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020-1164-90-000
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I I I � � I � � a ti 0 I \ ° \ a I A �. o .b v (=D A ~ CD Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 572822 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: Stone, Jaron &Crystal Hudson, Town of 020-1164-90-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: 6Z> 1 5 M ( 6-5 -F 07.29.19.991993 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER %., CAPACITY STATION BS HI FS ELEV. Septic 3 Benchmarkq•3 Alt.BM z' Ge Fit a , Aeration Bldg.Sewer `•� �� S Holding St/Ht Inlet 7 �.A l07•16 6.95 -7h. 37 St/Ht Outlet .7- 1-7 96- 15 TANK SETBACK INFORMATION TANK TO �P� WELL BLDG. Vent Air Intake :OAD Dt Inlet w� Septic 3� ) 7 7 L� ' Dt Bottom - i v —' Dosing pelf baf� Header/Man. $• 9 , 7� Dist. Pipe 4' L 9 Aeration 9 Holding Bot.System L.c �o.Z ,p Cf Final Grade 5 � 9?• Y PUMP/SIPHON INFORMATION if Manufacturer Demand St Cover_.t GOJ Z' `� •9 Model Number f4�- TDH Lift Friction A m Head TDH Ft Forcemain Length Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS -76 3 1" 't ^_ SETBACK SYSTEM TO P/L BLD�/G WELL LAKE/STREAM Manufacturer CHAMBER OR INFORMATION Typ//e Of System: i/ ,cacti* , f/I UNIT Model umber•L✓� DISTRIBUTION SYSTEM Header/Manifold �/ Distribution x Hole Size x Hole Spacing Vent Air Int e e� Pies �J Length Dia _ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ova I Depth Over xx Depth f xx Seeded/Sodded xx Mulched Bed/Trench Center 4 Bedrrrench Edges Topsoil Yes [] No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 1066 Marty Dr Hudson,WI 540)6(SW 1/4 NW 1/4 7 T29N R19W) Edgewood Estatgs Lot 61&62 63 Parc �o: 07.29.19.991993 1.)Alt BM Description= 2.)Bldg sewer length= 664- 56 = //b 4- r.GuJ 64-o6 •5,e_ :J-v f�, G ~y �•6 -amount of cover= �Z ,r n n -76 4 G; (0 Plan revision Required? Yes ;No Use other side for additional information. Cert.No. Date Insepctors Si ature SBD-6710(R.3/97) �✓�r�,., County cfsl Safety and Bt4ildings Division s_/• . fi 201 W.Washington 7 g � � Sanitary Permit Number(to be filled in by Co.) J Madison;WI Sanitary Permit AppliCatiOri State Transaction Number IX In accordance with SPS 383.21(2),Wis.Adm.Code;submission of this form to th,g���iM==gg'4T10j1ct COUNTYis required prior to obtaining a sanitary permit. Note:Application forms for statetb{� Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 4,4a u oses in accordance with the Privac y Law,s. 15.04 1 m Slats. Sa�f,p /6�� I. Application Information-Please Print All nfo a ' n Ci r Property Owner's Name 5 ' Parcel# 0ao _/4 41' W- &Vd Property Owner's Mailing Address Property Location `q �160—rl,f e Govt.Lot ( City,State �) Zip Codre, f Phone Number y. y. Section_,') T N, R circlE onri.� It Type of Building(check all that apply) L )ZQ I or 2 Family Dwelling-Number of Bedrooms �J Subdivision Name t Bloc 9jXW&V,( ❑Public/Commercial-Describe Use ❑ City of CSM Number ❑ Village of El State nOwned-Describe W �� l.�l` .Town of /cri lT(JQSO� III.Type of Permit: (Check only dne box on line A. Complete line B if applicable) ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. El Permit Renewal ❑ Permit Revision ❑ Change of Plumber [I Permit Transfer to New List Previous it Number and gte�sl � Before Expiration Owner /� ✓% 4 IV.Type of POWTS S stem/Com onent/Device: Check all that apply) j MNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pre eatment Device(explain) V.Dispersal/Treatnont Area Information: / Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed( System Evation'p— J/ /00 JU VI.Tank Info Capacity in Total #of Manufacturer „ e Gallons Gallons Units t j ;; y New Tanks Existing Tanks ,Q / 7 C e `� 5G. J a.U G y v, LU 0 9W Septic orbleid"'"nk Dosing Chamber ]� X VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plu r),s Signature MP/MPRS Number Business Phone Number Plumber's Address(Street,City,State,Zip Code) 171"0/i4 & 9pproved unt !De artment Use Only Permit Fee Date Issued Issuin gent Signatur Disapproved $ 7 n Reason for Denial y! Da `D l� At- IX.Condi4oyi for Disapproval 3 Ol A S I Yy ptic"tank,efiiiueht filter and' dispersal cell must all be services/maintained as per management plan provided by plumber. 2. A# ack tbq ?ents roust be maintained ae per Vpka*code/ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 in x II inches in size SBD-6398(R. 11/11) Pgof Private On-Site Wastewater Treatment System(POWTS) PLOT PLAT FILE INFORMATION PROPERTY LOCATION Owner ,Section. / , -T_4& N,R2Y_E o& _— — 0 PIN# � OCity, OVillage, Town of co �.Cc� County,WI ® cve/i S � ©�� -�dn - F 11 od i cl,e I�50 --- s 0 flop O C 614-c:- �J i CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: rcw) S-fQ,i Lv, Owner's Name: Owner's Address: le)6(p Legal Description: S fi)L / '72 .41 Township: r`ry �n County: Subdivision Name: Lot Number. la - Parcel ID Number. QAJ--&611 Page 1 index and title Page 2 Plot Plan Page 3 System Sizing&Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test&House Plans rr11 OO��? Designer/Plumber. � j jS •P��l/ _License Number: o�o)IW J, Date: c, iPr/9�?0/ - Phone Number "I/y���o�� Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 Pg of Private On-Site Wastewater Treatment System(POWTS) PLOT LAN FILE INFORMATION PROPERTY LOCATION Owner 1 1/a,Section N,R 7�_E o& 0 PIN# _ OCity, OVillage,OTown of Oaf //(0* 9U _ co �dso n comity,wi a cve/l ` �� � s 9. h p V Z4 mai n-4-&n 4�9 c d' 'L C dean- u� s o c4- op Op 11 14- C" ,g3 $` c e 3 c Soli Absorption Sysfm Cross 3ectton ft Final 4"Schedule 40 PVC Vent Pipe ft With Vent Cap Leaching ._.r. ' ' ft Chamber System Elevation .3 ft r Soil Absorption System Phan View ft •� ft Leaching Trench ft Chambers 4'Dia. Trenc4 Header Vent Or Observation Pipe Em Trench�" Leaching Chamber SLLpecific cations /r-- Manufacturer And Model EISA Rating sq ft per chamber Soil Application Rate a gpd/sq ft d Design Flow e --Soii Application Rate EISA= ��s hambers gP 9 3 rows of chambers each. Page of e' N 11 111 0 0 1 O LO CV9 Ci Ci r O N c .. LO r Q00 -fft:i O ti r i I 0 u' z ° LLJ � LU w w Z `= v LLI �n z cn w p ZO j WZ CZ ad � �' wLL wv LU J 7 O ' LO `^ m L? Z cn T w ® 2 m LL's WC? = O c6 IuC5 LO z Lo ��i�llllll�lllllllliillllllllli!iu�rl� ' � i � � i; �' i�''��II,% ��,,��V�!!II�!�!!!!�!�!!!IIIdII�I!Idlllll�!JIJ!61d11!!!�IIIII�I�!!�!!1�61!IIIIIIIIIIdlllll�!dllll�l�!IIL!!�!!IIIIIIII!�!!IIIIIIIIIIIIIIII'►IIIII�IIIIi 011�111111111111111111111111111111111111111111111111111�111111111111111111111111111101111111111111111111111111111�11 ;o��!�h IIIIIIIIIIII�!�IIILIJIIIIIIIIIIIJ�IIIII�!�IIIIIIIIIIIIllllll�illllldll!ILVIII!'III!IIIIIIIIIIII!i!!IIIII!III!I!II!li�! /Il��l.11lllddlllll �"�IffP'III'll'I'llllll'11f11111'li'll'I'11111'lull'll'II'i'I''lllil'I'llllll'11111'i'I'IIIII'I'lllll'Plilll`illlll'I'11111''i'IIIIIIIIIIIPIIIIII'il�lll�llli''� U�I�IIIIIIIIIIIIIIIIIIIILI!IIi llllillll�'I!!L..�I IIII II!'IIII_!� a — _ i -� - � �11►�1 IIII�I Iiiiiii i iii► ��►�����Illill I ��/ �1L1�llllll IIII I I II I 1 111111 ____ ___—_ . a .wiw�s ►j/��OKI✓ Z!NO N , o • • • 1 �, i l,�l:-' %` l i /�/ l/�/11�11 11'111 11/l i l I'l�/l 111111 l//ll rll'llllllllllllllllllllllll!ll, l�!�l l�lllllll;l �� � �\�yAAV��VVVVAVwvyw wvyw � �:/, � � �/� i/`/ � • • ei o = N 1 O Ci U') Ce,) Ci f Ce� ,r.. tf3 00 t[7 r Z 0 V) °v F-- a--_ W t= X W 0- i= co O c1- j W Z CA od X CC.. m ° C7 uj wU�. w = J Z v O = Q u� CD CD Q Z w J U JJ ® 2 h-- m = 0 � „ off U � ' Q Cl- a- � r Owner �AtZ0� ST�IV 020 ' ���y' Y�' 00(.7 Page Z of 3 F3-1 Property Parcel ID# Boring# ❑ Boring Pit Ground surface elev. '�• ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure 3onsistence ounclary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2 o- 9 io yA S/L if sbK /w fCz 0 >f . G . 010 Z 7 . 31 /D YP. 5 — StL 2f Sb?, C ! Co • $ 3 . 0 syR f 5bk n+v►fR a.,c; . Co . 8 F-1 Boring# ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2 F-1 ❑ Boring Boring# Ground surface elev. ft. Dep o limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure 7,onsistence Boundary Roots GPD/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *1---ff#1 ff#2 *Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD 5<30 mg/Land TSS <30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay. SBD-8330(RI 1111) Rlb* N4PAID Wis. Dept.of Safety and Pr 1 Services SOIQLUATI�L.l3 PORT Page / of '" Division of Safety and s 3 „ in accordance with SPS 385,Wis. Adm. Code County 5 G 0 -r• R i Attach complet`�site piar},ompaper RQ e(s��� i 8 11.2 x 11 inches in size.Plan must include,but not limite t�'Vertic ,s�'l�dila`3ntal reference point(BM),direction and Parcel I.D. 7 OQO 02.0 � i tance to nearest road. !i percent slope,scale oh dirr�, o�sj*�5rth arrow, and location and d s � w R ewe by Date 5 )5e print all information. 9 rovide may be us d for seconds ry purposes(Privacy Law,s.15.04�1)(m)).).Pers o al information Property Location Property Owner ��� Q SA�Ld� STD Govt Lot 5W 1/4�w1/4 S T 21 N R R E(or) �1l Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# �r 43 E126Ew oo P 65rA7",e S T , � . (o A 'JR ��� May City State Zip Code Phone Number ❑City ❑Village I 50T6wn Nearest Road t#V�So� Gvl• 5yo!(o (!vS/ ) r 3. S7 q9 14OP,50A.3 IMARTY JM- ❑ New Gor► ruction Use:PQ Residential/Number of bedrooms Code derived design flow rate b GPD Replacement ❑ Public or commercial-Describe: Parent material 1045.5 OVE/2 S/4N0 Y Flood Plain elevation if applicable !YJA ft General comments OOTW,+S#e5 -0• -USE /awER . 60 p�. Solt. and recommendations: 13�P�iG/�TiOw� Rf}TL'' FOR �J ..4zyY' Area Spot Tested suitable for ohu�. _/ - a conventional inground system(P.OAT.S.) 5 I ZIM y 5 yST'Em My • p Boring# F/I F] Boring /6• (o > 1�0 W W Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 / o• ioYR y/3 SIL fsbK �I,S cs . 8 z ?• 1 /0YR Sf& — /G- ZrM 1L. dl.s G5 D . z 3 I(• 2.8 ?.syR sL if Sbt�e �P, C'se -- /.0 89� ioyR � SL 2.fSbkft-PR ate — . � � 0 &F �o R 6, s — • 7 Boring# Boring 5• /'o "7 1 P:1 ® pit Ground surface elev. ft. Depth to limitint act r in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 0. 1 Io YR 511- 2f s bK 15 �s � F . � • � z •/� Io 1 f hK rm RS 8 3 ?.S - 5L 2--f s h nM f9 c w • 8 0•10 /o s -- s z.f s bK MA o O, 5 t / !o Effluent#1 =BOD >30<220 mg/L and TSS>30 <150 mg/L A "Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L CST Name(Please Print) Signature • CST Nu R zt 05ePLT Lt3Ri c4T' �/ 27-4 3 Address Date Evaluation Conducted Telephone Number -1 812. 10 " , Ave . SPRING Ukll wi. 7• aY.Iky 7/s• 1�oz y��z `1 14 n SBD-8330(RI 1/11) ��0.jZDil} STWJ E y' 060 Page Z of 3 Property Owner Parcel ID# 37 Boring# ❑ Boring !q / Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure aonsistence Boundary Roots GPD/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 * ff#2 o- q ,o YR y : s,L If S O< AV cs �f : 8 z 7 . 31 io yp. s - :5( L 2f sbk. R . 00 sL zfsbV- rm-FR CL' A: . G • 0 5 0 S � s Q a ❑-. Boring Boring# ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cant Color Gr.Sz.Sh. * ff#1 * ff#2 Boring Boring# Ground surface elev. ft. Dep o limi Pit ting factor in. ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell. Qu.Sz. Cant Color Gr.Sz.Sh. * ff#1 * ff#2 Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L 'Effluent#2=BOD e<30 mg/,L and TSS <30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access.services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. ssD-8330(RI 1/11) MARTY -RP . 0 Wti l F 15�51) kv M 5 -3M -To F �# z P o a` / I R 30 LOWEST coP.�E /3/4c/Khfo6 / I KS pxicl< oti 8 y RS �,�,ST old o uG- old F/AC E -Tov oF WATT I Eve v � _ a A J V o x o o 3 v � 0 T32, x O 1 11 1 3y o 133 \ w o } Y 3 `�� 303 Page f of 8 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. ABANDONEMENT: 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 ch. 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: i • 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 Name - Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Agency 4, COQ( Zd 41q- Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm 83.2212)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not ni mrantee the performance of the POWTS. POWTS OWNER'S MANUAL & MANAGEMEAT PLAN Page 6--of FILE INFORMATION SYSTEM SPECIFICATIONS Owner v o Septic Tank Capacity 5 g al ❑ NA Permit # Septic Tank Manufacturer le,,S r ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer P®I 10 k ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Commercial Units A NA Pump Tank Capacity gal 19 NA Estimated flow (average) -W gal/day Pump Tank Manufacturer J3! NA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer gr NA Soil Application Rate a gal/day/ft' Pump Model 14 NA Influent/Effluent Quality I'vIonthly average* Pretreatment Unit ,17� NA Fats Oil & Greas e (F OG) <30 m 9/ L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BQD5) <_220 mg/L ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Manufacturer Pretreated Effluent Quality JX NA Monthly average** Dispersal Cell(s) Biochemical Oxygen Demand (BOD5) :530 mg/L 19 In-ground (gravity) ❑ In-ground (pressurized) Total Suspended Solids (TSS) <30 mg/L ❑ At-grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-line ❑ Other: Maximum Effluent Particle Size Ya 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 every ,� ❑ months 0 year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume Inspect dispersal cell(s) At least once every 3 ❑ months A year(s) (Maximum 3 yrs.) Clean effluent filter At least once every ❑months 4 year(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) 10 NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) Ja NA Other: At least once every ❑ months ❑ year(s) IR NA Other: At least once every ❑ months ❑ year(s) 14 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 (Y3) 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, pretreatement 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 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. Page IV of 8 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. ABANDONEMENT: 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 ch. 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 should not be infringed upon � m disturbance and compaction ands 9 P stem. The re lacement area should be protected from P system. P . P b required setbacks from existing nd proposed structure,. lot lines and wells. Failure to.protect the replacement area Y q 9 P P Re will result in the need for a new soil and site evaluation to establish a suitable replacemen t area. Replacement systems must comply t com I 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 Name I=Deonjs Name Phone Phone . SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Agency Croix. ZO!!/rI Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm 83.2212►(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not m inrantr e the performance of the POWTS. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �(ql(!��'1 1510 2e' Mailing Address A&i✓ ,&I Property Address sdme (Verification required from Planning&Zoning Department for new construction.) City/State 4�0 , &//' Parcel Identification Number OSO—"41— 9(/ 0100 LEGAL DESCRIPTION , l Property Location , /�iU '/a , Sec. ` , T N R W, Town of 11U0SO1? Subdivision � q& 2 d s, Auto s , Lot# Certified Survey Map # , Volume �^ , Page# Warranty Deed # -7Z Q 5 3 0 p , Volume 2 !� , Page # 0 Spec house yes Lot lines identifiable 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 County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&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 wastewater disposal 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 Planning& Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this fo re 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 eed recorded in Register of Deeds Office. Number be ms NATURE OF APPLICANT(S) DATE r ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.08/05) +� Cam' � ' oil mgnl iii lowlikj9 If 43 42 62 63 } ► ► s 44 4 V. low ` 7 56 55 54 5 �" '," '• . _ _ M . ., . 1 2 2 9 9 i' 1 0 7 728536 KATHLEEN H. WALSH DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 REGISTER OF DEEDS CORPORATE WARRANTY DEED ST. CROIX Co., NI RECEIVED FOR RECORD This indenture,made this 25 day of June 07/02/2003 09:30AK 2003 , between PRUDENTIAL RELOCATION, INC., a Corporation duty organized and existing under and by virtue of the laws of the state of WARRANTY DEED COLORADO located at EX9PT # party of the first part,and REC FEE: 15.00 Jaron J. Stone and Crustal L. StnnP, hiic and and udfe TRANS FEE: 784.50 COPY FEE: part 1 e of the second part. CC FEE: Witnesseth, That the said party of the first part,for and in consideration of PAGES: 3 the sum of 261,500.00 to be paid by the said part leS of the second part, the receipt whereof is hereby confessed and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents does give,grant bargain,sell,remise,alien,convey,and confirm RECORDING AREA unto the said part ieS of the second part, their heirs and NAME AND RETURN ADDRESS assigns forever, the following described real estate, situated in the County of First Federal Capital Bank ST. CROIX,State of Wisconsin,to wit: 201 S. 2nd St. LEGAL DESCRIPTION ATTACHED AND MADE A PART HEREOF H14son, WT W16 O - //(o 0-00 Together with all and singular the hereditaments and appurtenances thereunto belonging;or in any wise appertaining;and all the estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of,in and to the above bargained premises,and their hereditaments and appurtenances. To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said part ies of the second part,and to their heirs and assigns forever. And the said PRUDENTIAL RELOCATION, INC., parry of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said part ies of the second part, their heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all encumbrances whatever, and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part, their , heirs, and assigns, against all and ever, person or persons lawfully claiming the whole or any part thereof, it will forever Warrant and Defend. In Witness Whereof, the said PRUDENTIAL RELOCATION, INC. party of the first part, has caused these presents to be signed by its President, and countersigned by its Secretary, at Wisconsin,.and its corporate seal to be hereto affixed, this 5th day of June 2003 PRUDENTIAL RELOCATION, INC. SIGNED AND SEALED IN THE PRESENCE OF X Y�r^�i''l�f1� (itCll Si � X / STATE OF-87h2 LA VbSe M le-fil o.- �Ga�l-il ob m0ntydv><�"- }ss ounty Personally came Wore me this 2 -clay of June 2pp3 L iQaQ i/Vl AJCt*k kctr an 6. Secretary of the above named Corporation, to me known to be the persons who execute the foregoing instrument,and lo me known to be such President and Secretary of said Corporation and acknowledged that they executed the foregoing instrument as such officers as the deed of said Corporation, by it's authority.