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HomeMy WebLinkAbout018-1090-57-000 q~ ~4' W;sconsin Department of Commerce PRIVATE SEWAGE SYSTEM •Safety and Building 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) 'ermit Holder's Name: City Village X Township Montbrand, Dan Hammond Townshi :ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ISG-~ ZS~ Dosing I `-"/ ~~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic t ~ So I 2 I '-'-"' Dosing ~t Lt ~ r ~ 3 1 , Aeration Holding PUMP/SIPHON INFORMATION Manufacturer ~O~c.LEf~ Demand GPM Model Number ~ 53 TDH Lift Friction Loss System Head ~-- TDH Ft Forcemain Length "l 0 Dia. p 2 Dist. to well SOIL ABSORPTION SYSTEM (Q~ck._ ~..fQ„v\r~ 1 ELEVATION DATA STATION BS ,~ HI FS ELEV. ' ~'Iz Benchmark S 63 (vs'.63 ~.~~ Alt. BM 8.03 tFs ~ 13• ~(.` Bldg. Sewer C ` , fS g~ I ° . ZI SUHt Inlet .or c/b•1~3' SUHt Outlet Dt Inlet Dt Bottom 13• S~{~ 2 • ~f Header/Man. (0.60 9g . 0 3 Dist. Pipe Bot. System ~.6` ~.9 3 .2 ~• 3 ' Final Grade St Cover p.sk ~r, 6.~ 9~8.43~ x•33 S •3a BED/TRENCH Width Length No. Of T nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~I r t ~/' Cato ~ G. SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man facturer: INFORMATION T Of S CHAMBER OR ype ystem: r ~ t ~ ` I ~ -~- UNIT el N er: v • ~~ ~ / DISTRIBUTION SYSTEM Header/M~an~if~old Distribution x Hole Size x Hol Vent to Air Intake Length Dia Length Dia Spacing I t7'a SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Oniv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center BedlTrench Edges Topsoil Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:J? /~/_QL Location: 1778 96th Avenue H/ram/mond,W~I,~54015 (SE 1/4 NE 1/4 16 T29N R17W) Pheasant Hills 1st addn. Lot 57 1.) Alt BM Description =Toy of •t'9~+^^a10.^\8'"~ 2.) Bldg sewer length = ZZr -amount of cover = `r ~ (00 So r Gx~er Plan revision Required? (~ Yes ^ No Use other side for additional f ation. SBD-6710 (R.3/97) ~ Date Insepctor's Signature e...eQ©~ CAuwe_ ~~- County: St. Croix Sanitary Permit No: 395287 State Plan ID No: Parcel Tax No: 018-1090-57-000 Inspection #2: ~-'-7'- Parcel No: 16.29.17.722 Cert. No. Wisconsih Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division } INSPECTION REPORT GEi~1f~RAL 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 Montbrand, Dan Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ ~,.. _ ~. .J / ~ 2. J,~ t Dosing ~~~ ~ /t ) .aa^ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ ~ / Dosing Aeration Holding PUMP/SIPHON INFORMATION Number _ ~S3 Lift Friction Loss n [/ee~ ~ ~ t ~uia.2 „ OCIJ/IRCIY VII VVIUUI LClll~lll DIMENSIONS ®C ~ ~/ r SETBACK SYSTlEM TO r0 INFORMATION Type Of System: ~,~,lJ ~ DISTRIBUTION SYSTEM Head TDH Ft . to Well No. Of Trenches /L BL G WELL .! /~1 ELEVATION DATA County: St. Croix Sanitary Permit No: 395287 State Plan ID No: Parcel Tax No: 018-1090-57-000 STATION BS HI FS ELEV. Benchmark Alt. BM r!~ r Z Bldg. Sewer ~~$~/ tt ( St/Ht Inlet q J ~ 1 , St/Ht Outlet Dt Inlet Dt Bottom 3 f~ll /L ~ Header/Man. Dist. Pipe r a t •~ r`e Bot. System ~ r 3 ~~ r, Final Grade St Cover Inside Dia. Header/Manifold q ~ _n L~ Length Ip•- Dia Distribution ~ l! ~ ~ ~^ PipecsL r L ~-~' _ Length Spacing x Hole Size x Hole Spacing Vent to Air Intake SOIL COVER x Prossura Svs4Pms Anly rY Mnund Or At-Grade SVStemS OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedfrrench Center Bed/Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~_~/ ~) Inspection #2: / Location: 1778 96th Avenue Ham(m''~o~nd, W(~I_5~4015 (SE 1/4 NE 1/416 T29N R17W) Pheasant Hills 1s Parcel No: 16.29.17.722 1.) Alt BM Description =-~v~ o ~' .~~CVL 2.) Bldg sewer length = 'Z, Z.-f~~ - amount of cover = > (,O . ~ l~ 3~ .~I,b~ ~ ~Ivt, ~ I . Plan revision Required? Ye ^ No Use other side for additions on. ~ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) ~ p r ~~g 6~ ~~ ~~ gS 3~~ ., Safety & Buildings Division • Sanitary Permit Application 201 W. Washington Ave. In accord with Comm 83.21, Wis. Adm. Code PO Box 7302 ~.,~+ y See reverse side for instructions for completing this application Madison, WI 53707-7302 ~~.rl~i~~*~~~ Personal information you provide may used-fe~s_e\ ndary purposes (Submit completed form to county if not OeptirtmenraE Cgmmerce [Privacy Law 5p'~4(1J(!~)) ; '~ state owned. ~ ~ ~.~ Attach tom lete Tans (to the coun co o e s stem, on a er no .less than 8-1/2 x 11 inches in size. State~anitary Pe it Number Check ~ ~ ' to previous application State Plan I. D. Number County GQ O ~ s~" r, ti G Location: I. A lication Information -Please Print all Informa p, property Location Property Owner Name ~ n ~ ~ ~ Lot Number Block Number Property Owner's Mailing Address ~9 ` FP~G - r ~ 7 ~ `~J ~ ~ ~ ~~00 _ Su~vision Name or CSM Number Ci~ State Zip Code P _Num~4?,.'',/,1~ [ ~ ~ei~~ l ~~GGS' ~~ Y, ,~ ~ ,.! -R y,~R '' ~'7 ° ~-+~ ^ City II. Type of Building: (check one) ~ ~ ~ Village ~ 1 or 2 Family Dwelling - No. of Bedrooms : ,.~, ^ Town of ~~~ ~o ,~ ^ public/Commercial (describe use):_ ^ State-Owned Nearest ©(~~~ r ~ ~ ~ ~ Parce T N ~( ~. ~~© Z X -~" '1 III. T e of Permit: Check onl one box on line A. Check box on line B if a licable 5 y 6. ^ Addition to A) 1 ew 2. ^ Replacement 3. ^ Replacement of 4. Existin S stem S stem S stem Tank Onl Date Issued Permit Number B) ^ A Sanita Permit was reviousl issued _,~ N. Type of POWT System: (Check all that apply) ~ ^ Sand Filter ^ Constructed Wetland _ ~`1on-pressurized In-ground ^ Mound ~Jr~ ^ Holding Tank ^ Single Pass ^ Drip Line ^ Presstuized In-ground ^ At- e ^ Aerobic Treatment Unit ^ Recirculatin ^ Other: V. Dis ersal/Treatment Area Information: 6. S st 7. Final Grade 1 Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate y Elevation Require~d^ Proposed Rate (GalsJday/sq. ft.) (Min.Jinch) ~ S~~ ~ ~~ ~j ~~ ~J 7 ~ ~ I - Plastic VII. Tank Capacity in Total # of Manufacturer Prefab Site eel F lass Gallons Gallons Tanks Con- Con- g Information Crete strutted New Existing Tanks Tanks ~ ~. ^ ^ ^ ^ t W t ~ -~ ^ ^ ^ ^ ^ VIII. Responsibility Statement I, the undersi ed, assume res onsibili for installation of the POWTS shown on the attached lans. Business Phone Number Plumbe s Si azure (no stamps): MPMiPRS No. Plumber's Name (print) /'~~ ~ ~ ~ {y ~ ~ ~ 7 ~ ~3 '~ <C lam` `"- "S ` '3" +- o`er Y Plumber's Address (Street, ty, State, Zip Code) IX. County/Department Use Only I u; A ent Signa (No scamps) ^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued g Approved ^ Owner Given Initial Adverse Surc a Fe2n ~ ~ ~ ' ~t •~~ ` Determination ~,7 ~ -t' _ J _ ,, X. Conditions of Approval /Reasons for Disapproval: „ y ~ ty,,i ~ez.w` f.C~NJtou+ .~~ls- a. =~A~1' t .....~ .. /(~~~ ir.9~J4( v~+~ tr~ , ~ ~' rI ~ ~tQ.t.~ K~~ "''A/ N 9 R !, ~ ya-m ~©~~ l~ f- ~.a sA- nT l~ e L LS ~~iE's7-.~-~d r?ia r Le~s~~ `~~~Ram~ ~~fo~s~ . _ r r l ~ ~ ~ r ~ ~ 1 I ~~/ ~ ~ , ~nr~. ~ 2.5'0 '~ ~_~ ~~ 7,..sj4 "_ ~~ 8~~, ~, _ ___ a ,~.~ S~3 0%/ ~~ ~ 9yy Wiacansin Oeparrtrnnent of Commerce SOIL EVALUATION REPORT • Divisan of Safety and Buildings ~ ~ ~~ m aoooraarwe wmr c~omm tsa, vws. fwm. ~.oae County ~ ~ rO1 X 11 md~es in size Plan must 8112 it l th h l t t l A ' an x . ttac comp e s e p an on paper no ess e include, but not flmited to: vertical and twrizordal reference point (Btd), direction and t~rCel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. "' ~' ; ~ r, Please print` ~' Reviewed by Date Pe~sa~ai information Ycu P ~Y ~ rwn (P Law. s. 15.04 (~) (m)). Property Owner ~- h -~~~a .., .~, ` Pr~~t _ d ~; , ~ .,,.; Govt. Lot 1/4~/~C1/4 S TZ Q' N R.~ E (or~ Properly Qwnet's fiAai6ng Address ,. ~t {l (~ Lot # Bbdc # Subd. Nine or CSM~ '~ City State ZP Cow,, ~~ ^ City ^ Ydlage Town Nearest Road. . ` is ~ ~j mo New Construction use: ~tesidential Tt~lti`ri~ei! ~ 3 _ `1 Code darned desgn flaw retie , ^ Replaoernent ~ ^ Public orcommercial - Parentmaterial ~ ~ Flood Plain elevation if c ~ s-f.t t»1 ~!c / p Q'7.,~'o Gow c r 9'~v and recommendations: • ,~~~ .e (..e V' • 7.~ • v C~ ft Pit ~~ surface elev. ~(,~,.ft Depth to Irtrrititirrg factor _~ in. Soy Rate Horizon Depth Dominant Cob Redox Oespiption Texture Structure Corrs~tenoe Boundary Roots GP D/(P in. Mur>sdl Qu. Sz. Coat Color Gr. Sz Sh. 'Effll:1 `Eff#2 ~ 2 ,-- L S G s - . Z ~ -~ t t=t t ~ ~ a ®Pit Ground ~rfaoe elev. a~•y ~+d. Depth to limiting factor ~_ irt. ~ Rate # ° ... Horizon Depth Dominant Cob Redox Description Texture Structure Coe Boundary Roots GP D/fi? in. Munsell flu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eif#2 -- ~ 2 +n~r c i v~ • 5 8 Z ~ -~ ~ c .- ~ 4 -' O "' ~ 1.2 z ~a ,- u' • Effluent #1 = BUD_ > < 220 and TSS >30 < 1 50 mall ` Effluent #i2 = 80D. 5 30 msVl. and TSS < ~ mgll CST Name (Please Prirm - CST Number dS Address Date Evakratiorr Corrducbed Telephone Number ~ r o ~~ i - y 7- GPD Property Owner Parcel tD # Page ~- ot~ 3 Boring # ~--~ Boring ~ Pit Ground surfaceelev.,~.~ft Depth to limiting factor ~ V Z in. Soil lication Rate ti i Texture Stnx~ure C.onsis6ence Boundary Roots GP D/tl? Horizon Depth in. Dominant Color Munseli on p Redox Descr Qu. Sz Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ 2 -~ k c . I.v .~ 3 ~~ - rns ~ m t _._.. ^ Boring # ~ ~°^^~ ^ Pit Ground surface elev. ft. Depth to limiting factor in. Sod. ication Rabe ~ion D d Texture Structure Consistence Boundary Roots GP D/i>? Horizon Depth in. Dominant Cobr Munsell es Re ox Qu. Sz. Cont Color Gr. Sz Sh. 'Eff#1 "Eff#2 ~# u ~ ^ Pit Ground surface elev. ft Depth to limiterg factor in. Soil Rate Horizon Depth Dominant Cob Redox Description Texture Siruchxe Consistienoe Bourxiary Roots GPDff~ in. Munsell Qu. Sz. Cord. Cobr Gr. Sz. Sh. '~~ 'Eff#2 ` EfNuerrt #1 = BODg > 30 < 220 mglL and TSS >30 < t50 mgll. ' Etfluent #2 = BOD, <_ 30 mg1L and TSS _' 30 mgll 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 608-264-87T7. sac-as3o ~emroo~ PAGE~OF~ NAME ~(~ ~1 +~ LOT#~ ~ LEGAL DESCRIPTIONS ~ '/4~UE'/<,S) (oT ZQ,N,R ~ ~E (or~ //11~~--~~ t SCALE: 1 "_ ~W BM I ELEVATION BOO • d I z ~~ BM I DESCRIPTION p ~ Co nc~ U i 1' ~"' X BM 2 ELEVATION GT ~ • 3 ~ V BM 2 DESCRIPTION~p p-~ 1z•~• CGvlc4.V ~ -E l/ SYSTEM ELEVATION)-oP y7•D~ ~,aar~ 97.00 ALTERNATE ELEVATION~Ic~• FS v CONTOUR ELEVATION ti~lA- i SIGNATURE ~ DATE ~~ ~U ~~~ . . ~~ ~, ,1 . 1K Frstll Ah Inlelt And Obtervollon ripe ~~ ADprorad Venl Cep AIInlmum 17~ Abore I lnol f..ade 2U ~ ~2~ Apore P/pe _ ~~ CoU Iron to flnol Grado Vonl Plpe Ma..n /iar Or $~n1 A~11C Cort__Iny l -~ rln 7~ App.epole / Over Plpe . Oltlrlbullon Plpe "_~ 0 0 0 0 0 -Tee - 6 Apyr epole PaneolA Plpe o Per lore led Plpe Beler o `Coep4np Terminellny AI Honour 01 Srtlem Ilr'V I t'~ t~ f 1~ n ~. 1 C~ t n r 1( -- ---• ------..~- ,-._ 1_~tJr, 1 1' In/l ~~~ ~ % r, SOIL FtL~ DISTIiIBU71 ~.I PIPE rnc.c ol* ~. i! APPROVED ~"'~~~fi-,G ,~,OV[R MAT~RI11L o"-~:9" ac .sTa~w .. 4R (~ARSU. HAy • j/ ~~;~\\~j.~ .... . .~ %. .EL~C/. o ~ F~eT~ ~"~ % .. ,.; DIS~"~iJR';T"1~7A1 1'irF ~u fir.: !1'T l.EA57 ~,~ I,r,.ICNES B,ELOu/ O.RIGI~,,AL GIRAO.E . ~.VIU !~ ~ L ,C t~ $ I ,; t ~ I ~J~C }.~, E::: kti,ll r A I,O / ~ t1!'. IC 7 r` 1 A /J 4 2 LAIC µ,E :i ~ F.,L O W F,I l,W,/~l ,G14' P, vO,E yr I If-W~"~ DFp rte GF F Xtl~~'ATi~~ I~fiaM .o~{iGr~~4~ f~~/.10~ wl~~ ~+~, ~ '~ tuc-+~Es r.-i.tfa~~'? glEpr~t~ ~~-~ Exc~lU~gT~~01J FKoM e~t(,t.f~~i. GR~~D;~ wi~~ aE ~._ INCNES 1 ~. ~~ L iG E L15C. A)l1MF'•F R: /// „}~._~~~ irn POWTS OWNER'S MANl1AL 8~ MANAGEMENT PLAN ILE INFORMATION -Owner n ew - J-A o. iT~tzt A,w~ D Permit # 39S Z$a' _ - ~ nce~~ta aeDAMFTFRS VYN\V~~ • ~-vim v .~ . ~-~ Number of Bedrooms ~ ^ ~• Number of Commerdal Units ^ NA Estimated flow (average) gal/day Design flow (peak), (Estimated x 1.5) ~~ gal/day Soil Application Rate 0, ~- gal/day/ftZ Influent/Effluent Quality Monthly average* Fats, Oil ~ Grease (FOG) <_30 mg/L Biochemical Oxygen Demand (BODs) <_220 mg/L Total Suspended Solids (TSS) <_ 150 mg/L Pretreated Effluent Quality ' ^ NA Monthly average* * Biochemical Oxygen Demand (BODs) _<30 mg/L Total Suspended Solids (TSS) <_30 mg/L Fecal Coliform (geometric mean) <_10' cfii/100m1 Maximum Effluent Particle Size ~ inch diameter SYSTEM SPECIFICATIONS Septic Tank Capacity 6rs0 gal ^ NA Septic Tank Manufacturer ~,,,~~,~ ^ NA Effluent Filter Manufacturer -Z~r,.~ ^ NA Effluent Filter Model ~ _ lap ^ NA Pump Tank Capacity gal ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ~- ^ NA Pump Mode! ^ NA Pretreatment Unit ~ NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Manufacturer Dispersal Cell(s) ^ In-ground (gravity) ^ In-ground (pressurized) ^ At-grade ^ Mound ^ Drip-line ^ Other: * Values typical for domestic (non-commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency dition of tank(s) i At least once every ^ months ^ year(s) (Maximum 3 yrs.) nspect con l t contents of tank(s) P When combined sludge a ume nd scum equals one-third (Ys) of tank vo ump ou rs ) 3 i rsa( cell(s) di At least once every ^ months year(s) . y mum (Max spe Inspect Clean effluent filter At least once every fa2months ^ year(s) controls 8t:alatm um At least once every ^ months ^ year(s) ~..NA p inspect pump, p Flush laterals and pressure test At least once every ^ months ^ year(s) ~ NA other: At least once every ^ months ^ year(s) ~ NA other: At least once every ^ months ^ year(s) ~ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Masi Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspet:tio~ must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure tl 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 (Ys) 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.1 13, Wiscon: Administrative Code. The servicing effluent filters mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or mo 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 produce or other chemi< that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the comer ter! riw ranlr(s'~ rarnovPCt by z SentaRe servic3nR opertor prior to use, ~i System start up shall not occur when loll conditloru are frown at ciw Inflitratlve surface. During power ouuEcs pump tanks may iii! above nomul hlghwater levels. When power !s rrstond tht excess wastewater will be discharged to the dispersal cell(s) In one large dose, overloading the till(s) and mry result in tht backup or surface discharge vl effluent. To avoid this situation have the contents of the pump Unk removed by a Septage Servktng Operator.prior to restoring power to the effluent pump or contact a Plumber or POWTS Malntalner to assist In manually operating the pump controls to restore normal levels wlthln the pump tank. Do not drive or park vehicles over links and dispersal cells. Do not drive or park over, or otherwise diswrb or compact, the area wlthln 15 feet down slope of any mound or at-grade soil absorption area. Reduction or eilminadon of the following from the wastewater stream may Improve the performance and prolong the life of the POWTS: antibiotla; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental Ross; diapers; dlslnfectanu; tat; foundation drain Isump pump) water; (rvit and vegetable peelings; guopne; grease; herbiddas; moat scraps; medications; oil; palntlnrz croQucts: aestiddes: sanitary napkins: tampons; and water softener brine. ASAN DON EM ENT When the POWTS fails and/or is permanently taken out of service the (oliowing steps stall be taken to Insure that the system is properly and safety abandoned In compifance with ch. Comm 83.33, Wlscortsin Adminlstratlvs Code: • All piping to tanks and pits shall bt disconnected and the abandoned pipe opsnings sealed. • The contenu of all tanks and p1u shall bo removed and property. dlspossd of by a Septage Servking Operator. Aher purnpi,~g, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, g~~avel or another Inert solid material. CONTINGENCY PLAN !f the POWTS falls an<i cannot be repaired the following measures have been, or must be liken, W provide a code compliant replacement system: A salable replacement area haw been evaluated and may be utllited for the location of a replacement soil absorption O system. The a lacement area should rotccte4 from disturbance and compaction and should not be Infringed tit r~nt,ir~A utba[ks rrAm lYlSrinQ and DrODOSe sw n we s. a are t0 protrct rep acement area v O O Replacement systems rnust comply with the rules In effect at that tlrne. A suitable replacement area is not available due to setback andlor soli ilmlUtlons. 8arrlrtg advances In POWTS technology a holding link may be Installed u a list resoK to replay the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site eva(uatfon must be performed to locate a sultabte replacement area. if no replacerrtent area is available a holding tank may be Instilled as a last resort w replace thr failed POWTS. Mound and at•grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconswalons of such systems must.comply with Lhs rules bt effect at that time. < < WARNING> > SEPTIC, PUMP AND OTIiER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TRfr'.ATMENT TANK UNDER ANY CIRCUMSTANCES. OEATH MAY RESIILl', RESCUE 4F A PERSON FROM TfiIE INTERIOR OF A TANK MAY f3E DiFFiCU1T OR IMPf1CC)RI i. ADDITIONAL COMMENTS POWTS INSTALLER Name {{+t,c t~~-rV6SS Phone 1 ~- (o$''f' 3~-3 c7 SEPTAGE SERVICING OPERATOR (PUMPER Name Phnn• POWTS MAINTAINER -.Name Phone LOCAL REGULATORY AUTHORITY AMY T tGO t X N ~nJ hon - 6 - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNBRSIi[P CERTIFICATION FORM Owner/I3uyer ~f 1 ~ V ~i /rj/V/ ~2J /~//, Mailing Address 1.S 7 ~/ r ~ S ~` Property Address (Vccificatioa required from P[aaaing Dcpartrncnt for acw coastiuctioa) _ - _ _ Ci !State ~IYI/~d ,[~ -, ty ~ Pat~ccl Identification Ilumbcr ~ ~ ~y 9(~ ' $~~-C~'~-} I:.E~AL DESCR.zP'I'XON Property Location sj% %, ,~ % Soc. 16 , T 2 -R / ~ W Town ,~-rr r~ ~ ~ of Subdivision ~~ ~~ GG /S ~. %~iD~ Lot#= . Ccetified Stuvey Map # _ bf y L/ ~`~_ Volume Page # ~~ Wsttrnatp Deed # ~ S^ ~,l ~l ~ Volume ~Q_`~, pie # _ D Spot $onse ^ yes ~ no Lot Lines ideutifiable,,~l yes ^ no ~~~moeo~fp~oarseptiCSy~oocldnsnItmi:spcauatohaadlewas'tcs.Properma ooasists of pao~ing ant the repti~c tact; evriy tl~sioc y~ ~ ~ if aeoded by a Iiacased ~t yva pat. into the rystcai can affcct~ae ~banctuas; of the septic taalc-ss.a ~ .ia the araste disposalsysbcm, T~ PAY owns sgcocx m :ttl~ m St (koac . D ~ cat~ficah'oa form, sig~aed by 6ne ~o~an~ct and dry a ?~P4~]~Y~plambcrirs~icbod ~~aliocasodpampatrecifyingt5az(Ijtheoaaite~ is ia. psvpa opa~ag oo~adition andfor f2) after • oa and pamping.(' may), the septic-tantcis less .than if3 toll ofofstadga. . ~- ~ wed hatne_rad the abome toga cad agme to maiatzia tiue pcsvate sewage rnteai wi8s ffia sbsadatds .~ fem. irereict. ss net by the Depattmont of a and the Dcpast<ncmt of Isatcr:l R,esoanxs; State of Wuoocsia.. Ce:ti~azxon ~ ~ ~Y'~ ry~cm Isar boas maintained mart be compLctcd and nctcrmod to tlbc St Q~oix.Couaty Zoning Office within 30 year' expiration date. SIGNATURE OF APPLICANT ~v~ /Df DATE OWN>R• CERZ'II;TCAZTON I (tee) oettify that all rtat~ oa this fours ace true to the best of say (our) knowledge. I (we) am (are) the ownex(s) of ~ Ply desecs~od ab b virtue of a warranty flood ~ R~~. of Deeds O+fl3cc_ sI tvRS o APPr1c.ANT ~ ~ DATE ssssss Arty iafotmation that Is mis 'wed ~Y teroult in the sanitary pumit being nvokcd by the Zoning Dcpasinscat. ssssss ss Iadade trtth thts application: a stamped warranty decd from the Register of Deeds otTicc a copy of the cestifiod eeuvcy map if rcfec+enee is made in the warranty flood von 1~l~" 1~;,~;~ ~Q5 ' STATE BAR OF WISCONSIN FORM i - 1998 ' WARRANTY DEED Uoaimenl Number This Deed, made beiween Ronald C. Bonte and Glenn A. Knudtson Grantor, and Dante P. Mon rlan Grantee. Grantor. for a valuable consideration, conveys to Grantee the following described real estate In St. CrOlX County. State of Wlsconsln (the 'Property'): Part of the SE a of the NE '~ of Section 16, Township 29 North, Range 17 West, St. Croix County, Wisconsin described as follows: Lot 57 of Pheasant Hills First Addition, filed May 8th, 2001 in Volume 8, Page 48, Document #644952 Tosether with all appurtenant rights, title and Interests. Grantor warrants that the title to the Property fs good, Indefeasible In fee simple and free and clear of encumbrances except Easements, licenses, zoning ordinances, and restrictions of record Datedthls 2_ t~-day of gi19tr4t ,-2Q~• ~~,(~ ~ ~') ' ~- c ~ (SEAL) (SEAL) . Ronald C. Bonte Glenn A° Knudtson AUTHENTICATION Signature (s) (SEAL) authenticated this day of , TITLE: MEMBER STATE BAR OF WISCONSIN (If not. authorized by X706.06, Wb. Slats.) 6 5 4 95$ K6liH:EEN H. WRLSH REGISTER OF DEEDS ;T. CROIX CO.. WI kECEIVED FGR RECORD 08-?6-zD01 6:30 A!1 idAkkANTY DEED ~Y.E49PT b CERT COPY FEE: COPY FEE: TRANSFEk FEE: 89.70 RECORDING FEE: 10.00 GAGES: 1 Recalling Area Narrle and Rettxn Addrsas jU 018-1090-57-000 Parcel Idwtllllcalbn Numbar IPIN) This 1S riOthomeslead property. (ls) (la noQ ACKNOWLEDGMENT (SEAL) State of Wisconsin, ss. St. Croix County. Personally came before me thla 7th day of Au.yust , .~~ .the above named Ronald C. Bonte Glenn A. Knudtson to me known to be the person S who executed the foregoing tnntrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY w ,~' •~ ~, ~' ~ t Ronald C. Bonte 1011 170th St o` ~ ;. '~~~ '~1"D2teSTUQIJ Hammond, WI 5401 5 (71 5) -796-5240 ,tary 2ublk,~ftaje of Wlsconsln cWnmlYg),on,; is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not 'ta°"~~. ~ ') necessary) ~.,:-~. .~~ ~~ Expires March 17. •-Nnnas o! persons dgning In any upacay rrwat be rypad a printed ialow tlsek argrwlun. STATE BAR OF WISCONSIN w4w,atn l.aaal atanY G.. inc. WARRANTY DEED PORM No. I - IPPt MawssuFaN, wr. 87/24/2001 08:00 7156845456 BAKKE EX PAGE 05 ~ ~ Amt t aat iuRE teaC ~ ~ .; t ,. C. , ~ ,'~~+' i 's ~, ~ l' . :t~,W' ' ~ .. •.•ti.t Y'r. •IJ t.r . tii.~M:~Lt~..• ~~ i L i i Q ~ x -. 1 Q .......... .......... ..s ... ti -!: ~ ~ i ~- - 0 ~ ~ ~ ~ ~ ~ • ~ • x }' bl~'r ~ s ~ ~~~ ~ ~ ~ ~ , F ' ±•~ ~ . ,~ it / ' - '` ~ ~ - _ ~ ~ r' ~ f ~ ~ 801. ~ ~ 't y ~i (~ r~ ~ s~ ~~~ ~~' ~~y s~~6 T2y~R ~~ ~ l~ ti ~.~ sv- nT ~'~ r` L LS ~,q~iPS7-k~~ rrTio /- L®7"s~~ `~~~Ra~~ ~ ~ ~-o lNo~s ~ I - _ _ I` _ ~ ~ -~ ~ l ~~ ~ , ~ ~ ~~ r ~ ~ 4~;T~, ~k~a . _. ~' «TY..e ~ 1~~-~ fe ~' ~ -~ ~ ~, . ,~ , ~; ~. ~_., _R 7,sr4 _ -~ 8~_ ~- _ _ r c , ,- ,~i~ g~3o%3/ ~~ 6 9~y