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HomeMy WebLinkAbout020-1456-19-000onsin Department of Commerce PRIVATE SEWAGE SYSTEM rely and Building Division r INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Miller Homes of Hudson, LLC Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: /~ a rn , ~sT TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~.~1~e~, : ~' s 1 Z56 Pa laG~ PL SZ Aeration Holding TANK SETBACK INFORMATION TANK TO P/ SbJ~ WELL BLDG. Vent to Air Intake ROAD Septic ~ 7 ~ A)~ z 1 ~ ~ ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number - ---- ____ TDH Lift Fr' lion Loss System He TDH Ft Forcemain Length Dia.- ` Dist. to Well SOIL A6SORPTION SYSTEM ELEVATION DATA d`j3 STATION BS HI FS ELEV. Benchmark q•(~Z~ f 9 ~ d f 6~ ~ AI~B tdr ~~~ ~31~ 2„~er.... 3, ~'g ~ /OV • y Bldg. Sewer 7 ~ ~3 ~~~ • (tic( SUHt Inlet q '~ ~. ~ ~ Z SUHt Outlet /b . I 9°/ • S Z. Dt Inlet ~ Dt Bottom ~ Header/Man. ~/ Z S gs, • 3~ Dist. Pipe Il•~es 97.~~ Bot. System Final Grade 9 , ~ /dQ .loZ St Cover BED/TRENCH DIMENSIONS Width I 3 Length t ~ Z No. Of Trenches Z C..t ~ ~ PIT DIMENSIONS ` No. Of Pits ` Inside Dia. ~ Liquid Depth ~- SETBACK INFORMATION SYSTEM TO P/L ~ BLDG ~~ WELL LAKE/STREAM LEACHING CHAMBER OR Manufacture= , i/~~r ~7Y Type Of Syst ^ $~ / 33 r ~ n ~~ UNIT Model Number. J ~ G~ -~J~ DISTRIBUTION SYSTEM E~a~ ZS t c3 = '~ CQ ~'~ dr,~ Header/Manifold p / Distribution x Hole Size x Hole Spacing Vent to Air Intanke ~( ~ Pipe(s) ~ ~ ~ S i h Di ~ \ o..~,~ i- Z N !( Length Dia pac ng Lengt a c SOIL COVER v Proccuro Cvcfwme Anly xx Mnund Or At-Grade SV5temS Only Depth Over / Depth Over xx Depth of xx Seeded/S ded xx Mulched Bed/Trench Center 2 / ~ Bed/Trench Edges Topsoil a Yes 0 No Yes ~ No J b~7 ~ \ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 1043 LaBarge Road Hudson, WI 54016 (NE 1/4 W 1/4 11 T29N R19W) Sunset Hills 1st Add Lot 19 1.) Alt BM Description = °~ ~ ~~ ~ I ~ ~ ~ ~ ~ ~: ,n.~ f' G QL~S a v~ 2.) Bldg sewer length = Z I ~~,~r-~ - amount of cover = ~ ~ Plan revision Required? ~ _, Yes No I_-~ ' 1 Use other side for additional information. ~ ~ lP Date SBD-6710 (R.3/97) Inspection #2: / /, Parcel No: 11.29.19. - ~ ~, ~ ~ ~- ~~ ~ J Insepcto s Signal Cert. No. 1 V' County: $t. CroiX Sanitary Permit No: 487972 0 State Plan ID No: Parcel Tax No: '~~~~ \H~ ~ 1 ~ a ~ o Section/Town/Range/Map No: 11.29.19. fe d Buildings Division County ` ~ ~ 2 W. ington Ave., P.O. Box 7162 S j ~.o ( ~seons~n De t M iso WI ~ ) 6-31~~~ ~~~ Permit Number (to be filled in by Co.) ,/~2c~} ar ment of Commerce IC Z T -t ,. Sanitary Permit App 'e ~ State lan LD mber . Nu In accord with Comm 83.2], Wis. Adm. Code, personal i onnati you pro~vOde~ ~ ~ ~~~ may be used for secondary purposes Privacy Law, s15.04 )(m) Proj t Address (ifdifferent than mailing address) ST. CROIX I. Application Information -Please Print All Information ZONING OFFICE ~ IO~-3 La p ~ n (1 D ~ ~ C Pro pert y Ow n er's N a me Parcel # Lot # B{ oo k # ' ~ ,t /J/f .} ~ y ~ C e Property Owner's Mailing AddressP rop e Location Bo '~/S / ~ /~'/., .~~//., Section l City, fate Zip Code Phone Number v,('_S ~ GCJ ~ s`( ~ ~ ~ 3~ (p' Z 7 ~ ~ (circle ) T R~E ~ 7~ N ; o _ II. Type of Building (check all that a I PP Y) ^ 1 or 2 Family Dwelling - Number of Bedrooms ~ - S toe ~C. ~~a. ~ Subdivision Name .--~SM~~Iumber ^ PublidCommercial -Describe Use Su .~ S ."r l4 i ~I ~ ~ ~ . nl ^StateOwned-Describe Use 6- ~v: s~ 9•~ ~rl~lD,f(A s•y' ^City ^VillageQ7'ownshipof ur~setw 6Zb . ,- CG7 mm~ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) d ~ _ _ c fb _ 0 A. New S stem ^ R lacement S stem Y ep y ^ TreatmentlHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a 1 Z- T w•, Z C ~ s.a.e. ~ ~. Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ~ Leaching Chamber ' -Q Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pro osed (st) System Elevation VI. Tank Info Capacity in Gallons Total Gallons Number of Units an facturer rQLs~s") Prefab Concrete Site Constructed Steel Fiber Glass Plastic New Tanks Existing Tanks 717 ~ ¢ I Lo ~ f"~ ~ ' (m/ '~ Septic or Holding Tank ~Zs o ~: 54~ Aerobic Tttatrnen[ Unit /~ ~ ~ ~• / ~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number ~' ~~ /uG ~ l ~ zz SG 3G /s = 6o-z5 Z s- Plumber's~Address (Street, City, State, Zip Code) ° b ~ ~,?ter /~.'.P ~- ~r/ so 4 Gv o/ VIII. Coun /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (i ludes Groundwater Date Issued Issuin gent Signature o Stamps) ^ er iven Reason for Den ~ I Surcharge Fee) ~~ ~ /~Q , O~ IX. Conditions o Approv al SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced f maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. ~•••••v~•~ p••~+ l~~ ~~~ ~.uuu~y umy J wr me system on paper not read than a1/l x L trachea in size SBD-6398 (R. O 1 /03) ~~' 76 Z A~ o ~' ~ ~ C~ _Q ~ I o ~ e ~ d ~ ` 4, ~K ~ p ~ ~ ~ ~ ~ ~ w, ~~~ ~ ~ ~- ~ d J J, ~~~ \ ~~~~~ ~/ v 'y ~ \ ~ '~~ ~ ~ I~ ~ ~ # t'Q ~ ~ qq(( \6! '`~ J ~ ~ ~ 0' ~ ~. V1 ~ Q \t - i ~ ~ ~ ~ ~ v ~ ~ ~ M d ~ t ~ , J ~ ''~ ~~ ~ ~ ~ ~ ~~ w ~~ `~_. _ _ ~LepY a ~i ~~ .-.~ r u ~ .. Q • d6. 76 ~. A~ ~ ~ l~ f~ ~~~ \ ~ ~~ ,- 'ter ~ '~ \ '~I ~ ~ ~ ~# t~o 4 o g N \ J ~ ~ \ ~ ~ Vl J ~ ~ ~ ~1 - ~ ~ o ~ ~ ~ y v r -' W m d ~ N M ~ ~ ~ ~ ~ ~ ~ \ d J ~~ ~ \fl N ~ d J ,~ $ I ~ c a ~ 4. h- d ~ i ~ ~~~ p ~ ~ K , ~ ~ ~: ~~ d ~Y ~ o k'~,A y ~' ~ ' ~ i 1" ~~ W ~~~ _ l- u ~,; ~- ~O$`Of~ r+oi M _ ~, ._~ .. ,~ .. a ~`'~ u M t JAN ~~ ~ ~~~`~'SOII~ EVALUATION REPORT Wisconsin Department of Com arcs r Division of Safety and Building 5 7 . i/R~Igddpde with ~o~r, ud~, Adm. bode 1881 Page r of 4 A.C.E. Soil & Site Evaluations L ZONING OFFI('F E~ ~~ ~ ~~ U Attach complete site plan on paper n size. PI~- D County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to n~rest road. . . Pen 'n from 020-1012-00-000 Please print all information. Ravi Dat Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~ a Ca< If,~" Property Owner Property Location Miller Homes Govt. Lot NE 1/4 SW 1i4 S 11 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 868 Kelly Road 19 Sunset Hills First Addison City State Zip Code Phone Number ~ City ~J ~Ilage ~ Town Nearest Road Hudson ~ WI 54016 715-531-0714 Hudson LaBarge Road New Construction use: f~'' Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement J Public or commercial -Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Recommend installing two trenches at 3' X 87.50' using twenty eight (28)11" Standard Bio-Diffuser Chambers at elev. = 97.00' ^ Boring # ~ Boring > 114" in. Pit Ground Surtace elev. 99.93 ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dift~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 1 0-8 10yr3/3 none sl 2fsbk mfr as 2fm,1 c 0.6 1.0 2 8-24 10yr4/6 none sl 2msbk mfr cw 2fm,1c 0.6 1.0 3 24-30 10yr4/6 none gr Is 0 sg ml aw 1fm 0.7 1.6 4 30-114 10yr5/6 none s & gr 0 sg dl - - 0.7 1.6 .aO 3s.i~~ .lb H#4 contains stratified layers of sand & gravel. Approx. 10 horizon consists of materials coarser than medium sand. ^ Boring # ~ Boring Pit Ground Surface elev. 99.51 ft. Depth to limiting factor > 118" in. Soil Appligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 1 0-8 10yr3/3 none sl 2fsbk mfr as 2fm,1 c 0.6 1.0 2 8-18 10yr4/6 none sl 2msbk mfr cw 2fm,1c 0.6 1.0 3 18-27 10yr4/6 none gr Is 0 sg ml aw 1fm 0.7 1.6 4 27-118 10yr5/6 none s & gr 0 sg di - - 0.7 1.6 3p,rZ (o(,,rL 'Effluent #1 = BOD ~ 30 < 220 mg/L TSS >30 < 1 mg/L Effluent #2 = BOD < 30 mg/L and TSS <~0 mg/L CST Name (Please Print) Signatur . CST Number James K. Thompson %z 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane. O . WI 54020 1227!2004 715-248-7767 Property Owner Miller Homes parcel ID # Pending from 020-1012-00-000 Page 2 of 4 Boring # ~ Boring 1/ Pft Ground Surtace elev. 102.35 ft. Depth to limiting factor > 125" in. Sat Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Coior Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/3 none sl 2fsbk mfr as 2fm,1c 0.6 1.0 2 10-36 10yr4/6 none sl 2msbk mfr cw 2fm,1c 0.6 1.0 3 36-41 10yr4/6 none gr Is 0 sg ml aw 1fm 0.7 1.6 4 41-125 10yr5/6 none s & gr 0 sg dl - - 0.7 1.6 6 ~ z vo . v H#4 contains stratified layers of sand & gravel. Approx. 10% of -+n.~>nn insists of materials coarser than medium sand. ^ Boring # J Boring _f Pft Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # ~ Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Coni. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 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. SOIL AND SITE EVALUATION ~ $$~ Page ~_ of a PROPERTY OWNER: Miller Homes PARCEL I.D.# Pendingfrom o20-1012-00-00o AC.E. Soil dt Site Evaluations REPORT MEMO Soil evaluation completed prior to plat review. Changes in lot line locations or building site may result in additional soil evaluations being required. Lot line locations must be verified prior to permit issuance and system installation. r P%~o~ ~.w-~ ~P~d ~ax.o' rol o' ~ ' ~ t < < ~ ~ ~ ~ ~ ~ ~ ~ ~ C a ~ ' l t 43 i i ~~ ~!~ ~/Q~Gt4'~i0rt Jai i • E!V-va~io~ -~- EXI.S tr'~ ~Qaccl.:~~ S SccASt ~f~Y/s 3.tc. i!, T , of . Sf •~i fie. c~/. ~e~ '~/~/ 99.0. Con~AW i ~` *- ` ~ ^ ~` a ~ ~ = r,~'~ s ~ ~~'ys ~tb•-~ ~ = Ass u.mt~d `~ ~ ~~ Q e 1 e% = /~ d7 ` s ~ '~`'~ 1 \ =p ~ \ ~ ~ ,. ~ ` ~ ~_ ~ r~ ` s ~ ~~ ~ ~ ~ t _~ ' tgz, ,tl if • ~ Afi; ~/° of ,C~rxe ~Ons~ • \ E/c~r = i~ ~~ A~. ~oFy T ~ ~ ~ ~s Polylok PL-525 Support Stantl Should you feel it necessary to add additional su ort to the PL-525 fil r pp to , use asix-inch Schedule 40 or SDR 35 pipe to extend from the base of the filter to the bottom of the tank. The extension pipe needs to be anchored to the filter housing with one or two #1 O.X 112" SS screws. -- Anchor 1-2 Stainless steel screws through housing and into pipe. Use #10 X 112" Pipe rests on bottom of tank J _ --_ ------ 6"Schedule 40 Pipe ~, S ~ ~ sow ~/ ~' ~/s ~„~ ~,~~" - Quick~rM STANDARD CHAMBEr~' ,~... ~uick4 Standard Chamber i t ,. __ _ _ 3,. _.. - --- ------- ---~ SECTION VIEW 'I MultiPort End Cap - -- I ~, ; ,, 'r~ it --- ~~ - ;:y ~ ~, ,~ , I + _.__ _~ I :~4~' FRONT VIEW _ - - - - __ ... 52" ------- ---- " ~r'" cC;TIVE LENGTH) --- ~---_-- __ - ~~ - - j - I , _l 'i - ~ ---._i ~. _~. ~---1 ~' i f '.7 .. e ~ ; ~ _ ~ ~ Ij ~~ j I _i .._ _ _ -- ---~ - I SIDE VIEW I\ . ~~ III'' ~/1!-,. ~, I _ - ~ TOR VIEW Quick4 Standard Chamber Nominal Specifications ^,lultiPort End Cap Nominal Specifications Size(WxLxH)~~ 1 ;>i~r$x~'t ,~`.~4'x52"x12" ;ize(WxLxH) 34'x16'x12' Effective Length >` ' ~ /^~: ~~~ ~ • }• 48" !avert Height 8" or 1.25' Invert Height, r l ~~;r ~ ~ ~,-,ti's .a+~ 8., `- ~1 i 1 (7.^ M 4 i i INFILTRATOR_SYSTEMS INC. STANDARD LIMITED WARRANTY ---. 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Ief!`5 Inr, •i~ 2(103 Inhllrglnr SYS tm< Inc ,. .. .. ~• -• POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of Z FILE INFORMATION Owner ~.-,,~ aI/~L ~~,~_ Permit # C~01C ~Z DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units NA Estimated flow (average) `- ~ d ~ al/da Design flow Ipeak-, (Estimated x 1.51 (~ ~© al/da Soil Application Rate ~ ~ al/da /ft~ Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOG) S30 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform IgQometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other. ^ NA 'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity (Z.'S d ai ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ~,Q i~ L ^ N.:, Effluent Filter Model ~ _ ~~ p ^ NA Pump Tank Capacity al ~A Pump Tank Manufacturer t~NA Pump Manufacturer ~yvA Pump Model ~iNA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~A Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event - Service Frequency Inspect condition of tank(s) ~ At least once eve ~'~ ^ month(s) (Maximum 3 ears) ear(s- y ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY,I of tank volume ^ NA Inspect dispersal cell(s) At least once every: ~ ^ month(s) (Maximum 3 years) ^ year(s) ^ NA Clean effluent filter At,least once every: ( - ~,. ^ monthlsl year(s) C NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) , Flush laterals and pressure test At least once every: ' ^ month(s) ^ year(s) A Other: At least once every: ^ month(s) ^ year(s) N'~ Other NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tang inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pona~ng of effluent on the grotfnd 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 IY,1 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and dispo$ed of in accordance with chapter NR 1 ? 3, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event -~'? J`rr,,`.~•~hAND OPERATION Page Tot ?/ F~o;new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shalt not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 1 5 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area, Replacement systems must comply with the rules in effect at that time. ' ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ T alua ' b ai e '~~Z01-/181T~11 `~C~2- /~/~1~/ ~-ONS`TRIl~?l p~ank ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name /~ kF aryl ~ l~ d ~F~~ Name Phone ~ ` L _ ~ S ~ , ~ ~'~ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone This document was drafted Name S ~' ( d 20r~(~ Phone ~/s- 30 (p- (D (~ in compliance with Chapter Comm 83.22(21(b1(tlldl&(f) and 83.5411-, (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIl' CERTIFICATION FORM OwnerB uyer Mailing Address Es s~ ~~ ~ ~ Property Address _~°_ ~ ~ ~ 4 /S O- /~- o i. S'fa /~o (Vcrificatioa required from Planning Department for new construction) © 20 - /o/ 2 - 0 m - o©o City/State •f-~~,~.s ~ -~ Gy / Parcel Identification Number o 2-0 - /n/ 3 ` S~ - °O d LEGAL DESCRIPTION Property Location ~ '/,, 5 w '/,, Sec. ~ T Z~' N-R /9 Town of ~vds o N Subdivision S~ ~ Sort' N ' ~~ s 1=. ('sfi ~~~: ~' ~ acv .Lot # ~ 9 Certified Survey Map # ~ ~/ S/.S ,Volume ~~ ,Page # ~ Warranty Deed # 7 SZo 5ra ,Volume Z 7// ,Page # ~ ~ Spec house ~1 yes ^ no Lot lines identifiable~`J yes ^ no SYSTEM hAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper mainte~~:e consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the s~•s:er: can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and b,.• a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal syscer_: 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 stznda-rds set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin, Certification. stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 3G da of th ear expiration date. NA PLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the o„Te~s; o: the pro c 'bed , by virtue of a warranty decd recorded in Register of Deeds Office. ~D / Z8/ O~- S A OF APPLICANT DATE • •"•' Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ` ` •• Include with this application: a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2711P y17 Document Number STATE BAR OF WISCONSRJ FORM l - 2000 WARRANTY DEED Thls Deed, made between Celeste M. Bennett andSlCie~thlD. Joers°ohs Grantors, and Miller Homes of Hudson, LLC, Grantee. BB p Grantors, for a valuable consideration, convey to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Propel") (if more space is needed, please attach addendum): Part of the NW'/. of SE'/. and the NE'/, of SW'/. of Section 1 1, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: Beginning at the NE corner of the NW'/. of SE'/. of said Section 1 1; thence West 2640 feet to a steel stake; thence South 613 feet to a steel stake; thence East 1320 feet to a steel stake; thence North 288 feet to a steel stake; thence East 83 5 feet to a steel stake; thence South 75 feet to a steel stake; thence East 485 feet to the center of Tanney Road; thence North to the point of beginning. I Recording Area ALSO A tl that part of the NE'/, of SE'/. and the N W'/. of SE'/. of Section 1 1 , Name and Retum Address Township 29 North, Range ] 9 West, Town of Hudson, St. Croix County, Sam E. Miller Homes Wisconsin lying Wly of the following described line: Commencing at the E'/. P•O. Box 151 t1~ corner of said Section 1 l; thence S89°30'00"W along the North line of said SE'/., Hudson, WI 54016 1296.55 feet to the point of beginning; thence S07°49'36"W 296.01 feet; thence S00° 1 1'33"E 107.1 1 feet and there terminating. Together with all appurtenant rights, title and interests. 020-1012-00-000 020-1013-40-000 Parcel Identification Number (PIN) Grantors warrant that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: None. Mail tax bills to: Sam E. Miller Homes P.O. Box lAi'tS/ Hud~sfon, WI 54016 Dated this 1- day of December, 2004. ~~ P R yv~~pt~tltt/r me kn a the person who exec d the foregoing instrument O p y~and kn d,gM~ t~e~~te AUTHENTICATION ACKNOWLEDGMENT STATE OFL~G(//.5C Vr1Sr~/,.SC V/tSr~ Signature(s) authenticated this day of ) ss. S~C~/ X~ COUNTY ) 7-1TLE: MEMBER STATE BAR OF WISCONSIN Personally came before me this ~~ day of December, (lf not, authorized by §706.06, Wis. Stats.,~ 2004 the a named Celeste M Bennett and Keith D Johnson t THIS INSTRUMENT WAS DRAFTED BY Kevin K. Shoeberg, Esq. KEVIN K. SHOEBERG, P.A. 1805 Woodlane Drive Woodbury, MN 55125 ~ (Signawres may be authenticated or acknowledged. Both TAMARA K, `'t ~ ~+ ~ HERBST ~ e . Be tt ei so 7'62_'040 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 12/09/2004 09:05AM b1ARRAHTY DEED EXEMPT i REC FEE: 11.00 TRANS FEE: 1979.00 COPY FEE: CC FEE: PAGES: 1 Public, State of ~~~C~iit 5~~ zmission is permanent. (If not, state expiration date ~•) •Names of persons signing in any capacity should WARRAITY DEED below their signarure. STATE BAR OF WISCONSIN FORM No. I - 2000 ~aT ,- _~~~~~~ --89.899 sq. R L.8.O. =891.0 BENCHMARK TOP OF REBAR ELEV. =921.52 C~ ~~8'W r,~ ~~ y 1 ~a .'~~ .' ... _....... . 87,E ~. R . 1. Q.O. ~ 824.0;. ~.... .mss....... .•''~ ~ ~ ~ ~ ~h~ .; ~ ~~ '~ !----m - I.~BARQ~ •' ~' /.i i li ~~ ~ Ir ~ ' I~ ~~ (~ •~ . ~ , _ ~ . , . LOT 1 ' ` ~ ~ ~. ~, I . ACRES ~ ~ ~I 95,820 SQ• FT. ~~ `~ ~ ~ ~~ ~ ~ ` ~~ T' ~ ~ ` ,~ ~ ~~ ~~ i ~.~' ~ 2'00.00' ( ,.~ ~J~4~.4~' !17 M A7 89°36' 18'W i = N89'S9'10'E 33' ~ 33' _ ~-- ~0~,~ 8 8' - / i ~ / ~ / ,~ Z i ' _ , 1332.82' LTV U c~ NJQ~W V4°J C1lOdl~ COUNTY PLAT OF: L~,~ , `~''° SUNSET HILLS FIRST ADDITION ~"°~ ~ Ipronawylam rnnpl ~ ~ ~ LOCATED IN PART OF THE NE114 OF THE SW114, PART OF THE NW114 amgawq ', p .An amtwm OF THE SE114, AND PART OF THE NE114 OF THE SE114 OF SECTION 11, °" ~ ~ ' o '~;.u~ ~ 1, ~'- T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN. rl~a~ I p xlraaw.mtpa,.n ~~ WOINEER 6 111pi Ir I1W10'A ~ a1PIFI FIf+rMGGiC y[~ 6$ WYIMSIMSI,rAa3 .. apxa.YYm.f}aF°lffi WW" Em~lILY5a1 N16prpOm ~:g (I --r nfK®aa I~ . ~~ ~~o hoc 7y151S `~15~~HSiti •~ - nuunylilea ~ ~[aslatnOmC1 ~; mrdc `i~ ,W,I ~: ar.aoDCoo.wo, ~ rr.~ wlpewmlra°a b ~ ' ~~~ lu+.axr ~ ~~~~~ ~~ I rm. ~I.I~p~ppx ' '°s .amru^ 1~. ~ ~, ~~ 7/ I~ SECTION 11, T29N, A19W v-pwl pflGVllp2fA&mapL SCALEWFEET 1'=100' ~~~ 1W 0 100 !On mrt male~asmnwumpenpnosa i pnlL Y1nf 9E lmla aYfE yE a6MTll61F Mrp,®mNrBBlf ulp,pMWRYnnlama I I nW Ia n6Ml. paa]IftSN6ppurpm p1lpnllalaSaLY4apmGIW4a W'MpGap/MOGYlY1fWx(lmma amaa4ppoarrRnlnFArIBIgIW.lirla I I pll6Oi oaaaam~lrs ~ ~ I mil' 90 g9~` 6~ I ' ti~ I a+a^ ; ~ ', sapc a-~.sffivl J_ ._, unlwuu[ !li'1306'E2l3T.N' i Imn 1R0 ~• a'a an ws alx nc° wms~e ~ ~"°I ~°"~xOiB"° lOT 13 I I I~ /uq.amuul~, nnmmwpalas; ~ LOT 1! , i auarmal ueaY LOT 14 i '~"• t ~ I i LOT 19 e.rq l ~. :~ alp r SETSY ~ eAal ~ ,rloY rm. rrm . ~y 1p ~ ~ ImLa. ~ lln•W V effiao > ~ FM ~Y'I si i /' ~ ~ s ~ ~ \ Im.a. 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