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HomeMy WebLinkAbout012-1017-60-000Wisconsin [)epartment of Commerce PRIVATE SEWAGE SYSTEM Safety and j~ilding Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Lee, Olaf Erin Prairie, Town of SST BM Elev: Insp. BM Elev: BM Description: r~ !~~/w TEA\~ 1'1ATA 1/arvn uvrvnm/~+ll~l~ TYPE MANUFACTURER CAPACITY Sep is w~ l o ~~ Dos ng ~B ~ ( ~.- ('~' 'I '] Aeration ( ~ Holding ~ ~, Y ~ .~~ TANK SETBACK INFORMATION TANK TO P/L WE~ BLDG. ~~ Vent to Air Intake ROAD Septic ' ; 3 2 2 / 77 ~~ Dosing Aeration Holding Pl1MP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss Sys Head TDH Ft Forcemain length Dist. t well enu eRCf1RPT1(1AI CVSTFM I ., I. ,._.-K / nn 1/ U County: Sf.l/r01X Sanitary Permit No: 515091 0 State Plan ID No: Parcel Tax No: 012-1017-60-000 Section/Town/Range/Map No: 06.30.17.876 STATION BS HI FS ELEV. Benchmark l-/y o~.~ oo~~ Alt. BM r-- ~- Bldg. Sewer L ~ t Inlet g-92 9 . zz S Ht Outer ~, S ~ Dt Inlet /- Dt Bottom ~ eader an. ~~ 0.8 0 . ~' Dist. Pipe 3"ivy pg p>3 Bot. Systemo ` ~- ~ `~~ Fina~lGrye.l~^ Z.~%t /aFlWi - 9 $ - ~ St Cover ~~ ~ ~ ~ S ~~ ~S~ ~~ C ~ p'h BED/TRENCH Width Length I Y No. Of Tren hes .. , PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1 SETBACK SYSTEM TO P/L BLDG WELL I-I,~ /STREAM LEACHING CHA 0 Manuf~ctu r: `~ INFORMATION Ty Of System: / 5 ~ j > ~~ ~ UNIT Model Number: ~ 7 r11CTRIRI ITIfIAI CVCTFM Sm~-~G, i,u~.~~-/1e2e. eader/ nifold I ( (~ S( Distribution / ~ Pi / ' x Hole Size x Hole Spacing Vent to Air ntake ~ ,~ , // pe(s) 1 , O Di ~ ll i n S ~ / ~ Ob Length is ng pac a Length C/lll /'`/l\/C~ ._ n-___..-., c~....a........ n..l.. .... M......d Ar a+-r_.~~lo Rvc}omc Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center BedlTrench Edges Topsoil {qT Yes ~~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~//,~j Inspection #2: / / Location: 1518 Cty GG New Richmo d, WI 54017 (SW 1/4 SW 1!4 6 T30N R17W) NA Lot/ ~ ~.~L ~~ ~ .{- Parcel No: ~06~./30.17.878 1.) Alt BM Description =~~ ~ ~y ~/L .~~ /~/ V / ~^^~" S~I 3~4 ~+6~.5 ys~"~ 2.) Bldg sewer length ~~d ^ ,).,,S~;Nt ~U ~ZQ ~Q,(~ J -amount of cover = ~'lw J f Plan revision Required? «T Yes ~ ~ ~ ~~ ~~' ~ Use other side for additional information. Date Insepctor's Signa re Cert. No. SBD-6710 (R.3/97) tt01111,17@r'C~M/I.gOV Safety and Buildings Division Com-tY S~ ~ ^ 201 W. Washington Ave., P.O. Box 7162 ~ ~ Madison, 53 7162 Sanitary Permit Number (to be led in by Co.) ~ 5/509/ Sanitary Permit Applicatlo ~' . d i h C o ' StaGeTransacxionNumba ~/~"' In accor ance w t s. omm. 83.21(2), Wis. Adm. Code, submission of this f rm to the app ate ental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-o WTS are submitted to the Department of Commerce. Personal information you provide may be used secondary Project Address ( d~erent thing address) T in accordance with the Priv Law, s. 15. 1 m Stats. i 5~~ L A Gcation Information - PI t All Information Property er's ame / Parcel # 1 - IDI 7 ~-(oC7 ~ ~n o Property Owner's Mailing Addresses Property Location / g ~ B f ~`/ ~ {~~~\ S`L`, S7 CROIX COUNTY C , Govt. Lot I City, State Zip Code one _ ~ ~„~"~/., 5 C.~/., Section ~P ~ 1 N ~ ~ p~ C" ~ ' ~ (circle one) ~ ~ c~ - T N R II. ype of Building (check all that apply) Lot # ] ~ w '3Q ; ~ Subdivision Name `'t'~ or 2 Family Dwelling - Number of B t4~ ^ lock # Public/Commercial -Describe Use City of ^ State Owned -Describe Use CSM Number ^ Village of ~ ff C'~ /~ ~+Q iOr15 ~~ ~ Town of ~ ~ -r ~ ~~ ~`~ /~ t`Clrr` i lII. Type of Permit: (Check on one boz on line A. Complete line B if applicable) `~' New System Replacement Treatment/Holding Tank Replacement Only Other ModiScation to Existing System (explain) S_ Zvi B. Permit Permit Revision Change of Permit Transfer to Lisst P-revious Permit Number and Date Issued ~3 ti ~ Renewal Before Plumber New Owner ~l..a ,C ^s. SG Ex iration IV. T e of POWTS S stem/Com onent/Devit:e: Check all that a Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mourd > 2a in. of suitable soil Mound <?A in. of suitable soil Holding Tank Other Dispersal Component (explain) ^ Pretreatment Device (explain) V. Dis ersal/Treatroeat Area Information: Desigr Flow (gPd) iga Soil Application f) ~ Dispersal Area Required (sf) Dispersal Area Prop~ed;Est) System Elevation ,a .,5 boo o~ ~ go VL Ta k Info Capacity in ll G Total ll G # of it U Manufacturer , ~ a ons a ons n s ~ U ~ ~ H ~ New Tanks Existing Tanks ~ ~ ~ ~ ~ HokimgTank ~`°~~ ~~ V t l ~, ~~'Q.f~ O Dosing Chamber `.. VII. Responsibility Statement- I, the undersigned, assume ponsib' for installation of the POW'I'S s the attached plans. 's Name ) Pl 's ign RS umber Business Phone Number t ~~ ~~S Plumber's Address (Strest, City, State, Zip Code) nth ` ~ C"' CIS VIIL Coun /De artment Use Onl proved Permit Fee Date Issu' Si ~.~.~ ea Dial $ ~17.r• ~ 7 ~ 09 IX. Conditions of AppprovaUReasons for Disapproval I SY3TEIIA tOW1VER' .3 OZ St{bT'C rw ~ I ~4 G c~ ~-- 1. Septic tank; efflutrtf fitter and . l1 ~ dispersal cett must all be servtces /maintained ~i0«-P.. as per management plan provided by plumber. ~ ~' ~M~ ~ ~ 2. All selbeck. requirements must be rrtaintainbd ~~~ ~ ~, J~ I ' • Attach to complete praas for the system anti snbmtt to the (;oanty onry on paper not Less man a 1rz: ti rnl:hl3 m srze SBD-6398 (R. 01/07) Valid thru Ol/10 ~i s w~~ S ~ ~3o N ~ ~~~ ~' Y ~t S5 ©3 ~ f 5f8 ~j ~~ Al.e~a~~c~rvio~~ ~- ~~r ~ ` ~ ~ rY1 N ic~ov ~s.~~ ~~ ~Po~Y (ok Jas Q`~'v~~ ~ ~ WesS~r-s 3 Tr~e v~c~~ ~ ~ ~ ~ Qo ~ W ,1 ~ ~ ~\ ~ I~ S~~\iOviS ~Z~OW ~~-~ ~, ~ a~~q ~~ sew' ~ ~-fib' -#~ aaos.~ ~7 dBm : T°~° ~ s4~ C ~` ~ c;b ~~[t8+n :t~~ ~s~~ Q~,~o E, ~' ~ ~, ~\R~ ~~ d ~i q5 ..__- ~. ~~° ~ 'o ~ ~~ X590 s~°~` ~~~ ~~~ ~'^ gam. ~~ ~ ,~ ~ \ ~ ~Q~ ~ ~,~~ 3~ ~ C~~~i Q ialt w~nsin Department of Commerce SOIL EVAL~,~-TION REPORT Division of Safety and Buildings Page t of Attach complete site plan on paper not less than 812 x 11 inches in size. PI t <° County .5~ C r n i~( inducts, but not limited to: vertical and horizontal reference point (BM), directi an '" ~ ercent slo e scale di i th l parcel LD. ~ p p , or mens ons, nor arrow, and ocatron and distance ton re C7 / - /p /) - ~ d - O Please print ail infon7:E~VEp Reviewed by 1 d Date d " 7/ Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 ( (m)). 0/ ~ -~ ~ • Properly Owner JUN 2 9 200 Proi~sertyy Location a T ~ -t ~. GovL Lot S ~ 1/4 w1/4 S ~ T 3O N R / ~or) W Property Owners Mailing Address ~ 3T c ~-~LANNING ~ ZONitdG O ~pE# Block # Subd. Name or CSM# 7 e ~ ~ ~ d 1 City State p Code Ph on e Number Cen1e~/ ~ l~e m Ss038 ( 51)~ S~'~)8~ ^ ty c ^ Village Town +~ Nearest Road ~ ~ G 6 - r, ra ri.~ ^ New Construction Use: (~ Residential !Number of bedrooms ~_ Code derived design flow rate ~/,5'O GPD Replacement ^ Public or commercial - Descxibe: - Parent material Flood Ptain elevation if applicable rU /4 fL General comments. *C / 7~ i and recommendations: '~, ~r ' Boring # t~l~tt ~~ G~ / Y_J Pit Grand surface elev. / !v' fL Depth to limiting factor ~ O in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stucture Consistence Boundary Roots GPDfft2 in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ ~'2-s r PO St / a M sbK Y>'1 Tr C t.tS a ~ i ~ i .3 s 37 7, s - IFS, ~fisbk e ~ - ; ,6 , D 7~ - /4 ~ b `~ -s "Drn 1x~ ~~ - / ~ Z a ~~# ° Boring. / / pit Ground surface elev. 3 I fL Depth to limiting factor 9 rP in. Soil Appiigtion Rate Horizon Depth Dominant COkx Redox Description Texttrre Structure Consistence Boundary Roots GP D/ftz kt. Murtseii Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 r~ 7 'Effluen t #1 = BOD. > 30 < 220 mnf 1. and TSS > < 1 50 mall ' Effluent #2 = BOD_ < 30 nw/L and TSS < 30 metC CST Narr~ .Print) Signat CST Number ~~ ~ ~ ~ ~ ~-~ ~ a ~ s3 Address Date Eva nation Conducted Telephone Nurr>ber ..... ........., r,,,,...., Property Owner V i' a ~ ~ 22. Parcel ID # ~ ~~ " ~ D ~ ~- toy - ESDC~ 3 # o ~~ ^ ~ Pit Ground surface elev. ~ n. Depth to limiting factor ~ly in Page ~ of Horizon Depth ln Dominant Coin M ll Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate GPD/ftz . anse Qu. Sz. Conk Cotor Gr. Sz. Sh. 'Etfi#1 'Eff#2 -3 3 D ~ S ~ Sl .?m SbK ~ Cr.J , ~ ~~ /a - oms ~ - , ~ I. Z l~ ^ Pit Ground surface elev. ft. r~,n, h, i~.,,N:.,., s„~.,. ~_ ^ # ~ Horizon Depth ~ Domirant Color Redox Description Texture Structure Consistence Boundary Roots -Soil Application Rate GPD/ft= . Mansell Qu. Sz. Conk Color Gr. Sz. Sh. 'Eff#1 'EtT#2 ^ Pit Grour~ surface elev. ft Depth ~ iimitino factor in_ ~~ # ^ ~~ Horizon Depth ~ Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Appli GP cation Rate DIftz . Muraail Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 `Eff#2 ' E11p~t #1 ~ BODs a gp < ~o mgtL and TSS >30 < 150 rng/L ' Etiluent #2 = BODa < 30 ~k and TSS < 30 rrglt. The Deparnnent of Cammerct is an equal opporhmity service provider and employer. If you need assistance to access services ar need material in an alternate format, please contact the departmcnt at 608-266-31 S 1 or TTY 608-264-8777. Property Owner ~ ~ Gl ~ ~ 2'C. Parcel iD # ~ / o[ '' I D ~ ~- jod ~ ~~ P a 3 Boring # ^ ~i~ a ~ °~ (~~ ( 4a Pit Ground surface elev... ft, De th to litnitin fact r ~~ P 9 0 ,_,_,~ in. Horizon . ~ Depth ~minagt Color Redo D i Soil Application Rate i x escx pton Texture Structure Consistence Boundary Roots GPDIft~ n. Munsell - Qu: Sz. Cont. Color Gr. Sz. Sh. ' ' " ( Eff# I Eff#2 D- v /® ~ ,~ °-' ~ ~ `~ 5 ~k M - r C ~ ,~' ~ ~ i to ~ 3 4 w ~' ~ Sl .? m SbK ~ Gc~1 , .~ 'L J /D p r+rl ~ ~ -- , 7 ~, Z ti I ~ ^ ~~~ J Boring # ^ Pit Grour-d surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure... Consistence Boundary Roots GPD/ft2 fn. Mungell (1u. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~~ # ~ ~~ ^ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Des Soil Application Ra cnption Texture Structure .Consistence Boundary Rood GPD/ffz in. Mansell 11u. Sz. Gorrt. Color Gr. Sz. Sh: 'Ef~#7 'Eff#2 ' Effluent #1 = BODE > 30 < 220 rng/t, and TSS >30 < 150 mfyL ~ 'Effluent ft2 = BODS < 30 mg/L and TSS < 30 rng/L The Departmem of Commerce is an equal oppottunity service. provider and employer. Tf you need assistance to access :services or need material in an alternate format, please contact the department at 608-266-31 S 1 or TTY 508-264_g777, ssn.aswts.,wo~ ©[~~ L~~. ~~~~,vz`~~, yYYIM ~p~FS S C`~.~', ~ i~ ~ ' y ~ aao~3 ~ ,~ 8m ,, ~ ~ ~sr~ ~~,~--- iq~ ~ ~9 ~s a ~~~~'" ~I °~ ~--____ _._.~ a ~1 ~'~~ Ei 9b ~ ~ ~ ~ r ~ ~s~ ei~o,~ i^w -'ti I`C11 r r ~ ~' E FS` ~~~/ ~ ~- N~ w ~ ~ CYt wi on~~ l~ ' ~l ~ 77 w,(lo~ Ruin ,,,~`l, ~~ ~h `~ 4N~~ ~` r! J_ - - ~~ ~~ -s.~.' ;~ ~ -~,q 3 ~~ ~` !~ ~ _. ~~~ ,~ ~ P~ ~~ --~ 0~ --~. ~~ ~ a _. ~__ gm ~, Fxs~~+-~ ~-+-~-. ®~~-`I ..g I ~~n l~ -~ ~r~r t'/`~`tri'~/J~`CwO~~( EZ12~3H _._-. _ _ 4ve vOOe f ~•~y: ~• •` vO eee401 eeQeee4 •-,~: - • -._~..:•+°~.• •.~+.• ~-4L. v00ePOe eve °.r .i: .i«.. ~ ~ 5.,.-~ f-0~ r vvv evv vva 4.6z5~- oev vov voe ~, vov vva evv roov e e„ v.v e aov Ove ~ vvsevvv sev rw= e s. v- e ~ o '-'- -vs+rvvv v. ra.e~estswvv veevvev 9'v -e eee •vtt'eOe ee•ReT1e •e-•vTe~ eveesov ieeeveeeeq'VOVVO et~Vtee r 2A}t__ ~ HOt10}a 36" 1 z- lfz" DIA. {typ.} Vold Yolume Void Coefficient in Agg[egate given at 57.4'/0. - O.D. of 4"pipe: = 4.623 inches 23125in Void volume per linear ft. = 3.14 • eft = 0,1 }~ ft' t2iaffr, • O.D. of sentercyiindu a T2.5 inches Yoid volume in a of cents' c ender =~3_ta • 5.25ia ?3I23iu t;~ ~ El2infR~ -3.ta.•~ t2infft ~ ~~•574=..422 ft' O.D. ofnuESide cylinders= f2 inches l Yoidvoiuincinotusidesytinders= 2.3.t4i lint ~ •.514=,gpl ft' [2ia I ft Yoid voletme at bot[orn between c cinders = lain bin _ 6h' ~ •. 0.2t3 ft' y `t2ui/fr • t2at/ft~~~3 t~t2inlh~•~ Void volume at outside borwm corners (l2 of void volume betvreen cylinders} 02 t5 /2 = 0.108 fN Total void volume = 0.1 t 7 + 0.422 + O,gp i + 0.215 + 0. t 08 s I -753 tasbic ft f ft Gallons per ft _ ! .753 X 7.48 a 13:1 eallans nee- tlnear ft. 3~tt~t0~ $,}4 EPA ~1g.gregate Trench System EZ12Q3H ~Z~'U1~ ~.. Ring~lndustrial Group 65 fndus~cia! -Pork Rd. • ~_ ~~~ ~QOki(1fld. fit!' L~~~$t~{)yy(~~1~~E}}7~~~~ y.y~~~'~u~-~_~- yy~~~~~~~~~~b''~w.. ~t~f •~~ - .4L .W.V -t~1(.~~`it J~IGG~. t Ol t tt~il ~tt~ Sal Interface Ares Sidewall n Sidewalk} Hottaota 2.00 Totsl Solt itrterface Ares Projectsd Trench Area Sidewal Height= t2 in. *2 = 2.00 Sq.Ft. Bottom = - 35 in. s 3.00 Sq.Ft. Projected Trttxch Area 5.00 Sq.Ft. tr IJ2 Circ. =18.84" x.32 ~ ~3 ~ 2+! 11~.mm = 3.14 Ift POWTS OWNER'S MANUAL & MANAGEMENT PLAN RtE tNFORn+tAnoN Owner Permit ~ DE&iGN PA#iAMETERS Number of Bedrooms ~ DNA Numtter of Public Facility Units ~ ^ tW4" Estimated fbw (average) Q aUda Design flow (peak}, (E~Ena#ed x i.5} ~(~ al/da Sol'! Application Rate t aUdaylftz Standard Infltsent/Efftuent Quality Monthly average# Fats, Oil & Grease (FOG) 530 mglL Biochemical Oxygen Demand !RODS) 5220 mg/L ^ NA Total Suspended Solids tTSS} 5150 mglL :P_I_ted~tflttentQttalitv~._____. --.. :.:.: ge , ...-_. Biochemical Oxygen Demand fBOD6) 530 mg1L Total Suspended Solids tTS$) 530 mg/L DNA Fecal Conform igeometric mean) 510' cfu/i00mI Maximum Effluent Particle Size Yin die. DNA Other DNA *Vakies typical for domestic wastewater and septic tank effluent. SCHEDULE SYSTEM SPECiRCATIONS Page ~ of Septic Tank Capacity ~ ~ ai ^ NA Septic Tank Manufacturer ~ S S ^ NA Ef'Huent Fitter Manufacturer DNA Effluent Fitter Model ~ DNA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump- Manufacturer ^ ldA Pump Model C! NA Pretreatment Unit ^ Sand/Grave) Filter ^ Mechanical Aeration ~ Disinfection ~ Peat Filter D Wetland D Other; ^ NA -. ~S~BfS8l~etltS}--- - _ ^ In-Ground (gravity) ^ At-Grade ^ Drip-Line ~- - - - --- pin-Ground !pressurized) D Mound ^ Outer: Other. DNA Other ~ O NA Other. ^ NA Senrice. Event Service Frequency inspect condition of tank(s) At least once every::- D monthls) earls) UNlsxiatutr~ 3 years) ^ NA Pump out contents of tanks} When combined sludge and scum equals one-third (Ys) of tank volume ^ NA Inspect dispersal aeN{s) At least once every: D monthis) setts?- (Maximum 3 years) ^ NA Clean effluent filter Qt least once-every; ) ~~ . ms 'DNA ~ s Inspect pump, pump controls & alarm At least once every: ^ month(s) ~ D years} DNA Flush laterals and pressure test At least otace every: D monthts} ^ year(s) ^ NA Other. At-feast once event: ^ monthts} - . D year(s) Q NA Other: ^ NA MAINTENANCE INSTRUCTIONS - inspections of tanks and dispersal cells shah be made by ~+ individual carrying one of the fotbwing tiixtr>s~ or c~tificetionss Master Plumber Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainef; Septage g Operator. Tank inspections must include a visual irtspeci'ron of the tank(s) to bentify any missing or broker hardware, bentify any crxks a''feaks, 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 ceNtsl shall 6e visually inspected to check the effluent fevels in the obsarvation pipes d to check for arty ponding of effluent on the ground surface. The pond'ing of effluent on the ground surface may indicate a-failing catdition anif requkes the immediate notification of the local n3gulatory aud'mrity+. When the combined accumulation of sludge and scum in any tank equals one-third tY3) ar more of the tank volume, the entire contents of the tank shalt be removed by a Septage Secvicatg Operator and disposed of in accordance with chapter NR 113, Wisconsin Admin'~strattve Code. .. All other services, including but not nmited to the servicing of effluent f'iters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shalt be performed by a certified POWTS Maintainer. A service report shah be provxled to the beat regplatory authority within. i 0 days of completbn of any servk~ event. sTART uP aNO ot~aTwN ~ ~of _°'1` For new construction, Friar to use of the POWTS check treatrrrent tarrklsl far the pres~ce of ,painterg Products or othar cherrrica~ that may impede fire treatment process andlar damage the dispersal c+eq(s)• ff high concentrations are detected have the corrbactts of the tankts) removed by a septage servicing operator.prior to use- System start up shad not occur when ~ cond)tiorrs are frozen at themfittrative surface, Dr~rg Power outages Pump tanks may fql above normal h~hwa'~er b:veis. When poww is restored the ex:wastewstar wig be d' to the dispersal cegGs) ~ one large dose. overloading, the cell(s) and may result in the backup or surface. d~charge of eff~errt. To avoid this situation have the contents of the .pump tank removed by a Septage Servicing Operator prrar to restoring power to the effluent pump or contact a Plumber ar POWTS Makrtairar to assist ~ manuagy operatMg tree purrs control m restore normal levels within-the pump tank. Do not drive ar park vehicles over tanks and dsai cells. Do not-drive or park over, arotherwise- disturb ar canpa~ct, the area witt~ir 15 feet down slope of any mound ar at-made s~7 ab~rption area. Reduction ar "e6minatron of the fogowmg from the wastewater :stream may improve the performance and prolong the -Gfe of the POWTS: arrt~atics; baby wipes; cigarette butts; condoms; ootton swabs: degreasers; dental flares; drapers; disirefectarrts; 'fat; foundarcion dram !sump Rump) water; fruit and veget~le peefmgs: gasoline: grease: hwbicides; meat scraps; medications; oH; Pe1n'dn9 t~~: P'd~: sanity napiims; tampons; and water softener brine. Af3ANDONM811T VYhen the POWTS fails and/ar is permanently taken out, of service the -fogawirg steps shag be taken to insure that the syst~n is properly and safely ab~tdoned kr canpgence wAfi chapter' Comm 83_33. Wi~cAnsin_Administrative Code: • Aq piping to tanks:artd pits shady ~ discawrected and-the abandoned pipe openings sealed.- • The contents of aq tanks and pits shag be removed and properly disposed of by z- Septage Servicing Operator. • After pumping. a!1 tanks and pits shall be excavated and. removed ar theft covers removed and the void space figad with sorT, gravel ar another inert sogd material. t3~tTM10tR11CY PLAN ff fire t~OWTS fails and cannot be repaired the fogowirg= measures have been, or must be taken, to provide a code aompaiant rapiacernent system: A stirtabte replacement area has been evairated and may tie utilized for the location of a replar~nerrt soil _abso<Pt~ systmn. The replacement area should. be protected from disturbance and compaction and should not be mfi'vrged upon by required setbacks •from exi§Wrg and Prapas~ stiucturB, ~-lines .and wails. F~'ture to Protect the replacemenrt xea wilt result in the need far a .new and site evaluation to estabfrsh a suitable reptacern~rt area. Replacement systems must comply with the mules in effect at that tam. ^ A suitable.. replacement area is not av~able due to smack andlar ~q Cunitscions. Ba~im9 advances '~ -POW. TS technology a hold'atg tank may be esstaged as a last resort to replace the faa'led POWTS. ^ The sRe has not !~ evaluated to identify a suitable reptacernent area. Upon faqure of the POWT'S a soil and site ev~uatron must be performed to locate a suitable replacement area- If no repiacemmrt area is available a holding tank may be installed as a last resort to replace the fai~d POVYTS. ^ Mound and et-grade sod: rr systems may be reconsDucced in .Piece foq°w~ng r~n°vaf of the biomaR at the «- ~: .in#iitrative: s~face. Recorrstttnstions-of suchsyst cotnpty~ Ynith the rules_kr effect:aCthattirare _._ -- T < <WARNING> > SEPTtC. -PUMP AND OTHER TREATMfM TANKS MAY CONTAIN LETHAL MASSES AND/OR MISIiFFlC1EN(i' OXYGlBli. DO NOT `HI17ER A St~77C, PUMP OR OTHt3t TREATN~IIT TANK UNDt9i ANY CBiCUMSTANGES. DEATH MAY RESULT. )iE$CUE OP A PERSON FROIYt THE INT>E~OR OF A TANK MAY t3E DIPFiCULT OR IMPOSSiBLE.- ADDITIONAL tbMMEt~TS nnuurc n~c-rer r rat '^Nante 0.v Phone ~ S ~. POWTS MAiNTAMItR1 Name.- . Rhone SEPTA6E SER1ilCG11t3 OPERATQR !PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Mares ~~ ~h ~ ~ Phone ~ ~p 'i'Ns document was dratted in compliance with Chapter Comm 83.22t2)tb)41)td)&tf) and 83.54(4 ), t2) & t3), Wisconsin Administrat)va Code. ` ~ ST. CROIX COUNTY SEPTIC TANK MAIlVTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Mailing Address i 7 Z ~ (.~~ ~6 t Property Address t,~` (~_~- (Verification City/State~ll~~~~ ~~~-~T._ LEGAL DESCRIPTION ~~ ~ t 7 C from Planning & Zoning Parcel Identification Number for new consiruct~i .)on.}on Cpl a-1Dr~-f~D-aac~ Property Location ~ c~ ~/~ , ~ w % Sec. ~~ T~~_N R I "7 W, Town of ~r a v~ ~rra ~ r< ~ Subdivision ~7~ ID. _ ~. n ~ ~ _ Certified Survey Map # Warranty Deed # SPA house yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St, Croix Caunty Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification fo owner and by a master plumber, journeyman plumber, restricted plumber or a licensed ~ signed by the wastewater disposal system is in proper operating condition and/or (2) after inspection and pur in ~f necess 1}the on-site Less than I/3 full of sludge. P mP g (i ary}, the septic tank is Uwe, the undersigned have read the above requirements and agree to maintain the. private: sewage disposal .system with the standards set faith, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. t'ertification stating that your septic system has been maintained must be completed and returned to the St. Croix County Plannin & Zoning Department within 30 days of the three year expiration date. g Uwe certify that all statements on this form are true to the best of mylour knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms _ _ SIGNATURE OF APPLICANT{S) ~l ~7/ r3 DATE ~`**~Y formation that is misrepresented may result in the sanitary permit being revoked by the planning & Zoning Department. *** nclude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if eference is made in the warranty deed. Volume ,Page # Lot # Volume a 9a y Page # SD3 Lot lines identifiable es no REV. !}8105) 81 1544 State Bar of Wisconsin Form 1-2003 WARRANTY DEED Document Number Document Name THIS DEED, made between Stoney River Development Corporation ("Grantor," whether one or more), and Olaf N. Lee ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Part of Southwest Quarter of Southwest Quarter (SW '/< of SW '/.) of Section Six (6), Township Thirty (30) North, Range Seventeen (17) West, described as follows: Commencing 200 feet West of Southeast corner of said Southwest Quarter of Southwest Quarter (SW %, of SW '/. ); thence at right angles North to South bank of Willow River; thence Southeasterly on said South bank to River to East line of said Southwest Quarter of Southwest Quarter (SW %. of SW '/e ); thence South to Southeast corner of said Southwest Quarter of Southwest Quarter (SW '/< of SW '/< ); thence West to point of beginning. ROISTER OF DBA'E~DS ST. CROI~ CO., NI RECEIVED FOR RECORD 11!08/2006 10:00AM MARRANTY DEED EIIEMPT if REC FEE: 11.00 TRANS FEE: 705.00 COPY FEE: CC FE£: PAGES: i ~~ Recording Area Name and Retum Address The IliverSank Attn: Valerie Mernmer / P.O. Box 188 ((,,/. Osceola, Wisconsin 54020 012-1o1~-bo-000 Parcel IdentiScation Number (PIN) This is not homestead property. (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: easements, restrictions and ordinances of record and vrill warrant and defend the same Dated October ~~ , 2005 Stoney River * Bv: Olaf L. its Y~fes; d e rte' (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated on ) ss. POLK COUNTY ) TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) Personally came before me on Oct ~;~., ~~-~ the above-named ~ 4Y ~~E}.~ .~.. ~ to b the petsq}ti(s) rho a eC~,utetl~ the foregoing a ow _ ~-cttltt: sate. 1, - ~: ~ Z~ . THIS INSTRUMENT DRAFTED BY: ` ~ ~ Priscilla R. Dorn Cutler * Pvl ~ ~ ~, Notary Public, State of Wisco t,~!~ Osceola, Wisconsin 54020 My Commission (is pe nt) ('~iopir~lttt `~ (y (Signatures may be authenticated or acknowledged. Both are oot oecesaary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THiS FORM SHOULD BE CLEARLY H)ENTIFIED. WARRANTY DEED ®2003 STATE BAR OF WISCONSIN FORM N0.1-2003 "Type name below signatures.