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HomeMy WebLinkAbout018-1050-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 463227 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: Jorgenson, Lillian Hammond Township 018 - 1050 -50 -000 CST BM Elev: Insp. BM Elev: BM Descr' ion: Section/Town /Range /Map No: DV ' U I t 22.29.17.350A TANK INFORMATION ELEV"OWDAT TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � l Benchmarr� 3, (,� 3• �V . � Dosing AI BM J w �Ob AIL :5 2a lo/ 3 Bldg. Sewer wer � ✓ � X. �/' PjSidi yz Holding SUHt Inlet 92, TANK SETBACK INFORMATION St/Ht Outlet l y y°�•b TANK TO P/L WELL BLDG. Vent to Intake ROAD Dt Inlet Septic t / �Q Dt Bottom ►6b i > ICY > Dosing !� Header /Man. Aeration U Dist. Pipe Holding Bot. S stem c/ PUMP /SIPHON INFORMATION Final Grade v+ Manufactu r !1:4— Demand St�ceF 1 , GPM 7 �"I��YS 3.ZS ��3b• /� Model Number � 13 10.31 R7 oq TDH Lift Fricti oss System Head TDH Ft Forcemain ength Dia. Dist. to Well J- SOIL ABSORPTION SYSTEM BEDITRENCH Width ^ I Length' f No. Of Trenches NSIO PIT Dl! "S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS s 2 SETBACK SYSTEM TO o P/L JBLDG WELL LAKE /STREAM LEACHING an / L INFORMATION CHAMBER ( / 44 Typ f System: r 1 6 j ` UT odel Number: Zo DISTRIBUTION SYSTEM ►�a� Spin Vent to Air Intake H Distribution x Hole Size x Hole Spac g H eade d / _— - ( L f 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 1 �j t J Bed/Trench Edges Topsoil Yes No ] Yes No { 6 16 1 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /a/� Inspection #2: Location: 1878 Highway 12 Hammond, WI 54015 (SW 1/4 SE 1/4 22 T29N R17W) NA Lot Parcel No: 22.29.17.350A 1.) Alt BM Description 2.) Bldg sewer length (p0 - amount f cover — p 7 hs K Q 1 P > q 2 a- 444 7 Plan revision Required? sl es No i Use other side for additional information. i 1..� � — - -- —� Date Insepctor's ignature Cert. No. SBD -6710 (R.3/97) A Safety and Buildings Division County 1 *1 201 W. Washingtor O x 162 Madison, W- Sa itary Permit Number (to be filled in by Co.) 608 ^ De artment of Commerce Aa ( ) Ma a State Plan I.D. Number Sanitary Permit Applicati n RE^ /J /A In accord with Comm 83.21, Wis. Adm. Code, personal informs n you provide pro t Address (if different than mailing address) D 1. Application Information -Please Print All Information may be used for secondary purposes Privacy Law, s 55 ((1 xm) .1 � ST. Property Owner's Name z�1111 U , r;� i P I # Block # Lot # �l L.�( - N Sa /off U - a� Property Owner's Maiiing Address roperty Location �G / 7 Section City, State 1 r Zip Code A Phone Number I'nb N V �� / (2, f� l T -RAN; R E II. Type of Building (che k all that apply) yj Subdivision Name CSM Nyt� er ❑ 1 or 2 Family Dwelling - Number of Bedrooms - v Iq - 7a ZQ T N ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use S — o? LJ .2.l-- J .1 ❑City_ ❑Village ownship of rK6 111. Type f Permit: (Check only one box on line A. Complete line B if applicable) A ' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. Permit Renewal Permit Revision El Change of ❑Permit Transfer to New �� � r D Before Expiration Plumber Owner o' IV. of POWTS System: Check all that appl Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Pamber ❑ rip kine ❑ Gravel -1 s Pipe ❑ Oth (explain) V. Dis ersaV'freatment Area In ormation: ' Design Flow (gpd) Design Soil Application Ra f) Dispersal Area Required (s Dispersal Ar Proposed (st) System Elevation (000 ' VI. Tank Info Capacity in Tota Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersig , assu responsibility for i Hatton of the POWTS shown on the attached plans. Pi �qte ri ) lum ignatu PRS Number Business Phone Number / ( / J a�3s 1 5 _ dL Plum is Ad ess (Street City State, Zip VIII. unt / epartment Use Onl nits Permit Fee inctu roundwater Date Issued Is mg Ag t Signatur tamps) Approved ❑ Disapproved Surcharge Fee) 60 ❑Owner Given Reason for Denial � IX. Conditions of Approval /Reasons for Disapproval O r tm t9hc, rm 4A4,: Lt Attac complete plans (to the County only) f the system on paper not less than 111191 x t t inches in size SBD -6398 (R. 01/03) 2,4 $-y A &k - / "z / 0' st- �j S tf , � 4 gm - a o x 13-3 8 O-f 0 B -! Ell a y _6 0 i a �� 187S r 3 4 3 Ile �ara/ 9 S O / ?,. I g z 2 ► Lod- Qb T, �Z WEO h' 5 -Pius' III ►ticNn�N►a � j _ o r-I o � a S c t 2 . 1 1 3 I Z'4; - rg�� RECEIVED 1602 Wisconsin Department of C kZi-jd IL EVALUATION REPORT P age 1 of 2 Division of Safety and Buildce wi Comm 85, Wis. Adm. Code Steel's Soil Service, Inc. Attach complete site pl ch n size. Plan must County St. Croix include, but not limited poin BM), direction and percent slope, scale or dimemd distance to nearest road. Parcel I.D. Please print all information. viewed Date Personal information you provide may be used for secondary purposes (Privacy taw, s. 15.04 (1) (m)). �/ Q Property Owner Property Location Jorgenson, Lillian Govt. Lot na SW 1/4 SE 1/4 S 22 T 29 N R 17 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1878 Hwy 12 na N/A City State Zip Code Phone Number J City I Village /1M Town Nearest Road Hammond WI 1 54015 1 715 - 796-2613 Hammond I Hwy 12 New Construction Use: oM Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: Parent material outwash Flood plain elevation, if applicable na General comments and recommendations: Additional Boring for the new system. Boring # I Boring 001 Pit Ground. Surface elev. 98.08 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr3/1 none sit 2msbk mfr cs 1vf .6 .8 2 8 -28 10yr4/4 none sicl 2msbk mfr gw na .4 .6 3 28-45 10yr4/4 none slAs 2msbk mfr gw na .6 1.0 4 45 -90 7.5yr4/4 none ms /cos osg ml cs na .7 1.6 5 90 -120 7.5yr4/6 none cos osg ml na na .5 .9 ® Boring # Boring �J/ Pit Ground Surface elev. 97.08 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -10 10yr3/1 none sil 2msbk mfr cs 1vf .6 .8 2 10 -25 10yr4/4 none sicl 2msbk mfr gw na .4 .6 3 25 -43 10yr4/4 none sl 2msbk mfr gw na .6 1.0 4 43 -75 7.5yr4/4 none ms /cos osg ml cs na .7 1.6 5 75 - 120 7.5yr4/6 none cos osg ml na na .5 .9 * Effluent #1 = SOD 5> 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS S mg /L CST Name (Please Print) Si e: CST Number David J. Steel 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 12/8/2004 715- 6845680 Visconsin Department of Commerce SOIL EVALUA I MN KtNUK I Nage ul )ivision of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County s-T Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Reviewed by Date Please print all information. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ropertyOwner Property Location 4 � Mel. j ©r -50 Govt. Lot � ll� 1/45 1/4 Sai•� Tod � N R l � E ( W rope rty Owner's Mailing Add Lot # Block # Subd. Name or CSM# 9 7S �� /� Village own Nearest Road ity State Zip Code Phone Number ❑City ❑ > � w ' jail ,mil tit o h GPD } New Construction Use: esidential J Number of bedrooms _ Code derived design flow rate �© jl�e placement ❑ Public or commercial - Describe ft. arent material ,� r . � 1 t1 tt,4 �.... �S (� / I ot7 - Flood - Plain elevation if applicable eneral comments " C l /' f C id recommendations: G�_S �` cam r Y a -e 9 Ov Boring # / E) Boring �� in. Sal ication Rate � it Ground surface elev. d ft. Depth to limiting factor �_ CJ P R GPD/ff iorizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary •Eff#1 •Eff #2 in. Munsell Qu. Sz. Cont. Color 3 S c .� Gr. Sz. Sh. I �- IO . b s� CL Ir - y.S to 4 f)S r�►- S - c i 546 ❑B ring in. ? ) Boring st 7 ft. Depth to limiting factor Soil ication Rate Pi Ground surface elev. Roots GPD/ff iorizon Depth Dominant Color Redox Description Texture Gr. zt Sh. Consistence Boundary •Eff#1 'Et7#2 J J in. Munsell Qu. Sz. Cont. Color S4-6)- Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L CST Number CST Na (Please Print) Si lure 4ate v1 k "0 S � � ` Tele hone Number E nation Conducted p Address I J � I , roperly Owner L 1 t a-v) o r F e V1 S a Parcel ID # Page of 3 ❑ g ��- 3 Borin # ��� 9 in. Ground surface elev. 97 a ft• Oepth to limiting factor Son q ication Rate l ' Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots .Eff#1 -Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. / O✓ O s I k S nc 7!i- I tl • � U S 14 1 /. Boring # ❑ Boring ❑ pit Ground surface elev. 7-3 ft. Depth to limiting factor 3 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots tEff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate ❑ Pit GPDM Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 'Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <_ 30 mg/L and TSS _< 30 mg/L 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. MID-8330 1 8.07/00) D S STEM OWA,= eptic taner and dispersal cell must all be serviced 1 maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances / 1 1 - RECEI x Safety an Buil trigs ivis n ty 1 *isconsin 201 W. Washi gton Avc., P.O. Box 7082 5 T Madiso WI S370, 41082 0(,' F ( itmy Permit Number (to be filled in by Co.) De grime ( 8) 261 -i 4Q � G OFFI i;,_ { nt of Commerce w,. - k.. -... 3 2,2- • • State Plan I.D. Num Sanitary Permit Application � In accord with Comm 8321 ` Wis. Adm. Cod personal ' provide , information u /�, 0. P� you P may be used for secondary purposes Privacy Law, s 15.04(1 xm) Project Address (i I. Application Information - Please Print All Information Property Owner's Name Parcel # Lo Bloc # I Property Owner's Mailing Address Property Location 9 7 9 /7 % I VR, , 3y9B 3 City, State Zip Code Pho Number U ( Section 7 S- 7ylr le 1 3 circle ) - T N; R / E orW IL Type of Bu ldIng (check all that apply) �• n / � rn 1 or 2 Family Dwelling - Number of Bedrooms Gf Subdivision Name CS N • 0 PubliclCommercial - Des'be Use S (,� �t y 1 / 0 State Owned - Describe Use - OCity OVillage . owaship cg ILL Type of Permit: (Check only one box on tine A. Comp a line B if applicable), - L c3 A 0 New System Replacement System ❑ Trea en olding Tank Replacement Only - 43- othe-r -mo f on to 'stir t B. ❑ Permit Renewal ❑ Permit Revision ❑ ge of ❑ Permit Transfer to New List Previo Al Date Issued Before Expiration Plu Owner r I b V. of POWTS System: Check all that a 1 (o ! ^ S yx Non - Pressurized !n -Ground 0 Mound :t 24 in. oCsu' ble 1 ' ound 4 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland 11 Pressurized In- Ground ❑ Iding ' Tank ❑ Peat Filter ❑ Aerobic Treatment Unit 11 Recirculating Sand Filter ❑ ' Recirculatin Synthetic Media Filter JOLeaehing ber D Line ❑ G e ess Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: / , 4,)-- - Design Flow (gpd) Design Soil Application Ra sf) Dispersal Area Requi cd (s Dispersal Area Proposed (st) System Elevapon 6 O I dn o la / / ao , y 1 9V VL Tank Info Capacity in 1W Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gagons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank lases l �,t J t Aerobic Treatment Unit Dosing Chamber r V show.n VII. Respon sibili Statement- I t undersined assume responsibility for installation of the n the attached pleas. Plumber's Name (Print) Plum Si azure P PRS Number Business Phone Number 80PV t o.357 pis- � g- yys Plumber's Address (Street. ity, Sta /J te, ip Coda) / VII . oun /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Age Si lure ps) I Surcharge Fee) �� Z ❑Owner Given Reason Cor Denial IX Conditions of Approval/Reasons for Disapproval .vA ,t21� �a$ .T 4y ' e c old 4 "k— (* _A $, og ( p C AI Z / - sy � , �r� - J 01,3,5 - g ENQ = 6-3 n fao 4y � lvn� �I �3 AA�' `'1 3/ 3 - 4� r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i Owner/ll�' L I � �► �+ J � ,2 > G� s o Mailing Address OF 0 /V vn S Property Address 18 7 (Verification required from Planning Department for new construction) ; 2,2, ;? 9. /7, 35 A City /State n �'l � - � _ Parcel Identification Number a 2 . 9 /7> 35 0 ,6 LEGAL DESCRIPTION Property Location SO '/4, 5 `` /+, See. a , T N -R / 7 W, Town of Subdivision °�- �`� �� , Lot # 1 Certified Survey Map # , Volume _ , Page # � , Volume I a 7 8 , Page # Warranty Deed # 10 Spec house 0 yes no Lot lines identifiable yes O no y SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Propermaiatenaaee 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge• I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the 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 returned to the St. Croix County Zoning Offiice'within 30 days o�three yea iration date. -ice SIGNATURE--&F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) Of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 1.231 z S P GNA APLICANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. •• Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Ow ne r r ILI- Septic Tank Capacity /a � S a l ❑ NA Permit # Septic Tank Manufacturer 61(/aj_QiL ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A ��� ❑ NA Number of Public Facility Units A Pump Tank Capacity a l ❑ NA Estimated flow (average) g al /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) (61� al /day Pump Manufacturer ❑ NA Soil Application Rate g al/day/ft' Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L X Ground (cravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L )< NA ❑ At -Grade ❑ Mound Fecal Coliform (geomet mean) 51 ° fu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 2 e ar(s) — ?j 13 m ) (Maximum 3 years) ❑ NA rls► Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ ears) E3 NA Inspect dispersal cell(s) At least once every: 2— 3 year(g) month(s) (Maximum 3 y n 1 onth(s) ❑ NA Clean effluent filter 4 f' `I At least once every: ❑ year(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ' ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: ❑ month(s) ❑ year(s) [3 NA Other: ❑ 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 (Y 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 chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, 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. Page of y START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) 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; r n tampons; painting products; pesticides; sanita and water softener brine. p p , 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 PO TS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replace nt system A suitabl replacement ar as been evaluated and may be utilized for the location of a replacement soil absorption system. T ent 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. T A r Iv alua ' gg a o m ank be ' e ai a '9fZU44I'B WITS FD+- A1� a&IS'7 RUC4 F ❑ 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 Name ;D(, Name Phone q q Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name , ( X e) 20AII Phone Phone 3W40- This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Wiscohsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85 Code 7 County S 7- . P16 I Attach complete site plan on paper not less than 8 1/2 x 11 inches in ize. include, but not limited to: vertical and horizontal reference point (BI directio. 6 percent slope, scale or dimensions, north arrow, and location and d' tance to nearest road. - pS - Ol3C7 Please print all information. 2 Rev w Date Personal information you provide may be used for secondary purposes (P vacy L4,i, C - 4 (1) (m)). ` /// Q PropertyJO /wner sc S� 41 / ! /� , ©Y Li S� l� Govt. Lot 1 5._1/4 S T o� N R 7 E ( W Property Owner's Mailing Add ss / Lot # Block # Sub d. Na or CS C City State Zip Code Phone Number ❑ City C3 Village own Nearest Road F New Construction Use: 94esidential / Number of bedrooms Code derived design flow rate �� GPD (replacement ❑ Public or commercial - Describ Parent material /�r. (I,a� �n�� S l �' / lot Flood Plain elevation if applicable ft General comments G�_5 z'n Fc�� o r 5 and recommendations: / Boring # Boring Ct 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 /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 3- Cct� t eC - l 5- Sr CL wt 3 - yS to 4 R f�.S��t- 5 • O a Boring # rpitring G round surface elev. 7. a $ ft. Depth to limiting factor > in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 - /C) IQ ,- s eLe I L s / t ' Effluent #1 = BOD > 30 220 mgA- and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg/- and TSS < 30 mg/L CST Na (Please Print) Si ture CST Number '-9 ' CO- ' vl V1 t -e .P 5D � Address Date E nation Conducted Telephone Number Property Owner Parcel ID # Page of F-T Boring # ❑ Bo g L� Pit Ground surface elev. �a ft. Depth to limiting factor 0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 • U Lo YP / to Boring # ❑ Boring ❑ pit Ground surface elev. 1 7 7.3 ft. Depth to limiting factor 3 � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 , - L b — F] Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. F-1 pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an altemate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. S B D -8330 (R.07 /00) 1 d f i t� I / S T �aoa�a SutY�lc a 1 5 of \ \, \ T, IA _ WE" Sh L��vc►`�' +fRoo" ry � x x ey EiU _ 6 -3 �y -10-6 z © C y DOCLWhT IW. STATE bAR OF WISCONSIN -FOklt l WAMANTY DEED A 0268 ut� 7"i' sif T"IS SPACE SESUVED FOR RECORDING DATA Stl // 1 t TMS DEED, made hot.. __ Zella Drummels kcG1STERS OFFICE 1 I� ST. CROIX CO., Wis. !� -- - Reed for Record this- Grant- a m John S Jorgen and Lillian A. Jorgens �Y �._- NU_____�l :14_72 1 " hu sband and Tfife aL creme.. Witneareth. That the aid ar Caant (or a rsiwMe cogaid*ratlon Thirty -ODE MOOU a nd Five Hun and no /00 -- -------------------------- .I .onyeya to Grantee the following described net estate in St. Croix -C-Unity. S&TURN To State of Wisconsin: Eh of SF's and E 10 rods G[ Wk of SEtr of Section 22 -29 -17 EXCEPT N TO acres thereo Tea Key s Thin is boomers" property._ .I li. U'1 ✓t Lil V a FFF. '1 �t I Tog*ther with all and sattpll +r the hercdiLm Mtu run eots and sppuracss theto belonging or is any N apparUia9ttC it And - - if •� warrants that the title is good, iad..feaaihle in fee simple and free and clear of encumbrances *seep( !: I i uu I A R and will warrapt and defend the same. Kxrcuted at Riv er F:t i I — - -- - -- this 12 th _ dry of I' I i� 1 S(GNE AND SEALED IN F [2F.S8NCB. OP � "„bY:�'_ _� A�/ i�f ` > 1 ($CAL) � i Zella Brummels J nl tt ;R•.S) I! f Viola 5, Hauth - }� ;i ;I Signatures of i 4 authenticated this _ _._ day of Tnt*: 11wmb., Stale Mo of Wiecoeeta er Other Peery . Aotborized under See. 706.06 via. STATE OF WISCONSIN i If St_C _ . County. t . s Personally crma before ma, this 12th _ �2 . j th. et e+e ne eea :ttlla itr umrwla `{ to me known to be the on who executed the fore teed t .o sane, it`G�� �Q 1► Pars -Din In strument and ackaowied .`- This instrument was drafted by WaLmA if William J. Radosevich — ' - *� If 408. - Second_ Stre - eit _ Netery PenimAt" Q w.i• "S N's tZa ty. q r I Hudson, Wisconsin 54016 'i The nee of wltaesses u opt toner. ily Coa.wissioe (8apt[es) {b) _. �!r ' [frmws of persons sirnins im eeY • •- pacity sh-ld bu typed er wined helo their -U."t tes. '� WARRANTY OWZD -STATZ BAR nr• WBco -Six H, MM AM ia:=E� S� P, TERMINATION OF DECEDENTS PROPEpTYINTEREST .. John S. Jot Berson ,T� REGISTER'S 0 €fiivE ,►ot>rds: of o+�n< or ca,►n, ST. C R OIX CO.. W1 878 Hwy 12 Harr- and WI 54015 ttse�d "�� rzr OF tk v. 3, 1997 397- 12 -415T NQV AM No 9:30 ESENTATION OF DEATH CERWICATE nYa artificatL ertify that f haw viewed a a ooPy d tits dewds oe Rar�rof thta dvc�rasrtt wRlr fheRaptaterdt?reds Wt of o as srwn h da cor4rW syoere dfs Oat sstdi b bcatad rise 6 � as Pere. 867.t}43i, 867.Otd. ThIs in root i properly is terminated under (check 0m). e a jolt t.nartt. 867.043 which pertains to pm" in which the decedent was had vendors Or vendo or mortgagee`s mrost, or had a We estate. *(you mud fi py de a co IAtY ©t��(� C of the document establishing joint tsnanw or fife estates 740 Mails Sts --8t IL 857.046 which pertains to (1) Pm"flY O a de sp scilied In a marital Ba WI Jifuwz property agreement, and �suEvi+wtshfp matter •( ou must pro4WG a copy of the document a �P Presentation of reef property tstt bpI ( etooe pt h ease of vends to or for �~ imm raen>ia in t e rest). Pa f tM � lmmedtatp d� * death preeentatfin of dont s� Flo joint tsnency, lfN setsts, survtvorshtp rrhsriW Pros y. P 'vsndvr cume interest, or mortgages Inter P►oPwq' This document cumber b t n E; . vokane 4 8 4 . Page -.d !check onr} Aomwde psscription of the real es tate. nd at th t • floe exuw of tend is era"t1y :.,�..� hw � +.wtt�f aT , •L ''caQ'�a� lirtarest} in d w same as an me document a COPY Of doer daxarouot m be attached to describe tt- mW e state The bqW desafpdorr Of the PmPwlp is as fdbws: (11 wrote ap.o. b rwsded +mach pagea) gin of SEk and E 10 rods of Win of SE% of Section 22-29 -17 EXCEPT N 70 acres thereof. and baf!ef, true, correct and compWs and is h wnfrw DECLAf1AMM. 4 ws decfars that this document ts, tG the bast d my (our} knomt attar page &l mity with the provisions and fimtatiome d fine Wrsconain Starves. fT ^lore space Oahe -. Uwe sad Addnee of perwa Fromm w Oaoedaht Liliiam_`A. Jorgenson Spouse a 1878 Hwy 12 The above named psrson(s) was sworn to t»kxs nh� on ( j This document was draftod W. Signatyre of notary or other person- - (print or type name bolml authorized to administer an oath (as per s. 70&ok 7%.07) rrn�nt[ print or type acme 7 N� �l�tAt x State of Wamnsut. r3wr+t!"wf � t 6 � �' t3 (l •r.�.0 %grw.l Demo Amuckar fWmW'1 W PW WON" :,s,sr,a�so Parcel #: 018- 1050 -50 -000 11/30/2004 02:52 PM PAGE 1 OF 1 Alt. Parcel #: 22.29.17.350A 018 -TOWN OF HAMMOND Current 1X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): * = Current Owner LILLIAN A JORGENSON * JORGENSON, LILLIAN A 1878 HWY 12 HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1878 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 18.000 Plat: N/A -NOT AVAILABLE SEC 22 T29N R1 7W 18 AC SE SE S 9/20 OF Block/Condo Bldg: SE SE EXC .06A TO STATE IN 603165 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 29N -17W Notes: Parcel History: Date Doc # Vol /Page Type 1278/101 484/239 2002 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/13/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 26,000 121,500 147,500 NO AGRICULTURAL G4 7.000 1,800 0 1,800 NO UNDEVELOPED G5 9.000 7,900 0 7,900 NO Totals for 2002: General Property 18.000 35,700 121,500 157,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 210 Specials: User Special Code Category Amount 010 - GARBAGE SPECIAL ASSESSMENT 60.00 Special Assessments Special Charges Delinquent Charges Total 60.00 0.00 0.00 Parcel #: 018 - 1050 -20 -000 11/30/2004 02:50 PM PAGE 1 OF 1 Alt. Parcel #: 22.29.17.349B 018 - TOWN OF HAMMOND Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): * = Current Owner * JORGENSON, LILLIAN A LILLIAN A JORGENSON 1878 HWY 12 HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.250 Plat: N/A -NOT AVAILABLE SEC 22 T29N R1 7W 2.250 AC S 9/20 OF E Block/Condo Bldg: 1/8 OF SW SE Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 29N -17W Notes: Parcel History: Date Doc # Vol /Page Type 1278/101 484/239 2002 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/13/2002 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 1.000 300 0 300 NO PRODUCTIVE FORST LANC G6 1.250 2,500 0 2,500 NO Totals for 2002: General Property 2.250 2,800 0 2,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User rY Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 va�� o � N CA) , w 1T T A,v �n,z W - ; 7 41 Fi Z a> ^ A y !J � I N j