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HomeMy WebLinkAbout006-1026-40-000S't. Croix County Planning and Zoning Friday, January 06, 2006 at 4:06:20 PM Detail Sanitary Information Page 1 oji Computer #: 006-1026-40-000 Sub/Plat: 80 acres Section: 12 Parcel #: 12.31.16.179A Lot: TN/RNG: T31N R16W Municipality: Cylon, Town of CSM: 114114: NE 1/4 SE 1/4 Owner: Kaczmarski, Wayne 2244 State Hwy 63 Deer Paris, WI 54007 State Permit: Issued: POWTS Dispersal: Mound Permit: Replacement County Permit: 0 Installed: POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Insaector As Built Plumber Other Requirements Additional Notes Monev Owed None No Smith, Gale the application and mound approval forms (#84- $0.00 None Signed Off: No 03853) submitted, but no permit issued. Paperwork filed with 2003 holding tank replacement permit - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner: Kaczmarski, Stanley 2244 State Hwy 63 Deer Park, Wi 54007 State Permit: 18020 Issued: 09/28/1978 POWTS Dispersal: Holding Tank Permit: Replacement County Permit: 319 Installed: 10/09/1978 POWTS Detail: NA Bedrooms: 2 WI Fund: POWTS Pretreatment: NA Notes Issuer/Insaector As Built Plumber Other Reouirements Additional Notes Monev Owed Harold Barber Yes Powers, Calvin soil report shows failing existing system with $0.00 Tom Nelson Signed Off: Yes borings taken around it (highest water estimated at 32". House in on comer of Cty. Rd. H and Hwy 63. 2000 gal. Wieser holding tank installed; permit filed with 1984 application (no permit issued) and tank replacement in 2003 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner: Kaczmarski, Mark 2244 State Hwy 63 Deer Park, W 154007 State Permit: 430232 Issued: 08/18/2003 POWTS Dispersal: Holding Tank Permit: Replacement County Permit: 0 Installed: 08/19/2003 POWTS Detail: NA Bedrooms: 4 WI Fund: POWTS Pretreatment: NA Notes issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Not determined No Bird, Byron Jr. Emergency replacement: elevation shots called in $0.00 Kevin Grabau Signed Off: Yes by plumber: no inspector available Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 8/19/2006 Wiscpnsin Department of Commerce Safety and Buitttk~g Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'erm't Holder's Name: City Village X Township «.~~ ski V~G•r'k L.~J~ :ST BM Elev: / Insp. BM Elev: BM Description: 1 t=o • o' ~ an ~ ~' b I•-~~e ~~ SANK INFORMATION E NATION DATA TYPE MANUFACTURER CAPACITY Septic - --, Dosing Aeration oldin 3~ W e~-k~ 1 ~ 3 ~-8'° TANK TO P/L WELL BLDG. Vent to Air Intake ROAD `~ yam' ~zs' 3~' Aerat~2 y S~ t 33~ I PUMP/SIPHON INFORMATION Manufacturer Demand M Model Num r TDH Lift ion Loss System Head TDH Ft Force n Length pia. Dist. to well SOIL ABSORPTION SYSTEM DIMENSIONS SETBACK SYSTEM TO INFORMATION Type Of System: Number: DISTRIBUTION SYSSE'IH \ \ / ~--~ Header/Manifold Distribution x Hole Size x pacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only zx Mound Or At- e.,~stems Only Depth Over Depth Over xx Depth of xx Seede xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ( Yes ~ No ~ ~ Yes L~1 No COMMENTS:~1(ICncLlud ~,(d~e dis/cr_epencies, persons present, etc.) Location: U~ ov n (S~1(4~W~/ 29 T29N R15W) NA Lot 1 1.) M Descripti 2.) Bldg se ength = Plan revision Required? Yes No • i19 2 Use other side for additional information. ! ~_ ~t ~' Date SBD-6710 (R.3/97) Inspection #1: ' ~ ~~ Inspection / ~~~[~ Parcel No:-3(, ~ (P r~ r Y -_--- r Ins ctor's Si nature Cert. No. / Y county: St. Croix Sanitary ermit No: Z3 a State Plan ID No: ~t~ l T.,~I.s . ,o . Parcel Tax No: ooW - I oZG. ' yo - w-p Section/Town/Range/Map No: STATION BS HI FS ELEV. Benchmark 0 •~3 ieo.~ acs. Alt. BM Bldg. Sewer , s-~ i ~TZ • ~o SU Inlet ~ ~ 9•~a ~ 9~•s~ S Outlet,' Q4 7• 9~ i19' ~}Tt~' ~ L 9.8~ `jo . 9s' Header/Man. Dist. Pipe Bot. System Final Grade St Cover .~•-r. ~3 9.9~ o. 93 , Sanitary Permit Application Safety & Buildings Division ~ In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. ~ ~ `~ See reverse side for instructions for completing this application PO Box 7302 SC0/1S~I1 Department of Commerce personal information ou rovide ma be used for second u oses y p y ~ p ~ [Privacy Law, s. 15.04(1)(m)] Madison, WI 53707-7302 (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) r e t ess an 8 -1/2 x 11 inches in size. County s State Sanitary Permit Number ^ heck f s e s appli lion to Plan I. D. Number I. Application Information -Please Print all Information <<< ; , ; ~ ~ ~~ Location: Property Owner Name ~ ~ ~ ~! Y Property Location ' / ~ FI I '~'~ ~ GlG~/T~ - ~ ~ 1/4f~14, S T ,N, Property Owner's Mailing Address ,( ,~L~ _.:....~W~,.~...~.....:.,:~.._. Lot Number BlockNum City, State ~ ,~ Zip Code Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) ^ city 1 or 2 Family Dwelling - No. of Bedrooms :~ ' ^ Village own of ~ ^ blic/Commercial (describe use):_ ~ ~ ~~~~ ^ State-Owned 3 ~ /~ /~ ~/~/~ G~ „/T ~ Nearest Road ~- / b Pazcel Tax Numbe ) ~ ~ ~ ~ III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. ^ New 2. eplacement 3. ^ Replacement of 4. 5. 6. ^ Addition to System System Tank Only Existing System B) Permit Number Date Issued ^ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ^ Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ~olding Tank ^ Single Pass ^ Drip Line ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating ^ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Perco]ationRate 6. System Elevation 7. Final Grade ~~ Required Proposed Rate (Gals./day/sq. ft.) (Min./inch) Elevation VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Cot(- Con- glass New Existing Crete structed Tanks Tanks J ~ ~~G, j ^ ^ a ^ ~ ~ /' VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumbe ' Name (print) ~ Plumber' tore (no slam :~ MP/MPRS No. Business Phone Number s7 r ~ .7~ iS"v~~ ~~~ Plum is Address (Street, City, State, Zip Code ~j ~~,/~ IX. County epartment Use Only Approved ^ Disapproved ^ Owner Given Initial Adverse Sanitazy Permit Fee (Includes Groundwater Surchazge Fee} ~ Date Issued Issuing Agent Signature (No stamps) ~ Determination 3zS-- g ~ X. Conditions of Approval /Reasons for Disapproval: ~- C~) se ~ l ~9s .~ ~ «~ Q~~ ~ ~ es~ ~ ~ ~^y~ - - ~ t~ ~ -~ - ~ .,o.a.-Q~-,ti,,~ed~ ~ ~-- Gt~-'~ ~ o 'ce SBD-6398 (R 0 /00) _ _ _ ` _ PLOT PLAN ,BCT Mark Kacxmarski ADDRESS 2244 US Hv 63 DeerPark Wi. 54007 ~E ~ /4 SE i /as ~ 2 /T 31 N/R 16 w TOWN Cyion COUNTY ST. CROIX __.____ ~- DATE 7'24-3 BEDROOM 4 MFRS Byron Bird Jr. 220527 CONVENTIONAL IN-GROU PRESSURE CONVENTIONAL LIFT HOLDING TANK XXXX LIFT TANK SIZE DOSE TANK SIZE MOUND___, SEPTIC TANK SIZE - HOLDING TANK SIZE-1260 gal LOAD RATE ABSORPTION AREA _ # of chambers ~- BENCHMARK V.R.p. Base of siding ASSUME ELEVATION 100° ^ BOREHOLE O WELL ~g,R,p, same as BM SYSTEM ELEVATION t0 be determi0ned ~3 Driveway US Hy 63 l' a ~f 4 bed b ~~ 1,5. ~t~o~~~~~iy _ ~ ~ ~~ S nF_~ ~ t. G~ 8~ ~p1NG ..---oRR~SP~NpENGE Co RD H S lei? ` ~ ~-' ~ 7 ~ - (~ ~. ~: ~~f `l ,_ ~ ~ ~scons~n Department of Commerce Safety and Buildings 10541N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264-8777 www. commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary August 11, 2003 CUST ID No.220527 BYRON BIRD JR BYRON BIRD JR. PLUMBING,INC 896 68TH AVE AMERY WI 54001 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/11/2005 SITE: Mark Kaczmarski 2244 Us Hwy 63 Town of Cylon St Croix County NE1/4, SE1/4, 512, T31N, R16W FOR: Description: Holding Tank 400 gpd. Object Type: POWT System Regulated Object ID No.: 915131 Identification.Numbers Transaction ID No. 896146 Site ID No. 663134 Please refer to both identification numbers, above, in all correspondence with the agency. The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: 1. Comm 83.54(2), A water meter shall be installed by a properly licensed plumber, on the water system, that adequately measures the amount of water used by the structure, excluding hose bibs and wall hydrants, which do not discharge into the sanitary system. 2. Comm 83.33 Abandon the existing failed system as per this section. 3. COMM 82.30(11)(c). Insulate building sewer where and as required. • Comm 83.61(5)This system is to be constructed and located in accordance with the enclosed approved plans and with the Holding Tank Component Manual, SBD-10571-P (R.6/99). In the future identify the Component Manual used in the design of all POWTS on the Index of your submittal. • Comm 84.10, All materials used in this installation shall conform to the provisions,of this chapter. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. ~. C~j~d ~~N, AT7N.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 S BYRON BIRD JR Page 2 8/11/03 Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely /~ ~ Thomas E DevereauxN Plumbing / POWTS Reviewer II ,Integrated Services (715)634-3026 , 7:15 am - 4:00 pm Mon. -Fri. tdevereaux@commerce. state.wi.us WiSMART code:=7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 r PLOT PLAN PROJECT Mark Kaezmarski ADDRESS 2244 US Hv 63 DeerPark Wi. 54007 NE 1!4 SE i/4S 12 /T 31 N/R 16 W T,,O//~~WN Cylon COUNTY ST. CROIX MFRS Byron Bird Jr. 220527 ``r'~2~.r5.~~~j DATE 7-24-3 BEDROOM 4 CONVENTIONAL IN-GROU PRESSURE CONVENTIONAL LIFT HOLDING TANK XXXX MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 3 1260 gal LOAD RATE ABSORPTION AREA # of chambers BENCHMARK v.R.P. Base of siding ASSUME ELEVATION 100° ^ BOREHOLE ~ WELL +ag,R,p, game aS BM SYSTEM ELEVATION t0 b@ determi0ned Driveway ~s° CoRDH HOLDING TANK CROSS-SECTION Weather Proof Junction Box Final Gra Water Tight Seal Blind C.I. Plug Approved Yent Cap ~- ,,~4" C,I.. 12a Minimum Vent Pipe Approved Joint 4" C.I. High Water Alarm Switch 3" of Bedding Under Tank i 4" C, I. " ~ µoa ~ SPECIFICATIONS Owner's Name: ~~~~~1 . Address: {I u1~~ TANK New ~ Existing Le Discr~ption. 5 /d~c? Manufacturer: ~,~~.~ ~ j ~ unicipality: Gy o.~ Tank Size: ~_~~~_ all~ons- y~_ ~7t Ciro: ~c ~ ^° ~LUMQER/DESIGNER Signature: License Nu Date: ~ ALARM Manufacturer: Model Number:iT^`'~ ~~~ Switch Type :~"'~- ~,~ NUMBER OF BEDROOMS: GALLONS PER DAY:_~pQ, Approved Locking Manhole Cover With Warning Label Attached And Padlock 4" Minimum 18" Minimum Approved Joint w/ C.I. Pipe Extending 3'~ Onto Sal id Soil All 3 Tanks Typical of Each Other Byron Bird Jr. Plumbing Inc. User Manual Owner= /~ar ~tT~G211~-~~5~ Location, 1 /4~1 /4 SST ~ N/R~_W Township~~~? Lot_ ~ubd name or GSM County ~ ~'"~~ ~ The owner is responsible for operation and maintenance of the system, locking device, alarm, and must maintain an access road. The county is responsible for inspection of the site before, during, and after construction. The holding tank must be serviced ay a licensed pumper. An alarm system is installed to activate when the tank is 90% full. At the time of the servicing, the service.provider files a report with the department or designated agent. A remote reading water meter must be installed on the water supply of the facility that discharges into the holding. tank. Phone Number Installer ~^o~-r ~ No. ~6~4576/.~ Pumper_ _ No. ~'~~ _ y~~~ Health Authoriy ~~ - ro~~~ No, F3~6' `f~ Contingency Plan: If the tank were to fail, the owner shall have the tank pumped and properly abandoned by license provider. The tank than must be replaced by a licensed Master Plumber or Restricted Master Plumber: 1640 ' ~ SOIL EVALUATION REPORT Page 1 of 4 Wisconsin Depargnent of Commerce A.C.E. Soil & Site Evaluations Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8'/2 x 11 inches in sip Plan~rpp~~~+.+__~~,.......-•-------°~ St. CroDc include, but not limited to: vertical and horizontal reference int (BN~~~aFe~t ~ '~ Parcel LD. percent slope, scale or dimemsions, north arrow, and locatio and di 006-1026-40-000 Please print alt informatio ss~~ p e ewed,By Date ide may be used for sscondmy pu s (Prive~ f~, s. ~ci.(~(1 ~?(~~ ., ~d~l„6f . I ~ ZOO Personal information you pov Property Owner , _~ `;, , .P~°p~y~ 4~tion Mark & Rachel Kaczmarski ~s.~,~ ~~~IGF~ ( NE 1/4 SE 1/4 S 12 T 31 N R 16 W Property Owners Mailing Address o Block # Subd. Name or CSM# nor nor Na 2244 Co. Hwy 63 City State Zip Code Phone Number J City ~ Village iI Town Nearest Road Cylon U.S. Hwy 63 & Co. Hwy H Deer Park ~ WI 54007 715-263-3620 Code derived design flow rate 600 GPD New Construction Use: J/ Residential /Number of bedrooms 4 Replacement `,_( Public or commercial -Describe: Flood plain elevation, if applicable nor Parent material Glacial Til General comments and recommendations: Site unsuitable for POWTS. Groundwater monitoring may result in suitable system area being identifie . Boring # _:~ Boring 21 ° rn. Soil Application Rate ~/ pit Ground Surface elev. 101.37 ft. Depth to limiting factor --~ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 Gr. Sz. Sh. *Eff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color 1 0-12 10yr4/3 none sil 2fsbk mvfr as 2f,1 m 0.5 0.8 2 12-21 10yr4/6 none light sl 2msbk mvfr cw 1fm 0.5 0.9 3 21-26 7.5yr4/6 f2f 7.5yr5/8 light sl 2msbk mvfr cw 1fi 0.5 0.9 - 0.4 0.6 4 26-36 7.5yr4/4 m2d 7.5yr5/8 sl 1 msbk mfr ~+ _ - 0.2 0.3 5 36-44 5yr4/4 m3p7.5yr5/8 scl 1csbk mfi a Boring # ~ Boring 11 ~~ Soil Application Rate t/ Pit Ground Surface elev. 100.56 ft. Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Grt Sz~Sh. Consistence Boundan/ Roots *Eff#1 PD/ft*Eff#2 in. Munsell Qu. Sz. Cont. Color 1 0-9 10yr4/3 none sil 2fsbk mvfr as 2f,1m 0.5 0.8 none sil 2fsbk mvfr cw 1fm 0.5 0.8 2 ~1 10yr5/4 - 0.5 0.8 3 11-20 10yr5/4 f2f7.5yr5/8 sil 2fsbk mvfr cw _ 0.4 0.6 4 20-28 7.5yr4l6 m2d 7.5yr5/8 sl 1 msbk mfr cw _ _ 0.5 0.9 5 28-40 7.5yr4/6 map 7.5yr5/8 sl 2csbk mfi ite does not meet A+4" requirement. uent #2 = BOD < 30 mg/L and TSS <_30 mg/L * Effluent #1 = BOD ,? 30 < 220 mg/L and TSS >30 < 150 m /L CST Number CST Name (Please Print) Signature: ,~~,----- 3602 James K. Thompson ' Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted X15-248-7767~r .... .,.,.,. 5/16/2003 __ . .y:, d . o ~ O ,, o ~~ ~~ W +~ M ~ \ ~ 3 ~~ ~~ ~~ C r C ~; ,Z d I" j~C ~ ~ ~ q~ ~ a ~ o N ~V ~~~ r ~ ,~ ,h ~/ ~~~' ~~ ~~ ~o ~~ a ;~ d~~ f, R ~ p N ~ ,u '~ d d ~' d f ~ ~ ~ Q ~ ' ~ ~3 i c.9`C~ ~* ~~ v~ ~ba ~'' v d' ~. W~~ ~ X~p ~~ w Q W s-,-a,~, au ~d b ~~r..d S ,~ b d~ 3 N ,~c O y a ~'b~ ~~ ~ ~~ ~~ _ _` ~~~~ ^~~ Z ~\ C 'L O -~ ti ,` wa ~ ,. t' HOLDING TANK SERVICING CONTRACT' Contract Date ~~ 3_0 3 `_ _ _ _ This contract is made between the_ ._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Holding Tank Owner(s) Name(s) and i Pumper'i Name (~r~ 2 K ~CZZ'~t'zS K ~~,e,t: I~c`L~2s K % I `~ _,_ We acknowledge the inst/a~llation of (a/)~hiolding tank(s) on the following property: (Provide legal description:) ~~ l~ ~~ ~~ S /~ ~3 l e~~ ~6 ~ ~y~n ,T ~ I. The owner agrees to file a copy of this contract with the local governmental un{t here(nafter cal{ed the "lfiunicipaliry", which has signed the pumping agreement required (n Ch. iLHR 83.18 (4) (b), Wls. Adm. Code and t with the County of ..l 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for ail charges Incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for. the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: ''- ' a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; ' f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. a. This agreement will remain In effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a Copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print). I Ownor'a Signature(s) i~~ ~ 1L~°t;C2~~ K; ~ ~A„ 1. ~. a,'~ ` .. , ~~' I ~ _~-. Pumper'a Name (Print) I Per's tgnatur \ \~ ~ Pumper's Registration Nember Subscribed and sworn to before me on this date: Notary Public commission expires: ,ff"~~/,®!~ 560.7514 (R. 09/88) This Instrument was drafted by the State of Wisconsin Department ' -! 2365 P 035 735678 oocumentNamber/Planl.°•"°• HOLDING TANK AGREEMENT REGISTER OF DEfiDS ST. CROIX CO. , MI This agn3ement is made between the government unit and holdin tank owns s . RECEIVED FOR RECORD ""~ ,~~ ~~ /Q ~ ~ 08/14/2003 0+! :15PM ~( L~ a C~iur~S~~ HOLDING TAHx AGREEMEIIT ~~~ ~ J ~t~7 TRAKSEFEE: 11.00 parcel Identifier number (P114) AgreertleM COPY FEE: n CC FEE: DOIo- 2 - -a00 e~`Q ~`~3 PAGES: 1 vemmenW Uo t Holding Tank Owner( We adatowlodge application is being made for the installation of (a) holding tank(s) on the following property: (Provide legal land description. Use reverse side if additional space is needed) /I EYs! SEl~s! Sac.. ~~. T. 3 ~ /t _ . ~_ IGiJ. T . of G,/~ . Se<. c.~ik ------------------------------------------------ or that mntiaued use of the ezisting premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. ALw, the property cannot now be served by a municipal sewer, oz any other type of private sewage system as permitted under Ch. II~ 83, Wis. Adm. Code, or Ch. 14b, Stets. n n t ~ n - As an inducement to the C-~. 0 7- dG • ~/'O j~Y to issue a sanitary permit for the above described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Ch. II.HIi 89, Wis. Adm. Code relating W holding teaks. If the owner fails to have the holding tank properly serviced in reapoose to orders issued by the governmental unit to prevent or abate a human health hazard as described is s. 254.b9, Stets., the governmental unit may enter upon the propertq and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the ta: bill as a special asseaement for current services rendered. The charges will be esseseed as preecn'bed by e. 66.60. State. ~ 2. The owner agrees, pursuant to s. ILIIR 85.18 (10), Wis. Adm. Code, to have a water meter installed is a new building or sew structure. The water meter shall be installed by a plumber authorized by the State to conduct such iastallatione, with said installation complying with State regulatioaa and manufacturers specifications. The owner agrees W be finally responsible Sor the purchase, installation, maintenance, and repair of the water meter, sad agrees to allow the governmental unit to enter the above described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and coat incurred by the governmental wait for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in ouch a meaner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges maybe placed on the tax roll as a special awessment • for the abatement of a human health hazard, sad the tax shall be collected sa provided by law. 4. The owner, except as provided by e. 146.20 (3) (d), States, agrees to contract with a person who is licensed wader Ch. NR 113, Win Adm. Code, to have the holding tank serviced and to file a Dopy of the contractor the owner's registration with the governmental unit. The owner further agrees W file a eopY oi~ay changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from t]us date of rhaage to the service contract. b. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code. who shall submit to the governmental unit sad the county on a semiannual basis a report in accordance with s. I1.~iR 83.18 (4) (a) 2., Wis. Adm. Code, for the serving of the holding tank. In the case of registration under s. 146.20 (3) (d), Stets., the owner shall submit the report to the governmental unit and the county. The governmental unit or county maq enter upon the property to investigate the condition of the holding teak when pumping reports and meter readings may indicate that the hohiing tank is not being properly maintained. 6. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. IIdiR 83, Wis. Adm. Code. Ia addition, this agreement may be canceled by executing and rewrding said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, sad assignees of the owner. The owner shall submit the agreement to the register of deeds, sad the agreement ahaU be recorded by the register of deeds in a manner which will permit the exist~t}ge of the agreement to be determined by reference to the property where the holding tank is installed. ;. ; ~~ ., Notarized Owner(s) Signature(s) Unlt Official Title -Please Print '(~~ No •• s•. _ ~ ?L Drafted b~~4r>7e.5 ~ O»~ $pr~ t'ersoael iarolmetios you govide awry be reed Wj~~i~i~j,'t.w, s.IS.04 (IXa)1• M /lelellll/~~ ' ~o~ 1420PACE 64 STATE SAR OF WISCONSIN FORM 1 - 1982 601$61 WARRANTY DEED DEEDS REGISTER O F DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Marlys I. Kaczmarski p4-¢0-1999 dt00 AN YARRANTY DEED EXEMPT f Gnuttor, CERT COPS FEE: a~ Mar W. Kaczmarski and Rachel J. Kaczmarski COPY FEEe TRANSFER FEE: 300.00 husban and wife, as survivorship marital property RECDRD116 i=EE: 10.00 PAGES: 1 Grantee, Witnyysse[h That the said Gtarttor, for a valuable oonsider,<=ott_ of One Dollar ($1 00) and other valuable consideration St. CCO1 X THIS SPACE RESERVED FOR RECORDwG pATA conveys [o Grantee the following described real es[ate in (_OUn[y, State Of Wisconsin: NAME AND RETURN ADDRESS Schanon Mortgage, Inc. 228 N. Keller Avenue Amery, Wisconsin 54001 006-1026-40; 006-1026-50 PARCEL IDENTIFICATION NUMBER NE} of SE} of Section 12, Township 31 North, Range 16 West. AND NW} of SE} of Section 12, Township 31 North, Range 16 West. This 1 S homestead property. (is) (14)fsiSt>f Together with a-I and singular the hereditaments and apputtenances thereunto belonging; And M 1 I K z warrants that the title is good, indefeasible in fee s[mple and free and clear of encumbrances except easements, reservations and restrictions of record, and zoning regulations and will warrant and defend the same. Dated this 16th aay of Apri 1 ,19 99 (SEAL) (SERI.) . Ma s I. K z ski (SEAL) Signature(s) AUTHENTICATION authenticated this day of . 19- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Seats.) ACKNOWLEDGMENT (SEAL) /O State of Wisconsin, ss. POLK County. Aprl~ally came before me this 16Lh day of , 1~ ,the above Tamed 1~]~~I Kaczmarski to me known to`be~ the perso y~tg executed the foregoing itutnument and gcFnowl e a J THIS INSTRUMENT WAS DFIAFTED BV / !///~ James A. Kru a, Attorne at Law ~ ~7.`^f--"~ P 0 Box 168, Amery, Wisconsin 540ak='NOTq, taI'1'~ (Signatures may hr authemicated or acknowledged. Both a~rjot ~.~My ~~ nrcessar)~.) .+ :. A • Nartxa ~>i prtsms.~gnmg m any:apxny should by typed m printed blow dkL~nurfji....~~ 0... el "~~Schd...,r.~ Polk County, Wis. m is permanent. (If no[, stair expiration dare: Wi,COMn LpM LAaN. Co.. Inc. MiAve~IcN. Wi,. WARRANTY UPhU J 2365P 035 DocumentNumbedPlan I.D. No. ~ HOLDING TANK AGREEMENT This agreement is made between the government Z2~f ~ Gc. S hwy. CO 3 Parcel identifier number (P[N) Agnxrnent ate 0000-- D 2l0- - o0O o~p ~`CA~ Governmental U/nn~it Holding Tank Owne h G~ l~v ~OYi ~ . (.../'o i Y~i.. GcX. ~d!~~` ~Q GL [_ ~1tLt Lr z~I796tYcSrci We acknowledge`that application is being triads for the installation of (a) holding tank(s) on the followin/g'"p'ropeCrt'y/; (Provide le~gfal l+an~d description. Use reve-rs-e~-side~if/a+ddnitional spacLe is n/e7ed~ed) ~~7y sC/~ ~. ~i(. /. 3/H_.~ ~/e ~. /N. ~J7" C".i~//Yl 7t. t..l U~~ 735678 REGISTER OF DEEDS ST. CROIx CO. , WI RECEIVED FOR RECORD 08/14/2003 04:15PM HOLDING TANK AGREEMENT i:zawr # REC FEE: 11.00 TRANS FEE: COPY FEE: CC FEE: PAGES: i or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. II.IiIi 83, Wis. Adm. Code, or Ch. 14b, State. //~~ As an inducement to the C.m. ©'~ ~ • ~/ O I Y to issue a sanitary permit for the above described property, we agree to do the following. i. Owner agrees to conform to all applicable requirements of Ch. II.IiR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit to prevent or abate a human health hazard as described in s. 254.b9, Stets., the governmental unit may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stets. 2. The owner agrees, pursuant to s. II,Fi1Z 83.18 (10), Wis. Adm. Code, to have a water meter installed in a new building or new structure. The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulations and manufacturers specifications. The owner agrees to be finally responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit to enter the above described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and coat incurred by the governmental unit for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank is such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costa and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner, except as provided by s. 146.20 (3) (d), State., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contractor the owner's registration with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. S. The owner agrees to contract with a person licensed under Ch. N1Z 113, Wis. Adm. Code, who shall submit to the governmental unit and the county on a semiannual basis a report in accordance with a. II.IlIt 83.18 (4) (a) 2., Wis. Adm. Code, for the servicing of the holding tank. In the case of registration under a. 14G.20 (3) (d), Stets., the owner shall submit the report to the governmental unit and the county. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. Thin agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be canceled by executing and recerding said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall at}bmit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the exiatdi}tie of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) -Please Print Gov mmental Unit Official Name -Please Print Subscribed an sit o b~fq~ ~n this date: 'yr,a~J K`. ,r ,. Notarized Owner(s) Signamrc(s) Govctnmenuil Unit Official Title -Please Print ~" . Notpfy Public ._ Drafted by~~drrie.5 ~ orr~rjpr7 Personal information you provide may be used „~....:: ..ts.a pXm)1~ • AS BUILT SANITARY SYSTEM REPORT ~'YER ' ~ ~ : ~ - , TOt~INSHZP (~4~~-. SEC. T~_N, R~~W ~0. ADDRESS - ~ , ST. CROIX COUNTY, WISCONSIN. '3DIVISIGtI , LOT LOT SIZE - . PLAN VIEW •Distances & dimensions to meet requirements of Hb2.2O SHOW EVERYTHING SvI'fHIN 100 FEET OF SYST1'M ,~ !!^^ r ~v ~?r ,~~~U.~'W~~ ...__~_ - --.__. ~.t TIC TANK (S)~~ MFGR.~j,~; ,.: cd RS .CONCRETE STEEL ~ . . NO. of rings on cover~_ Depth /.~''~;,;,,,• P.,~r _ pRY WELL 'NCHES N0. of width length .area ~ no. of lines width length area _ depth to top of pipe ~~~~ ~~~ .;RELATE ~ r~ :u~C RATE ~- AREA REQUIRED AREA AS BUILT • ~fi9~ ~'D.~.vTs P+e a ~b.~ ~'. ~ =d X19'9/ ~ ` ~ -,claimer: The inspection of this system by St. Croix County does not imply complete -:pliance with State Administrative Codes. There are other areas that it is not possible/ inspect at this point of construction. St. Croix County assumes no liability for :item operation. However, if failure is noted the County will make every effort to :.ermine cause of failure. .BASES AND OILS,~SHOULD NOT BE DISPOSED THROUGIi THZS SYSTEM. . ~INSPECTOR D,4TED ~~ "'" ~ ~ ~ ~ PLUMBER ON JOB ~J _... . LICENSE NUMBER.. L ~ l ~~ K.~ _ _ ' .,>•-4n..~p...,~- :....:. a....M,.,.~,.....-,..~:.~.... e..,.,..,;.,».....n,y„,.,ar,. .,,.,....-..w•. .L-.~.:_.~., .~.+..;.:~...e.r..R...:..:..,..:...w.,„r:..,w..~_ v!v;~'._.~+n.w'+..'t~d"""_" r ~ .. ~ 5 • • . • ~ w • . • REPORT ~Or IITSP~CTIO?t--Ii?DYJZDiJAL SEI~)AC:E DISPOSAI, SYSTFI~i . ~ SrtniL-ary Pernit .3/~ • - ~, ~' State SepCic o~ v. ~/ , ".A'IE 1~.. ~ TO?•IIISHIP ~ ,~aZ~. ~~ % S~ % ..,~~°~-tc ~ t. Croix: County ~• .~x2e ^ gallons . '?umber of- Coaoartments ~. ~~ Distance Front: '~~ell _ ~'6O f_ ft, ~ 1270 or greater slope ~-- fi. . ~ ~ Building ' ft. Wetlands _ f: • ~ Iiig~i~aater ~ ft. . ~. DISPOSAT.. SYSTF:T ___~__. Tile Field or Seepage Pit(s) • i distance firom: tell _ ft. 12%.or greater slope ft $uildin~; Wetlands f FIILn li~;hwater f t , . ______ . Total length of lines ft, i~Tumber of lines Length of each line ~~ft, Distance etween lines ft. Width of file trench ~ .~ft. Tota ab i,on area - ~ sq. ft. Depth of ~ rock belot~s rile ~pth of rock over file in.. Cover . .. ~nver.rock,, Depth of the below grade in. Sloe of . trench __~___in ner ln~) ft. Depth to Bedrock ft. Depth to Around water ft. PITS ~ .. =umber of wits 0 is' a diameter ft. Depth below in1eC ft. Gravel a-r _-__,yes no. .Total absorption area ~ \ ,. __________s q . f t . ~ . .Square feet of seepage trench bottom area required ::quar~ feet of se age *~' are re uired Insnccted by: Title':. . Approved ~~ Date ~ ~_____197~. ` ~~.. ReJected Date 197 ___. • . ,' . - ,~~. ' . . / ~• . •~ O~ r f . ` ~ Q~ • ~ ~ l//r//)// C~> ~./ ~ ~ ~. ~~J~ ~~ u v ~ ~ 4 ~~2~~f V L z~~~ ~~~ i ~ ' `~r. __ t'J' r . iy r -.-. ~_ J ,/VT r ! '`r ~ t V/v ~~~ d 6 ~~- ~~ r ~ i 1 M i~r ~- v ~~~ ~~, ~ .~ ~ _~ y) ~~ i. -l~ t!~ ~`\ -i.~ .~: ~~ ~, ~~. ~.. 0 - C y O 4. C O ~ U LS • ~ \ t~ ."~ us f2. ~ V _S~ "',° U w -- ~l ••'+ ~~i ~ ~ ~ 4 a~ ~ ~ 4 ~ a:~ .._~ ~_f ~- _ .. c ~ 4' ~ ' e ~ O F-S' t ~ ~_ ~ z-y , cz ~~ ~ ~ - ~;:: ` (J G '} ~ t L ._ ~, ~ - ~ k, C ~`~ ~I ( ~.Y ( ~` I : f~ V7 ~ ~. 1 =~ ~ f , • y .f. ~ t ~ ~ '' , ~ , u~ = Z ~ ~ ~ o V ~ _ ~ ' S:L ; ~c~. -; ~`~~ '~ ,~ ~ _ ~V ry ~ ~ ~ ~ ~ ~ -~ ~ -~~ 3 ~ = ... ~ ~~ ~ AUG 1 ~ ~~8 ~I ~ Q ~~-~ G~ .m« , F V 17 ~ „3 .S \• ~ , ,. Q/ ~~ ,, t j._ h p./' 1 gy ~~ ,.-~ , ,~ ~~ ~~ ~~ ~~ k' .. ,,~ ~~ `~. LC 1 ~ _ I ~' I ~ ~ ~' y ~ ~ ~f ~'ti ~ ~ .. ~ -.; .~ ~ ~. ~ - s 1 i ~i f ~.. t ~/ ~ , ~~ 4 J ~~ . ~~'~ ~ ~~~ o~ o~ ,~,~. ~~' c ys ~y~t ~ ~. .~ y ~ . ~. . ;°L 4 ~ tt t~~'"~ ~ a ~r ~ ~ a`~/ _ ~v r t-. ` G °: ~ ~. • q, f S `~N ~ C ,j ;~ 1 J~. .`. ,.~ ~ ~ C ." G .~1 l ~V,1Y ~ y ~ ,/f l -~ ~ ~C ~;" ~ i~ k~, ~~~' Pf ,!'~~ ~~ ~~~~ ~ 1 ~~'~'~~. ~~ AUG 14 ~~~ _ ,~ f S~ .-~~-~.f - ~Iv ~ ~ S ~~ ~'~ ~'y ~T ,~~ F ~\ '~.~~~~ t _"',~ i~ w PLB67 State and County State Permit # F Permit Application County Per # for Private Domestic Sewage Systems County *DEIVOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # ~a ~ ~~~ A. OWNER OF PROPERTY Mailin Address: ~~~ r ~ Q ~ ac, ~ y ~ ~ 1r I 1~~. ~..~ ~,.~ B. LOCATION: '/ '/, Section ~, T~ N, R~~ (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village ,+.. ~ Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family ~ Duplex No. of Bedrooms_~` ~ No. of Persons~_ D. TYPE OF APPLIANCES: Dishwasher YES _~ NO Food Waste Grinder _ YES~NO # of Bathrooms Automatic Washer YES ~NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity ~o 00 Total gallons No. of tanks / 4 New Installation ~ Addition _ Replacement _ Prefab Concrete ~ ~` *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1 Total Absorb Area ~-~~- sq. ft. New Addition Replacement *Fill System See age Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches See ge Bed: Length Width Depth Tile Depth No. of Lines See age Pit: Inside diameter Liquid Depth Tile Size Per nt slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certif' d Soil Tester, NAME ~ I ufJt V' C.S.T. # ~l~"-s~/ and other information obtained from ~"L/t''1°~~+ (owner/builder). Plumber's Signature - P/MPRSW# ~S b 3 Phone #.•~y~ - J~~~-f Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). /~ ~ -k- ~ ~ ~t _ ,Q 1 _ _ _ ~; .Y _ ~~. __ _ ~: _ _. _ _ ~ _. _ - ~ ti ' - __.. •~ / L Do Not Write in Space Below - FOR DEPARTMENT USE ONLY p ~ ~, c~ ` ~~ Date of Application - ~ ~ Fees} Paid: State 0 ©~ C nt~~~_ Date Permit Issued/R ' (date) - - ~d _Issuing Agent Name Inspection Yes~No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, M/~DISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1 /76