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042-1057-20-700
County: St. Croix Wisconsin Department of commerce PRIVATE SEWAGE SYSTEM ermit N Safety and Building Division INSPECTION REPORT 569598 0 (ATTACH TO PERMIT) ID No GENERAL INFORMATION Personal information you provide may be used for secondary purposes[Privacy Law, shag 4(1)(m)]. No: Permit Holder's Name: City Village X Township 042-1057-20-700 Warren, Town of Dalton, Steven M. No: CST BM Elev: Insp.BM Elev: BM Description: 20,29.18.319A70 1060 /aa ` o ELEVATION DATA TANK INFORMATION CAPACITY STATION BS HI FS ELEV. TYPE MANUFACTURER Be hmark' ,�^ Y-7�r�0 ^� I6 (0. Q Septic Z s o 7 Alt.BM 6� �S.✓/�? �G O� Dosing 6. �p Bldg.Sewer Aeration • SUHt Inlet 5L5'v Q'• � 97•Z Holding 1 St/Ht Outlet 5.� � �t �, g'�• � r TANK SETBACK INFORMATION TANK TO A t PS WELL BLDG. vent to Air Intake ROAD Dt Inlet �s Q f �- ,v Dt Bottom Septic Q He r/Man. ,OI GA 9./ /4" Dosing Z Dist.Pipe D 9•/ q6 Aeration Bot.System / O• L S t7� Holding - -- Final Grad 10/- PUMPISIPHON INFORMATION Demand St Cover '3 /A/. / Manufacturer GPM Model Number l 2, TDH Lift Friction Lo stem Head TDH Ft Forcemain Length Dia. Dist. Well SOIL ABSORPTION SYSTEM 2 L C PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth BED/TRENCH Width Length I No.Of Trenches / DIMENSIONS (!p_ 1")--- LAKE/STREAM LEACH N Ma cy • /' ' `� SETBACK SYSTEM TO P/L BLDG R WEL dey Model Number: INFORMATION Type Of System: ,go -L •+��-� D RIBUTION SYSTEM x Hole Size x Hole Spacing Ven Air Intake Header anif�d Distribution' �p /� / An h Pipe(s) /',�� ' �— v Length_ Dia Length w Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched t Depth Over xx Depth of xx Seeded/Sodded Depth Over Topsoil Yes 0 No Yes 0 No Bed/Trench Center ^ Bed/Trench Edges COMMENTS: (include code discrepancies,persons present,etc.) Inspection#1:�/�/� Inspection#2: / / Location: 827 106th Street Roberts,WI 54023(SW 1/4 SE 1/4 20 T29N R18 ) NA Lot (J� Parcel No: 20.29.18.319A70 . . =70 o.F�'I�nuz.,ti>Cco-�crux `�fl� � 3 1.)Alt BM Description y, 1 2.)Bldg sewer length -amount of cover� �8 n N� ��h'"'"�"""' .l �,�,p/f �-_ —_��' v 3--— /- I•__ �T Plan revision Required? ❑ Yes No � i 2 j __ _(,�,�y�1,� Use other side for additional information. I--1— _ Insepctors ignature cert.No. SyS •eXX,tJ.e.Jr.o �7 SBD-6710(R.3/97) r M S C , dam 0 � a Q q ILI QN r K� Q }Iq � County Safety and Buildings Division ST• C I�C 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) 'ya Ps A P LA I D Madif Sanitary Permit Applicati 2 7 ?0 1 4 State Transaction Number In accordance with SPS 38321(2),Wis.Adm.Code,submission of this ford g&�o ental unit 7V A is required prior to obtaining a sanitary permit Note:Application fon¢ -K _ ed to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal inform. a ndary purpos in accordance with the Privacy Law,s. 15.04 1 m,Stats. S(��] L A / Application Information-Please Print All Information (J Property Owner's Name Parcel# SMYC 6A 7-0IJ p z—io5- 7- Zo— 706) Property Owner's Mailing Address Property Location ?3 J3/2�'1/� !> Govt.Lot �. 3��/�-�o City,State Zip Code one Number ✓� , 5 1 Z� l Cd Ph Nb S /<, /., Section (C W y' Q 2 S 1 p=(circle one) II.TT�pe of Building(ccheck all that apply) Lot# T 2G' N; R U E or W 11Y1 or 2 Family Dwelling-Number of Bedrooms Ll --7 Subdivision Name Block# ❑Public/Commercial-Describe Use ❑ City of El State Owned-Describe Use CSM Nu mb�er v ❑V e of -7/ &1 _ own of NE E III.Type ermit: (Check only one boa on line A. Complete line B if applica e) A 4/New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B• ❑Permit Renewal ermit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued B fore Expiration Owner C/ SW — (,P Z/ /y IV. a of POWTS System/Component/Device: Check all that apply) 7 on-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of'suitable ssoil/� ❑ Holding Tank ❑Other Dispersal Component(explain) Pretre ent Devi (explain) V.Dis ersaUTreatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpds fl Dis ersal Area Required(s fl Dispersal Area Proposed(sf) System Elevation D• `7 ?5 7 g0� . VL Tank Info Capacity in Total #of Manufacturer c Gallons Gallons Units New Tanks Existing Tanks w ° w P / a U c; H rn w 3 i% Septic or Holding Tank Dosing Chamber / ,v /'Ft 0 Responsibility Statement- I,the undersigned,assume responsibility for installation of the P shown on a attached plans 1 ber's Name(Print) Plumber's Signature © MP RS umber Business Phone Number Iz?e lumb 's Address(Street,City,State,Zip Code) ,6 Z_ V cell Coun /De artment Use Only Permit Fee Date Issued Issuing Approved 11 Disapproved 017 Sign ❑ Owner Given Reason for Denial DL Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 8 112 z 11 inches in size SBD-6398(R 11/11) X71 G 2 a 0 a � N r4 a �. 0 0 ` 0 ti `� r I 11 .0 � Soil Absorption System Cross Section ft 4"Schedule 40 Final Grade PVC Vent Pi e With Vent Cap ft 9b. b�� Leaching Chamber ft b 7J System Elevation ft ft Soil Absorption System Plan View 8S ft ft ft Vent Or Observation Pipe Leaching Trench 1 Chambers 4"Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model_�U "GK V �y EISA Rating z"'O sq ft.per chamber Soil Application Rate - 7 gpd/sq ft • 0 gpd Design n Flow_ pp Zu- 9 • Soil A lication Rate _ EISA= `f� Chambers 2 rows of Z Z— chambers each. Page of s .. 'CID AEG iOt11d (�111 P A A Wis.Dept.of Safety ancr `if�TM ``86IL EVALUATION REPORT Page of J' Division of Safety�iSDt' h� ���MENT in accordance with SPS 385,Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must C-c.io X include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. a percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Please print all information. R wed b Dat C� Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). , CiG��+✓� (� Property Owner Property Location Dg/—f N Govt.Lot W i t/437-£1/4 SZ u T 1 g N R !q E(or Property Owner's Mailing Address Lot# Block# Subd.Nam or CSM# City State Zip Code Phone Number ❑City []Village ®-Town Nearest Road 'Y-0z.< ( ) 1�, ,�.c-�-�- /off New Construction Use:,® Residential/Number of bedrooms Y Code derived design flow rate ("'06 GPD ❑Replacement ❑ Public or commercial-Describe: Parent material Flood Plain elevation if applicable ` ft. General comments 5 yt,'(��,/ p YAV�, /0-k J and recommendations: q� ( 0 3 Boring# Boring ❑ ® Pit Ground surface elev.�d�'•d ft. Depth to limiting factor 7/ ;L-7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPDfft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2 S'tx P,► -- j of @ •� �- 7°� oS ,,l _ -7 1-7- ❑ Boring# ❑ Boring © pit Ground surface elev. T V ft. Depth to limiting factor>�L� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence [oundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2 7- • 3 *Effluent#1=BOD 5>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L Number CST Name(Please Pri � Sign re CST L'2-87x- G.w Address 66ate Evaluation Conducted Telephone Number SBD-8330(RI 1/11) Property Owner Parcel ID# Page Z- of F3-1 Boring# F1 Boring v ® Pit Ground surface elev./OL• O ft. Depth to limiting factor 3 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 °-iz laJ"Z as ��' . 41 - 7 jv - z .,3 ?S,57 ,5 _ C62 tj L 1 Boring# ❑ Boring F-1 ❑ Pit Ground surface elev. ft. Depth to limiting factor 1n• v/Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft I in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 .0#2 F-1 Boring# F1 Boring 11 pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPDfft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 *#2 *Effluent#1=BOD 5>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD 5<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. SBD-8330(RI I/11) OF Z Li � b � a I ICA 1 o d � � u � A � � w a N 0 o � o ►r P: County A Safety and Buildings Division Sf L iL dl' �C 201 W.Washington Ave., P.O. Box 7162 Sanitary permit Number(to be filled in by Co.) 7 r Ma I 17 7162 5( State TransactiorLNumber Permit Applicationb 3 In accordance with as l 2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior t ning a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. Q''7 1()6, —fyr I. Application Information—Please Print All Information Q 2— Property Owner's Name Parcel# 165 7-- Zo - 76o Property Owner's Mailing Address Property Location Govt.Lot . 311 mil d "— 70 City,State Zip Code Phone Number �`lv ��, aS _ %4, Section Z O X,0� Z 3 Z QI (circle one) II.Type of Building(check all that apply) � Lot# T N; R E or W ❑1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name (}K q,h ��� Block# El Public/Commercial—Describe Use ❑City of ❑State Owned—Describe Use CSM Number e, '749 lot ❑Village of ✓ 2Z�-22 110 $� ®Town of a titi-ti✓ III.Type of Permit: (Check onlk one box on line A. Complete line B if applicable) A. w System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Mo ication to Existing System(explain) IL B. ❑Permit Renewal El Permit Revision El Change of Plumb"E] 1"ran Lis vi mit Number and Date Issued Before Expiration IV. a of POWTS System/Component/Device: Check all that a on-Pressurized In-Ground ❑Pressurized hi-Ground ❑At-Grade ElMound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑ tment Device(explain) V.Dispersal/Treatilr6t Area Information: _ c S 3 'A Y6 Y o d ;C Ai U S Design Flow(gpd) Design Soil Application Rate gpdsf) Dispersal Area Required(sf) tspersal Area Proposed(s System Elevation VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units c New Tanks Existing Tanks 5 �t:J fi r o eptic o Holding Tank � sV � � Lk �J Dosing Chamber VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. mber's Name(Print) l �r Plumber's Signature MP S Number Business Phone Number a d k C _ C P tubers Address(Street,City,State,Zip Code) f ° • Z k Ac,K 15 YS 3 VIII. unt /De artment Use Onl Approved ❑ ' approve Permit Fee Date ssuQed Issuing ent Signature ❑Owner Given Reason for Denial $ `1,75' ( f 0 IX.Conditions of/Approval/Reasons for Disapproval 3) ✓I Q k,' IJCI (`n J�d1 e. vte...� �ow�4.a�a,ti e.�_ t." tank, �tsrd o �+ "I ceA Mst all 1� f trlakitairwd w� �{-1 1M.a.�+�'e ..tee.. �. a �t�+� L gs per management plan provided by'plurnb�T. i t •A11spokrtequhar+►Kt�s�- l/�iL 1 d tv 2- . 6 B� —/d 7�.5 Cook ordfi at: Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398(R. 11/11) Feb-06-2014 03:45 PM St. Croix County Plan/Zoning 715.386-4686 1/11 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: d I j 6,v Owner's Name: +z'o f d `�D 0 Owner's Address: ,3Q Legal description: _ z d Z 4 A., tiN Township: �Va ,tom County; S �✓L o Subdivision Name: Lot Number. �o Parcel ID Number. Page 1 _ Index and title Page 2 Plot plan Page 3 _System Slzln2&Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Oty Se tic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments:Sol!Test&House Plans DeslgnedPlumber e- sl.lcense Number 2 Z Z a-7 Z Gate: - 5-i Phone Number Signature Designed pursuant t4e In-Ground Soil Absorptlon Component Manual for PowTS Version 2,0 SBD-10705 P(N.01101). Page t i v v N o n_ 3 Nr _ N � a b o -r o Q y , 3 w In j� b 141 Z Soil Absorption System Cross Section ft Final Grade 4"Schedule 40 PVC Vent Pipe �7, f 1 8 With Vent Cap a 6 ft Leaching Chamber ` ft d— System Elevation a ft r ft Soil Absorption System Plan View (�P6 ft ft III �ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model ti EISA Rating 20-0 sq ft per chamber Soil Application Rate .7 gpd/sq ft (&o0 gpd Design Flow; - 7 Soil Application Rate EISA Chambers 2 rows of Z Z chambers each. 7-aae i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS •� Owner . -� Cr Z) a j �6 N Septic Tank Capacity 0 C) al ❑ NA Permit # Septic Tank Manufacturer 4L ❑ NA DESIGN PARAMETERS Effluent Filter Manufactu er 7 ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 0)&=7. ❑ NA Number of Public Facility Units -42-MA Pump Tank Capacity gal ``❑'W Estimated flow (average) gal/day Pump Tank Manuf cturer J3-NA Design flow (peak), (Estimated x 1.5) j al/day Pump Manufact er tD-NA Soil Application Rate • —7 gal/day/ft' Pump Model 63-NA Standard Influent/Effluent Quality Mont ly average* Pretreat en ee Unit „J2--NA Fats, Oil & Grease (FOG) 530 m L ❑ San l Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) <_220 mg -E7 NA ❑ Mecha ical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinf ction ❑ Other: Pretreated Effluent Quality Monthly ave ge Dtsper 1 Cells) ❑ NA Biochemical Oxygen Demand (BODS) <_30 mg/L In- round (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L A ❑ -Grade ❑ Mound Fecal Coliform (geometric mean) <_10" cfu/100ml ❑ rip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. ❑ N her: ❑ NA Other: ❑ NA f 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 very: ❑ month(s) (Maximum 3 ears) ❑ NA ear(s) y Pump out contents of tank(s) When com ned sludge and scu equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least ce every: ❑ month(s) (Maximum 3 years) ❑ NA =B-Vear(s) Clean effluent filter At lea once every: months) ❑ NA • ear(s) Inspect pump, pump controls & alarm At list once every: ❑ onth(s) 44-NA ❑ ar(s) Flush laterals and pressure test A east once every: ❑ m th(s) EMA ❑ yea s) Other: t least once every: ❑ mont s) O-ITA- ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispe/sdge hall be made by an individual carrying one of the foliowi g licenses or certifications: Master Plumber; Master Plumted Sewer; POWTS Inspector; POWTS Maintainer; Septage ervicing Operator. Tank inspections must include a visuion of the tank(s) to identify any missing or broken hardware, id tify any cracks or leaks, measure the volume of combin and scum and to check for any back up or ponding of efflue n on the ground surface. The dispersal cells) shall be viected to check the effluent levels in the observation pipes and to heck for any ponding of effluent on the ground surfaonding of effluent on the ground surface may indicate a failing cond 'on and requires the immediate notification of the to tory 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 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. GMW(4/01) i sz t------------ i 0 zri:A R Ilid 3t 5 .2 m zg Z C tr I-M 2m; V) M —Q-Ft pvSc ra T; t 0 Cv > ct Alft. Y gj 1 V1= u ow m mi ZI ' START UP AND OPERATION i Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. _ System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipe's; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: g—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 b``{{ 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 J f Name -Y t�• Phone pl Phone , SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone 71 jS& , ��8b 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. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of t FILE INFORMATION SYSTEM SPECIFICATIONS Owner '--"eV C 1W H6/V Septic Tank Capacity i z a U gal ❑ NA srmit # Septic Tank Manufacturer SO If ❑ NA DESIGN PARAMETERS /J Effluent Filter Manufacturer ray` ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model f n ❑ NA Number of Public Facility Units P-NA Pump Tank Capacity gal J0-NA Estimated flow (average) (oa o gal/day t Pump Tank Manufacturer `IB A Design flow (peak), (Estimated x 1.5) 200 gal/day Pump Manufacturer 11�NA � Soil Application Rate gal/day/ft z Pump Model �7'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 (BOD5) <_220 mg/L .4TNA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality average Dispersal ❑ NA Biochemical Oxygen Demand (BODS) <_30 mg n-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :530 mg/L J21NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <_104 cfu/100ml ❑ Drip Line ❑ Other: Maximum Effluent Particle Size Yg in dia. „J].NA Other: ❑ NA Other: ❑ NA Other. ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. 'AINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: —0-year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: /. - earls) ❑ month(s) ❑ NA Clean effluent filter At least once every: /.S �-year(s) ❑ month(s) U-NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) 0-RA Flush laterals and pressure test At least once every: ❑ year(s) ❑ month(s) ❑ NA Other: At least once every: ❑ year(s) Other: ED 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 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. GMW(4/01) Page of 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. 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 wipe's; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed- _ — `• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: 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 b 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 1 14, Name S -t-e Phone f Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 51 , C'. #1 2 Phone Phone 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. Feb-06-2014 03:45 PM St, Croix County Plan/Zoning 715-386-4686 2/11 ST.CROIX COUN'T'Y SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIIFICATION FORM Owner/Buyer Mailing t1 ddress 93 a B t. Srry► . r'id J f �iV�' Property Address - $a l /GA 4 Sf• (Verification required from Planning&Zoning Department for new construedon.) 0:J60 City/State et . livi LEGAL DRSCRIPTION Property Location;5_1 '/,,3�F t/4, Sec. Z°.T L°I N IZ l e W,Town of Subdivision Plat - ,Lot#, 7 / Certified Survey Map# �/`f�8l ,Volume 2—`'�/ -1,,Page# So• J 'Warranty Deed# �D�t/11 tfJ � �7 (before 20MVolume gad Page# 5/1 Spec bousVyes 0 no Lot Imes idantifiab46 yes 0 no SYMM_MA.IlV'`T'RNANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance oonsisu of pumpim out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the sysmm can affect the fi notion of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§Comm.53.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to Si.Croix County Planning&Zoning Department a certification fbrrn,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(ifnecessary),the septic tank is lose than W MI of sludge, Uwe,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 Commove and the Department ofNah al Resouroes,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 ca tiff that all statements on this form are true to the best of my/our knowledge. i/we amlare the owner(s)of the property described above,by virtue of a wff7 deed recorded in Register of Deeds Offce. Number of bedrooms SICNATURE OF APPLICANT(S) DATE **"Any inibrmadon that is misrepresented may result in the unitary 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 cartified survey map if reference is made in the warranty deed. (M.09/07) lb. .+,ii 4 6 i ii 887468 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 01/28/2009 08:OOAM CERTIFIED SURVEY MAP CERTIFIED SURVEY MAP VOL REC4FEE:PA15.005tiO3 LOCATED IN THE SW Y4 OF THE SE Y4 AND THE NW Y4 OF THE SE Y4 COPY FEE: 2.00 OF SECTION 20,T29N, R18W,TOWN OF WARREN, ST. CROIX COUNTY,WISCONSIN, S89°04'58"W LEGEND WY.CORNER OF SEC.20. S89°04'58"W� 3915.39_ ( ALUMINUM CAP FOUND) { i$ 1304,79 - INDICATES SECTION CORNER ( � F4 F (AS NOTED) BEARINGS REFERENCED TO THE EAST • - INDICATES 1'IRON PIPE FOUND WESTy SECTION LINE OF SECTION 20. p - INDICATES V X 18' (OUTSIDE DIAMETER) ASSUMED TO BEAR S89°04'58'W. Lu o IRON RE-BAR WEIGHING 1.502 LOS/LIN.FT.SET 1 w uJ ■ - INDICATES Y4'REBAR FOUND UNPL 1TTE® +o C INDICATES PROPOSED DRIVEWAY LOCATION LANDS ��Cr u' N89°04158"E 562.28' ----- - I W el.—0 OWNER/SUBDIVIDER STEVE DALTON -_ 816 106th STREET To Be Dedicated to the Pub0c ------------° ROBERTS,WI 54023 12'Utility Easement ------------------ -------------N89°04'58'E 496.25' --- �St�SbotnTine of- theNWY4oftheSEY4. I _ _LO_T8 _ _ _ N� nu' ,87,120 SQUARE FEET 2.00 ACRES Approximate North line of s. 2 I N�•0456 E 496.17' the SW Y4 of the SE Y4. �I O ' c I H �I AKW;THE DRAINAGE FACT ITY I " LOT Lu L SHOWN ON LOT 5 WILL BE I b MAINTAINED BY THE OWNERS OF I ti I %A J THE LOTS SHOWN HEREON AND z ; PROPOSE IN ACCORDANCE WITH THE CS D 87,120 SQUARE FEET PROVISIONS SET FORTH GNTHE i DRIVE (2.00 ACRES) HOME OWNER'S ASSOCIATION � AGREEMENT AS RECORDED IN DOCUMENT N0. i N89'04'58'E 498.08' N07T.THE NET PROJECT AREA OF y', 17 Utility Easement LOT c LOT 5,EXCLUDING THE 50'SETBACK °- V FROM RIGHT-OF-WAY,THE DRAINAGE �I EASEMENT AND A I6'SIDE YARD ' \ `, 87,120 SQUARE FEET o SETBACK=33'036 SQUARE FEET 2.00 ACRES (Q76 ` I.%, ( ) LOWEST BUILDING \ , OPENING=993.35' `S 0)v \ �` ELEVATION=1000.71' ELEVATION=995 x xW-1 W42-E 449.4'1' r JO * 2 -6S � ze3.or * s R B �; ` I S- 2 NEW R HMOND•_ \ LOT 5 F i = s � \ m wi � \ 87,120 SQUARE FEET Lu 'a \ \ (2.00 ACRES) i a LOWEST BUILDING OPENING=993.35' � I S67°40'40'W \�a ` 1.51' x \�Q, g` S82°4724-W 36 1 ELEVA ON L®T 4!Cam iJ97.14' I - -- L------ -� \ Scale in feet 1"=120' if C-S�K AV Loro aam \ xl_a_�-__._+i ce_ _Yan_ ®L" 97 PG.4444 \1 ` � 0 120 240 1 SHEET 1 OF 3 DRAFTED BY: S.E.I. REV�;EDOaos-roa 1 of 3 Vol 24 Pn,g-, 5603 W!- .�U4 ( PAGE 516 6466�►4 STATE BAR OF WISCONSIN FORM 2-1999 KATHLEEN H. WALSIi Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO. , WI This Deed,made between Archie Denucci and Ella Denuccl,as RECEIVED FOR RECORD Trustees of the Archie Denucci and Ella Denucci Revocable Trust dated 05-29-2001 11:00 AM September 14,2000 WARRANTY DE EXEMPT 0 l Grantor, and Steven M.Dalton,a single person CERT COPY FEE: COPY FEE: TRANSFER FEE: RECORDING FEE: 12.00 PAGES: 2 Grantee. Grantor,for a valuable consideration,conveys to Grantee the following described real estate in St.Croix County, State of Wisconsin(if more space is needed,please attach addendum): Recording Area Name and Return Address SEE ATTACHED First Federal Savings Bank LaCrosse 201 So.Second Street Hudson,WI 54016 This deed is given in fulfillment of that certain Land Contract between the parties hereto dated December 12,2000,recorded December 18,2000 in Vol. 1568,page 213 as Doc.No. 635444 0424057-20-000 Parcel Parcel 1 Identification Number(PIN) This is not homestead property. 14:0 (is not) Exceptions to warranties: Easements,restrictions and rights of way of record,if any. Dated this A"- ' day of May 2001 a Archie Denucci * *Ella Denuccl AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signature(s) ss. St Cc* •y County } nx authenticated this day of Personally came before me this•'".. y day of May 2�0 - named 6N Archie Denucci and Ella Denucc' 'o �•� hie w Denucci and Ella Denuccl Revgt bi usRaate t*. ber 14, 2000 TITLE:MEMBER STATE BAR OF WISCONSIN to me known to be the personFts o etc et the fordgoing (If not, instrument and acknowledged tt:�c�8yie `Q r authorized by§ 706.06,Wis.Stats.) THIS INSTRUMENT WAS DRAFTED BY _ / k-. -) '••''' ••••ST Attorney David J.Estreen Notary P.4i-,State of Wisconsin 304 Locust treet,Hudson,W1 54016 My Commission is permanent.(If not,state expiration date: (Signatures may be authenticated or acknowledged.Both are not necessary.) �- Ci - Zc3dt ) Names of persons signing in any capacity must be typed or printed below their signature. inrormar on Fmtessiona�a comvenr.Fwd-6 tea 21 eoo-sssc.W STATE BAR OF WISCONSIN WARRANTY DEED FORM No.2-1999 Vol- 1647PAGE 517 PROPERTY DESCRIPTION A parcel of land located in part of the SW'/4 of the SEl/4 of Section 20, T29N, R18W, Town of Warren St. Croix County,Wisconsin,described as follows: Commencing at the SE corner of said Section 20;thence S89°10'58"W 1302.28 feet along the south line of the SE/4 of said Section 20; t E'/4 of said Section 20 to ° � �� t line of the SW/4 of the S thence N00 08 34 W 371.09 feet along the has ° �� 51'26"W thence N00°08'34 W 280.52 feet along said east line;thence S89 the point of beginning; 358.70 feet;thence S22°19'20"E 108.35 feet to the point of curvature of a 433.00 foot radius curve, concave westerly, whose central angle measures 24 122'00", whose chord bears S 10°08'20"E and measures 182.76 feet;thence southerly along the arc of said curve 184.15 feet;thence N89°53'54"E 286.08 feet to the point of beginning. Above described parcel contains 2.00 acres, 87,120 sq.ft. ROAD EASEMENT An easement on a parcel of land located in part of the SW'/4 of the SE'/4 of Section 20, and part of the NW'/4 of the NE'/4 of Section 29, both in T29N, RI 8W, Town of Warren, St. Croix County, Wisconsin, described as follows: Commencing at the SE corner of said Section 20; thence S89°10'58"W 1602.70 feet along the south line of the SE'/4 of said Section 20 to the point of beginning;thence S02 120'40"W 35.21 feet;thence S87 155'37"W 66.17 feet along centerline of 80th Avenue; thence NO2 102'40"E 415.07 feet to the point of curvature of a 367.00 foot radius curve, concave westerly,whose central angle measures 24 122'00",whose chord bears N10°08'20"W and measures 154.90 feet;thence northerly along the arc of said curve 156.08 feet;thence N22°19'20"W 135.25 feet; thence N89°51'26"E 71.27 feet; thence S22°19'20"E 108.35 feet to the point of curvature of a 433.00 foot radius curve,concave westerly,whose central angle measures 24°22'00", whose chord bears S 10°08'20"E and measures 182.76 feet; thence southerly along the arc of said curve 184.15 feet; thence S02°02'40"W 375.11 feet to the point of beginning. Parcel #: 042-1057-20-700 06/13/2014 09:14 AM PAGE 1 OF 1 Alt. Parcel#: 20.29.18.319A-70 042-TOWN OF WARREN Current OX ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 01/28/2009 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-DALTON, STEVEN M STEVEN M DALTON 930 BRAVE DR SOMERSET WI 54025 Property Address(es): `=Primary "827 106TH ST Districts: SC=School SP=Special Type Dist# Description SC 2422 SCH D ST CROIX CENTRAL SP 1700 WITC Notes: G�-ICx.J Legal Description: Acres: 2.000 SEC 20 T29N R18W PT SW SE; BEING CSM 24-5603 LOT 7(2.000AC) Parcel istory: Date Doc#- Vol/Page Type 01/28/2009 887469 EZ-U 01/28/2009 887468 24/5603 CSM 06/07/2004 765184 2591/048 TI 01/15/2003 705988 17/4444 CSM Plat: *=Primary Tract: (S-T-R 40%1601/4) Block/Condo Bldg: 5603-CSM 24-5603 042-2009 20-29N-18W SW SE LOT 07 2014 SUMMARY Bill#: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 08/06/2010 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 2.000 400 0 400 NO Totals for 2014: General Property 2.000 400 0 400 Woodland 0.000 0 0 Totals for 2013: General Property 2.000 400 0 400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 7-A Y's) r R E V OV L.,.D JUN 18 2014 T.CROIX COUNTY Wagonsin le>iEUOPMENT SOIL. EVALUATION REPORT Page / of 3 Division of and Wlldings in aocordgtlre with Comm 85,1Me. Adm. Code City Attach complete alto plan on paper not lees than a 112 x 11 Inchee in site-Plan must Include,but not limited to:Vertical and horizontal reremnce point(BM),direction and Parcel I.D. ZO— paro6nt alopo,aoaic ordimondwo,north arrow,and location ar,d distance to nearer;►rnarl Q� '+1156 7 ` P1easa print all Information. [Irby Date Q� Perionil Information you pravtde may ha used for oouandury purpoeea(PrWgy Law,a.1 6.04(1)(m)). PropertyOwner ) 11 Property Location b ei 1 TD I`j taovt Lot i'`' �Z W4 f 114 L V T 9 N R /iii' E(or)W Property Ownera Mailing Addriass Lvt#► 61QGK u r Nt r z;perF 8 j /4G, -t`, ,Sf 7 state Zip Dodo Phone Number 0 City ©Village LBTown Nearest Road lo&4+5 It-j" SYvZ (7(S)719-3538 I &t_,,,L f >LeN 1 /U(a. -5t. Now ConeAruotien Uaa.N ReBldenthhl 1 Numtror of bod..,C, A Codo dvrivad daaign flow rate t;Pfl I]Replacement ❑ Public or commercial-Deuwibe: Parent material Flood Plain elevation it applicable ft. General oomments and recorpmendations �, Baring# boring Ground surface elev. i/. S ft Depth to lirniling Factor>/ 8 in. Pit Sod Application Rafe Horizon Depth DartknmdCukx RaduxDoeuQtion Texture struaturo Coneictenes Boundary Roeba GOUlt11 in. Munsell Qu.Sz. Cont.Color Gr_Sz.Sh. -Eff#1 `Eff#2 95 — . Z • 3 . � � 3-3:71 7 J h,� Y/y' -- v o �, C w -- 1. Z .t ❑ goring p p Borinpl# Pit Ground surface elev. !� / ft, Depth to limiting tacmr���� in. Soil ApgjqLbon Rate HHd i2m Depth Dominant Cola Redox Deseription Texture Structure Cbnslatence Boundary Rooto GPDIfF in. MairbEdt Qu.3z Ount.Oolor Qr.Sz.Sh. e e vi,-- a S /V1 Z • 3 — /. Z- 5 I Effluent#1= BOO,>30 220 mck and TS8>40:5 150 mgll "Etfluont rk2 80D :3D rngll and 1'33 530 mplL CST (Please Print) Signature CST Number cc Date Evatuarlon Conducted Telephone Number 0 I� 1 ,^,,,T,,,1-' ♦111 , gb7C i-,QbrT tib:4T RAr�7/R7./TO Property Owner Pawal ID# page oZ o1 L-3] Doing# Oodng Ground surface elev. qv � ft Depth to YmiUng faclar >/r� in, ry ® pit Soil Application Rate Horizon Depth Dominant Color Redox Descripton Texture Structure conslstance Boundary Roots GPDIfE in. Muneell Qu.Sz. Cont.Color Or.tiz,tin. "EMI •EM2 � .3z /Qy� A y,'1, Gz /mss 157bIC ter-•7�- Q ` Z S 3 ?.S`I K-Yi -7? Boring# (� ❑ coring u ❑ pit Ground surface elegy ff. 17Apth in IIrYJWiO factor in. yoN icaUen Rate Horizon Depth Dominant Color Redox Description Texture Stnrcture Consistence Boundary Roots GPDAt' In. Munsell Qu,Sx, Cont.Color Gr.sx,8h. *Eff#1 •Eff#2 ❑ Boring LL�� Boring# Ground surface elev. fL Depth to Smiting factor in. --JJ ❑ Pit Soil Apoicaticm Rate Horizon Depth Dom De inant Color Redox scription Texture Structure Consistence Boundary Roots GPD/ft? in. Munmll Qu_Sz, Cont.Color Gr.Sz.Sh. 'Eff#1 '002 II *Effluent#1 =BODO,}30_<220 rnf�l and TSS>30:150 mlyL *Effluent#2=BODn g 30 ntglL and TSS{30 nVL The Department of Commeree is an equal opportunity service proNider anti employer. Il•you need assistance to zteeess services or need material in an alternate format,please contact the department at 608-256-3151 or TTY 608-254-8777. sdo-ua�op�trlroo) Z0/Z0 39Vd XJ3 9111I}U-Z A d 9VZ688b5TL 6V:9T 800Z/8Z/10 c S � s i N w a, N C a Z �