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HomeMy WebLinkAbout030-2079-50-000 co (n f oCl) f3vc~ t7 3 o fD c CD m 3 3 r' # 0~ o o y o ° 03 (n ic 0 0 N N w o ° CA o ~ w °w ~ 57 z S C rt S C rt N_ L Ca 0-+ CL CL 3 3 N 0 H 0 ~ a. n <D y 'p 01 O ° C3 01 a s N N C 0 a > c fD p O N y O n., O - 0 N (D 7 O- 7 C C 7 CD co v (D w v (D D) 7 7 to f0 f/1 S O N a O O N a 7 7 7 D) _ V to 0 0 > > CD y ° 0 n RL N O R O c o 0 0 n c m A~ a a o o o _ f~ 0 ° 3 to N 3 a c 0 ° p p _ a (n z D N p (n v D _ Z ~p (D co D N fD Z k N a N CL = 9 CD c N N 3 0 o o m l 3 p°°~ p 77, _ 00 a ~ O O a O. 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S N y (D Qm f M 0 CD ;r 00 =r f E; L's (on m aM - N C CD S D) N ft ~ o 'o (D -0 CO 0 CL a CD SU CD < o ~ a3 U2 m ao v v CL C) N 0 CD I, qb co m w N N EL CA C, M b 00 0 m i p o o c °o CL °o OL Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 552396 0 GENERAL INFORMATION 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: Village X Township Parcel Tax No: Woitas, Mark & Ma City St. Joseph, Town of 030-2079-50-000 CST BM Elev: Insp. BM Elev: BM Description: ? Section/Town/Range/Map No: 019' 0 f v L /L , 33.30.19.672 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /qQ~C~ D mg ,1 .v~W ~ Y Alt. BM Old 4aye tit Aeration 6 BI gj Sewer U l ✓ j"L,v_,d daf~ .S . s D,e 5 Holding St/ Inlet TANK SETBACK INFORMATIO sUH u 22 Z, Z 7) TANK TO P/J_ WE BLDG. Vent to Air Intake ROAD Dt Inlet B Septic - Dt Bottom ~ 5i Header/ n. -3. Z G`Z~n r c >1 c Aeration Dist. Pipe , / fti Holding Both_/ (L 11Ih~ Gi S ~ 14 Final Grade , PUMP/SIPHON INFORMATION cc{ G14~ S g/S Manufacturer V 1111N Demand St Cover / GPM V r .7 / fo Model Number TDH Lift Friction Loss System Head TDH Ft I 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 BLD WE "ems LAKE/STREAM LEACHING Ma rer L INFORMATION CHAMBER O 7 V~ Typ Of System: / r ~ Model N ber: DI TRIBUTION SYSTEM ,7 Ll Header/ nifold Distributio / rle Size x Hole Spacin Vent to Air (Intake b Pipe( s) l(1 Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth ver xx Bed/Trench Center Bed/Tre ch Edges Top oil h of xx Seeded/SoddeFol d Yes No I FE-1 Mulched Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / r ( Inspection #2: Location: 1222 Red Oak Rd Hudson, WI 54016 (SW 1/4 SE 1/4 33 T30N R1 9W) Oak Knoll Lot 15 ` Parcel No: 33.30.19.672 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover s Plan revision Required? 0 Yes W/No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. lea; ,~.s .-.s~v/~.~ .1~'-.s.~~/.3.~- T.~or~/ ~f'iF~l ~ of lL%/"7~r Uri 7jon'o ' I " l Goal fSalr<k.~1~ ' °~G rc ~~ae c~e~1 { ' Vlei .o .gr~s r -3 ! p ---6--~, 9 ~o c ~~.,=vim V f 0PY ot J -1 L County ;1 Cexi f Safety and Buildings Division g. 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) sp Madison, WI 53707-7162 State Transaction Number ,,aMfy Permit Application N In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (i different than mailing address) the Department of Safety and Professional Serv ies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1) m , Stats. 1. Application Information - Please Print All Information Property Owner's Name Parcel # IA,, (93 - - &I Property Owner's Mailing Address Property Location 7 2) Govt. Lot l/ J /__-2._22 &'r, d~ .1 2da City, Sta zip Code Phone Number _TUZ y, y,, Section (circle one / T Q_ N; R ~ e or II. Type of Building (check all that apply) Lot # Subdivision Name 1 or 2 Family Dwelling - Number of Bedrooms r1l, ~ Block # ouz ❑ Public/Commercial -Describe Use ❑ City of CSM Number El Village of El State Owned -Describe Use Town of III. Type of Permit: (Check o on line A. Complete line B if applicable) A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) Chan List Previous Permit Number and Date Issued B. ❑ Permit Renewal El Permit Revision El ge of Plumber ❑ Permit Transfer to New Before Expiration Owner N~Yt(L_pyl ~GB'Y~ IV. Type of POWTS S stem/Com onent/Device: Check all that a 1 X Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ A -Grade ❑ M u d > 24 in.of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ` =Zretreatme t Device (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate( dsf) spersal Area Required (sf) Dispersal Area Proposed (sf) }System Elevation Y5 7- 8~0. . y5 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units r, 2 N U New Tanks Existing Tanks u o a U in ti w C7 C. Septic or Holding Tank x L i VII. Reaoo sibility Statement- I, the undersigned, assume responsibili r installatio 9e POWTS shown on the attached plans. Plumb 's ame rin t Plumber's S' natur MP/Mf Number Business Phone Number - 8 - 1-2, rlLy_ Plumber's ddres treet, City, S Ate, Zip Co VII oun /De artment Use Onl Permit Fee Date 11sued suing Agent S natu e Approved ❑ Disapproved $ ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER /J / ar~Z/,,~I~ ) &1.2.91 o 1 Septic tank, effluent filter and ~ ~r►~'' dispersal cell must all be serviced / maintained as per management plan provided by plumber. Gb1891ed" t~..ns for the system and sub it to the County only on paper notdess than 8 112 x 11 inch n size as per applicable r tl- SBD-6398 (R. 11/11) I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: _ R)1,'~i9 S fps Owner's Name: 14 Owner's Address: - Legal Description: Arz 7-,:?, Township: County: Subdivision Name: Lot Number: /5 Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Designer/Plumber: - License Number: d Date: Phone Number 791Z Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS version 2.0 SBD-10705-P (N.01101). Page 1 ~c7{ol own Yealvil- 0,914) k14"i i xxv~,~~ q % R, r~9 1 t/ a ~EvAR SAFETY AND BUILDINGS DIVISION Plumbing Product Review 7 P.O. Box 2658 0 Madison, Wisconsin 53701-2658 9 S P S y TTY: Contact Through Relay Scott Walker Governor ~cstu aPtis`~ Dave Ross, Secretary June 14, 2012 WIESER CONCRETE PRODUCTS, INC. MARK WIESER 2815 RILEY RD. PORTAGE WI 53901 Re: Description: SEWAGE TANKS, CONCRETE Manufacturer: WIESER CONCRETE PRODUCTS, INC. Product Name: SEPTIC, PUMP, SIPHON, AND HOLDING Model Number(s): W320-MR [43 IN. L.L.; 7.42 GAUIN., 96 IN. MAX. DEPTH OF BURY; 153,0 GPD WHEN USED AS A SEPTIC/PUMP BASED ON A 3 YR. SERVICE INTERVAL FOR RESIDENTIAL WASTEWATER; TANK DIMENSIONS (OD) = 50 IN. L X 58 IN. W X 46.5 IN. H] Product File No: 20120225 The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance with chapters SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of June 2017. This approval is contingent upon compliance with the following stipulation(s): • This product is approved to use the following: - Four inch pipe inlet located in the edge of the tank cover. - Four inch discharge opening in riser. - Two inch schedule 40 PVC cast in riser for electrical wiring. - Four inch pipe openings located near the bottom of the side or end wall for siphon, pump and holding tanks. - Steel locking cover for the access opening. - Pipe materials constructed in conformance with Table 84.30-2 or 84.30-11, Wis. Admin. Code poured into tank cover or access cover. - Eight inch threaded plugged opening in access cover. - Six-inch diameter opening in lower portion of the interior wall for siphon, pump and holding tanks. - Department approved effluent filter installed in accordance with the product approval for the filter including a properly sized and located access opening for service and maintenance. • This tank must be designed to withstand the pressures to which it will be subjected. • The manufacturer must keep at the manufacturing plant a set of plans and specifications bearing the department's stamp of approval. The plans and specifications must be open to inspection by an authorized representative of the department. • When this product has an effluent filter installed in an interior wall, the space between the top of the interior wall and bottom of the tank cover must be sealed with a material that will withstand the environment in the tank and in a manor that will prevent waste from passing over the interior wall. SBD-10564-E (N.10/97) File Ref: 12022505.DOC WIESER CONCRETE PRODUCTS, INC. Page 2 June 14, 2012 Product File No: 20120225 • When this product receives wastewater from dwellings and is used as a septic tank, it will produce an effluent quality with a maximum monthly average value for BOD5 of greater than 30 mg/L and less than or equal to 220 mg/L TSS, or greater than 30 mg/L or less than or equal to 150 mg/L TSS, and F.O.G. of less than 30 mg/L. • BEDDING: Bedding must be capable of bearing the weight of the tank. Bedding material must have the ability for 100% to pass through 3/a inch screen. Bedding thickness must be 4 inches minimum compacted (thickness may vary due to soil conditions). • BACKFILL: Sidewalls of tanks must have dry backfill materials that have the ability to pass 100% through a 2- inch screen. Provide a min. 12 inches on all sides from bottom to top, placed with a backhoe or concrete bucket to avoid impact loads on sidewall of tank. No compaction of backfill material is permitted on sidewalls; if more than 85% modified Proctor compaction is required, then use 3/8- or 3/4-inch washed gravel for backfill material. The department is in no way endorsing this product or any advertising, and is not responsible for any situation which may result from its use. Sincerely, Jean M. MacCubbin, CST Engineering Consultant—Plumbing Products Review DSPS WEST, Safety & Buildings Div. PO Box 2658 201 W Washington Ave. Madison WI 53703-2658 M-F 700-330 Phone: 608-266-0955; Fax: 608-283-7456 E-mail: Jean. MacCubbin@WI.GOV v a z n m r ' z 58" AS REQD N n 4" I ;a 46j" 50" m my o m co m a m 0 UP 484" m m 1~ 1 - - -11 0 4" CAS 40 \ m m I 1 II c= m < 3 < o U P 48" L _ - J a 4" CAS cn ~I dc: N N m m g m m m a m rn z ---I a I N m D r n r r v N ~5 Z 0 ° D m 0 X o c -mi -mi m om x~ N a 0 n 0 Z DVZ -QmoZE2> ODO c0 vx 0 z 0 > ij t° N°° 5c o02A ~Fz ~D Nm n Co N n ~z° mNO -irk ~~0- rw~ (!1 K~ ZZ = N Z (n2 F' 0 1~ W~rODODm~ w s m N --1 o m \ ~ a --I > 1 --4 OOD D IrTI O s s~ n 0 O~ 9D X 000 6 a 1 O MLm)ai ~m ~~~0.-s I v a z O W -n as ~W0, 0 (n to z O N s o a > m°m~ 1 N r CO N D z p r mm m N °c o v ° cm o a D -n y z 1-N, ~m a z =rZ r~ p n z o n H 0 ~v v O CD O 0 N -I Z m co z r p D v o m 0 20 C) r ;o m V1 0 O 0 m r m 7o C o z r 0 No < co ;o D H m 'n IT! 0 \ W320-MR m DRAWN BY: SME SCALE: 1/4"=l'-O" PRE-POUR: ConCAETE REV. N0.3 m MIEBER I ~ SEPTIC MANUAL DATE: JANUARY 2012 DATE:. 3/20/12 POST-POUR: \ Z W3716 US HWY 10 MAIDEN ROCK, WI 54750 ° REVISED JAN. 2012 800-325-8456 FILE: W320-MR E Soil Absorption System Cross Section ft 4° Schedule 40 Final Grade PVC Vent Pipe ft With Vent Cap Leaching Chamber V~ft System Elevation -aft ft Soil Absorption System Plan View ft r ~ ft ft Leaching Trench 1 Vent Or Obc rvaton Pipe Chambers Coid nx > 4° Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model EISA Rating, F sq ft per chamber S I Application Rate _ gpd/A0 ft gpd Design Flow 1 '7_ Soil Application Rate zg~2 EISA = Chambers 2 rows of chambers each. s Page of DXT INSTALLATION INSTRUCTIONS POE ~ ~ fnc. Innovations PrDrainage ADsion &WastewateraterProductoducts gste ofPoVokInc. PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS Center filter with opening . i' - - - - 7 U., -j ¢O S e Additional pipe or Polylok Extend & Lok- Glue for centering Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCtIONS Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back DO NOT USE B if necessary, into the the housing making sure ~ (B) Pull the filter out of the housing. the filter is properly alighed WHEN FILTER IS REM (C) Hose off the filter over the septic tank. and completely inserted. USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover WHEN CLEANING FILTER septic tank. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owmer/Buyer Tailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State - Parcel Identification Number G C ? 0-7 50 CDC) LEGAL DESCRIPTION Property Locations V., V., See. 7T",ZL N RZ~_W, 'T'own of //!2 ~~-/9 Slubdivision . 4W 2 ~ / / , Lot # Certified Survey Map # , Volume , Page # ~ I Warranty Deed # Volume page # Spec house yes Lot limes identifiable no SYSTEM MAINTENANCE AND OWNER CERTMCATION Improper use and maintenance of your septic system could result in its pry failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a lion punier. What you Put into the system can affect the fimetion of the septic tank as a treatment stage in the waste disposal system. Owner mainteVmee responsibilities are specified in §Comrr83.52(1) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to submit t0 St Croix Coaaty Planning & Zoning Department a certifimm6m form, signed by the ov; ner and by a master plumber, journeyman plumber, restricted plumber or a licensed pu®per verifying mat (1) the on-site ;-,mstewrater disposal system is in proper operating condition and/or (2) after inspection and puauping (if necessary), the septic tank is less than 1/3 full of sludge. V we- the undersigned have read the above requirements and agree to w2intain the private sewage disposal system with the :ada.:;s se: forth herein as set by `h.° 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 retuned to the St C roim County Planning & Zo--,u*--g Department w tl= 30 days of the three year expiration date. Y c cep- that all stateme= on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE x *-Amy information that is misrepresented may result in the sanitary pemui being revoked by the Planning & Zoma$ Department ode ~zth this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if =g-a- ca is made in the wnarranty deed. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing se tic nd/or dose tank presently serving the following residence: /9444K 0,Y,'s (Street address), f! „ram located at: _ 5-t1 '/4, .SF 1/4, Section ,3_-", Town3,r_N, Range W, Town of _!!i4 , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or len h of time: gallons minutes Tank Capacity: Construction: Prefab oncrete _ Steel Other Manufacturer (if known): ')=2L- h ✓Age of Tank (if known): hermit umber (if known) ki klrq-KAJ .J ( icerised Plumber Signature) (Print Name) A6 ~ L (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page Zof FILE INFO TION SYSTEM SPECIFICATION Owner Septic Tank Capacity al ❑ NA Permit # 5,5 2 Se tic Tank Manufacturer ❑ NA Effluent Filter Manufacturer o NA DESIGN PARAMETERS Effluent Filter Model o NA Number of bedrooms ❑ NA r"/k (Pmp Tank Capacity al ❑ NA Number of Commercial Unit ❑ NA Pump Tank Manufacturer ❑ NA Estimated flow averse al/da Pump Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) al/da Pump Model ❑ NA Soil Application Rate 7 al/da /ft Pretreated Unit Influent/Effluent Quality Monthly Average* ❑ Sand/Gravel Filter n Peat Filter Fats, Oils & Grease (FOG) <30 mg/L n Mechanical Aeration n Weiland i Biochemical Oxygen Demand (BODs) <220 mg/L ❑ Disinfection ❑ Other: ( Total Suspended Solids (TSS) <150 mg/L Manufacturer Monthly Average** Dispersal Cell(s) Pretreated Effluent Quality p NA XIn-ground (gravity) ❑ In-ground (pressurized) Biochemical Oxygen Demand (BODs) <30 mg/L o At-grade ❑ Mound Total Suspended Solids (TSS) <30 mg/L ❑ Drip-line n Other: Fecal Coliform (geometric mean <104 efu/100mL i Maximum Effluent Particle Size '/s inch diameter * Values typical for domestic (non-commercial) wastewater and septic tank effluent. Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once ever o months_ F 4ear(s) (Maximum 3 rs) Pump out contents of tanks When combined sludge and scum equals one third (Y3) of tank volume Inspect dispersal cell s) At least once eve ❑ months 0( ears (Maidmum 3 rs) Clean effluent filter At least once eve ❑ months ear(s) Inspect um um controls & alarm At least once eve ❑ months ❑ ear(s) P(NA Flush laterals and pressure test At least once eve o months ❑ ear(s) j NA Other: At least once eve ❑ months ❑ ear(s) ,,NA Other: At least once eve ❑ months o earls 0 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 ('/3) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less 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. 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 my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s) removed by-a septage servicing operator prior to use. ~ ~START UP AND OPERATION raye 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 94 Name Name 142 Phone 92 Phone $EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S Phone Phone this document was dre-st c_r ance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 2 3 `I 4 P 5 0 9 733457 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 08/04/2003 08:00AK WARRANTY DEED THIS DEED, made between Stephen R. Golubic and Jill C. Golubic, EXEMPT I husband and wife, Grantor, and Mark L. Woitas and Mary B. Woitas, REC FEE: 11.00 husband and wife, Grantee. jan4- k~ TRANS FEE: 839.70 Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE: the following described real estate in St. Croix County, State of Wisconsin: CC FEE: PAGES: 1 Lot 15, Plat of Oak Knoll in the Town of St. Joseph, St. Croix County, Wisconsin. Metro Legal Services EDIRET 400242 A Recording Area 282659 WD 209315 Name and Return Address: Edina R ty. Title, Inc. /YI; 400 "d St. - Suite 115 3 oq Exceptions to warranties: son, WI 54016 1!J 105 Easements, restrictions and rights-of-way of record, if any. 400242 - u~.ck 1 /Yl 030-2079-50-000 Parcel Identification Number (PIN) This is homestead property. Dated this 30th day of June, 2003. 1 l~J id C- * Ste h ubic th C. Golubic * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. authenticated this 30th y dNO,WARRON Nbt1Afy Public Personally came before me this June 30, 2003 the above named Stephen R. Golubic and Jill C. Golubic, husband and QMW-ul * wife to me known to be the person(s) who executed the TITLE: MEMBER STATE BAR OF WISCONSIN forego in strument and acknowledged the same. (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY *Di Barron Notary Public, State of Wisconsin Edina Realty Title -Doug Berg My commission is permanent. (If not, state expiration date: 400 South Second Street #115, Hudson, WI 54016 11/19/2006 ) (Signatures maybe authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000 \ ° d" ^Cj ' fig`''` $ f ti'--154.08'- - - - -300.00'.- - -90.00,- ~9~Or odd 60`3 O Cr N89°49140°W s 544.08 '2 2ee° C WHITE-- OAK LANE 7z 33. W49'40" E 52 162' 14764t'30- 66. ,9 F 'LpO~gQ~ I ti9gop1 q1® _ I4 I I °o F Y a 0 O o- 0 t M ~I 5 I` ~ W t• 1 S 89°49 40° E "n N 323.27' N I I.L Q 16 CD_, 1 g 2 o I -~-92-49.40. 9.' 4 9' 4 0 E i 524.87' W N 'M v I S 89°4940„ E 1 M I 425.54' 0 5 33°4940„ - 5 6 6 5 N I 0 i 1 3 14 ► I i I 1 1 86' I z6o4'~ n~~ IW I,., 44 00 \ 13 q0 a~. f 19U. a1 Q 0 2 ©dp.. n i ^4 57.45) 10 ' 8 30"W s 89'49 40, E 550.10 a O I! llll Wisconsin Department of Co ro*rChL,nSOIL EVALUATION f1' 'CTR Page-/- of Division of Safety and BuildingsNN/NG "iwjGwith Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. s, north arrow, and ration and distance to nearest road. slope, percent scale or dimension viewed Please print all information. 2 D71 f Personal information you provide may bA used for secondary purposes (Privacy Low, s. 15.04 (1) (m)). Property Owner Property Location Govt Lot 11 114 S T N R&- /,((or)4) Property Okwes fling Address Lot # # Subd. Name or CSW State Zip Code Phone Number Q City Village j3Town Nearest Road Q New Construe Use Residential M umber of bedrooms Code derived design flow rate Zlpk~ GPD Replacement / ❑ Public or c ommerdai - Describe: Parent material / Hood Plain elevation if applicable fL General comments and recommendations: Boring # ❑ Boring o ® Pit Ground surface elev. 1 R~ft. Depth to limiting factor -,6212 in. Sol Rats Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots In. Munsell Qu. Sz Color Gr. Sz. Sh. #2 9 9 d a a Boring # Q Boring W $ SL' W Pit Ground surface elev., ft. Depth to limiting fader in. ~ Apfficadon Rate Horizon Depth Dominant Color Redox Descriptim Texbxe Structure Consistence Boundary Roots GPDffF in. Munsell ou Sz color Gr. Sx Sh. `EB#1 -Eff#2 4 q • Efli eM #1 = BOD > 30 220 mg1L and TSS >30:5 150 mg& EMyW #2 = BOD ,:!L30 mg1L and TSS < 30 mgR CST ire - CST Number Address Eva Conducted Telephone Number 1 Property Owner Parcel ID # Page of ❑ o BodM# Boring Pit Ground surface elev. P! 7S ft. Depth to limiting facto in. Soll Application R Horizon Depth Dominant Color Redwc Description Texture Structure Consistence Boundary Roots GPDia'E< in. Munseff Qu. Sz. Cont Color Gr. Sz. Sh. 'Ef1#1 -Eff#2 7 - d Boring # ❑ Boring ❑ Pit Ground surface elev. fl. Depth to limiting factor in. Sod Application Rae . Horizon Depth Dominant Color Redox Description Texhffe Structure Consistence Boundary Roots GPD/W In. Mnmseli Qu. Sz. Cad. Color Gr. Sz. Sh. 'EW1 •E1~ a Boring # ❑ Boring Pit Ground surface elev. R Depth to 1"muting fade in. El Sod Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPQ ff in. Munsefl Qu. Sz. cant color Gr. Sz. Sh. 'Eff#1 'EW • Effluent #1 - BODS > 30 220 mg/L and TSS >30 150 mg& ' Effluent f2 = BOD5 < 30 mglL and TSS < 30 nVL. 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. s8D4330(L6W) 1 / - vo~ air ono 09k°~GL +~/4/li✓rf~i j /Ym~.cs~ a2~ r r: 9 Wn1l ovd7 0 r ~ I l ~9 t