HomeMy WebLinkAbout034-1072-60-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
552335 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:
Frye, Harold Leroy Famil Trust Springfield, Town of 034-1072-60-000
CST BM Elev: IBM Description: Section/Town/Range/Map No:
32.29.15.487
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing I Alt. BM I 116(c# R A&LaUerr Bldg. Sewer
Aw
Holding oJ~ ~ St/Ht Inlet
i
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic bbd /D7 2_7 / Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. 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 xx Mulched
Bed/Trench Center Bedfrrench Edges Topsoil
Yes Ed No 0 Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 679 Cty Rd NN Wilson, WI 54027 (NW 1/4 NW 1/4 32 T29N R1 5W) 40 acres Lot ` j Parcel No: 32.29.15.487
1.) Alt BM Description = J ~n Oct ` G ~`v~ coo'-,
2.) Bldg sewer length = - I I
- amount of cover
1
Plan revision Required? Yes
Use other side for additional informati o
on.
SBD-6710 (R.3/97) Date Insepct Signatur Cert. No.
08/27/07 ICON 15:28 FAX 715 386 4686. W001
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P7~ A 47i np
wigov and wags Divi '
~►OI ashmgton Ave, P.O. Box L 2~ , 'S(
p\X yG 17F \C'~ WI 53707 7162 PamitNumber(ro be Sled is by Co.)
° 5:5233
S ~ermit Appheation State Try Number
In accordance with s. Comm is. Adm. Code, submit of ft form W dieappropriate A W
it is required prior to .batwing a sanitary permit. Nate- Aviation forms for slate-oHmed POWTS aregorerrmrrnal
Project Address (if difFaatt drat mu7 address
submitted to the )
parposes Department of Commerce, PtzsomaF inforntmiam you Provide may be, used for seoondery ~ IS c r+
en accordance with tbeprivacy I.aw x.15.0" I otStats.
1. - Infortttrad=-Phase PHOAdhibrmxtisa --(o79
C N w ~b~~
Property owner's Name Parcel d
g e- f" ~9 a v /-4 , ~G u S' t l'02 U' i ~-1/i 7L 6 0 61
Property Owner's Waling Address hopetrty ]r ocatioa
! ~l - Ct /Z d Govt Lan F 7
City, State Zip Cade Plane Number s dZ j V ~ /le Y 1 5 ~~1 / C ~ (/S ~ 7£ ~ - < t ~ {Cwrle cue)
11. Type ofBuilding (dwcit all dak apply) Lots T _L r1 R-/:J__E or W
Eit or 2 fvamily Dwelling - Ntatber of Badmoms "2- Subdivision Name
aW~ Blodr P
❑ PubliclCommorcial - Desmibe Use 13 City of -
❑ State Owned -Desrribe, Use -f-' , CSM Number ❑ vllase of
Q / /t & VgTown of .5,PC, h 4 r
Ill. Type of Permit: (Grade ly one box oWlae A_ Compic* 8ne B if applIcable)
A. Q New System Repla n System Treaunem/HoWd'sn Tank Rqlaarnax Only Q Oder M Mmarion W Existing System (explain)
B. O Permit Renewal Q Peoria Revision ❑ Change of Plumber Q Permit Transfer to New inlet Previous Permit Number and Date Issued
Befem Expituion owner
W. Type: of POWPS S ice: Crack all (rat apply)
O Nom-Pressurized to-Ground O Passurized in-Ground Q At-Grade ❑ Mouwd>24 vL ofsuiable sod ❑ MovrW<24 uL ofsuiablesoil
Ebldnrg Tank D Oder DWcvW Compom (explain) Q WW cMncat Device (explain)
t : D' raalf Tree Area lnbrosatiaa-
Design flow (gpd) DosW Sol Appimioe !Disposal ate{gpdsf} Area Requirai (sf) Disposal Area Proposed (st) System Elevation(
3 ° G -
VI. Tank Info Capacity in Tatar for Manufacturer
Gailons CraPons Units
New ratles ramks m e 1 A 1 1
'~oa~~ L✓ :'GS e2
~s
V11. Responsibility Statement- I. ae insaRatiom of the POWTS wawa an tiro attaered phum
Plumber's Name ((tint) Sigtmpre PRS Number Business Phone Nurnber
Plumber's Address (Street. C Sate, Zip Codo) _
Yv, 13,y- X63
VII (Oman rhoest the Only
O 0armit FeelT Date l A Signature
XAppiro-d
C iren I for Denial S `Q 5V • ij
t.K. Conditions of APlslavaf/Reasoasfur-Disapproval
17 nck~j o Sa ; l w S let j : ro oJ eA.. 41Q„~ 4,1,
!'e,~e~ .
Attack % csmptek phars fw the ssstns ■ W submit a the curly only m PPO art less Bros It rn: It hselrs is so e
W. 0i/07) Valid thru 01/09 .
08-27-87 17:35 TO: FROM:715 355
HOLDING TANK SITE PLAN
Project Frye Holding Tank
QN Legal Description: NW1/4 NW14 S32 T29N R15W
Subdivision Name:
Scale
1 in = D ft Parcel ID: 034-1072-60-000 Lot No.:
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'age 3 of 4
CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project Frye Holding Tank
Owner Harold Leroy-Family Trust Frye
Address 181 Cty Rd NN
Spring Valley, Wisc. 54767
Legal Description NW1/4 NW14 S32 T29N R15W
Township Spring Field County St. Criox
Subdivision Name Lot No.
Parcel ID Number 034-1072-60-000
Plan Transaction ID Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Soil Evaluation Report Page 5
Designer Joe Stang
Signature Phone No. (715) 684-5166
License Number 223475 Date 04/20/12
Designed pursuant to:
Holding Tank Component Manual For POWTS
-5BL Ive ss-- PCA). a 3/0 7 J
Version 4.0 (04/03) Pagel of 5
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10571-P
6/11/1999), and the St. Criox County Sanitary Ordinance.
1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 600.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 10 business days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with Comm 83.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons should be contacted:
a. Installer Joe Stang Phone: 715-684-5166
b. Service Provider Phone:
c. Co. Zoning or Health Dept. St. Croix County Phone: 715-386-4680
11.
Project: Frye Holding Tank
Transaction Number: Page 4 of 5
I
i
HOLDING TANK SITE PLAN
Project: Frye Holding Tank
N Legal Description: NW1/4 NW14 S32 T29N R15W
Subdivision Name:
Scale
1 in = O ft Parcel ID: 0341072-60-000 Lot No.:
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HOLDING TANK SPECIFICATIONS
3 Number of bedrooms 5' J r ( Alt, X- 5 Jot
Non-residential estimated flow (gpd) 15tx
2000.0 Minimum holding tank volume required (gal) n
3000.0 Proposed holding tank capacity (gal) ^ v ~ccd(
Wieser Concrete Tank Manufacturer `41
WLP3000MR Tank model number
SJE-Rhombus Alarm manufacturer
Tank Alert 1 Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 27110 Ibs Weight of tank and cover
48.0 Liquid depth below inlet invert (in) 1.10 Safety factor
8.0 Maximum depth of soil cover (ft) 20602 Ibs Weight of anchor required
64.0 Height (in) Outside 6.5 Soil cover req. for anchor or
184.0 Length (in) Dimensions 5.1 yd3 Concrete counterweight
102.0 Width (in) Only
HOLDING TANK CROSS SECTION
manhole cover with
locking device and finished vent cap
junction warning label grade
box ~ ~ -
4" min. 12" min.
23 in. r"
Manhole and vent locations
conduit vent pipe
18" min.
- tetherweight -
12.0 In. building sewer
service inlet
blind plug alarm on Note: All tank joints,
to seal and joints between tank
outlet openings and piping are
Electrical as per 36.0 in. sealed watertight. All
NEC 300 pipe and vent materials
and Comm 16 comply with Comm 84.
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project:
Transaction Number: 1234568 Page 2 of 4
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Apr-19-2012 0725 AM St. Croix County Plan/Zoning 715-386-4686 1/2
I
SEPTIC or HOLDING TANK SERVICING CONTRACT
ritf ate ,
Tis contract Is merle between the
Tank Owner(s) Name(s) and Purnpsh Name j 0 ~ (-'P. V \A-'
Ida -ro \ e T3~~ i~t5 s,.Ot >1't-{z` orl
ft acknowledge the Installation of (e) septic/holding tanir(s) on the t it ng property-
(Provide legal descriptionx
1. The owner agrees to file a Copy of this contract with the local governmental unit (St Croix County
Planting & Zoning Dapartment) to document maintenance by a cerdfied septage servicing operator ss
required in Comm 83.52(l)(e)2. WIN. Adm. Code and the approved Component ManuaL
3. The owner agrees to have the se p&Aolding tank(s) serviced by the undersigned pumper and gum utecs to
permit the pumper to have access and to enter upon the property for the purpose of servicing the
septic&okiirtg tank(s). The owner agrees to maintain the access road or drive so that the pumper can
service the septic/holding tank(s) with the pumping equipment The owner Mother agrees to pay the
pumper for all charges Incurred in wrvicing the septicMokling tank(s) as mutually agreed upon by the
owner and pumper.
3. The pumper agrees to submit to the local govemmental unit (St Croix County) a report for the servicing of
the septidbolding tank(s) on a monthly basis. The pumper further agrees to include the following in the
monthly report
a. The name and address of the person responslbla for servicing the septic/lmkiing raulq
b. The name of the owner of the septidholding tank;
c. The location of the property on which the sapticlhokling tank is installed;
d. The sanitary permit number issued for the septic/holding tank (if known);
c. The data on which the sapticUlding tank was serviced;
f The volume In gallons of the contents pumped from the aeptidbolding tank for each servicing
g. The disposal sites to which the contents from the septic/holding tank were dalivm&
4. This agreement will remain in effect until the owner or pumper terminates this contract In the event of a
change in this contract, the owner agrees to file a copy of say changes to this service contract or a copy of a
new service contract with the local governmental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on We date:
2 /y
Today's Dace
A~a
Ptmtpees Name (Print) PumWa Signature Notary Public Signature
a L~ ~3 ~titi pa- o~
Pumper's Registration Number Commission Expiration
64-19-12 89:44 TO: FROM:715 386 4686 P81
ST. CROIX COUNTY
SEPTIC TANK MAIN MANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Mailing Address 18 C+ y R d 76 7
Property Address le'7 ci & d N N , l s : s c. 4 O 2.7
(Verification requioed from Planning & zoning Department for new construction.)
City state Parcel Identification Number 01. 14 - to 7 Z- (P 0° o b
LEGAL, DESCRII 7 N
Property W% ion W %4 , t'~ W V4, Sec. 3 2 , T 2 9 N R 5 W. Town of c.~
Subdivision Lot #
Cetrdfled Survey Map # , Volume , Page #
Warranty Deed # G~ 2 l ! S , Voltune r) Page #
Spec house yes p Lot lines idemsable ® no
SYSTEM MAINTENANCE AND OVVNER CERTIFICATION
Improper use and m datenme of your septic system could result in its pie fa&M to handle wastes. Proper
mains nsim consists of ping out idle septic tank every three years or sooner, if needed, by a licensed pumper. What you Pm into
the system can affect the function of the septic tank as a treatrocrit stage m the waste disposal system. Owner Wince
respotmb>'Mites we recited in $Comm. 8352(1) and in Chapter 12 - St Croix County Sanitary Ordinance.
The property owner agrees to subunit to St: Cwc County Phmoing & Zomog Department a certification form, signed by the
owner and by a master p journeyman plumber, restricted phunbar or a licensed pumper verifying that (1) the on-she
wastewater disposal system is in proper epwathig condition and/or (2) stew mqmztm and pumping (if necenary), the septic tank is
less than 1/3 f dl of stodge.
Uwe, the undersigned have reed the above r and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Dept of Commerce and the Department of Natural Resources, State of Wiscansin.
Certification stating that your septic system has been wed dust be completed and returned to the St Crone Comity Planning &
Zoning Department within 30 days of the three year expio tioa date.
Thee certify that all statements on this faros are true to the bed of my/our knowledge. Uwe smJffie the owner(s) of the
property described above, -by virtue of a waaamy decd recorded in Register of Doeds Offroe.
Number of bedrooms
y /19/2ciz
SIGNATURE O APPLICANT(S) DATE
*""llny info on that is misrepreaeuted may result in the sanitary permit being revoked by the Plmmmg & Zornag Daps
Include with this application a recorded wairamy deed from fire Register of Dads Offree and a copy of the cxttifxed survey map if
r fteax is made is the waaauty deed.
(REV. so"
DOCUMENT NO. WARRANTY DEED TM.S RPACC RC_4RVED POR RCCORDIHG DATA
STATE BAR OF W 1str;iuri;Siid -
4211z 7a ®GOx 1 V V rnuI. t4
RzG4S *S C) fw 1-I Ce
7th
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,i 30
. { >ad _ _ Z-) A
it. conveys an3 ts'arrants to Harold LeRoy Frye-Fami2r.-Tr4st_
ii lMbW ei 04"1
n
-
- . RCTt.. TO
-,I . I- -
. . -
~i the following described real estate in _._.t.. wIQ1X......_.._._ .....County,
~tata of Wisconsin:
?-he W,J-of the NW- of Section 32, Township 29N, :angr, 15 W, Tax Parcel No:...
Township of Springfield.
~s
977
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Thia 1 - -S--not -
j? homestead property.
(is) (is not)
Exception to warranties :
easements, righrt of ways, and liens of record.
_ 19
I' Dated this _ . . . . day of c c y . .
......(SEAL) y .....(SEAL)
i
ii * Jennie .Frye..........._...
I, _ (SEAL) . . .(SEAL)
-
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Aii THENTICATION ACKNOWLEDGMENT
Signature (a) Jennie - Frye............. STATE OF W.-_ f-; a51ti P
` - f • -
v / ...........................count;:. i
autheitr;,A oP- Personally came before me this _ ._.day of
19.. the above named
Lf ,ri. S..,i..'ia
.
~ttin}3~,.'_
TITLE:,AFH~I~ BAR OF WISCONSIN
authorimd-bl,~•s 166.66, Wis. Stats.) .3 , m- 4r,nwn to he the person . . -h. executed the
.
foregoing instrument and acknowledge the same.
TI-IIS INSTRUMENT WAS DRAFTED BY
c r
t larrimaruack Low Off._ccs
Notra,y Public County, Wis.
(Signatures may be authenticated or arknowledeed. Both My Commission is permanent. ((i' not, state expiration
are not tIieesaatr•) s-. a...
•Names of Perv.,ns aianinR in any -n-itr .sh-!d Ac tyn^•i ..r I. ,~~ntr•.1 n~1„cc tnrir pia nnr.., n•<.
~gq
y TE RAR n7+ wtscoN Sty:
N. 2- 1.1,42 Stock No. 13002
IiGMillerCplgr,l ~nRM
. I rj
VYsconsin Departure t of C merce
SOIL EVALUATION R Page 1 of
Division of Safety an uildings
Nb..16~Qlrdan with Comm 85, Wis. Adm. Code
Attach complete sib plan on pa 11 inches in size. Plan must Co St. Croix
include, but not lim' d to:;rruMA point (BM), direction and Parcel I.D. 03 1072-60-000
percent slope, scale or i atttS4v, and location and distance to nearest road.
`ease print all information. Review by Date 7C
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). y GS
Property Owner Property Location ■
Harold Leroy Frye -Family Trust Govt. Lot 1`1W 1/4 NW 1/4 S T 29 N R 15 E❑(or)~W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
181 Cty Rd NN
City State Zip Code Phone Number []City []MIlage E]Town Nearest Road
Spring Valley Wisc. 54767 ( 715-781-0925 Spring 14cid Cty Rd NN
New Construction UseE] Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD
Replacement Public or commercial - Describe:
Parent material Glacial Till Flood Plain elevation if applicable 91A ft.
General comments HoldingTank
and recommendations:
❑ Boring # 11 Boring
Pit Ground surface elev. 97.20 ft. Depth to limiting factor 3 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ffz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-3 10YR3/3 sil lflp mfr as 2m 0.4c 0.6
2 3-6 10YR3/3 c2d10YR5/6 sil 1 flp mfr cw if 0.4c 0.6
3 6-18 10YR5/6 c2d10YR5/6 sic 2mpl mfr cw lvf 0.0 0.0
F 2 Boring # ❑ Boring 97.20 2
El 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/f?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-2 10YR3/3 - sil 1 flp mfr as 2m 0.4c 0.6
2 2-5 10YR3/3 c2d10YR5/6 sil lflp mfr cw if 0.4c 0.6
3 5-17 10YR5/6 c2d10YR5/6 sic 2mpl mfr cw lvf 0.0 0.0
* Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L )Effluent = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Thoams w. Gedatus 962178
Address Date Evaluation Conducted Telephone Number
Stang Plumbing & Electric P.O. Box 263 Woodville, Wisc. 54028 4/4/2012 715-684-5166
-
Property Owner Harold Leroy Frye -Family Trust Parcel ID # 0341072-60400 Pege, 2 of
3 Boring # Soxmg
Ground surface elev. 100.00 ft. Pit Depth to lanitin9 factor' 2 in. Soft Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIIF
in. Munsefl Qu. Sz. Cont. Color Gr. Sz Sh. *Eff#l *Eff#2
1 0-2 10YR3/3 - sil 1flp mfr as 2m 0.4c 0.6
2 2-8 10YR3/3 c2d10YR5/6 sil HI mfr cW if 0.4c 0.6
3 8-18 10YR5/6 c2d10YR5/6 sic 2mp1 mfr cw lvf 0.0 0.0
❑ Boring # Boring
Pit Ground surface elev. ft Depth to rvnitirrg factor in.
Sod AMication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfF
in. Munsefl Qu. Sz. Cont. Color Gr. Sz Sh. *Etf#1 *01#2
D Boring # H Boring
Pit Ground surface elev. fL Depth to lirnniting factor in
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflF
in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *E1f#2
I
I
Effect #1 = BODs > 30 < M0"& and TSS >30 < 150 ' Effluent #2 = BODS < 30 trgfL and TSS < 30 tngll.
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 608-2648777.
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4.pr-14.2012 07:25 AM St. Croix County Plan/Zoning 715.386.4686 II IIII
III VIII I
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111111
8055155
Tx:4041076
Document Number Document 'n 955097
BETH PABST
St. Croix Court
REGISTER OF DEEDS
Holding Tank Agreement ST. CROIX CO., WI
J to Plan Transaction Number- RECEIVED FOR RECORD
i gal )-e- RoV Fryer 04/25/2012.12:04 PM
Name-(Owner) Typed or printed EXEMPT
Being duly mrn,states, under oath, that: REC FEE: 30.00
1. He/she is the owner/part owner of the following parcel o£land PAGES: 1
located in St Croix County, Wisconsin, recorded in Volaine 74p-6
Page _q'g Z- Document Number '1-11175 St. Croix County Register
of Deeds Office: Reaotm Area
A parcel of land located in the W% of theN! / of Section 14W and R~urn Addroae F/
~JT j N-R_(W,Townof rlatalCt Lg(j MKI
St Croix County, Wisconsin, being / 81 G1
my described as follows (include lot no, and subdivisiordCSM or all ~y~ ~'7
detailed legal description): 7>ti w ~Z or- ! 1.~. Al LL) %t -(U L -60--"a
2 % 6-. Parcel ldemlAcagon Number (FIN)
Agreement Date: y~i,S SQL 3 z T L~ N i A
sH., lJ a ~ spf;'.~ ~ e loll
iNe aopwvrladge that applkaeon 6 being made far the Inalatla~n of (o) holding s) the above described property or that coMinuad use of the
exl$tlm9 Premtaea mqulrits Olaf a holding tens be Installed on the properly for the purpose of proper conlelnment of :swags. Also, a murnklpa] sewer
cannot now serve the property. or any other type of private onshe wastewater treatment system as pemstled under Comm 83, Wk. Admin. Code, or
§ Ch. 146. WIS. afain.
As an inducement to me comb to issue a ea bey, permit for the abovaslesatoed property. we agree to do the fallowing:
1. owner agrees to conform to all applicants requirements of Own n Wk, Adm. Code rsbting to holding tanks. If the owner falls to have the
holding tank property serviced In response to orders Issued by the govemmamal unit or Ore Department of Commerce to prevent or abate a
human healm hazard as described in a. 254.39, Stare., the govanunental unit (Town) rosy enter upon the property and service On tank or
cause to have the tank to be serviced end charge the owner by placing the ohs" on the tax bit as a special assessment (or current services
tendered. The charges will be assessed as pwacdbW by c 05.0703. Stela
3. The owner agrees, pursuant to Comm 88.04(2) end Comm W0(3)(e), We. Adm. Code, to two a water meter Installed In the Structure. The
water meter *hog be Imitaaed by a plurnbor authorized by the Department of Commerce to make such Inatagatiom with said Instonallan
complying vd[h State regulations and manuraaurars epeytkauorre. The owner agrees to he financially responsible for the purchase,
Inamtiason metntenanu. and rapdr or the wrier motor. and agrees to allow the governments] unit or the, Department of commerce to antar
the abovadeacdlred propEAy on a regular bases to read and/or Inspect the water meta
3. owner agrees to pay all charges and coats incurred by the goverimenrel unit or county for Inspection, pumpfng, hauling, or otranvlse servicing
and mslrttahning its hold)ag tank In such a manner as to prevent or abate any human health hazard caused by the holding tank. The
governmental unit shall reedy the ownerof any auto that shag be paid by Ina Owner Within thirty (30) days from the date of notes. In the wW
the owner does not pay the mats withln Mlny (30) days, the owner spectmoagy agrees that ell the costa and charges maybe placed an the tax
roll in a special asw amWtfor ms abatement of a human health hoard, and the lax shall be mgeated as provided bylaw.
4. The owner agrees to contrast with a parson who Is IkerweE under Ch. NR 118, wig. Adm. Code. to have the holding tank serviced and to vie
o ropy of the aanlraet vAN Ure govsmmentst unit The owner further agrees to to a copy of any ahangOS to the sefvlea contract, of a COPY of
a new eervlr» mntrecf wkh the govsmmemal uM within ton (10) business days from me data of change to me Service canhau.
5. The owner agrees to contract with a parson gamed under Ch. NR 113, Wis. Adm. Code, who ones submit to the munpr on a semiannual
basis a report detailing the ssrviciny of Ito hofdMg lank. The govemmeniol unit or county may enter upon the property to Invols ate vie
condhion of the holding tank when punping report and meter madtrps may Indkats mat gig holding tank Is not being propery
6. TNs agreement will remain In 00001 only until the county office responsible for the regulation of private Orsini wastewater treatment "Ums
certifies that either a municipal sewn or a private ample wastewater treatment system that compW with Comm 81 Wis. Adm. Code Sarvra
vie properly, In addition, tits agreement may be canceled by executing and remRling Said csrttffceddn with reirerenoe to this agreement In
such manner which will permit the existence of the cerggcagon to be determined by reference to the property.
7. This agreement shag be binding upon the owner. the hobs of the oomaa and anbftes of the owner, Tits owner shag submit this Vgreemafd'
b the register of deeds. and the agreement shag be recorded by the rooster of deeds in a manner that will permit the esNnc l
agreement to be determined by reference to On prop" where the hoidmg I" Is installed. C~~
-Sutscribed Owner(s) Name(a) - Please print an sworn to ore me on -ft dam: a '
70.,... Signature(s) No Publib
1 Unit Official Name. 7186 - ase P My Expires r f~
:4. Grp x GFY •y 4
00 in at Unit tXfl pnaWre ors d or. /1
p vfdsmay ueedroraemndaryputpo (Privacy a o4( (m))
"THIS PAGE Ia PART OF THIS LEGAL DOCUMENT- DO NOT REMOVE"
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