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HomeMy WebLinkAbout020-1452-08-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Bu'vding Division 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 LaCasse Develo ment Hudson, Town of CST BM El~v: Insp. BM Elev: BM Descri o / TANK INFORMATION ELEVATION DAT TYPE MANUFACTURER CAPACITY Septic / Dosing ( ,t J ( ` Aeration Holding TANK SETBACK INFORMATION TANK TO P/L y W~ BLDG. Vent to Air In ke ROAD Septic ~~ / ~O' Z~ Dosing Aeration Holding PUMP/SIPHON INFORMATION ~7f-1'AVtl-~-t~ Manufacture Demand GPM Model Number TDH Lift Friction Loss S TDH Ft Forcemain Length Dist. to Well SL71L ~4gSORP~I"ON SYSTEM /_ S /rn U U .- ~L (_ St. Croix 463448 0 I 020-1452-08-000 Sectionli'own/Range/Map No: 13.29.19.2896 STATION S HI FS ~ i LEV. Bench ' Alt. B ~ , ,{ ` Sl. ~ (~. zs Bldg. Sewer ~.~ qZ. Q~ O Sit -c3 9~, ~ svHt o~ ~ • ~ ~ ~ / • 3 Dt Inlet ~_ Dt Bottom / Header/Man.~~ , b S t ~~~ ~~ 9 0• ~~ Dist. Pipe ~~ b / 0 C ~~ a, p~ G ~ / D. 7~ Bot. $~m ~vstc~,ove, B 3 /0.9 ~. 7 Final Grade ~ ~ n~ s° ~ O o U ~~ / 7 st Cover ~ ~ r1 ~ L~l, ~J•S-9S BED/TRENCH Width ~ Length N . Of Trench s PIT DIM NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~ ~ ~ ' ~ SETBACK MATION SYSTEM TO P/L BLDG WE LAKE/STREA LEACHING CHAMBE 1v1: irec ~ /_ ~ Y` INFOR Type f System: ~ n ~~/ /~ ~ / IT Model Number: - 6 fit' ~ DISTRIBUTION SYSTEM Hie der/Manifold Distribution //,,~~ / ~ x Hole Size x Hole Spacing L th Di ~ ~ Pip s)~2 ~ S acin th Di L ~ ~/ ~ ~ ~,/~ ~ t(/~ en a 9 9 a en P 9 4n11 C[]VER v D.•ncm~ro Cvc4nmc only vv Mnnntl C)r 04-r~PAfIP SVC}PrY1S OnIV Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center •(~ ~ 1 Bed/Trench Edges Topsoil Yes No - Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ ~ / ~~., Inspection #2: / /_ Location: 816 Dove Cou~~r~~t ))HudsJon-, lWI 54016 (SW 1/4 NW 1/4 13 T29N R19W) Bluebird Meadows Lot 8 1V`/~,J Parcel No: 13.29.19.2896 1.) Alt BM Description = W~ -~. ~ ~ / ~ ~~~ ~ ~~ ~tc~2itJ 2.) Bldg sewer length = 1 2 / -amount of cover =_ ~ 3 ... p .. I L---- -~ -- IQ I ---- -- ___ _ __.. --- -- - -~ -~ - ~ __ Plan revlslon Re ulred? ___i Yes ~ I ~p Use other side for addltlonal Information. No L ___ _~_____ ~ ~ '~___._.-_ ' L - ~-' Date ~ Insepctors Sign lure - Cert. No. SBD-6710 (R.3/97) Vent to Air I - - - -- 7 ' S d Buildings Division County 201 W Wash' Box 7162 ~ ~ isconsin 5~ ~~s Sanitary Permit umber (to be filled in by Co.) De artment of Commerce (608) 266-151` '' i` Sanitary Permit A ' on `- ~ p p~'i~ State Plan I.D. Number /~ In accord with Comm 83.21, Wis. Adm. Code, p onal ' u'~r~ovide , fj may be used for secondary purposes Pri cy Law- ' `t~: Project Address (if different than mailing address) I. Application Information -Please Print All Information Property Owner's Name I ~ ~ Parce # Lot # ~ Block # ~- - 20- 1452-68 -aob Property er's Mailing Address Property Location ) % ~% ~f S i City S e Zi C d Ph N b <, .~ u ., ect on ~i~ , p o e one um er (circle one) ' N R~E W ; or II. Type of Building (check all that apply) _ _ ^ / k ~~- O q~ ~1 or 2 Family Dwelling - Number of Bedrooms 'F~ /'t n/ ~~ Subdivision Name GSM Alainbcr ^ PubliclCommercial -Describe Use ^ State Owned -Describe Use ~ t^-~ r 2 ity Village,~rTownship of ¢.~. III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ~ New System ^ Replacement System ^ Treatment/I-Iolding 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 of POWTS S stem: Check all that a - 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 Fil Leaching Chamber ^ Drip a Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment A n: Design Flow (gpd) Design Soil Applicatioq Rate(gpdsf) // Disp rsal Area Required (sf) ' Dispersal Area Proposed (sfJ System Elevation / / ~ ~ 7 D. ~/ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~ ~ I l ~ n Aerobic Treatment Unit ~ ~ ~ /~ Dosing Chamber VII. Res nsibility Statement- I, the undersigned, a e respo ility for installation of the POWTS shown on the attached plans. Plum er am (Print) Plum is at MP/MPRS Number Business Phone Number P um er's ddress (Street, C'ty, State, Zi Code) <~~ VI . Conn /De artment Use Onl Approved ^ D' roved Sanitary Permit Fee (includes Groundwater D ssu Issuin ent Sign o S ^ r~ eason for Denial Surcharge Fee) ~ ~~ 5 (r, ~~ IX. Conditions of ApprovaVReasons for Disapproval rJ/~' ~~e(~ IMUg ~ J 6w s3Y8TEMOMINIER: /Vtc ; v`~-en4 ~c Q cc~~ ~ Y1 . . .. ., ,. ~t..~a,l•~ra,~ p dhp~rsal qN must sN be services / mairMawd ~-p ~20w v~Qil., _ ~ pK manapentertt plan provided by plumber . 2 setback rogttiremertts must be maintained as per applicable rode / o-dinances. cumpew pwm ~zv me.a,oaary onry~ ror toe syscem on paper not teas than alit x 1 t ivcties in size SBD-6398 (R. 01/03) ~ - ~ ~~ u~~~~1G J~-/.~~ W W ~ -~ ~~. ~ ti Z~ vy` ~~~ (~'"' ~~ ~ .~,~, - ~sc~~/-,~yt~~ sic /-3-7d`TiL~1~/1~'~ i ~a~ ~~ ~,.'°~~ ~~ ~~ ~ / ~,/~' ~ / ~~/ ¢ ~ar 8 J ~~~~ 0 ,~~~t~~K / ~ ~/'1 ~r°r1c -,~~/moo - 7 3 ~~ cy yyl r e /y >'r1e ~,t ~9, z 1 ~4 yO ~ Sc~~ .~~-- i ~~~~- ~- 3x9s'" ~7~ ~~ ~~~ ~ / ~~ ~~ ~~ . ~ ~~`,~- ~~~-~J ~,~~~z~iG J~-/~~ ~~ '~ V ~i ~,~ la~~~' ~;P L \ ~ ~~ ~` ~ ~' :~,~,- t ~~x ~~ ~' ~~,~~ ~t,~~-c~ ~s ~ 0 ~~i~k° ,~~1~ ~a~s~/~K / ~ 6~' ~~r°r~C ~kl/~rJO - ~'3 e~~ ,r~~~9ey~'/~ ~ a ~7'1~ ,~ X97 ~ ~ ~~/~- ~7- 3~gy_ ~~ ~~s ~~ ~ r~ ~~ N~ ~lmfs ~/ ~1Pr W~STSURN~ SUpI~LY INC. ~n ~~ ~~ ~G r ~ ` 97' ~~ ~~ i~ 93, ss ~~ yoss 7~~~sk~/= 378.E ~ ~- 3X9~~ ~~,~~ = ~ ~.~-/ ~.~~, a ~' ~~S ~~c~ ~s ~~~s MUSTEE W ` ~ Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in accordance with Comm 85, Wis. Adm. Code 1488 Page 1 of 3 Steel's Soil Service, Inc. County Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must St. Croix indude, twt not limited to: vertical and horizontal reference point (BM), direction and and location and distance to nearest road. north arrow scale or dimemsions percent slope parcel t.D. , , , Pending Please point all informativ[~. ._,~ a wed By ~ Date Personal information you provide may be usrd for secondary purposiis (Priv taw, s. 15.04 (1) (m)). , f Property Owner ± Properly Location LaCasse Development , Ind. ; r;; ,, Govt. Lot na SW 1/4 NW 1/4 g 13 T 29 N R 19 W Property Owner's Mailing Address ~ Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" ! ; 8 na Bluebird Meadow City ~C,od~ p-h~rtaWum ~ City ,_f Village ~Fj Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd New Construction Use: jl Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD ~~J Replacement ~ Public or commercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 93.55ft . Tren ed and depth to code 4.OOft below grad. s spac / ~` n ~ wail a Boring # ::J Boring ~ ~ ' 1 r Z~ ~' 120 i R Pit Ground Surface elev. 97.55 ft. n. Depth to limiting fact ate Soil Application Horizon Depth Dominant Color Redox Descriptan Texture Stricture Consistence Boundary Roots GP *Eff#1 D/ft= *Eff#2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh . 1 0--13 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 13-24 10yr4/4 none sl 2msbk mfr cs na ~ ~~ 3 24-120 7.5yr4/6 none Is osg mvfr na na .7 1.6 9 • -~~ Boring # J Boring Pit Ground Surface elev. 97.55 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depih in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Stricture Gr. Sz. Sh. Consistence Boundary Roots GP *Eff#1 D/fl= *Eff#2 1 0--24 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 24-38 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 38-78 7.5yr4/4 none cos/Is osg mvfr cs na .7 1.6 4 78-120 7.5yr4/6 none Is osg ml na na .7 1.6 ~~ D 5~ * Effluent #1 = BODs> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and l 55 < 3u mgiL 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 Baldwin WI 54002 8/20/2004 715-684-5680 Property Owner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # ~ Boring Pit Ground Surface elev. 94.75 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots D *Eff#1 *Eff#2 1 0--12 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 12-26 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 26-90 7.5yr4/4 none ms osg ml cs na .7 1.6 4 90-120 7.5yr4/6 none cos osg ml na na .7 1.6 I ^ Boring # ~ Boring J Pit Ground Surface elev. ft. Depth to limiting factor in- ~ Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ~ Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stn~cture Consistence Boundary Roots in. Mur~sell Ctu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mglL 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. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200th St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 Lic. #248956 SWl/4,NWl/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 8 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your l use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. / Legend / 1"=40' Benchmark Ele. 100.00Ft of 3/4" pvc pipe ~- ~~Alt Benchmark Ele. 99.70Ft op of 3/4" pvc pipe ^ =Borings Boring Elevations B1 = 97.SSFt ~~r ~ ~ B2 = 97.SSFt ~ B3 = 94.75Ft ~~~ B4 = OO.OOFt ti~ ~~ ~n~ ~ ~ ~~~~ ~r ~ ~ ~,~a j ~~-~ ~~, ~~?~r i ~ ~`~ ~ ~~ 2~,0~ ., ~~ ~ M , x _ ~~~ ~ ~ ~ ......... .~ .~ ~. X N r ~ O 3 ~ X: ~ :~ ~ ° ~ . W ^ ' ~ ~ ~ N W . . oao Owl ~ ~ x '` ~~p i ~ ~ y~ ~ ~n N OE6 F a d - II ~ ' ._.. ~ ~ j X ~ ~ I 111 t0 YI ..~ r .c s ~ ~ ~: ~:~ .oc ~ ~ _ ~ ~ ~,P v w X off` ~ X °° ( 1 ~ 'O . x ~~ Q ~ r y v - ~ ~ ; to WX • ~ ~ , ° ~ ~, ; s °' ~ ~ ' ~ , X ; ~ ' ' i ~ a w f ^ is + r.; ~• ! ~ o n ~ 'a A 0 ~ -1 ~ 1 ~ ~ i ~ ' ~ ~ j: I r • b ~. ~ j ~ ~ J a ~ ~ ~,. ~ ~ ~ V i rj b 1 x x w€ ~ a,.z , ~n w. ~o v~~MS ~ x ~ __ ~- ~ ~ Ct~PY 1488 Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings Steel's Soil Service, Inc. in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than SY= x 11 inches in size. Plan must i l d b St. Croix nc u e, ut not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. Pending Please print all information. Reviewed By Date Persons information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Properly Owner Property Location LaCasse Development , Inc. Govt. lot na SW 1/4 NW 1/4 S 13 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" 8 na Bluebird Meadow City State Zip Code Phone Number ~~ City : ~ Village ~ Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd / New Construction Use: ~ Residential /Number of bedrooms 4 ode derived design flow rate 600 GPD Replacement >? i Public orcommercial -Describe: Parent material _Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 93.55ft. Trenches spaced and depth to code 4.OOft below grade. Boring # .~ Boring /' Pit Ground Surface elev. 97.55 ft. Depth to limiting factor 120 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft' in. Munsell t1u. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0--13 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 13-24 10yr4/4 none sl 2msbk mfr cs na .4 .6 3 24-120 7.5yr4/6 none Is osg mvfr na na .7 1.6 Boring #=Boring Pit Ground Surface elev. 97.55 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DIft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0--24 10yr3l1 none sil 2msbk mfr cs 1 f .6 .8 2 24-38 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 38-78 7.5yr4/4 none cos/Is osg mvfr cs na .7 1.6 4 78-120 7.5yr4/6 none Is osg ml na na .7 1.6 "Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/L and TSS < 30 mg/L CST Name (Please Print) ~ nature: ~ CST Number David J. Steel / ;~-; ~ 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680 Property Owner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # ~ Boring /' Pit Ground Surface elev. 94.75 ft. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth Dominant Color Redox Descri tion Texture Structure Consistence Boundary Roots P in. Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0--12 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 12-26 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 26-90 7.5yr4/4 none ms osg ml cs na .7 1.6 4 90-120 7.5yr4/6 none cos osg ml na na .7 1.6 ^ Boring # ~i1 Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Applicator Rate Horizon Depth Dominant Color Redox Description Texture Stntcture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring #_.:` i Boring _r; 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. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = 80D S> 30 < 220 mg/L and TSS >30 < 150 mglL * Effluent #2 =GODS < 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. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200` St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 Lic. #248956 SWl/4,NWl/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 6843449 Bluebird Meadow, Lot 8 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 time the soil test was conducted. Legend / 1"=40' • =Benchmark Ele. 100.00Ft ~ Top of 3/4" pvc pipe • =Alt Benchmark Ele. 99.70Ft Top of 3/4" pvc pipe ^ =Borings ~ Boring Elevations B1 = 97.SSFt ~~ `~ t B2 = 97.SSFt (0 ~ B3 = 94.75Ft (.~ B4 = OO.OOFt ~~~ ~- ~~~~r ~- ia~~ ~ ~, ;~. ~~?`~Y n~ r' ~ ~~ ~~~ i~~ ~_ ~~,o~ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer 1. r4 ~'~ 4„s.~ ~.~.t/,Q.Le f,~.+...~' lclie Mailing Address ~'~~,~_I~_~Q 11<u ~ s ~ Properly Address - ~ c~ ~., i'` (Verification required from Planning Department for new construction) City/State tom, %~~ Parcel Identification Number 6 2ts - /45 Z - a~ - ~ LEGAL DESCRIPTION Property Location ~ t~ '/,, ~[ ~ '/,, Sec. ~, T Z 9 N-R~~,W, Town of Subdivision ,~ L N P,~(,,e.~;r~ Certified Survey Map # ~ ~~~-~ /~ f 3~ ' ,Volume Lot # ~_. Page # Warranty Deed # ~ ~ zZ3 ~ .Volume Z~'f / ,Page # 3'~ Spec house ^ yes C~ no Lot lines identifiable] yes ^ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal 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 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 30 days of the thre year a piration date. ~ / /mss SIGNA OF PLICANT DATE OWNT.R CERTIFICATION I (we) certify that all statements on this form are tnie to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property descri ed above, by virtue of a warranty deed recorded in Register of Deeds Office. y /2 T l'e s'~ S ATURE F APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include witlr thls application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed POWT$ OWNER'S MANUAL & MANAGEMENT PLAN,.,,. , PaQa 1 0l ~ _, _. FILE fNF r-~---- ', Owner Perm t ncelnM DAR~MFTFRS Number of Bedrooms O NA Number of Public Facility Units (1~-NA Estimated flow laverage- r} al/da Design flow (peak), (Estimated x 1.51 al/da Soil Application Rate al/da /ft~ Standard InfluentlEffluent Quality Monthly average ' Fats, Oil & Grease (FOG! 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/l. ^ NA Total Suspended Solids tTSS) 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 (geometric mean) S10° cfu1100m1 Maximum Effluent Particle Size Ya in die. ^ NA Other: DNA *Valuas typioal for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS ~ Septic Tank Capacity - ~ ~ al ^ N`' ~ Septic Tank Manufacturer ~" ' " ~ O N~ Effluent F11ter Manufacturer ~• { D N~, j Effluent Filter Modal O N!; Pump Tank Capacity al p' N~,_I Pump Tank Manufacturer -~ N~~ Pump Manufacturer ~ -N~` Pump Modal , ,{ l°' N~` Pretreatment Unit ~'` CI Sand/Gravel Filter O Peat Filter O Mechanical Aeration Q Wetland D Disinfection D Other: Dispersal Cell(s) ^ N!~ ', in-Ground (gravity) O In-Ground )pressurized) ^ At-credo D Mound ^ Drip•Lina Q Other, Other: ^ Nt~ Other DNA Other: DNA MAINTENANCE SCHEDULE 7 Service Event Service Frequency D monthtsl (Maximum 3 years) DNA Inspect condition of tank(sl At least once every: aarls- •, f, pump out contents of tank{s) When combined sludge and scum equals one-third lYs1 of tank volume ^ NA ~ monthlsl'``` (Maximum 3 years) ^ NA Inspect dispersal cell(s) At least once every; j~ yearls- _ Clean effluent filter At least once every: ~ l~year(s1 ^ month(s) ~Nf. ~ Inspect pump, pump controls & alarm At least once every: D ear(s) ^ month(s! r: ~ ~ NA Flush laterals and pressure test At least once every: ^ ear(s- Other: At (east once every: ^ manthts) Q ear(s) O NA Other ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following lioenses or certifications: Master Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer; Septags ServiainS Operator. TanK inspections must include a visual inspection of the tank(sl to identify any missing or broken hardware, identify any oraaks or Teaks, 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- shalt be visually inspected to check the affluent levels in the obsaivation 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 ttrt; immediate notification of the looal regulatory authority• When the combined accumulation of sludge and scum in any tank equals one-third tY3i or more of the tank volume, the antiru contents of the tank shall be removed by a Septags Servicing Operator and disposed of in accordance with chapter NR 1 1 s, Wisconsin Administrative Coda. ~ '• All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWT5 Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service avant. QMW lan) ~ START UP AND OPERATION ' For 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 celHsi. If high concentrations are detected have the contents of the tankls) removed by a septaga 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 highwatar levels. When power is restored the excess wastewater will bo discharged to the dispersal cell(s) In one large dose, overloading the oeltlsl and may result-In~tIN baokup of surfaoa discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servioing Operator prlorao teetering power to the effluent pump or contact a Plumber or POWTS Maintainer to assist In manuaNy'operating the pump' controls to restore normal levels within the pump tank. Uo not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise. disturb or compact, the area withjn 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides;,:meat-scraps;-.medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of st;rvice the following steps shall be taken to insure that the systtyni 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 r3e~led,r, 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 remgVed aid the void space filled with soil, gravel or anothor inert solid rnatoriaL CONTINC3ENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, o 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. CI 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 PaWTS.~---j~~~- ~ - - fa The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area,. If no replacement area is available, a holding tank may be installed as a last resort to replace the failed POWTS. ., ., .. ;:... _ _:.. _: Q 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 alt 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.RE$ULT. REBGUE pF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSI6LE. ADDITIONAL COMMENTS ... ~,~<,. ,+r .'^.,°:!Ct ef:i?4.~s/ ,;t ,;r~n't fit" i POWTS INSTALL POWTS MAINTAINER ' ~ Name Name i P hone Phone _~ - / SEPTACiE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Narne Phone Name , ~, .~ Phone -~~ ~: ~ ..,,;- ..,.. ~ ~~ ~'I ~ his document was drafted in compliance with chapter Comm H3.22(2)Ib)I1)(dl&If) end 83.64111, (21 & (31, Wisooniin AdminlattatNe Code. ~~ ~.! M ( x ~ X ,~ ~ ~ - - N N tNl~ N 'Y' ,~ tC X: ~ w ~ W ~r a r- i ~ N w r j. ~A 0; X ..~ aN O tD i N ~ A -+ ~ " ,~/ n R? ~ " • Og8 1 a 1 .£ E r ~ ~ ~n:.. j m b ~ ~ ~ r ~ i .. ~ ~ "~ '~P v X 4 ~ ~. ~o ~;, x ~ obi ~ ~ ~ j ~~ X °° I ~ N '~' 1 0 V IV ~' I X o ~ ~ 1 ~ ~'- ~a I ~© .~ , wX o w ~ ~ ~ ~ ~' X i t`~° a N W r; ~~ n ..~: I r b ~. .~ . ~ I a X ~ J / I n m ~ m . .. ~, ~ I :~ . d~ ~ I ~~; ~t X ~ i ~~ x • x ~E ~ ~ ~ N - - f/~ !1l ~O f/LMS ~ X ~ ----- d0 3Nl~~ !~ H' _~sc 'J. 26~11.I^ 399 + STATE BAR OF WfSCONSIN FORM 1 - 2000I Document Number WARRANTY DEED This Deed, made between Rvaald G. Raymond, Loretta &. Raymond, husband and wif® Grantor, and LaCasae Development, Iac a Wisconsin corporatioa - - _ _ -Grantee. Grantor, for a valuable consideration, conveys to Grantee the following . described real estate in st. Croix. County, State of Wisconsin (the "Property") {if more space is needed, please attach addendum): Southwest 1/4 of Northwest 1/4 of 5ectioa 13, Towaship 29 North, Range 19 West, St. Croix Couaty, WI Recording Area 77236 KATHLEEN H. MALSH REGISTER Of DEEDS ST. CROIX CD. , 1fI RECEIITED FOR RECORD @8/Z0/2084 11:55AK YARR~~j ~ EED RfiC FEE : 11.08 ?RA1t5 FEE: 2250.00 CQPY FEE: CC FEE: PAGES: 1 Name and 4016 r Together with all appurtenant rights, title and interests. aza-lol~-30-000 Farcet identification Number (PIN) This not homestead property. {is) (is not} Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and ciear of encumbrances except anctuabraacea of recasd Dated this da of Au st 2004 . *Ronald G. Ra AUTHENTICATION ~ ~„ turner Signature(s) Tra y pyotary authenticated this day of ,~~,{~~~! 0~`~~t 1 * TITLE: MEMBER STATE BAR OF WISCONSIN {If not, authorized by §7Q6.fl6, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Radmoa Law Chartered (Richard Lau) 2217 Vine 3t., Suite 204, ~iudsou, WI (Signatures may be aut}-enticated or acknowled¢ed. Bath are not necessary.) v-~.e.~t~ ~ r -~.. /C~- m ~xd *Loretta 8. Ra and * ACKNOWLEDGMENT STA F WISCONSIN ) c ) ss Y ~ County--~~ ~~~--1-- Personaliy came before me this day of August 2 0 (?4 the above named $onald G. Raymond aad Laretta~. Raymond hu an n w f to wn to be e n who executed th ~~ wledged the same. Cu _ ,/dot ~ Notary Public, State of Wisconsin My Commission is~permanent. (If not, state expiration date: "Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No.1-2000 ~~ Redmon Law 2217 Vine St Ste 204, Hudson WI 54016-5864 Phone: (715j 386-0100 Fax: (715),386-0700 Redmon Law Chartered T4926305.ZFX Produced with ZlpFOrmTM by RE FormsNet, LLC 96025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 383-9805 wrvw.zioforrn,com X jj 'IO~i'__'e'; X ai F O ~ ~ ~ !~; E° .- ~ ~ ~ `t' S !I ~ ~ ~ .t N ~ ~ ~ .~ rn °' ~ ~ 4 ~ a~ .J ~ r ~. ~ Q ~ t ~ ~ ~ ~ ~~ 1 ~ d 1 ~ '~ .~ 1 ~ ~ ~$ 1 l ° ~ N~ ~ .~ ®, ~ of `~ nj I ~ ~ ~ ~ ~`' . 3 ~ [~~ , x~ "~°~ ~ ~- ~ r 170 .:. ~ 8~r - ~ ~ ., ~. ~ o X ,. -:~, ~ >s :~ ~~ ~, o .~ .~~ ~ ~~ ~o a~ ;~ acv ~~ x ~~ N~ r~ ~ ~ N ~ ~ .. ~ ~~, ~ N , ~ .~ .~.,.. l ..~,..~ Parcel #: 020-1452-08-000 05/06/2005 08:52 AM PAGE 1 OF 1 Alt. Parcel #: 13.29.19.2896 020 -TOWN OF HUDSON Current ', X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 10/06/2004 00 0 Tax Address: Owner(s): " =Current Owner " LACASSE DEVELOPMENT INC LACASSE DEVELOPMENT INC 573 CTY RD A HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description " 816 DOVE CT SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.670 Plat: 10/34-BLUEBIRD MEADOW 020/04 LOTS 1114 SEC 13 T29N R19W PT SW NW BEING BLUEBIRD Block/Condo Bldg: LOT 08 ' MEADOW ( 04) LOT 8 (2.670AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-29N-19W SW NW Notes: Parcel History: Date Doc # Vol/Page Type 08/20/2004 772236 2641/399 WD 9n(1~ CI IMMARY Bill #: Fair Market Value: Assessed with: Valuations: Description Class Acres 0 Totals for 2005: General Property Woodland 0.000 0.000 Land Improve Last Changed: 03/07/2005 Total State Reason 0 0 0 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