HomeMy WebLinkAbout002-1055-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 574319 0
GENERAL INFORMATION 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:
Anderson, Linda K. et al 4 I 1 Baldwin, Town of 002-1055-95-000
CST BM Elev: Insp.BMlev T Description: nn Section/Town/Range/Map No:
/J U UC-d/-(�`1-"-' 23.29.16.345A
TANK INFORMATION 4 ELEVATION DATA
TYPE MANUFACTURER �ti� CAPACITY STATION BS HI FS ELEV.
i
Septic Z,,� 3, � Benchmark
Dosing I r� Alt. BM
�. ,Y C?
Aeration Bldg.Sewer
S, 7 9-T
Holding �i� r O St/Ht Inlet 9 C)
�jr.
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 7 / /� � Dt Bottom
Dosing Header/Man.
Aerati Dist. Pipe
Holding Bot.System
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift riction Loss System Head TD Ft
Forcemain Length Dia. . o well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L AlffG IWE LL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
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
Depth Over Center Bed/Trench Edges Topsoil Yes No [ 1, Yes No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 843 250TH ST Baldwin,WI 54002(NW 1/4 SW 1/,4 23 T29N R16W) m tes&bound Lot Parcel No: 23.29.16.345A
1.)Alt BM Description
2.)Bldg sewer length= 5
-amount of cover= 1 I
Plan revision Required? -I Yes KNO /k -s T 75
Use other side for additional information. -- vv
- - ;Ilnspctoes--- -
SBD-6710(R.3/97) Date e Sign re Cart.No.
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Industry Services Division sr ��tai
` 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.)
P.O. Box 7162
S r C�0 Cc) � tAENS Madison,WI 53707-7162
S of -7#3I �
�0 anitary Permit Application State Transaction Number
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if diffe t than mailing address)
AA-
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary �^
purposes in accordance with the Privac Law,s.15.04(1 xm),Slats.
1. Application-information-Please Print All Information
Property Owner's Name Farce)#
Property Owner's Mailing Address Property Location
9'13 o?s0 � sT Govt.Lot �, 3 4 5,4
City,State Zip Code Phone Number , ,
/ A) /.,S(J V.., Section 23
WDoDl1/LLE LIZ 3-Ye.2 8 (circleone),
II.Type of Building check all that apply) Low#� \
T ,?9 N; R_�iEo
01 or 2 Family Dwelling-Number of Bedrooms /,t /J Subdivision Name
y Block#
❑Public/Commercial-Describe Use l4 G¢vim G
❑-Qity'af
❑State Owned-Qescribe Use CSM Number [{- tfagt of /�
6 l /1`t, 18 Town of 9 440Adl J
l dddLLL (�,ti,
III.Type of Permit: (Checkjonly one box on line A. Complete line B if applicable)
�' ❑New System y ,�Replacement System ❑TreatmenVHolding Tank Replacement Only ❑Other Modification to Existing System(explain)
B• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date,Issued
Before Expiration Owner
IV.Type of POWTS System/Component/Device: Check all that apply)
11420;, rued In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound?24 in.of suitable soil ❑Mound<24 in.of suitable soil
Holding Tank D Other Dispersal Component(explain) ❑Pretreatment Device(explain)
is ersaVFreat nt Area Information:
Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
Vl.Tank Info_ Capacity in Total #of Manufacturer
Gallons Gallons Units � „ �� v_
New Tanks Existing Tanks :° c y
Sep"or Holding Tank
Do0 - ov / L✓ EsE2. �ce�rcS i6
Dosing Chamber
VII.Responsibility Statement-I,the undersigned,al.-Ar-ponsibitity for installation of the PO S shown on the attached plans.
Plumber's Name(Print) Plumbe's Si re WP/MPRS Number Business Phone Number
/rrxef rxor 715, 3s-114 a V
Plumber's Address(Street,City,State,Zip C de)
-?*/9 41 Z- sy i
VIII.County/De artment Use Only
pproved isapprov .$erjmi Fee Date Issued u/ Issuing A Signature
ven Reason for Denial (D� ZZ �T
IX.Condit' s ofApproval/Reasons for tsapproval !
o 5 3�,� e, Z4�A �o '
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Attach to complete plans for the system and sub it to the tounty only on paper not less than 8 U2 x 11 inches in size /!
SBD-6348(R0313)
Pg—�of
Private On-Site Wastewater Treatment System(POWTS)
Index and Title Sheet
Owner: #4 LAA✓ ,1 olwxv.a RY3 .S Yo e?e
Project Name and System Type: I"V--fAl T0,YA4f1.1J
Location: 8Y3
Street Address
.1vA1, SO, ?3, a 9.v is 4)
Legal Description
Township/County
Contents: Page 1: r rl rte .�yEE7r
Page 2: �LoT 1-1A4y f
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Page 4: �A.►la/FACr'ut6.es 7�W p�cs
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Page 8:
Page 9:
Attachments: /�o�oi.✓G %.g.✓.r �b/IEE.•sEAvr' t JEilylG/A✓6 �.�ruas"
„7o✓L Eyi9L4llrie,! QEi°ocf
Plumber/ ar: ,y /y,y-rafs roo r Signed:
Credential Number: Date: 6-7- aiy
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3 Number of bedrooms
LA!�O— Minimum holding tank volume r'e'q'uir'ed(gai)
Tank Manufacturer
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Alarm manufacturer
Alarm model number -4
oPW At E,o v-
X jof roundtank
lbs Weight of tank and cover
Liquid depth below inlet invert(in) Safet~ fec-tor
N'laxii-num depth of soil cover(TI-) //,94 jibs Weiq'hir of anchor required
SS, Heghtlin) 0 1,
"n, Soil cover reQ. for anchor or
VVidth (in)
flULUIRU I AFMIX %.,KUZI� SECTiON
manhole cover with
junct;on lockina devir!e and finished vent cap
ial-cl
box
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24 in- V 1 IY'min
Manhole anrd vo-rit lor--,tior
conduit
vent nip.-
rnav be reversed.
18"
1 building sewer
service A.
blinid plug alarm on I Note: All tank ioinl--,, ;Dnri I
to seal
joins beiween Tani(-Outlet openings and piping a-
=;ectrical as per •
I NEC 30 a2G in. sealed watertight. All pipet
an'd van't materials
cumply
with SPS 84. .9'
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Project: --------
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Private On-Site Wastewater Treatment System(POWTS)
HOLDING TANK SYSTEM - USER'S MANUAL
i
A. SYSTEM OPERATION: and hauled to a Proper Point
The holding tank system serves to contain wastewater on a site until the contents are pumped P F P
of disposal by an individual certified under Wisconsin Administrative Code Chapter NR114.
Wastewater from your interior plumbing system enters the building sewer that terminates at the inlet of a prefabricated
concrete holding tank system. The tank system has a switch that is set to activate when the liquid level reaches a point
12"below the tank inlet_ The switch activates a high water alarm located inside a tank alert box that is installed on a
pedestal or inside the dwelling. When the tank is full of wastewater,the switch will be activated and cause an audible
alarm to sound. A switch located on the tank alert box can turn off the audible alarm. The liquid waster carrier contracted
to service the holding tank system should be called immediately after the alarm is switched off. There is only a limited
reserve capacity left in the holding tank system after the alarm has been activated.
B. DESIGN FLOW:
The holding tank system has a total wastewater capacity of goo o gallons. Servicing intervals cannot be predicted,
as every household has varying water use habits. Use of water conserving fixtures and water conserving practices will
increase the number of days before the tank needs to be serviced by a liquid waste carrier.
C. WARNING:
Failure to have the holding tanks serviced on a timely basis may cause wastewater to back up into the dwelling and/or
discharge from the holding tank's manhole cover. The discharge of sewage to the surface of the ground-is a public health
hazard and subject to enforcement action by Sr. 1XCounty.
Soil settling around the tank perimeter may occur after it has been backfield_ All depressions caused by soil settling
should be filled with soil material to prevent surface water collection. Depressions left unfilled may allow surface water
to freeze and cause frost damage to the manhole riser ring joints or the other tank components.
Do not drive over or near the buried holding tank system with any vehicle or construction equipment. This action may
result in a cracked tank(s). This type of damage may allow groundwater to enter the holding tank(s)and increase the
frequency of pumping.
Many disease-causing viruses,parasites,and bacteria are present in the holding tank's wastewater. Even the slightest
exposure to wastewater may adversely affect ones health and increase the risk of serious illness.
Please note that the owner of this POWTS must provide the septic servicing operator with reasonable access to the
tank(s). This may include(but is not limited to)construction of a designated drive or servicing pad to within 25
horizontal feet and/or to within 15 vertical feet to bottom of the tank(s),foot traffic over and through property,or vehicle
traffic over and through property.
D. TROUBLE-SHOOTING
1. Wastewater backs-up or overflows manhole cover:
a. High water alarm not working.
b. Tanks not pumped.
2. High water alarm not working:
a. Tank alert box not plugged into electrical outlet.
b. Audible alarms switch on silent mode.
c. Tank switch installed improperly or defective.
d. Tank switch electrical connections faulty.
e. Electrical line to switch defective.
3. Groundwater entering tank:
a. Tank manhole riser ring joints leaking.
b. Tank sidewalls or base cracked.
Pg_7 of 8
E. MAINTENANCE:
1. The hank alert box has a test boom that should be pushed once a-month to assure the high water alarm system is
wouIang may
2. The Boat containing than high water alarm switch may need to be cleaned whenever scum or solids build up on its
outer Accunrlatimr of solids our the float may interfere with switch aetivatiam.
3. All manhole cdvem padlocis sum M be oiled or greased Periodically to c asu m fine nwvement of lock-
4. The loddag device should be inspected afkar each tank servicing to prevent unautimimed entry.
F. CONTINGENCY PLAN IN TEE EVENT OF FAILURE:
A badly trackod holding tank may need to be replaced depending upon the amount of damage and the crack's locatiam.
The tank Cdr should be contacted to make a determination as m whether the tank can be rcpai vd or needs
reptawernent. Groundwater may enter the cracked tank requiring more hequent servicing by the contracted liquid waste
carrier until the tank is repaired or replaced.
G: CONTACT'S IN THE EVENT OF COMPONENT FAILURE
REGULATORY AGENCY: Sr, lit oix Ca. Zo.✓i.� oFF/c
-
NAME OF INSTALLER: Name:
Address: 0?8/9 <u,,y - fir,
L✓-r �5-y75-1
Phone: 7iS a?3S- y6311
TANK 1V NUFACI'URFMt: Name: Z4,11csEx �.✓c.c�rE
Address: V 3716 G1.S,41w r. Io
/t'9�DE,✓ DLOG� W Z Sy�so
Phone: /- 800 -3.75-8ys4
HIGH WATER ALARM
SYSTEM MANUFACTURER: Name: S T �iyo�►.sys
Address: moo. lID. ilio. 40K /708
DErQois' 1ipKES /lit/ S6sa.Z
Phone: =888- 3 ya-,s7s3
Pg G of S
Private 0"Ite Wastewater Treatment System(POWTS)
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System(POWTS)has been
maintauned designed,and is to be installed and
according to Comm 83, Wis.AdmuL Code,the Holding Tank Component Manual(SBD-1 o8ss-i°
(N.03/07),and theSr.CR l.�Cou my Sanitary Code. dEa S/a.✓ ,�O
1. This POWTS is designed to accommodate all wastewater generated by a
2. The owner of this POWTS is responsible for system
in the attached Bolding Tank Servicing Contrac and operation
nd} including
aintenance Agreeanents. visions_
3. Each time the wastewater in the tank reaches 90%of the s n
inlet(at which time the alarm will activate),the � )���'or a level of I2 below the . .
called to empty the tank's contents and dispose of them in accordance c th NR 113, isA�t Cabe
4. At each service event, the service provider should visually-
manhole cciver(s)and v - inspect the condition of the tanl�risers and
verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action.All
shall comply with the county sanitary ordinance and Comm 83 and 84 Wis connective actions
.AdnL Cods_
5. All service events or inspections of this POWTS shall be reported to the county within 10 business days.
6. The owner may not remove any of the wastes from the holdin
removed by any person not authorized to do so under Ch.281,W-1s. Staturtes.The discharge ofwastes
tank to the ground surface,including intentional discharges and discharges caused by neglect,
constitutes a failing POWTS and may result in issuance.of correction orders or a citation by the county
or state_
7. No one should,enter a holding tank for any reason without being in full compliance with OSHA
standards for entering a confined space.The atmosphere within these tanks may contain Iethal gases,
and rescue of a person fivm the interior-of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired,a code compliant replacement holding tank
may be installed in the same location(a new sanitary permit is required for such a replacement).
Connection to municipal services would also be considered at this time if they are deemed available to
the property.
9. if this POWTS is replaced,or its use discontinued,components no longer in use it shall be abandoned in
accordance with SPJ 383.33 Wis.Adm.Code_
10.If there is-a problem with,or question about-this-installation,the-following persons should be contacted:
a. Installer._ Z /'7 ,' {raat' /'lamas --U7-Ty 8 Phone-
. 7vs a 3 s
b. Service Provider. A Qc SEiric vl�avicE Phone: >ir
c_ Regulatory Agency: .Sr. elao�x Z.. Za.�i JG OLf/GE 7isr 38l- 5i«b
E. MAINTENANCE: Pg_7 of 8
I. Tic rank alert box has a test.butbun that should bq pushed once amxmth to assure the high water alarm system is
wonting Ply -
2. The float containing the high water alarm switch may need to be cleaned whenever scum or solids build up on its
outer smfaee. Accumulation of solids on the float may interfere with switch activat m.
I All manhole coves padlocks should be oiled or greased Periodically to ensUue free Movement of bock
coasPonents-
4. The locking device should be inspected after each tank servicing to prevent unauthorized entry.
.
F. CONTINGENCY PLAN IN THE EVENT OF FAILURE:
A badly cradmd holding tank may need to be replaced depending upon the amount of dame and the cxacles location.
the tank n1anufachm aboard be contacted to matte a determination as to whether the tank can be repaired or needs
rePboemalL Gkou gdwater may enter the cracked tank mqun-mg more frequent servicing by the cow liquid waste
carrier until the tank is repaired or replaced.
G: CONTACTS IN THE EVENT OF COMPONENT FAILURE
REGt ATORY AGENCY:
pis ---
NAME OF INSTALLER: Name: Vii,,, /li rrtE sr�x r
Address: a8i 9 K�Aio ' Sr,
Phone: _ his
TANK MANUFACTURER Name: �E.tE'c L d.✓G.t ErE
Address: V 371e AK S. I'0
Phone: l 800 -3.zs-gys6
1UGH WATER ALARM
SYSTEM MANUFACTURER: Name.
Address: Lo. Flo. Po. �ox /708
DEfQoir 6i9KES /gill S6SO.Z .
Phone J=888- 3 Ya-,S7s3
Tank Anchoring: All tanks must be anchored whenever they Ore installed in a saturated
conditions. Using soil as the anchor has become,an acceptable alternative to concrete.
Flotation potential is the displacement of the tank calculated by its volume in cubic feet.
Line A Calculate cubic feet of tank.-,/1r�sG 2 .��6� �Q�• �:f� �`°`�''"" rA�„�CcJL/�,?vau-�=�r��
,
5's inches high, x inches wide,x /6!y inches Long,
cubic inches.
Divide this number by 1728 to equal-, Sal .cubic feet-
Line B Next convert the displacement to the weight of water.
-?/1742: y
-in/ (from line A)cubic feet x 62.4 (weight of 1 cubic toot of water) x 1.5(fudge factor)
8 9y lbs of lift potential.
Line C Calculate weight needed to counter buoyancy.
y� �Y lbs. (Displacement weight from line B.) - �. i'8 _lbs. (weight of taDk from
manufacture)=1bs. Of soil needed to anchor tank.
Line D Weight over the tank cover needed,plus safety factor.
/5 7yI
Rinches wide of tank cover x y inches long of tank cover,divided by 144
_ /0? .3 Square feet of cover x 0.083 ( 1 inch in foot decimal) _ 9 o7 cubic foot
space of l inch of tank cover.
Line E Calculated weight of 1 inch of space over entire cover.
o 7 cubic feet of space(from line D)x I 0 lbs./cubic foot of= `0_7 lbsAnch
space above cover.
Line F Calculate inches of soil needed to counter buoyancy .
7y/� lbs. (from line Q divided by 90 7 lbs. per inch of soil(from line E)= o?4.7
inches needed over tank cover.
<.4^4< IN S3",4 14.4 j"io,J uljGL ,t'G'�uisL� �?�.� vF sc,�L c�ae z au�.Z . y a✓.e GovE�t
8 Tx44200030 5
Document Number Document Title
998815
St. Croix County BETH PABST
Ho/ding Tank Agreement REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
Permit Number- A)A 07/18/20141,23 PM
EXEMPT #:
Name-(Owner)Typed or printed REC FEE: 30.00
being duly sworn,states,under oath,that: PAGES: 1
1. He/she is the owner/part owner of the following parcel of land
located in St. Croix County, Wisconsin, recorded in Volume /Z S(.
Page G 3 I Document Number 543(,'70 St. Croix County Register
of Deeds Office: Recording Area
A parcel of land located in the P W '/4 of the 60 1/4 of Section Name and Retur A ress
23 ,T 7-9 N-R /to W, Town of
BAt ,,111-1 , St. Croix County, Wisconsin, being kJoo�✓, elite..j &,J-r- 546z,%
duly described as follows(include lot no. and subdivision/CSM or
1055 95 -moo detailed legal description): N l Z 4 AlW Vq o4- 5w V'q
Parcel Identification Number(PIN)
l$ Sut e.� Z3
Agreement Date: !#
s.�
z9 �. /L.w
We acknowledge that application is being made for the installation of(a)holding tank(s)on the above described property or that continued use of
the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also,the property
cannot now be served by a municipal sewer,or any other type of private onsile wastewater treatment system as permitted under Ch.SPS 383,Wis.
Adm. Code,or Ch. 145,Wis.Stats.
As an inducement to the county to issue a sanitary permit for the above-described property,we agree to do the following:
1 . Owner agrees to conform to all applicable requirements of Ch.SPS 383,Wis.Adm.Code relating to holding tanks. If the owner fails to have
the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate
a human health hazard as described in s. 254.59,Stats.,the governmental unit(Town)may enter upon the property and service the tank or
cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current
services rendered. The charges will be assessed as prescribed by s.66.0703,Stats.
2. The owner agrees, pursuant to s.SPS 383.54(2), and SPS 382.40(3)(e),Wis. Adm. Code,to have a water meter installed in the structure.
The water meter shall be installed by a plumber authorized by the Department to make such installations,with said installation complying
with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation,
maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above-
described property on a regular basis to read and/or inspect the water meter.
3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise
servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank.
The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty(30)days from the date of notice. In
the event the owner does not pay the costs within thirty(30)days,the owner specifically agrees that all the costs and charges may be placed
on the tax roll as a special assessment for the abatement of a human health hazard,and the tax shall be collected as provided by law.
4. The owner agrees to contract with a person who is licensed under Ch. NR 113,Wis.Adm.Code,to have the holding tank serviced and to file
•copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract,or a copy of
•new service contract,with the governmental unit within ten(10)business days from the date of change to the service contract.
5. The owner agrees to contract with a person licensed under Ch. NR 113,Wis. Adm. Code,who shall submit to the county on a semiannual
basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the
condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems
certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch.Comm
83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
��►\11111!1/�
7. This agreement shall be binding upon the owne p! hdrs bf,> l�Qrner,and assignees of the owner. The owner shall submit this agreement
to the register of deeds, and the agreemeni�`uha�b C{MG register of deeds in a manner which will permit the existence of the
I agreement to be determined by reference too$ I warty T ere td g tank is installed.
y -
Owner(s)Name(s)-Please Print .t A ubs%Nbed and sworn to before me on this date:
UBLIG
Notarized Owner's Signatu W'$\\\` otary P
Ief
Governmental Unit Official Name,Title-Please Print My Commission Expir
Govern tat Unit Official i nature Drafted by:
Q a,� a rr•' �.� S,f- Gins:x- 60
Pe76nal lr�iliifation you provide may be used for seccifidary purposes[Privacy Law s.15.04(1)(m)]
THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE"
This information must be completed by submitter document title.name&return addre ss.and PIN(if required). Other information such as the
S. @►/@$68,85!ffftMliM,'btc.may be placed on this first page of the document or may be placed on additional pages of the
document.Note: Use of this cover page adds one page to your document and$2.00 to the recording fee. N9sconsin Statutes, 59.43.
HOLDING TANK SERVICING CONTRACT
This contract is made between the Holding Tank Owner(s) and Certified Operator
Contract Date Sanitary Permit Number(to be added at time of permit issuance)
3?. 4
Holding Tank ) Name(s) Certified Operators Name
Parcel I Number Property Address
002- 2 2;-D� 51'PwT Wwi) I t.,6- w
We acknowledge the installation of(a)holding tank on the following property:(Provide legal description of property)
1) Owner agrees to file a copy of this contract with Sr. C"ao.x County.
2) Owner agrees to have the holding tank(s)serviced by the pumper and guarantees to permit the
pumper to have access and to enter upon the property for the purpose of servicing the holding
tank(s).The owner agrees to maintain the access road so the pumper can service the holding
tank(s)with the pumping equipment.Owner further agrees to pay the pumper for all charges
incurred in servicing the holding tank(s)as mutually agreed upon by the owner and pumper.
3) Certified operator agrees to submit reports for the servicing of the holding tank(s) to Sr. GeoiX
County, as required by SPS 383.55, Wis. Adm. Code. Certified operator further agrees to
include the following in these reports:
a. Name, address and registration number of the person servicing the holding tank;
b. Name of the owner of the holding tank;
c. Location of the property on which the holding tank is installed;
d. Sanitary permit number issued for the holding tank;
e. Dates on which the holding tank was serviced;
f. Volumes in gallons of the contents pumped from the holding tank for each servicing;
g. Disposal sites to which the contents from the holding tank were delivered.
4) This agreement will remain in effect until the owner or certified operator terminates this contract.
In the event of a change in this contract, owner agrees to file a copy of any changes to this
service contract or a copy of a new service contract with Sr. e'aax: County whenever such change
takes place.
Owner(s) Name(s)-Please Print Subscribed and swom to before me on this date:
tel
� -
Notarized Owner's Sign refs) Notary Public
Ce ed O ame-Please
On My Commission Expires
Sf jy\J'Z�-�
rtifiad for Drafted by:
e ' Operator Regi i Number
Personal information you provide may be used for
secondary purposes[Privacy !Jaws. 15.04(1)(m)]
DOCUMENT NO WN M 3—l6a2
QUIT CLAIM DEED
Marjorie L. Johnson
7 ,
qunim to Linda Anderson, Lov ne KistiTi�_r, '
via--K-iesow, 'AUG I 1 1997
Ws tenants in Common
9:45 A M
It the following described real estate in x County.
State at Wisconsin-
"U"N TO A
II North one-half (Nl}) of Northwest quarter (NWk) y/0
of the Southwest quarter (Swk) , Section
Twenty-three (23) Township Twenty-nine (29) Tax Parcel No:,
North, Range Sixteen (16) West. �{
I.
FEE
1. �
�) This s
_.ftornestead property.
Dated this day of
-(SEAL) (SEAL)
Marjorie L. Johnson
--(SEAL) -(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
iiI Signatureis?
STATE OF WISCONSIN
County
auttent,catec!this--aa),of-- 19 Personally came before me
Of rl
Marjorie L. Jo
TITLE MEMBER STATE BAR OF WISCONSIN
to me known to be fne oe7son_-__.__wno eXeqCL'tPfj f-le
authcl--Zed by§ 706 06.VV.S Stals i foregoing instrument and aciK"wittoge the same
_S:1.S7 A.-%IEN-1.
• AS=P.A.TEC)a,
X. Rivard
Rivard _E ��_tewart
Schernbera.
C
'T
Mbenoulon ie WI_ ' Notary Pabi,c_ ---l- I .V.s
iS,gna!ures •iay be autmen. t.cated ack"wiedged 801m My Cow ss,c, is permanent 15 not. state e,io-atte-
are not necessary I
Sr.3 —
C,uIT CLAIM oef) STATE BAR oF WISCO,,4S-N Ns<n 7 a• 0• 5 0 F•02.0ti 7 le--Bad' V1 5430-020A
FOAM No 3—1982
t
Property Owner A.4,1 Parcel ID# Page ? of
F Boring# Boring ,r
0 Pit Ground surface elev. 97 ,Y 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#12
YiL a
.7 - .1 /o Y t -r,/,Y /o rR
3 SYLS-/V ca o 6 +ss s,l
Boring# LJ Boring
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
Boring# Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/(F
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2
*Effluent#1=BODb>30<220 mg/L and TSS>30:5 150 mg/l_ *Effluent#2=BODS<30 mglL,and TSS<30 mg/L
SBD-8330(R07/13) '
::t i
t0 7 , f
Wisconsin Department of Safety and Professional Services page /_Of 3
Division of industry Sennces SOIL EVALUATION REPORT
in accordance with SPS 383,Wis. Adm• Code County
Attach complete site plan on paper not less than 8112 x 11 inches in size.Plan and Parcel I.D.
66Z-
include,but not limited to:vertical and horizontal reference point(BM),location and distance to nearest road. Date
percent slope,scale or dimensions,north arrow,and Revie by 9 Z
please pant all information. mow,s. s.oa(�)(m))• /
Personal information you provide may I used for secondary purposes(Privacy
Property Location r-�
Owner 114 114 S T d N R /G ten(° w
Property Govt Lot L✓
Al D �✓sO Lot# Block# Sebdce or CSM#
Property Owner's Mailing Address — Nearest Road
8 y3 a?So r./ r. ge own
State
City Tap Code Phone Number
/- d/66E �✓I y� ( ) GPD
0 New Construction Useo Residential l Number of bedrooms
--.Z—Code derived design flow rate S/SD
Public or commercial-Describe: ft
Replacement � Flood Plain elevation if applicable
Parent material LDESS ouER y-iLL />1oa�2o�/� �aLDi•JL TASK S/TE
General comments T,sa C7L6D So&s rrLY �fELo✓
and recommendations:
Boring trort Rate
Boring# 93.3.s ft. Depth to limiting factor '�--in. ��
a a Pit Ground surface elev. GPDH!=
Structure Consistence Boundary Roots
Texture •Eff#1 -Eff#2
Horizon Depth Dominant Color Redox Description Gr.Sz.Sh.
in. Munsell Qu.Sz. Cont.Color
an d/3 �'� c c✓ � IC
9_/3 Ya 413 oe /a
/3,t 6 7.S%'K s/j/ a
E•J /tip .vraic of -3
oTTG .4
Boris# a Pit Ground surface elev.
J3.y ft. Depth to limiting factor t 9 in. Soil ration Rate
Roots GPDW
Horizon Depth Dominant Color Redo.Description Texture Structure Consistence Boundary •Effl11 -Eff#2
in. Munsell Qu.Sz. Cont_Color Gr.Sz.Sh.
/o Yet. -32
_ 1
.2 —/`/ /o 2 S ly L o YA S.t .S6 S�
3 /y aG 7,5-Y4 s/y .T 4 Y s-/,2 si!
•Effluent#1=BOD >30:5 220 mg&and TSS>30:5 150 ml 'effluent#2,=Bil _<30 nv&and TSS_5 30 mglL
CST Name(Please Print) Signature CST Number
Address ON p Conducted Telephone Number
1503 Fairway S>t.
SBA-8330(807/13)
(I)715-834-8610 (C)715-577-4383 ►
CST,WRS-224974,D-1152
Property Owner .h j Parcel ID# Page a? of 3
3 Boring# Boring it
pit Ground surface elev. 97 V ft. Depth to limiting factor < G 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. *Ef1#1 *Eff#2
.7 - .7 /oYL rlv 10.2,//"YAt.t sG S/I
t
L.7[� o YR L .? 4/-,6 S,
F—I Boring# J Boring
n 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
F—I Boring# Hpit Boring
Ground surface elev. ft. Depth to liming factor in.
Sal 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=BOD6>30<220 mg/L and TSS>30<150 mgR *Effluent#2=BODS<30 mg/L and TSS<30 mg/L
SBD-8330(807/13)
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Parcel #: 002-1055-95-000 07/14/2014 04:06 PM
PAGE 1 OF 1
Alt. Parcel M 23.29.16.345A 002-TOWN OF BALDWIN
Current 41
ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units
00 0
Tax Add�qss: Owner(s): O=Current Owner, C=Current Co-Owner
O-ANDERSON, LINDA ET AL
LINDA ET AL ANDERSON C-KISTNER L, KIESOW S
KISTNER L, KIESOW S �� S
371 TOWER RD
HUDSON WI 54016
Property Address(es): *=Primary
*843 250TH ST
Districts: SC=School SP=Special
Type Dist# Description 7
SC 0231 SCH D BALDWIN-WDVILLE
SP 1700 WITC Notes
Legal Description: Acres: 20.000 ri Ckv\--
SEC 23 T29N R16W N 1/2 NW SW 7
Parcel History
Date Doc# Vol/Page Type
08/11/1997 563670 1256/631 QC
Plat: *=Primary Tract: (s-T-R 40%160%) Block/Condo Bldg:
*N/A-NOT AVAILABLE 23-29N-16W
2014 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/08/2013
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 17.500 2,500 0 2,500 NO
UNDEVELOPED G5 0.500 100 0 100 NO
OTHER G7 2.000 8,600 26,500 35,100 NO
Totals for 2014:
General Property 20.000 11,200 26,500 37,700
Woodland 0.000 0 0
Totals for 2013:
General Property 20.000 11,200 26,500 37,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch M PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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