z Boring # ❑ Boring jOv O © pit Ground surface elev. ~~ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 5- ? /d j L r,.s i-t-- c 2 ~ 0, ,6 2 q- ,?6 7, S~V * SL 2,8I~Jd,E c w 2 4, s 4 , y A- W 75-1,( k4 /5 c w 1 0.7 /.2- V W- /0 75-Y? 0// A14- '~h S/~ 0, 7 J e 2 9CL" * Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Pnnt~j Signature CST Number g rd'l V~/-) e// X-- Z3 /3// Address Date Evaluation Conducted Telephone Number 3 2 cc 4-,-e f0^e,-r- f' 6A Z 6 - Zv - ©--Z As- 7- Y7- 3Za,? SBD-8330 (R07/00) t Property Owner e c c-., iii' Parcel ID # Page Z of ❑ Boring Boring # Depth to limiting factor J in. F-31 ®Pit Ground surface elev. .Sft• g ~ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 0-/z to ~ X Z- 2" O. V O.6 2 /2- 2 3 1 -T/ ,Z- ,2 f~ k CeJ Z 0 ,t O.8 1- Yf ~,3 r~ % N s cis G G 4- 0,-7 /,Z joy PA e- 0, -7 ~Z ❑ Boring ❑ Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ❑ Boring # ❑ Pit Boring ❑ Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L 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-8330 (R07100) Property Owner ~4 d G TT /Cj~ ems Parcel ID # Page Z of 3 Boring # ❑ Boring F-31 pit Ground surface elev. 6/ 1 Sft. Depth to limiting factor, in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Z 12- 23 10 3 Y 77- Y? 0,71 1,2 ff 109 e- 0.,7 ~Z Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor in. ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L 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-8330 (R07/OD) 7)WNER Paae 3 of 3 Name P/",: "/1' f r lot.-, e/j- tiBrian Parnell Address /f 4~1~~ cam= CST 231314 Date 6- Z o- 6 2 enchmark 1 L A), ~11 enchmark 2 6p f~ ~c/ lam. oL3 see _ Ifl-soll Boring 1--j ~ Suitable Area F = 40' Scale - Ii ! --r-- -_T--*--------r--1- --fit-r--! ! j - ---i-7-7-7- a i A 7---7 -T--- -~----i --r---'- ' _i i , - 1- j- -T- r --T--y- -j - _ - -1--i - - r - 7---t-r- --+---1 - r - r-.-- i j j ' ~~0 !E j ~ ~ I 4dl Y_~ i.-_i--r---~- ---r--t--1-- ' j-- ' I ; I I ~ i i ~ 7 i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT ® Sanitary Permit No: 453151 0 GENERAL INFORMATION (ATTACH TG PERMIT) State Plan ID No: Personal information you provide may be used for se dary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Hartman, Mike M Q C I ( Somerset Township 032-2167-35-000 CST BM Elev: Insp. BM lev: BM Description: Section/Town/Range/Map No: 26.31.19.1415 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark i Dosing Alt. BM Aeration BI g. S er Holding St/ t Inlet TANK SETBACK INFORMATION St/Ht utlet 7-1 TANK TO P/L WELL BLDG. Vent to A Intake R D Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pi Holding B . System Final Grade PUMP/SIPHON INFORMATION Manufacturer Deman St Cover GP Model Number TDH Lift Friction Loss System Head DH Ft Forcemain Length F5ia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded Ix Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes i No Yes ' No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 622 196th Ave Unknown (SW 1/4 NE 1/4 26 T31N R1 9W) Pinecliff Lot 35 Parcel No: 26.31.19.1415 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes -j No Use other side for additional information. 1 Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) 1 I Safety and Buildings Division County Nvisconsin 201 W. Washing on Ave,., P.O. Box 7162 Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266-3151 dA-Z Sanitary Permit APP FA`t110_ ~E State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code' personal information you provide may be used for secondary purposes rivacy Law, s15.04(1)(m) Project Address (if different than mailing address) 1. Application Information - Please Print All Info ation Property qy;qdr's Name "0. OFFICEr Parcel # of # 3S Block # filr11.e G V C 2- 2 (ol - 3S-eytSDC• !~{IS 11 Property/Nvner's a5- Address Property Location 7 if U L,1, Section _ Ci7Sta. Zip Code Phone Number (circle w~e) ~_,J 14 ),1 s-~z N; R~ ort')Ar' II. Type of Building (check all that apply) oto ►t,t.t er - ,{I or 2 Family Dwelling -Number of Bedrooms ubdivision Name L 27,j S, ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use .2 ❑City illage Township of i III. Type of Permit: (Check only one box on line A. o lete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. List Previous Permit Number and Date Issued ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) bl~ Non -Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter eaching C r rip Line ❑ avel-less Pipe. Other (explain) V. Dis ersall/Treatment Area In rmation: .i] Design Flow (gpd) Design Soil Application f) Dispersal Area Re ire sf) Dispersal Area Proposed (st) S stem Elevation VI. Tank Info Caaci ~ i of Number ; P tY n Manufacturer Prefab f -Site " - Sti el Fiber Plastid Gallons Gallons of Units do E oncrete Constructed Glass an Existing ~e (L 1 L New Tanks Tanks Septic or Wding Tank _ S Aerobic Treatment Unit 7`- Dosing Chamber w VII. Responsibility Statement-1, the undersigned ssume responsibility for installation of the POWTS shown on the attached plans. Plumber' Nam (Print) ,'.Plum is gnat MP/MPRS Number Business Phone Number 3 3 PI mber'.i~Address (Street, City, S te, Zip C VIII. County /De artment Use Onl pproved ❑ Disapproved Sanitary Permit Fee, (ytcludes Groundwater T~Dq ssue Is ing ens Signature (N Stamps) Surcharge Fee) `I¢f~tt 2-S 19. ❑ g&mer Given Reason for Denial IX. Conditions o Approve "Orions ft I DiSAPPI 0931 SYSTEM O R: 3 t 1 Septic tank, effluent filter and S = dispersal cell must all be serviced / maintained as per management plan provided by plumber. P I S d' -A-AA 2. All Sel Eck req' bltements must be maintained l as pel*'applicable"code/ordinances, t7 iVj tV C~YQ S I 16th dhiaplow ptatNl (to the County only) for the system on pdlWr-not less than 81/2 x 11 inches in size SBD-6398 (R. 01/03) \s o ~ \ 1 71k 1 1 47 \ 3 f \ i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 1141, Septic Tank Capacity al ❑ NA Permit # 5 / S Septic Tank Manufacturer S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units j2f NA Pump Tank Capacity al ANA Estimated flow (average) gal/day Pump Tank Manufacturer -41 NA Design flow (peak), (Estimated x 1.5) , al/da Pump Manufacturer ANA Soil Application Rata al/da /ft2 Pump Model ANA Standard Influent/Effluent. Quality Monthly average" Pretreatment Unit ,ANA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODE) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODE) 530 mg/L 0-In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ,ANA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA .v_,- ..~.yw,.. _ ~.~r;n: ...,T.~.M,.k._...::.:. _:..w,.: _ _ , fnonth(s) Inspect dispersal cell(s) At least once every: year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least-oncgrbven' ❑ month(s) El NA -0 year(s) Inspect pump, pump, controls& alarm At least once every: ❑ month(s) __O~NA ❑ ear(s) Flush laterals and pressure test At least once every: 13 month(s) A!I' NA ❑ year(s) Other. At least once every: ❑ month(s) ANA 13 year(s) Other. [J 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 tank(s) 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 observation 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-fecal regulatory authority. When the combined accumulastion of sludge and scum in any tank equals one-third IY3) or more of the tank volume, the entire contents of the tank shall. iberremoved by:& Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative God. f _ All other services, including but not limited ,>9 the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be proyidp`d} to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. IT, • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technob a toI" tank p be~iRstalled~as a last Tresort _to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. 0 Mound. and at-grade;, soVabsorptiQn.; systems may _ be .reconstructed in place following removal of the biomat at the infiltrative surface. WQnstructions 9f, such systems must comply with the rules in effect at that time. «WARNING> ? cup SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN, DO NOT ENTER A SEPTIC, PUMP OR`07HER TREATMENT TANK UNDEWANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIO .*'A TANK'MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS. ;ic. tn. u , POWTS INSTALLE POWTS MAINTAINER Nam y Name Phone .Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Rhone Phone t a!lu El- - This document was drafted in cornpttande}wlth chapter Comm 83.22(2)(0111d)&If) ".54(1), (2) & (3), Wisconsin Administrative Code. F ST. CROIX COUNTY SEPTIC TANK MAINTAINANCE AGREEMENT AND ONMERS)EUP CERTIFICATE FORM Owner/Buyer Ak kJ G~GL✓t YW4n~- 102!!" Mailing Address 7,-fq L. A-A Property Address 1 (Veri&caim regtmed an~gDeparrmeut for new cmttucti ` City/State d~Jt W - Parcel Identification Number-2p--f 2(-T 3S-~ ~~~5) LEGAL DESCRIPTION Property Locations it) 'f4, IU E/a Sec. ?6 T,LN-R1&, Town of Subdivision Lot# Certified Survey Map#tt//-- , Volume Page Warranty Deep ~T ~ - Volume 2 q2--z page Spec house yes no Lot lines identifiable _2!~jyes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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 fimchon of the septic tank as a treatment stage in the waste disposal system The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterpliunber, 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 th Department of Commerce and use 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 Zoning Office within 100 days of the three year expiration date. j SIG C DATE OWNER CERTIFICATION 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. T~ SIGNA P DATE Any mformabm that is rnwWreamted may resuh in the sanitary permit being revokedby the Zmmg Depattmeo Include with this apphcabw a aimed warranty deed from the Repta of Deeds offioe a copy of the aetified survey map trefacam w=de in the wwwty deed VOL 1571"C A24 STATE BAR OF WISCONSIN FORM 1 - 1998 16::3 Is. 1 04 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS CORRECTIVE ST. CROIX CO., WI Document Number RECEIVED FOR RECORD This Deed, made between ANTHONY TEASLEY AND 01-02-2001 12:00 PM D'ARCY ALLISON-TEASLEY, HUSBAND AND WIFE WARRANTY DEED EXEl+.PT N 3 Grantor, CERT COPY FEE: AKA PINECLIFF PARTNERSHIP COPY FEE: and TRANSFER FEE: RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in ST. CROIX County, State of Wisconsin Recording area (the 'Property"): SOUTHWEST QUARTER OF THE NORTHEAST QUARTER, SECTION 26, Name and Return Address TOWNSHIP 31 NORTH, RANGE 19 WEST. HEYWOOD & CARL, S.C. 204 LOCUST STREET, BOX 125 BY ACCEPTING AND RECORDING THIS DEED, THE GRANTOR IMPOSES HUDSON, WI 54016 AND THE GRANTEE ACCEPTS THE FOLLOWING COVENANTS AND RESTRICTIONS WHICH WILL RUN WITH THE LAND AND BE BINDING UPON GRANTEES AND ALL FUTURE GRANTEES OR OWNERS: 1. USE OF THE PROPERTY SHALL BE RESTRICTED TO SINGLE 032-1072-60-000 FAMILY RESIDENCES AND MULTIPLE FAMILY OR OTHER USES SHALL Parcel Identification Number (PIN) BE PROHIBITED. This IS NOT homestead property. F{s (s not) 2. THERE WILL BE A ONE- HUNDRED (100,) BUILDING SET-BACK ALONGG)THE ENTIRE NORTH BOUNDARY OF THE SUBJECT PROPERTY TO MAINTAIN A BUFFER BETWEEN THE SUBJECT PROPERTY AND ADJOINING PARCELS LYING NORTHERLY THEREOF. 3. HUNTING ON THE SUBJECT PROPERTY SHALL BE PROHIBITED. THIS DEED IS GIVEN TO CORRECT A CERTAIN DEED DATED OCTOBER 23, 2000, RECORDED OCTOBER 24, 2000, AS DOCUMENT 632297, RECORDED IN VOLUME 1553, PAGE 138. Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except EASEMENTS, COVENANTS, AND RESTRICTIONS OF RECORD CC~~ nn 2000 Dated this _sZt day of DECEMBER (SEAL)' (SEAL) ANTHONY TEASLEY (SEAL) D' ARCY ALLISON-TEASLEY AUTHENTICATION ACKNOWLEDGMENT Signature(s) ANTHONY T A4~ T FY AND State of Wisconsin, ss. D'ARCY ALLISON-TEASLEY ` C~ ~ I County. 2000 Personally came before me this ,o its) day of F MR .R authenticated this day of T) the above named (31 tiLt.61. cY r 4 ece a ko t C~ 1 Q'' ° 1 1jrY% - ! uU TITLE: MEMBER STATE BAR OF WISCONSIN to Of not, me known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. JUDY K. TANNER r ) r Notary Public-State of Wlsm"SA THIS INSTRUMENT WAS DRAFTED BY - HEYTJOOD & CARI, S.C. 204 LOCUST STREET 61 Notary Public, State of Wisconsin HUDSON, WI 54016 My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not 15 necessary) Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. I - 1998 Milwaukee, Wis.