Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
024-1032-10-400
1 I U d l I ~ 1 ' C ~ I 1 a IV' 1 a: I to F-- I w I 1 w I 00-109 t I I ' 1 1 1 d 1 1 1 1 / 1 i ~Ne ~ I U.J Z C W i > a 1 a E a I f p 1 (L 1 w 1 arc 0 1 1 C t 1 i w ,4 Z I f 1 140' D, fl?l I I i ~ 1 1 1 C9 1 I 1 C3 Ix o Q 'i i~ ~ ~ ~A ~ i~ #IOII, il-~~ YYi~ ~ ~ i ~Y ~ ~i ,I~,AI~ Irir111 i ~~1 ~ rA~ _ _ 13381S H10/1 ,ccs•oa0 I 0000 956-V-509 T99 u0oU0SAIJ00 Yoo do E 0000 _ ® o c~ v ® o 3"' j U. z o (n :D `6'mi+ N O O O E E m ZZOVS IM 'SIIEJ AM16 'I@@JIS MOLT TOT mam m +.oo c N .v}tea ~ ~ma< o uJOg MO - tule3 ua®qag U J J O W W N W W ti W ~ 7 rn ° ti j J 3 0 w ¢m_ W C? U F- ~ w a ~O ? X X ro N O wN~ w w N 7t Q r .D O x q Y f EA g H N 0 3 J @a. m Cm~ CM) @ N O N .0-~9T .0 :8L I r - - - - - - - - - - - - - - - - - - - - - - - - - - m ~ I I k~J NOU2i_HSVM~~ _ N~V21 FISb'M _ _ N V2i HSVM 110VAOW3il 318NAOW3i! 3 I III II II II ~ II II I I II II I II II I ---OW S cr CJ moll o m yOMO im li l~ 01--82 u V) r II II I II I .0-.6 a T I-:9T I I I O] I o m - O ~ I ® I I I iv I _ L I x I ~ i o I 0] ,Q), ° 0 K I a x l O o Z LK -_.S- I W H I m U W_ II-- s I' I o F _ ~LL 0 00 go ~I 00 I F _ 00 O NIN -ZW CEO J u o m ~J 0 = Z HIN ~ I I o r O' .6 V rl o I L'i r.n A Q o v - - - - - - - - - - - - - - - - I r x6~L I I I I II N , II ~ ll O s I I ~ XO I I~ I W I I m N W uj I ~ m 0 I I ~ H~ Q I I ' J O _ - _ I I .~-i Q aJ I I U N tV K Q ~ Wlnw II za m as I I $ I p I I ON ~ a s (AN XX L I II I - I I I II ~ F , z II I ® x I k" J N I~ 6~ v0i O ✓ x - . Ala % vm F I I 3Np I I O I N ~N I I W I I Q. I O F O li I~ I N m N , I~ I N W I m) m ~ n J J O n o O O 0 3 p 0 N N C m W N C 7 w aO NO M Q aQC~ 3 n Wwzz X X 1'00.-. a e Q zWaz ' m M n, ~ON~Q w NJ~Q(Y .J O Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St, Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578939 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: F City Village X Township Parcel Tax No: Schoen, Gerard Pleasant Valley, Town of 024-1032-10-400 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: c1g. I+c/ CpVC r ~lL 6Se-. 28.28.17.203D TANK INFORMATION ELEVATION DATA TYPE MANUFACT CAPACITY STATION BS HI FS ELEV. Septic Bench r 1(gyp 1 r e"Ip Dosin Alt. BM ✓ L U- Aeration Bldg. Sewer Q p ding Inlet TANK SETBACK INFORMATION OuIn Cr 5! TANK TO 'Slip/l WELL BLDG. Vent to Air Intake R Dt Inlet Septic Dt Bottom Dosing Header/Man. AeraMIT ) u N 2 f ~V~r Dist. Pipe - V ~ Bot. System / Final Grade PUMP/SIPHON INFORMATION Manufacturer D and St Cover GPM Model Number AT@ Ld,'A 1. 1 ~V / ~ Q5.TDH Lift Friction System Head TDH Ft 1 11 C Forcemain ngth Dia. Dist. to Well S in C&66 ~ SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia_. Liquid Depth DIMENSIONS 1--- SETBACK SYSTEM TO P/ WELL anu acturer: INFORMATION CHAMBER OR Type Of System: ~J 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 Bed/Trench Center Bed/Trench Edges Topsoil Yes Q No --M-Ys--R No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / / Location: 105 170th Street River Falls, WI 54022 (SW 1/4 SW 1/4 2,8~..TV \28N R1 7W) NA Lot 3 Parcel No: 28.28.17.203D 1.) Alt BM Description= fiV~- ..-H((I In ! 4 wo\ 2.) Bldg sewer length = 5-~y 3 "4 y~ C 1n Q r - amount of cove' p /1, I } W L6dC~ T Plan revision Required? Yes No ll 1 g (a~ ~ Use other side for additional information. Date Insepctor s Signatu Cert. No. SBD-6710 (R.3/97) i O rn rn m -0 0 0 0 I J 3A€HO SNIISIX3 f \ loldaalakui aseaIE) €e'50E0L \ laqure dwndjAuel aadas ? ° ) I 9 le~C3d9?GOOI uo13eu,gwo~ ° l} I } ? T 11l \ 5NIC-11.11S 03SOdOdd l.. A v 1~ I f ---------f ---1 .~-BLZ-1 i I kVAA AO iH`JI21 CV08 'Cl County p Safety and Buildings Division J ELI 4, 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) Madison, 53,707-7162 Soso ' "'A Wn 5~l IBCV~9 C( Permit A lication State Transaction /Number D In accordance with S3 Wis. Adm. Code, submission o his form to the appropriate governmental unit / v ` (.l~O is required prior to obta~~hti8 sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address if different than mailin address) the Department of,.S and Professional Servies. Personal information you provide may be used for secondary I$ 165 I 1 lS purposes in accordAce with the Privacy Law, s. 15.04(1)(m), Stats. 1. Application Information - Please Print All Information Property Owner's N Parcel # tie Sc o e UC-5-11 U 2~~ I(~32_ IU --yoU Property Owner's Mailing Addre Property Location /0,~ / a t+► Govt. Lot _~W -2 D) City, tate Zip Code Phone Number Section l v e Y / ~t & W ~O'Z 19~~' UJ ' ~J T 0 N; R / !circle one) EorW II. Type of Building (check all that apply) Lot # 3 ❑ I or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # 4 LL), Public/Commercial -Describe Use e ❑ City of ❑ State Owned - Describe Use / L CSM Number Q ❑ Village of _ V11/6! /k m e✓~JQ / I J1Z/ /I 15 1 &To-of ~ eQSQRf eo III. Type of Permit: (Check only one box on li A. Complete line B if applicable) L-wic A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only er Modification 7mg ' Cd s4e 'l /4 fPrce 7~or LiaLPrevious Permit Number and Date Iss d B. ❑ Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that a 1 ) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 i e soi Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain) f e S 7h~~✓e ~O V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation / H H (o -e xl s f-i.,J Cqf VI. Tank Info CapaciVy in Total # of Manufacturer Gallons Gallons Units p o New Tanks Existing Tanks o v u c a P. U rn H w C7 a Septic or Holding Tank 1 O 0 0 ©if1~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Pber's Name (Print) Plumber' ign ore M104PIRS,Number Business Phone Number 2 t! S ~s Tir yzs 3-ry~~ P4au( C S S 1h ~e Plumber's Address (Street, City, State, Zip Code) Aloe,- 30 ?Vf fQ Ac G(J ` V )!I. Count /De artment Use Only Approved ro Permit Fee Date Issued Issuing Agen5'at e III ❑ caner Given Reason for $ bb ✓ r' IX. Con"tp# AFReasons for Disapproval 1. Septic tank, effluent filter and 3 b7X/S•-hny S yJIP (579353) US l A o n ve r tec~ dispersal cell must be serviced /maintained 3 sec( r~o~ re S ida->1,H c, WAS C a9>' u bra 1 as per management plan provided by plumber. M .Ga ( S~ Z 1a r\ 2. All setback requirements must be maintained 'tb J as per applicable code/ordinances. rack UI_-b'On fa rrY1 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) PAUL CJ STEINER Page 2 4/17/2015 In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 85.00 Fee Received $ 85.00 Balance Due $ 0.00 Patricia L Shandorf POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633 (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm r ptir~Ttirg4 DIVISION OF INDUSTRY SERVICES 5~~' l0n 10541 N RANCH ROAD 2 o i s ~ HAYWARD WI 54843 Q S Contact Through Relay i 3 httP://dsps.wi.9ov/pro9rams/industrY-services P www.wisconsin.gov S FE' L S sroN Scott Walker, Governor Dave Ross, Secretary April 17, 2015 CUST ID No. 225451 ATTN.• POWTS Inspector PAUL CJ STEINER ZONING OFFICE STEINER PLUMBING & HEATING ST CROIX COUNTY SPIA N8230 945TH ST 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/17/2017 Identification Numbers Transaction ID No. 2520768 SITE: Site ID No. 802351 Gerry Schoen Please refer to both identification numbers, 105 170TH St above, in all correspondence with the agency. Town of Pleasant Valley CONDITI St Croix County APPS SWl/4, SW1/4, S28, T28N, R17W FOR: DEPT OF S Description: Addition of tank only PROFESSION Object Type: POWTS Component Manual Regulated Object ID No.: 1527903 IN❑ Maintenance required; 446 GPD Flow rate; Commercial System, Effluent Filter, Miscellaneous Review DIVISION OF The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes _ and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced ab SEE CORK The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This approval is only for the addition of the grease interceptor. The assessment of the absorption area for compliance with Comm 83.25(2)(b)2, Wis. Adm. Code as it relates to treatment capabilities is the responsibility of Septic tank Croix county. • The added tank shall be used as a grease interceptor. • The inlet baffle must beat least 1/3 of the liquid depth per SPS 382.34(5)(b)f. The outlet baffle shall beat least 2/3 of the liquid depth of the tank. • The system has become an at risk system with yearly inspections of the dispersal cell required. • A component specified in this POWTS design requires servicing at an interval of 12 months or less. Pursuant to s. SPS 383.21(2)(c)5, Wis. Adm. Code, if any part of a POWTS requires servicing or maintenance at an interval of 12 months or less, a notice of the need for such servicing or maintenance must be recorded with the deed for the property. If the maintenance or service notice has not been recorded, a sanitary permit can not be issued by the sanitary permit issuing agent. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. I Mound Septic Sizing Verification Use Table A-383.43-1 Dining with Toilet and Kitchen Waste without Dishwasher and Food Waste Grinder 5 gallons/meal x 38 meals = 190 gallons Employees 13 gallons/employee x 2 employees = 26 gallons Floor Drains 25 gallons/drain x 3 drains = 75 alb Daily Flow 291 gallons Use Table A-383.46(6)(b) Oversizing 1.5 x Daily Flow 1.5 x 291 alg lons 436.5 gpd The existing system is designed for 450gpd. (Original Transaction ID # 2406859) Exterior Grease Interceptor Sizing Based on SPS 382.34(5)(c)2b and c C = (MxGxH) / (2xP) M = Meals Served/Day G = 3gallons/Meal Served H = Hours/Day Meals Served (at least 6 hours) P = Meal Periods/Day (1, 2, or 3) C = (38x3x6) / (2xl) = 684/2 = 342 gallons* *Minimum Size is 1,000 gallon NOTE: The county conditional use permit only allows fifteen events at this site per year. Monitoring Plan Once per year check for ponding in mound inspection pipes. If no ponding, no action taken. If there is ponding, re-check each week for up to four weeks. If there is no ponding at the end of five weeks no additional action is needed. If there is still ponding at the end of five weeks the mound will need to be re-built or an aeration unit will need to be added to the septic tank. I 2~Page STEINER PLUMBING-ELECTRIC-HEATING INC. N8230 945th Street River Falls, WI 54022 715.425.5544 1 Fax 715.425.8818 steinerinc.net March 24, 2015 Gerry Schoen 15370 Afton Blvd Afton, MN 55001 Site Location: SW SW % S28, T28N, R17W 105 170th Street Town of Pleasant Valley/St Croix County Parcel ID 024-1032-10-400 Ot4r\ -Y D\jLD 'XIF I TY ~,ck AL rJ(E- Index ~sTRY :~E~'1t~~'~ Title Page 1 Calculation Page 2 ~SPONDEN Site Plan Page 3 Floor Plan Page 4 Paul ci Steiner Master Plumber: Paul C.J. Steiner, MP#225451 1 Page STEINER PLUMBING-ELECTRIC-HEATING INC. N8230 945th Street River Falls, WI 54022 715.425.5544 ( Fax 715.425.8818 steinerinc.net March 10, 2015 Gerry Schoen 15370 Afton Blvd Afton, MN 55001 Site Location: SW 1/ SW S28, T28N, R17W 105 170th Street Town of Pleasant Valley/St Croix County Parcel ID 024-1032-10-400 Mound Septic Sizing Verification Use Table A-383.43-1 Dining with Toilet and Kitchen Waste with Dishwasher and Food Waste Grinder 7 gallons/meal x 28 meals = 196 gallons Employees 13 gallons/employee x 2 employees = 26 gallons Floor Drains 25 gallons/drain x 3 drains = 75 gallons Daily Flow 297 gallons i Use Table A-383.46(6)(b) Oversizing 1.5 x Daily Flow 1.5 x 297 gallons 445.5 gpd The existing system is designed for 450gpd. (Original Transaction ID # 2406859) .Paul CJ Steiner Master Plumber: Paul C.J. Steiner, MP#225451 24 HOUR DEPENDABLE, OUALITYSERVICE 2-3 v O C r m P51 R~= - fn n cn z 0 1 D m r , o m m - - _ - - _ , A ~ 1 m , / /r Z r m r f-7 Ln ~ r Z Z p > m m m f g C ~ --I 1r^1 D tDi>O y mpmOZM>o x 4h~vJ ~ O D Cl) ~T. O SAO?-Oi=p~Or~ ~ ✓tzj G oc m ~ tic zm C-) rm W<~rnswr''Aw~ Ctzj LZJ D O J co ~ or -~O?OA H H D rnL~ O T D W~w0~0~ H ti O r C C, r m m 00 x nE ~ to o y tzj C. NJ m o~ Z cn co O H~ o z W 9 O O X A N m F-^_ O O cn ro SEE m oo z O o_ My n t 0 r 0 M m Q1 D CA -4 G7 ° ~v • r S STEINER A PLUMBING ILECTRIC • HEATING INC. N8230 945th Street River Fails, Wl 54022 f 715.425.5544 { Fax 715.425.8818 ( steinerinc.net i At-Risk POWTS Servicing Contract Contract Date: w f This contract is made between the Owner of the At-Risk POWTS and a licensed service s provider. At=isk POWTS O Her(s) Name(s) Service Provider Name Steiner Plumbing & Electric Inc. Owner G rry Schoen Owner: Paul Steiner We acknowledge the installation of a Private Onsite Wastewater Treatment System considered being At-Risk pursuant to the Department of Safety & Professional Services High Strength Wastewater Policy of April 1, 2009, on the following Property: MANGE o+in bit S}r e Address: 15370 Afton Blvd gi}c -sS : Ib5 1 *7 54022 Afton, MN 55001I~~ ~o~tl S' Site Location:SW 1/ SW 1/ S28, T28N, R17W 105 170th Street Town of Pleasant Valley/St Croix County Parcel ID 024-1032-10-400 _ - Existing System State Transaction 'M # 2406859 • The Owner agrees to file a copy of this contract required under the provisions of SPS 383.52(1)(c) with the governmental unit responsible for the regulation of POWTS, St. Croix County. • The Owner agrees to have the At-Risk POWTS monitored to detect early signs of failure on- month, or less basis in-accordance-with the management plan-as follows:..... _ o Once per year check for ponding in mound inspection pipes. If no ponding, no action taken. If there is ponding, re-check each week for up to four weeks. If there is no ponding at the end of five weeks no additional action is needed. If there is still ponding at the end of five weeks the mound will need to be re-built or an aeration unit will need to be added to the septic tank. 24 HOUR DEPENDABLE, QUALITYSERVICE 0 • The Owner or Owner's Agent agrees to submit the required inspection reports to the governmental unit, St. Croix County, within thirty (30) calendar days of the date of the inspection in accordance with SPS 383:55(2): • This Agreement will remain in effect until the Owner or Service Provider terminates this contract. In the event of a change in this contract, the Owner agrees to file a copy of any changes or a copy of a new service contract with the governmental unit, St. Croix County, within ten (10) days of the date of change, or execution of the new service contract. i Owner(s) Name(s) (print) Owner Signa (s.... 2 s16 D /V I 9. i 5 Service Provider's Name Se e P ovider's Si ur Paul Steiner Service Provider's Credential Number: MP#225451 Document Number Document Title $ Tx:4247214 6 St. Croix County 1011596 BETH PABST POWTS REQUIRING a SERVICE INTERVAL REGISTER OF DEEDS of 12 MONTHS or LESS ST. CROIX CO,, WI RECEIVED FOR RECORD 05105/2015 11:08 AM State Plan Transaction Number - 00 EXEMPT REC FEE: 30.00 COPY FEE: 2.00 Name - (Owner) Typed or printed PAGES: 1 Being duly sworn, states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number 941 t_I I St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the ~J 1/4 of the SO 1/4 of Section Name and Return Ado~~ $ , T 2 N - R W, Town of ~ T9~ n/ 5 V~ea%lit'-- VaJU;M , St. Croix County, Wisconsin, being J537-0 F SSpp duly described as follows (include lot no. and subdivision/CSM or A P/ 4W detailed legal description): Mq 032- 10- 0 Parcel Identification Number (PIN) Vol. 2) 5219 Q2h1~2 2v ~5 Agreement Date: As an inducement to the county to issue a sanitary permit for a POWTS requiring servicing or maintenance at an interval of 12 months or less on the above-described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of SPS 383, Wis. Adm. Code relating to service and maintenance requirements for the proposed POWTS (Private Onsite Wastewater Treatment System). If the owner fails to have the POWTS 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 to maintain a contract with a licensed POWTS maintainer for the life of the system. The POWTS maintainer will perform periodic inspections as required by the Department. These inspections are to be scheduled every 12 months for the life of the system. 3. The owner agrees to contact the POWTS maintainer immediately upon any malfunction of the system as to not create a human health hazard as described in s. 254.59, Stats. 4. The owner recognizes that the county, Department of Safety and Professional Services, or POWTS maintainer may make periodic inspections of the components to complete performance monitoring. 5. The owner or the owner's agent agrees to report to the department or designated agent at the completion of each inspection, maintenance or servicing event in a manner specified by the department or designated agent within 10 business days from the date of inspection, maintenance or servicing. 6. This agreement will remain in effect only until the county office responsible for the regulation of POWTS certifies that the system no longer serves the property. 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. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the Register of Deeds, and the agreement shall be recorded in a manner that will permit the existence of the agreement to be determined by reference to the property where the service is required. `~~~Illtlll//~~~ Owner(s) Name(s) - Please Print Sub bed and sworn to before me on this date: is e ~~Mq 4r, 6-C N arized Owner' Signatur Q • ot}trg~Z % f~v Go ernmental Unit Official Name, Title - Please Print q ]'E M~- mmission E ires % 0, y 1_c r\4 Jse T-tchn06&-a S-fi. rlroix cbbvo Governmental Unit Official Signa ure Drafted by: 4 Pe onal information you provid ay be used for secondary purposes [Privacy Law s. 15.04(1)(m)] A~ "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" This information must be completed by submitter, document title. name & return address. and PIN (if required). Other information such as the granting clauses, legal description, etc. 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 paqe to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 574353 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: Schoen, Gerard Pleasant Valley, Town of 024-1032-10-400 CST BM Elev: lnsp. BM Elev: BM Description: Section/Town/Range/Map No: „Lr tT p 28.28.17.203D DATA ELEVATION TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic N,^~ MOO Benchmark t iC) Dosing Alt. BMA 2 I 'Ll I0). ~ - - q(o Aerr4rvtr T I LTu 1- o Bldg. Sewer ( ; _ ; Heldme/'- St/Ht Inlet 1 q'7/ 8 et I rj TANK SETBACK INFORMATION u TANK TO P/L WELL BLDG. Vent to Air Intake ROAD et-Inter Septic / Ho' vo I Dt Bottom 9 / 2G) Dosing HO) ~ ~1i Header/Man. Dist. Pipe JA I m Holding- Bot. System L1 ' 160 • -1W PUMP/SIPHON INFORMATION Final Grade N i' -12tl Manufacturer Demand St Cover 6r Q`C~ q 1wLDS GP (J Model Number }-P~}/ I U v11 Ue- 2 96 5j TDH Lift Friction System Head TQ~ u~ Ft v Li + ~fy1 ~Q ~ Forcemain Length Dia. Dist. to Well 1v ~y~,~ *2 . ,e ABSORPTION SYSTEM t V h Inside 6nBEbDrqrENCH Width Leng No. PIT DIMENSIONS No. Of Pits Dia. Liquid DeptO"W 0) DI SIONS SETBACK XEMO P/L BLDG WELL LAKE/STREAM Manufacturer: INFORMATION CHAMBER OR Type O System: en- 7A UNIT odel Nu 1v DISTRIBUTION SYSTEM Header/ManiVid it Distribution i / x Hole Size l I I x Hole Spacing ; Vent o i I ke Pipe(s) -11L 1 Length Dia Length Dia % " 1 pacing_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 'W l V Depth Over Depth Over 7TOpsoil Depth of r xx Seeded/Sodded ul ed Bed/Trench Center > Bed/Trench Edges es i` s? No es i ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspeection #1:0/ / Itj Inspection #2: Location: 105 170th Street River Falls, WI 54022 (SW 1/4 SW 1/4 28 T28N R1 NA i of Parcel No: 28.28.17.2 _ ~ k ~ ~ ~ Z.. a 2 ~oo~~~> C hui wl sit (bc~S 1.) Alt BM Descriptio 2.) Bldg sewer length 1)t wt ler✓/~ - amount of cover = Plan revision Required? Yes 1-~ No Use other side for additional information. ~_~_vC_- - - - Date I sepctor's Sig Cert. No. SBD-6710 (R.3/97) ° 114 -•r o € 'lei d' 44. o f - * _ + ; c rn t v~ i• 41 49k ! u I ~ Vy ; ~ u ~ ~ o a p u~~ D E r a 1 't ~ r D ~ ` •3 ~ c.9 ~ 4- 0'a CZ°C~ v i d 11 °y .fli L-N S7 7 Safety and Buildings Division County 5~. Gra ~ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 AuG UsN 5 7 zv35 .=11% co iv in , l~~ ermit Appli ion State Transaction Number (p~M~,U z 4b s 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 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 , Stats. L Application Information - Please Print ormation Prope er's N Parcel # 4 A!2 f J v 51~ Ile ` ~ C 4o cov- - ~v Property Owner's ailing Address Property location I 263 Z J Govt` Lot n ,0 City, tate Zi Code Phone Number SLCJ _M Section 41 G` f /rcrrcle one 6J I"~(S' T N. R E r ! II. Type of Building c eck all that apply) Lot # 2 ~1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # ❑ Public/Commercial - Describe Use 145 &M q ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of 1/y/ C7J /1A 1*4 r~ ❑ Town of yl Q ✓ (J~ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 5 A' A❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New evious it Number and i5ate Issued Before Expiration Owner IV. Type of POWTS S stem/Com onent/D 'ce: Check all that apply) ❑ Non-Pressurized In-Ground Pres d In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable so( Mound < 24 in. of suitable soil q ❑ Holding Tank ❑ Dispersal Component (explain) ❑ Pretreatment Device (explain) / V. Dis ersal/Trea nt Area Information: Desi FI ( d) Design Soil Application Rate(gpds Dispersal ALea Fequired (sf) Dispersal Area Proposed (s System Elevation VL 'tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 412 ~2 New Tanks Existing Tanks 5 ` U Un H y) w 0 M. Septic or Holding Tank s b Dosing Chamber VII. Responsibility Statement- L the undersigned, as a responsibility for installation of the POWTS shown on ttached plans Pl er's Name (Print) Plum 's nature MP Business Phone Number 1AA Z/ Plumber's Ad ess trees, City, S Zip Co ) VIII oun epartment Use Only Approved ❑ rsapprove Permit Fee Date Issued issuing nt Signature $(025 , oa ZS / eason for Denial ? V- FF DL Condit M seasons for Disapproval J m ~1 'laMt, eAlt 1~!@{ T Aispeysal oad.musf all be IWAp / Maintained as PN'matagenwnt plan provideq byPlumaef: are-, 2. +c Aa rPainfai~ ss Par applkabla oodr% eruAt~1. 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) CHARLES L WEBSTER Page 2 5/29/2014 is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(1). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice, f(71 andorf Please Include a Copy With Your lan Reviewer to at Services 4 g Payment Submittal. 7810, Fax: 15) 634 150 , M - F 8:00 a.m. - 4:45 p.m. WiSMART code: 7633 rf@wiscon gov k cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. o AR DIVISION OF INDUSTRY SERVICES 10541 N RANCH ROAD P HAYWARD WI 54843 3 } D S Contact Through Relay p www.dsps.wi.gov/sb/ 7 S o~ www.wisconsin.gov ~~~SSIONA~ 5~ Scott Walker, Governor Dave Ross, Secretary May 29, 2014 CUST ID No. 220673 ATTIC- POWTS Inspector JUN CHARLES L WEBSTER ZONING OFFICE OMMUN yo co?~~4 WEBSTER SOIL TESTING & DESIGN ST CROIX COUNTY SPII~i ,Q, U N5815 770TH ST ELLSWORTH iVT WI 54011 HUDSON WIC 54016 ~<Op F CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/29/2016 Identification Numbers Transaction ID No. 2406859 SITE: Site ID No. 802351 Gerry Schoen Please refer to both identification numbers, 1~9N 105 170TH St above, in all correspondence with the a enc - Town of Pleasant Valley .6PR0 ~ St Croix County rlePT OF SA SW1/4, SW1/4, S28, T28N, R17W S,0NA us0r IBS FOR: _ _ - - N OF °~j' g;;10 Description: Mound, 3 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 1486097 J Maintenance required; 450 GPD Flow rate; 17 in Soil minimum depth to limiting factor from original grade; S C Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component U Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter 5EE CORRE The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384.10. No fixture, appliance, appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it Webster Soil Testing & Sewer System Design Charlie Webster, Owner N5815 770th Street Ellsworth, WI 54011 WI Licenses: MP220673, ST220673, PE18803 Phone (715) 273-3430 POWTS Index Sheet Page 1 of 8 Mound System for a 3 Bedroom Residence Property Owner/Gerry Schoen SW1/4 SW1/4 S28, T28N, R17W 105170th St Town of Pleasant Valley/St Croix County Parcel I. D. 024-1032-10-400 Page 1 Of 8 Index Sheet No 1( Page 2 of 8 Plot Plan 'ED Page 3 of 8 Plan View Cross Section Y AND S Page 4 of 8 Distribution Pipe Layout ay SE- V1 Page 5 of 8 Pump Chamber Layout ..CRY Page 6 of 8 Pump Performance Curve Page 7&8 of 8 Management Plan SpON CE CHARLES L WEBSTER i " E-18803 i' Ic 1 ; ~ FLLSWORTH r kI i WIS. Component Manual Used: Name: Mound Component Manual for POWTS Version:2.0 SBD-10691-P Dated: January 30, 2001 NZ h ~ y 6 e y n o C1. 'a ( v t ,i A ~ L v c y' ' ~ o G, n Mti I icy * u k~ U% Y C4 0 0 t \\(T, M tr 4 't- t'' Q t 4 it o4 lL°i i C d ~ 111i' ry 0~ z -Z 5~; 5l a p~ s3a v a a` y a ! I 1 W. { c Setioer~' Pages Of Approved Synthetic Covering PrSTM c- 33 Distribution Pipe Medium Sand H G Topsoil 7- a F Elev 3 1ov Q 3 % Slope Bed Of -j 2 2 Force Main Plowed Aggregate From Pump Layer Cross Section Of A Mound System Using Ea~h• A Bed For The Absorption Area F Mi ~O" g~tf G 0--SFt. A 6 Ft. H O Ft. Linear Loading Rate=,6-0'GPD/LN FT B 73- Ft. Design Loading Rate=O.a,7GPD/SQ FT j Ft. i 74Cecss b•X ~ \ J Ft. rAK.i del//«~t ) K / f Ft. /t fe,.L l t- 17 Ft. W 3 Q Ft. L 6%,4•-to - Observation Pipe A A7 - Distribution Bed Of' 2 z " 4 Pipe Aggregate L Observation Pipe,` (ancb►bz securely) O~sc~vdf%o•e o-• es fi, ~l1Ye ~ /+s.i►.Is,kt.. ~-r~.'IC,)1•.cfC~ e 1 ~ ihehe~ ~t ~awv• ~°~a~~~~ d c~ 'r v 7~~cbettot•.► C7.hchcs s/.ttexs~$~be sccu~~/ d~rc~ro~oQr Plan View Of Mound Us!!kg A 6-ed For The Absorption Areo q Il7 Perforated Pipe Detail /11" 0 End View Perforated y PVC Pipe 'o a L Holes Located on 8oitom, SC f al~fid%~ Ate Equally Spaced - J ~ Disttwution 1 Pipe Sec ~ dcrtl,l P Oistributioa Pipe. Layout s 3 Ft. X 3 I nches S°C"•1~ _ aG~. S~p y Inches Hole Diameter /d Inch Lateral I~Inch(es) Manifold Inches Force Main Inches 1~ - - 0 of holes/pipe adce s d. CS X _ }4re4 c%o/,* Invert Elevation of Lateral s /oo S- Ft _ i I ..~lOV Place 1st hole/Rig-from .c*de,C1db,4►f6*f44"940J With succeeding holes at-?6i;., intervals. /V/ auti of l°/a k t ~r (9 e C~o e/7 page 0, CO rry DiAI ~:,a .S(~Q/, C 11 y ~//0Gt„~.,~j C~i l AIr~CH r' 'I q/rer.,.ft to C-l,at sc,ltd 40 ,6N;«Ae40g r40-1 C wehQ6bY4 (No Scale) w: th ~o C r, cwcl- Approved Locking Manhole Covers ~ /''i'" `e'''r ~•pe~ )1p{'t wa., /of i6 c ra 6 11 of K~ With Warning LdbelS Attached .1'r`'i "'•+ia'owor ~ ~ rv 6/. c 6 cf b e w 7","a d i t Tt 71/tC Weatherproof Approved _ 4;0411,",194. c% 97.0 Junction Box Vent Cap 12" Minimum ; t - 4" Mini mum i ' Quick 18" Minimum Disco&ct i 4dJj, Gv*j. 1/4" Weep Baffle Hole POA or LPp r, ve d Alarm Qy eld,'✓s /eM t On B i 8:..a~ *APPROVED Off 64 F~-^ 71.3 off- coyor y.. JOINTS WITH `dcC.Fr APPROVED PIPE p``•..P 3' ONTO D j SOLID SOIL Conc. 31,0!-k i 3° of Bedding Under Tank-/ Number of Doses: /Per Day Gallons Per Day/ADO es: 15'8 Gallons Volume of Sackflow:..~ ' oGallQns Tank Manufacturer: W,,'efe.- C.neFefe- Total Dose Volume: /dj Gallons Tank Size-Septic/Pump: loot, Coo L, Gallons Alarm Manufacturer: SJ-E ~h 6 Model Number: j-,a, & 41e,* Capacities: A ap inches or „333' Gallons Switch Type: MeG R.,; + B 2.inches or~Gallons Pump Manufacturer: 5'."-/ d + C=inches or /t,! Gallons Model Number: 7/ E PO 4 ~ + D=inches or Gallons (Minimum Discharge ate: ;Z d'.S- Total.....- 3,6" inches or. G Gallons 'vertical Difference Betv4een Pump Off and Oist ibution Pipe: ?.Feet Minimum Required Supply Pressure:../. 3 CS o~............ +,-FFeet "dFeet of Force Main x c2 97Friction Factor/100 Feet: +CZ2 eet Inch Diameter Force Main Total Dynamic Head:...= /6.&7F_eet Internal Tank Dimensions: Length/S04a; Width 53,~v; Liquid Depth J?6 ..r`t /ef ~ '~..~e'+c~icS' Pu-•..`p ! a7 ~ Ca~naei /t~.7t~Z.a~/is~s ~bc ~'l. 4 Gu ^ JblQh { ~r ~ei-~y -~c40e, ffud um. 3871 EP04 EP05 APPk=nM • Fasteners: 300 series Fully subrner~d in high ■ Motor Housing Cast iron 5p~ifipfly designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubric a ti and efficient strength, and durability. • Effluent systems dry without damage to feat transfer. ■ Motor Cove: Thermoplas- components. • Homes Affil" for tic cover with integral handle • Farms motor. and float switch attachment n • Heavy duty sump • 115 Single phase: 114 HP . points. ; muiM indatia { • Water transfer or 2;i0 V, 60 .Hx,1550 Aed and ■ Pwer Carr Severe duty • Dewateri RPM, built in overload with ~ automatic reset tared oil and water rradstant. • EP05 Single phase: 0.5 HP, ■ Gl be ring lower SPECIFICAMM 115 V, 60 Hz, 1550 RPM, heavy duty beating Pump: EP04 built in overload with m EP04 . Thermo- consbltctton. • Solids handling capability. automatic reset plastic Semi-open design new -mm 'A' maXdmum.• . • Power cord: 10 foot PUMP • Capacities: up to 55 GPM. standard length, IN Sim with out vanes for I Y~o ee~saoatloa mechanical sew • Total heads: up to 24 feet with three pmng grounding Win' 41 • Discharge size: I'M NPT. plug. Optional 20 foot Thermo- CSA listed model numbers • Mechanical seal: carbon- length, 1613 WN with plastic endoeM design for end in OF or "AC".) rotary/ceramic-stationary, three prong groundg-dug improved pert - BUNA-N elastomers. (standard on Ep05). ■ Casiag ad Bye: Rol • Temperature: th~mopiastic design provides 1049F (40°C) continuous superior streno and 140°F (60°C) intermittent corrosion resistance. • Fasteners: 300 series METERS FM stainless steel. 10- • Capable of running dry.without damage to s 80 components. i Pump: EP05 8- 9 Solids handling capability: o maximum. £ S° • Capacities: up to 60 GPM. _ s 20 • Total heads: up to 31 feet • Discharge size:11& NPT. z s- o Mechanical seal: carbon- c 15 - 'f rotary/ceramic-stationary, Q 4 BUNA-N dastomers. • Temperature: 3 ao 104-F (4(rC) continuous 140-F (60.°C) intermittent 2 c✓ . ems. 5 p~ OL Of" 10. -30 1 40 so GPM 0 2 4 6 8 10 12 mslh CAPACITY ®1985 Goulds Pumps, I-- Eftcbw May,. 1995 BW1 y(^~ POWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page_ 7 of V FILE INFORMATION SYSTEM SPECIFICATIONS Owner G c r„ S~ c septic Tank Capacity Io o p al ❑ NA Permit # Septic Tank Manufacturer W"eu e'- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Poi /o f( ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model ❑ NA Number of Commerclai Units XQ4A Pump Tank Capacity 6-c d ai ❑ NA Estimated flow (average) ,,,?p c? gayday Pump Tank Manufacturer Cwt/ , es cam. ❑ NA Design flow (peak), (Estimated x 1.5) aye Pump manufacturer u w d ❑ NA Soil Application Rate ; 4 Z C C _.f, 0- ,2 aU /ftz Pump Model ❑ NA Influent/Effluent Quality Monthly average' Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ SandfCravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODE g20 ❑ Mechanical Aeration ❑ Wetland mg/L Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other. Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BODE) 530 mg/L ❑ in-ground (gravity) Cjn-ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At-grade Mound Fecal Coliform (geometric mean) 510' c1u/100m1 ❑ Dri ine ❑ Other Maximum Effluent Particle Size Y. inch diameter • VWWN Vpial for domestic (aon-o~ ) wastewater and septic tank effluent. values Waal for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every ❑ months )Kyear(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (V of tank volume Inspect dispersal cell(s) At least once every _:j:" ❑ months ear(s) (Maximum 3 yrs.) Clean effluent filter W At least once every ❑ months ,year(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA As'/V e P d a Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA , /Ve e of e d other At least once every ❑ months ❑ year(s) X NA Other At least once every months ❑ year(s) XNA d„r a/~jy,Itrj/Mr~c very .~Y~~~s. ~vcYeca,.• d tf ri ~F M~' I-cevrw,ws~ MAINTENANCE INSTRUCTIONS yowic/tr., every t',+<1 to ~~•r~.4 p••~~~r+a dwh~~ot ♦he ~..Jy~th inspections of tanks and dispersal cells shall be made by an kldividual drying one of a following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintalner, 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 oeli(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 ()r,) 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, pretreattment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A SeMce 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. ~1oc,.~ c✓ /R !t Tar- V Nry' JChoen Page V of system startup shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above nom highwatsr levels, When power is restored the excess wastewater will be discharged to the dispersal o*s) in one lafge 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 Open W 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 dispersed calk. Do not drive or park over, or otherwise disturb or compact, the area within IS That down slope of any mound or at-graft soil absorption area. Reduction orellmkotion of the following from the wastewater stream may Improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cue butts; condoms; oration swabs; degreasers; dental floss; diapers; disinieotants; 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. ABANDON14TENT When the PO% TS falls and/or is permanently taken out of service the blowing st shall be taken to Insure that the system is properly and sallfely abandoned In compliance with ch. Comm 83.33, WYisoonsin 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 propery domed. 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 materiel. 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 system. The replacement area should be protected from disturbance and compaction and should not be inbinged upon by required setbacks from wdsft and proposed structure, let lines and wells. Failure to protect the nit area will result In the need for a new soil and site evion to establish a suitable replacement area. Replacement systems must comply with the rubs 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 faded 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 I POWTS INSTALLER POWTS MAINTAINER Name pen !~f/Q Xc a t~ y Name q- y-r c 1/.r X. Phone 7/,S e-Z / - c> Phone 71.s' SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name />~~~~.//s s~ f,4c± Agency Phone Phone .71ss- 386'"- 6cf~0 This document was drafted the stalls of the Green take, Mar+gt~afea and Waushara County Zoning and $anibtion agencies. This document meets ;he minimum nequin m mts of ch. Comm 83.22(2)(b)(1)(d)&M and s3.W), (2) & (3), Wks Adrsde ative Code. Use of this document does not guarantee the performance of the POWTS. GMW (got) #1694 J$CQn$J/j SOIL EVALUATION REPORT Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Steel's Soil Service, Inc. Attach complete site plan on paper not less than 8%x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. - / Z -✓t3"~~ P/ p n all pr Reviewed By Date ~t Personal information you proe m used for (Priva Law, s. 15.04 (1) (m)). 71,Z Us Property Owner Property Location K & D Holdings LTD ° JUL 6 200 Govt. Lot na 1/4, SW1/ , S28, T281N, R17W Property Owner's Mailing ST CF20iX COUNTY Lot # Block # Subd. Name or CSM# 15370 Afton Blvd. SO 3 na CSM-Pend City Mn t ~ City D Village ❑ Town Nearest Road Afton 55001 651-998-0540 Pleasant Valley D S 170Th St ® New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD ❑ Replacement ❑ Public or commercial - Describe: na Parent material Low ridges and foot slopes of ground moraines Flood plain elevation, if applicable na ft. General comments Mound design, system elevation 99.59ft based on contour line elevation 9 . and recommendations: q 117 Boring # ❑ Ground surface elev. 98.40 ft. Depth to limiting factor 24 in. ® Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-11 10yr3/2 none sil 2msbk mfr rs 1c .6 .8 2 11-24 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 24-48 10yr4/4 c2d5yr5/6 scl om mfr na na .0 .0 2] Boring # ® Ground surface elev. 98.40 ft. Depth to limiting factor 17 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef= 1 0-8 10yr3/2 none sil 2msbk mfr cs lc .6 .8 2 8-17 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 17-48 10yr4/4 c2d5 r5 sicl om mfr na na .0 .0 water at 24" * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 S30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signature: CST Number David J. Steel 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St. Baktwin, WI 54002 6/9/2005 715-760-0347 SBD-8330 (R07/00) Pyl3erty Owner K & D Holdings LTD Parcel ID # Pending Page 2 of 3 3 1 Boring # ❑ ✓ ® Ground surface elev. 97.00 ft. Depth to limiting factor 23 in. Soil Application Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fts in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 *Eff#2 1 0-11 10yr3/2 none sil 2msbk mfr cs 1c .6 .8 2 11-23 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 23-48 10yr4/4 c2d5yr5/6 scl om mfr na na .0 .0 water at 27" ❑ Boring # ❑ Ground surface elev. ft. Depth to limiting factor in, ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 -Eff#2 ❑ Boring # ❑ Ground surface elev. ft. Depth to limiting factor in. ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#t -Eff#2 Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 <150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) steel's sou swAm. Inc. . t• STEEL'S SOIL SERVICE INC. 3 of 3 David J. Steel K&D Holdings LTD 994 200t` St. CST-POWTSM SEl/4,SW1/4,S28,T28N,R17W Baldwin, Wl 54002 Lic. #248956 Town of Pleasant Valley, St. Croix Co. Direct 715-760-0347 CSM Pending Lot, 3 Fax 715-684-3449 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown, as permanent lot lines were not established at the ti a the soil test was conducted. Legend N 1" = 40' I ♦ = Benchmark Ele. 100.00 ft Top of 3/4" pvc pipe • = Alt Benchmark Ele. 99.90 ft Top of 3/4" pvc pipe = Borings Boring Elevations J / 4/5.3 t- s'r B1 = 98.40 ft ' ~ B2 = 98.40 ft ,.o B3 = 97.00 ft !f B4 = 0.00 ft 4 170' 2 I 15 ~ may' Y~ 33 /57' 5` a~J i cps C~7.6°` RECEIVED E32 6 7 6 2 AUG 2 3 2006 KAY _21 PH GE 5219 ' REGISTER OF DEWAIMW EDS ST. CROIX CO. 1111 RECIVED /051200% 03E69pM CERTI FI M S V RV YIV 06 LOCATED IN PAR OF THE SW1/4 OF THE SW1/4 CERTIFIED SURVEY MAP OF SECTION 8, T26N, R17W, TOWN OF REC FEE: 13.00 COPY FEE: 3.00 PLEASANT V LLEY, ST. CROIX COUNTY, PAGES: 2 WISCONSIN. W1/4 CORNER SECTION 28 I o0 08'48"w OWNER SURVEYOR K & D HOLDINGS, LTD EDWIN C FLANUM 5370 AFTON BLVD. S. NORTHLAND SURVEYING, INC. 17 MG`~I~~G~144LSD [>=QG~JD~ AFTON, MN 55001 P.O. BOX 14 ROBERTS, WI 54023 1 1 - - - - -N89°42'54' W 1312.62' -x ix-~-=- 33.Q0' 1279.62' N I 6' I Cl NORTH LINE OF THE S1/2 OF THE SW1/4 LOT I LL o g w I S 8 12.05 ACRES INC. RNV 0 1~ (524,916 SQ. FT.) S 1 I ® ® 11.75 ACRES EXC. R/W 1 ® (511,716 SQ. Ff.) I ' 33 33 90, N89°42'54"W 1311.96' a AL 1278.96 e I 1 so:a-o'„ , LOT 2 w I ? 3- Q p 12.04 ACRES INC. R/W W II I co. tl I_ c7 z \ 1 (524,650 SQ. FT.) o N 0 0 a I IgN- ~ wti r II Gc~ g w 11.74 ACRES EXC. R/W J O _ v * m• w Z (511,450 SQ. FT.) 1- W ( I LOT 2 IS SUBJECT TO AN EASEMENT r L'I I S: FOR INGRESS AND EGRESS TO LOT 1 cf) ~~a 1 o N89°42'54"W 1311.29' 33.00' 1278.29 Z aiW LOT 3 I I~ 13.39 ACRES INC. R/W Q v°v 1~°v (583,451 SQ. Ff.) 13.06 ACRES EXC. RAN I U (568,909 SQ. FT.), I 1 I NORTH LINE OF THE SOUTH 66' OF THE SW-1/4 _Q d I 6' I 33.00' . I T 1 7 66' WIDE ACCESS EASEMENT FOR LOT 3 Z cr~ I I - z e CENTERLINE OF TRANSMISSION UNE Q - - - - -1 - - - - - - - - - - - - x-x-x_x-z SW CORNER SOUT LINE OF THE SWi/4~ CENTERLINE OF EXISTING DRIVE x k-x " S89°19'79"E I SECTION 28 SC LE IN FEET 1" = 200' MmG° mip mp) D=AHD'(:~B N S1/4 CORNER 200' 0 200' SECTION 28 00 LEG ND ` N\\„H1\INIIIIN//y/~~~' ¢ o g SECTION CORNER POSITIONED FROM -x-x- EXISTING FENCELINE `zs Q ti v X TIES OF ECORO • , 50' ROADWAY SETBACK LINE y, FLANUM = w w 1" O.D. IR N PIPE FOUND R g_2gg7 A, SOIL TEST FOUND 3 AMcRY a v~ Z 3/4" X 18" IRON REBAR SET WEIGHING ~s WIS Z = ¢ 1.50 LBS. PER LINEAR FOOT ® SOIL TEST FROM SOIL 1 o TESTER'S MAP m OU I I EASEME T FOR INGRESS & EGRESS THIS INSTRUMENT DRAFTED BY KEVIN REED JOB NO. 06-07 DATE 02-03-06 REVISED 05-24-06 SHEET 1 OF 2 SHEETS 1 ot2 Vol 21 Passe 5219 II lllllllllllllll I III III i ~ ~I III I I Rn4475n Tx4n3262q State Bar of Wisconsin Form 1-2003 WARRANTY DEED 947410 F BETH PABST t 3 Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 12/16/2011 3:02 PM THIS DEED, made between K & D Holdings Ltd., a Minnesota Corporation EXEMPT#: NA REC FEE: 30.00 e ("Grantor," whether one or more), TRANS FEE: 225.00 f and Gerard E. Schoen PAGES: 1 1 € ("Grantee," whether one or more). { Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address needed, please attach addendum): Gerard E. Schoen Lot Three 15370 Afton Blvd. S. (3) of Certified Survey Map in Volume Twenty One (21) of Certified Afton, MN 55001-9734 Survey Maps, Page 5219, as Document Number 826762, filed in St. Croix County Register of Deeds Office on June 5, 2006, being located in the Southwest Quarter of the Southwest Quarter (SW 1/4 of SW 1/4) of Section Twenty-eight (28), Township j Twenty-eight (28) North, Range Seventeen (17) West, Town of Pleasant Valley. 024-1032-10400 j Together with an appurtenant easement for ingress and egress over and across Parcel Identification Number (PIN) the West 1,277.60 feet of the South 66.0 feet of SWIA of SW I/4 of Section 28, Township 28N, Range 17W, Town of Pleasant Valley, as created and described in This is not homestead property. } that certain Easement Agreement dated April 28, 2006 and.filed with the St. Croix (is) (is not) County Register of Deeds Office on May 9, 2006 as Document No. 824861. } Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Restrictions, reservations and easements of record; and Grantor certifies grantor does not know of any wells on the property. 1 Dated December 15, 2011 K t&OLDINGS/. e (SEAL) (SEAL) * * Gerard E. Schoen, President ° (SEAL) (SEAL) Z * * Kurt R. Fuchs, Vice President AUTHENTICATION ACKNOWLEDGMENT Signature(s) I' 1 STATE OF MINNESOTA ) ) ss. authenticated on DAKOTA COUNTY ) x * Personally came before me on December 15, 2011 TITLE: MEMBER STATE BAR OF WISCONSIN the above-named Gerard E. Schoen, President and Kurt R. j Fuchs Vice President of K & D Holdings Ltd. i (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. 4 A - - - - THIS INSTRUMENT DRAFTED BY: I a * DMIEL J. RMEGEL Donald J. Fluegel, Esq., WI Atty. #1005189 NO" 1111118ft 999 Westview Drive, Suite 1, Hastings, MN 55033 Notary Public, State of Minne z My Commission (is permanen ANARIM11ft JAL 111.116 e (Signatures may be authenticated or acknowledged. Both are not ne p NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 * Type name below signatures. 1 of 1 q ! RECEIVED 8 2 6 7 6 2 AUG 2 3 2 AL,~~_ PAGE 5219 _ RDCsISTER Oog DSBM~'" ST. C802X CO. MI IYED BECE FitCpRD CERT1 FI S V RV e~.os.z 63.-own LOCATED IN P OF THE SW1/4 OF THE iV /4 COMIFIED StWV" MAP OF SECTION 6, T28N, R1 TW, TOWN OF MW "Mt 13.4* - cE1PY pmt 3.08 PLEASANT V LLEY 8T. R C OIX COUNTY PAGES t 2 WISCONSIN. W1/4 CORNER SECTION 28 4e W OWNER SURVEYOR ! ! K & D HOLDINGS, LTD EDWIN C FLANUM 14 ! ! o A SA~ONFTMN BLVD. S. P ORTSHOX NO SURVEYING. INC. CU1- - - - U - - - - D-- ROBERTS. Wt 54o23 ! N69042'SA W 1312.62' ~.-k 33.00' 6' N NORTH LINE OF THE +I S1/2 OF THE SW114 ti ! ( LOT1 of w $ $ 12.05 ACRES INC. RAN z ! ! ~ 524,918 SO. F7. c ® 11.75 ACRES EXC. R/W 3 ! ! ® ~ (511,716 SO. FT.) ! 13 3 t 33,9(Y N89°42'S4"W 1371.96' 1278.96 .p! ! 906a y LOT 2 z= d ! 12.04 ACRES INC. R/W U I °v z (524,650 SO. FT.) c7 N !S2 ¢ 11.74 ACRES EXC. R/W Y (511,450 SO. FT.) T W t! - ! } LOT 2 IS SUBJECT TO AN EASEMENT r FOR INGRESS AND EGRESS TO LOT 1 r qq ! ' Q ' N y 89°42'S4'W 1311.28' A d 12 3.00 3 Z 1 a~ LOT 3 ~I ! s 13.39 ACRES INC. R/W Q ! 3 ~,~Q (583.451 SO. FT.) t ! ! I !1 13.06 ACRES EXC. R1W i t U (588,909 SO. FT.) i ! !I 6' ! NORTH LINE OF THE SOUTH 66' OF THE SW-I/4 ! o 33.00 66, WIDE ACCESS EASEMENT FOR L.OT 3 t - --m - _ - _ _ _ --w,- ~C. p yMe~•O~I - OF 1iiANS_I,MSSION U_NE - - - g - - - - ---A^Z-- SOUTI LINE OF THE SW CORNER SW1/4 CENTERLINE OF EXISTING DRIVE k kV , 1 ' I SECTION 28 SCALE IN FEET 1" = 200' x 3 0. S7/4 CORNER N 200' 0 2Op, SECTION 28 lu 00 ° LEG ND " SECTION CORNER POSITIONED FROM EXISTING FENCELiNE SC~ ' X TIES OF ECORO C. Sd ROADWAY SETBACK LINE FEOWN W,kM4 v r 1' OZ. IR N PIPE FOUND 5-2487 SOIL TEST FOUND Ahf2RY _ iNIS/Jy/ z w p 3/4'X 18' IRON REBAR SET WEIGHING ¢ F 1.50 LBS. PER LINEAR FOOT ® SOIL TEST FROM SOIL TESTERS MAP _ II m w C] I I EASEMENT FOR INGRESS & EGRESS THIS INSTRUMENT DRAFTED BY G' KEVIN REED JOB NO. 06-07 DATE 02-03-06 REVISED 05-24-06 SHEET I OF 2 SHEETS 2 of Vol 21 Pet.-,e 5219 i Marcel 024-1032-10-400 04/18/2007 02:51 PM PAGE 1 OF 1 ' Alt. Parcel 28.28.17.203D 024 - TOWN OF PLEASANT VALLEY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 07/19/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - K & D HOLDINGS LTD K & D HOLDINGS LTD 15370 AFTON BLVD S AFTON MN 55001 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 105 170TH ST SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 13.390 Plat: 5219-CSM 21-5219 SEC 28 T 28N R17W SW SW CSM 21-5219 LOT Block/Condo Bldg: LOT 03 3 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-28N-17W SW SW Notes: Parcel History: Date Doc # Vol/Page Type 06/05/2006 826762 CSM 03/16/2004 756707 2527/152 WD 10/01/2002 692325 1994/20 WD 03/18/1998 575280 1306/519 WD more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2006 Description Class Acres Land Improve Total State Reason I Totals for 2007: General Property 0.000 0 0 0 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 t e 6Aj Parcel 024-1032-10-400 06/04/2014 08:45 AM PAGE 1 OF 1 Alt. Parcel 28.28.17.203D 024 - TOWN OF PLEASANT VALLEY Current FX-1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 07/19/2006 00 0 Tax Address: Owner(s)' 0 = Current Owner, C = Current Co-Owner GERARD SCHOEN 0 - SCHOEN, GERARD 15370 AFTON BLVD S AFTON MN 55001 Property Address(es): * = Primary * 105 170TH ST Districts: SC = School SP = Special Type Dist # Description SC 0231 SCH D BALDWIN-WDVILLE SP 1700 WITC Notes: Legal Description: Acres: 13.390 SEC 28 T 28N R1 7W SW SW CSM 21-5219 LOT 3 Parcel History: Date Doc # Vol/Page Type 12/16/2011 947410 WD 06/0512006 826762 CSM 03/16/2004 756707 2527/152 WD 10/01/2002 692325 1994/20 WD more... Plat: * = Primary Tract: (S-T-R 40%160%) Block/Condo Bldg: * 5219-CSM 21-5219 024-2006 28-28N-17W SW SW LOT 03 2014 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/19/2014 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 7.000 1,400 0 1,400 NO 10 AGRICULTURAL FOREST G5M 6.370 14,700 0 14,700 NO 10 Totals for 2014: General Property 13.370 16,100 0 16,100 Woodland 0.000 0 0 Totals for 2013: General Property 13.370 78,300 0 78,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Cen eel', Mailing Address _ ZZZ2 Property Address (~w 165 70 4-L -6 e (Verification required from Planning & Zoning Department for new construction.) ti City/State ltl~l Parcel Identification Number (0, 2 W(~~: LEGAL DESCRIPTION Property Location~~ 1/4 Sec. , ' TJ~' N R W, Town of ~ Subdivision Plat: , Lot # . Certified Survey Map # Volume C9 , Page Warranty Deed # 7 / TL (J (before 2007)Volume , Page # Spec house ❑ yes ❑ no 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 §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The properly 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. 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 Safety And Professional Services 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. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE * * *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. 04/12) 1 i ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Cpt,~ A eel', Mailing Address 4 Property Address 9'4 e- (Verification required from Planning & Zoning Department for new construction.) 1 Number ~;~'~Y` ` \ Parcel Identification City/State (.!/1 ~ LEGAL DESCRIPTION C , W, Town of .~Q Property Location 1/4 e7 k 1/o Sec.Q ' Ta'z N RZ Lot # Subdivision Plat: Certified Survey Map # a , Volume , Page # dl Warranty Deed lL d (before 2007)Volume , Page # Spec house ❑ yes ❑ no 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 §SPS. 383.52(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 Safety And Professional Services 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 form are true to the best of my/our knowledge. I/we am/are the owner(s) of the prope descr' d above, by virtue of a warranty deed recorded in Register of Deeds Office. Nu ber of b ooms GNATURE OF APPLICANT(S) DATE * * Any lormation 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. 04/12)