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020-1447-03-000
C 0 M ~ m ~; ~ w C h O O N n N ~~ ti C '~ d '~ 3 •~ N ~~ ~U .~ •~ ~~ v r`I~i r 0 Cd W ~n Y~1 C~ .~ e~ A rn ~ ~~ ~ a Z T ~ z o wz~yv' V y, T T N OI ~_ °: 0 U co R a fA J V 0 0 O ~ M C n N O H ~ G O p N ~ 7 O ~ 2 w xt a a d ;v ~ ~ ~ v a ~ v c 7 LL 3 3 ~ m Z y E =~ O a m c ~ p0 ~ T C ~ Y N U N '~ 7 N ~ O a m o ~= Q Z ~Z .. r+ {6 X10 w 'coa` ~~~~ 3 ~ ~ y N N ~ N O 2 N O O U m a a ~ y ~ N C C E Y ~ N m ~ O w € a a c m N V 3 0 O ~ d O C O (0 U O a`~i E o :: Z a f6 N O N ~ y '~ ~> 'O N Q ~ Y C~ C N N N L 0 T f0 i m ~ rn a ~ N } ... ~ O] C m Q Z in C O C O } N ~ C .~. Z ~ ~ 0 .~ Q Z "O m` O .m U .o N C 0 .~ .~ Q z N a m 0 ~ ~ U d p C ~ N d ~ ~ C N '~ L ~ ~ Wisconsin Department of Commerce :PRIVATE SEWAGE SYSTEM Safety and Building 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 Bast, Kernon Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: `~~ ~NYI, ( ~, c~ ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic i 'S~.• ~t ~ z SLS ~'b ~ ~ a c..k.+ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic .7, ~! ~ , / ^ ~ V l J al J i / Dosing Aeration Holding , r PUMP/SIPHON INFORMATION Manufacturer Demand GPM e Number Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Cro]X Sanitary Permit No: ~ t 463427 ~ State Plan iD No: Parcel Tax No: 020-1447-03-000 Section/Town/RangelMap N `~ .29.19.2834 STATION BS HI FS ELEV. Benchmark ~+ ~ r~~` ~ I / Alt. BM t,,b,,f k o~~ 3 , ~ ~ ~ • 3s Bldg. Sewer ~ ~.~ ~S r SUHt Inlet ~•35 .J /~, t'` 'f7 SUHt Outlet 9.63 /dd ~ I l Dt Iniet Dt Bottom ~~ ~ Header/Man. n r 1 Dist. Pipe IZ •~ -3.~ 9 7 9co•5 Bot. System e.' ~ • Final Grade 7,~5 /6z • r 5 St Cover L ~{ • S.J /l~rj _ ~, TI ! 3.83 ~5 ~~ i 3 /5• q,~. BED/TRENCH Width ~ Length / ~ ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 / ~ C~3 ~L> Y ~ f~ , _ ~ _ _ /~ YK ~~~ ~ ~- SETBACK N SYSTEM TO P/L BLDG W ELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: 1 ~ ~~~r ~Tz INFORMATIO Type Of System: ~ ~ ~~ ~ ~ ~ / `~ - I~ ~/ UNIT ' Model Number: Q ~ / J ; DISTRIBUTION SYSTEM ]~ /SA.~.I.. 4~.5 /tstf>~S~ . Header/Manifold /~ ~ Distribution x Hole Size x Hole Spacing Vent to Air Intake ~e ['~.. ~ Pipe(s) \ ` ` S i L th Di \ ` w ~ ~ C' ~"' Dia Length pac ng eng a ,/ .~ . Coll CCIVFR ., o~e~~...e c..~re..,~ n.,i., v,. Mnnnft nr ~f_rrade Svstemc Only Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center / _ l~ y ~ Bed/Trench Edges ~ Topsoil ~ _, Yes No Yes ~ No :4 COMMENTS: (Include code discrepencies, persons present, e/t~~ Inspection #1: / / Inspection #2: / / Location: 941 Pup Circle Hudson, WI 54016 (NW 1/4 SW 1/4 '[A4 T29N R19W) Coyote RidgelLo_t 3 Parcel No: 14.29.19.J2-83~ ~ 1.) Alt BM Description = ~~~ ~ au~ / ~ t ~'" ~~S ~ ~'$ ~~'""'~ ~, tis ~- ~ 2.) Bldg sewer length = Z (~ - amount of cover = /' / Glet~a~C'trF~~ ~- ---~ ~d"~1 d(bn{~-- wp(,)L i;,J-~ ~~ "? Use otheris de for additional in Yes o formation. (~ ~ ~~~~` L_-YJ ---- L---.~ ~ _ _ -- _ __ -- - - Date Insepc rs Sign re Cert. No. SBD-6710 (R.3/97) I'~ n n n Safety an gB m rotswn County_~ / . S ` ~ ~ 201 W. Washin ton Ave., P.O. ox .~~ C+ S t ~ I~~O ~~~ Madison, Wl 53707 - 7162 Sanitary Permit Number (to be tilled i y Co.) Department of Commerce (608) 266-3151 ~ G/`/I N P D b s Sanitary Permit Ap In accord with Comm 83.21, Wis. Adm. Code, perso ie F 1 informatlon~otT'p~ddC'D um tate an . er ~~ may be used for secondary purposes Privacy aw, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information -Please Print All Informatio }~ ~j~ // ~, ~ J (~, ~ •( / 7 (/ Property Owner's Name ZONING OFFICE # Bl ock Lot # Parcel # 3 , z~3 pe[rt~y Owner's Mailing Address Pro~ perty Location r o P J / ~ ~ / ~ ~ Section /" ~ ~/< Sul'/ City, State lip Code Phone Number . , ~~~. ~ ~ ~ circle ne) T ~ N; R~E II Type of Building (check all that apply) . L or 2 Family Dwelling -Number of Bedrooms Q~ G.I7 S/`~ , Subdivision Name C Number ^ Public/Commercial -Describe Use ~ ~~- ^ State Owned -Describe Use ^City_ Vill ge ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) tj 7 + Q, j - ~y A' New System ^ Replacement System ^ Treatment/Holdin Tank Re lacement Onl g p Y ^ Other Modification to Existin S stem g Y B• ^ Permit Renewal Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner /1/_ 2 („~ Z~ -j t0 t~ IV. T e of POWTS S stem: Check all that a t ~ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constmcted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/1'reatmentRrea Information: ~ Design Flow{gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) S stem a ti G / VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel b Plastic Gallons Gallons of Units Concrete Constructed Glass New Isxisting Tanks Tanks Septic or Holding Tank 0 ~ /~s~ Aerobic Treatment Uni[ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for i allation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb 5i Za e MP PRS Number Business Phone Number ~~~~ ~ urG~,~~ a 3S ~ 7~~- a~ 6 ~ 6 Plumber's Address (Street, City, fate, Zip Code) ~ ^^SS ~ ~ '~~ Q V VIII. Conn /De artment Use Onl roved ^ Di prove Sanitary Permit Fee (includes Groundwater Date Issu Issuing nt Signat St s) Surcharge Fee) ~ ! Q ~ ^ O ven Reason for Dema ' (O [X. Conditions of Approval/Reasons for Disapproval / ~ SYSTEM OWNER: 3) ~G~ ~ ~'~ 1. Septic tank, effluent fitter and dispersal cell must all be services /maintained as pet mama~ement plan provided by pknnbef. 2. AN sNb~ck tequNwnstxs must be rtgkttairlW ats p,- atppMcatbb code / ordkwtces. Attach complete plans (to the County only) for the system on paper not tess man ati~ x i i mcnes .n six y~ ~/ SBD-6398 (R. 01/03) ~- rr- N G~ S ~ ~. ~ / ~ S 9.sa ~ ~= a _ ~~ r PD 'DL~- 1 ~`~90 ~~ 3 3 - is ~^- r~-- y~ 9 y /3/"~ ~I = ADO ~ 7~~ ~/' /% "/°</~ ,~ r ~~ ~~~ T•a~ T.3 ~ ,\ `~y ~ t i r=1=gyro ~ ~`-( ~3 Ta;gq~ ~~ v'~ ~'~ ~ y X ,''~ - ~ RECEIVED > O JUN 0 G 2005 S ~ ~° Wisconsin Department of ~~ t~ivisian aSatetyand t3ulldin ION REPORT ' ST.CROIXC LINTY ZO wlth m 85, i ~ ode Attach complete site plan on ess n x aches in size. Plan must County S include, iwt not limited to: vertical and horizontal reference point (BM), direction and y ' Percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parse! I.O. Please prlnf afl fnlorntaffon, Reviewed by Pari0nsl infarrru80n you Prov7da may ba uaed for aeco~ary Pw'POSes (Prhracy Law. s. 75.01(1) (rti)), Property Owner ~ (~ G ~ / Property Location c. 5 r' Paso I of 3 Date PrvpertYOwner'aMailinpAddress Govt. Lot 1!4 1/4 S f~ T ZR' ~ R f E (or)(eU Lot # Block # Subd. tJarne or tSbt# S'~te P Phohe ~ C Ut t R +`,~ ^ City ^ V(Ilage ^ Town Nearest Road ) e ~~ ®~` Consauc~On tJse: Residential / Number of bedrooms ^ Replacement ~ -~--~- Mode derived deslsn flow rate ~/ S'cJ ~/ O ~ t3PD ^ Public or commerdat -:Describe: _ Parent material ~ c. 5 h Flood Plain elevatbn if applicable ~. ti i l4- ~, reootnations: SY'~` "'~ -e 1 t ~ ~ ~ ~ S~ . Qew~~„-jc 5 ~r {ZE~Lc A~PI~'e5 ,~,T B~r;~.~s tF l / ~' Z- L%_J ~~# f~ ot~'nry G1'ellndxtirrsraal~v ~"(!Uv M n-~~a~.ye.~__._j__ J~/1 _ , ... __,~ . ... ..........y ......... _ . ,.. Sod icatlon Rate. Horizon [lepth Dominant Color Retiax Desai ption Texture StrucXure Consistence l3otu~dary Roota G in. Munsep Qu. Sz. Cont. Color Gr. Sz. Sh. `Ef(#S 'Eft#2 ~ o- d - 5~4~ GmS m~r^ C S i' C ' f !'G ~~". 1N~ ~ r r ., • # ~ ~~ L~'~ Pit Ground surface elev. ` ,d ft. i~epth to Iimitins factor 7 Z ~ in. Soq Rate Hotimn Depth Dominant Color Redax Desdiption Texture Sttuc~ttre Consistence 6otNXlary Roots GP OlfE ~. MunseU Du. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff1l2 L - ,6 s- s. ~ l yvi ~ Je, ~ e, r - ~ - ~ ' ` Etlluent #1 = 800 > 3f) ~ 220 mgiL and 7SS >30 _< 15 0 mglL ' Efiuent #2 ~ BOO _< 30. malt. and TSS <_ 30 mpA. CST~~Nsiit'ne (Please tfir~) riue CaT t+kariber ' f'fsfCs ci !~' r Date Evalpatbn CondUCted Telapfarte coars/ocsraes ~ 'LLL8.69Z•809 A.LL ao i S [ £'99Z•809 is lua~ls~P a~ loelooa oseaid 'isuuo3 nseual~a ue ut (suolvw p~u to sa~uu~s ssaaoa o~ ~aus~stsss paau no~t~1 •ia6oldcua pus i~pinoid aarnlos ~lunuoddo ~snba ae sc aaiautwo~,~o ~uaugasdaa aqy 1!~ 06 > SSl P~ 'V~u 0£ > X409 • ZAE l~{Y3 . V~ 041. > OE< SSl P~ ll8ul OZZ a 0£ < 1Q08 * L# I~MIL3 . Z##3. L#113. '4S 'zS 'lfl •+oloJ 'ri~J 7S '~O NSW '~! ~ dfl W~2i ~P~B ~u~3sl~'J em~g del ' ~1~ X23 lueu!-uoa 4ldgQ ~I+oH elgLi uollg~! WS ... w..«............a.,.. Nd h r'"••7 B Z#1t3. L#Jl3. '4S '~S '~fl ~I~'J 'luoJ 'zS '~ IIeS~W .~ ~1/(] dJ $l~ii ~P~B +~lsl~J e~1~WS e~rgxgZ 0 ~Pe21 lueWwoO 4idaQ ~it~Fi alga uoJi I.pS •ia ~~ Bumum a- olden •u •nAie aoguns Dur~~ 1!d (-1 ~-'"'1 ~~ o = ~ Z#l13. l#JL3. '4S ZS '~fl ~lo'J 1~ 'ZS 'n0 IIe~W 'ul dila dJ slooa IGepunog e~ualslsuofl e~MS emucel ~lidW~O ~Pg2t ~'J lueulu~0 4ldeQ ~H gl~! UOIIBJ! UoS .~ -~-~-~-• fig; 6ullBull of 41deQ 'U --~T'~819 s~glms pul1W~ lld ~~ ~ # X08 ! Z ! .--T" ~v .Z eBed ~* l~ ~e , cL n~ # dl l~gd ~(, c~ >,,~1 ~eun~+0 ~tl~gdad M . PAGE ~OF~ NAME ~a ~ ~ LOT# ~ LEGAL DESCRIPTION '/a ~/a,S/S T Z`I,N,R iq E(OR~ SCALE: 1" _ ~Q BM 1 ELEVATION ~~. CU BM T DESCRIPTION -fyl,~ ~~ I% uG ~~~~ BM 2 ELEVATION ~-_- 'R--- BM 2 DESCRIPTION --~" f'Y s v SYSTEM ELEVATION SYSTEM TYPE ~r~,~lvrvit~'v~a.~ ........ SIGNATURE ~ ~_• ~" .___~_ DATE ~ - ~Z -OS Safety and Buildings Division 201 W W hi County J~ ` ~ m ' . as ngton Ave., P.O. Box 7162 I U ~sc~n~~n Maaison, WI 53707 - 7162 Sanitary Permit Number (to be filler to by Co.) De artment of Commerce (608) 266-3151 ~ 2 Sanitary Permit Application EGE Plan .Number R In accord with Comm 83.21, Wis. Adm. Code, personal information you vide may be used for secondary purposes Privacy Law, s 15. 2 '~ Add s (if differe nt than mailing address) I. Application Information -Please Print All Information 1X g pVNTY C~ ) ~~ P(,lP C-1 CE Owner's Name ~ 'Lo~t~# Block # + Pro O er's ailing A 1 - Property Location ~ ~' State ` r~ ~p a Pone Num A~.il/V'b, Section ~ ~ ~ II. T e of But din ~ yp g (check all that apply) ~ T N; R E or W 1 or 2 Family Dwelling - Number of Bedrooms S Subdivision Name ~ M Number Public/Commercial -Describe Use ^ State Owned -Describe Use ^City ^ it o ip of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) ~ ~Zp _ - ~ ~ o-pp 2 3 . A. ~lew System ^ Replacement System ^ Treatment/Holding 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 1V. T e of POWTS S stem: Check all that a 1 ;. 3 Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Reciroula ' Sand Filter ^ ~1 Recirculating Synthetic Media Filter ,Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) ~ ~'~'" ~ 3 V. Dis ersal/I'reatmentAres Information: Desigr~~gpd) Design Soil Application Rate(gpdsf) Dispe ~ Required (sf) Dispersals Proposed (stem 'on r ~ - ~ QQ ( d ( ~~ ~- /~r~ ~ 1 ~ VI. Tank Info Capacity in Total Number anufacturer Pref Site Steel Fiber Plastic Gallons Gallons ofUni ~ I Con Constructed Glass ~(~ ~~ r~~-_ ~ New Fadating C- Tanks Tanks " ~ ~ 7T `^''°`~" ` Septic or Holding Tank ~ So ~ l rr Aerobic TreatineM Unit Aoaing Chamber VII. Responsibility Statement- I, the undo igaed, assume respo 'bility for iastallatioa of the POWTS thowa oa t6e attached pleas. ' ' tier s N e ( t) PI s Si MP R tier Busin Ph rre Number r~ ' ~ 1 mber s~ Ci ,Zip Code) ~" VIII. Coun /De artment Use Onl Approved ^ Dis( Sanitary Permit Fee (i udes Groundwater Date Issued Issuing t Signahue o Stamps) Surchar~ Fee) \ ?,,~ ef'6ive ^ Own eason forDenr JvUr-- ` ~ 13C. Conditions of Approval/Reasona for Disapproval ?j~ P~~ uJ ~ l~ I -./ . SYSTEM OWNER: _` _- _s ~ ~©- ~ ct 1 Septic tank, effluent filter and l~'"~~'-''r ) 1 dispersal cell must all be serviced /maintained CM rog ~,p .~~~, ' ~ -~ca~ ~p ~ as er mana ement l id d b l b , _ 7" -" ~ p g p an prov e um y p er. Jt~ t ~;~~ ~ ~..Q~ ~ 2. All setback requirements must be maintained as per applicable code/ordinances P~ _ p _ _ N~~ ~ ~ tv~ `'^"'t~ Can ~,-> t n •~ Attach complete pleas (to the County only) for the ryatem oa paper not leas than illl :11 iachn in sire o-,,, o `~12~0~' P.,Q~.w~. ~i.r ~ ~ o~-ul SBD-6398 (R. 01/03) ~~ ~ a~.~- ~-~"~C ~.~ ~ ~ ~-~ .. --___ ~~ .~. ~~`~ "'""`~ ---~ , w ~- ~~~ ~ ~~ ~ o~ ,O- 1 1~ W 1 O W l~ ~~oPv o~~'ZS `'1 Q `~ g ' o D '~ ~ ~ ~ ~ ~ '~ ~ ~~ ~~ ~. ~ 1 ~ \ o ~~ ~ -~ d ~~ C~ ~ 0 ~~~ W ~ ~ It ~~ i~ ~` ~ `~A ' _ V ~S ^\ ~ ~ .. ~~ •~, ~`~-~° h ~' zr~. ---~ .~ ^~ o~~~S ~Q~g, o O ~ ~ ~ ~ ~ ~ ~~ ii ~ ,1 ~ \ o ~;~ ~- w ~ d ~~ ~ '' ~~~. ~~ 0 O w w~ 1 ~ ~~ ~i 6~ ©~ ~ ~ O W l~ ~~~ lc )~ it '~ ~ ,~ ~ ~ W ~ ~ ` '~ ~ RECEIVED Vlf~soonsin~of ~ SUi EVALUATION REPOR'f• t)Ivision of Safetyattd Burbkgs .' (~ ~ f 'J Q ~ n n n 3 ~ ~ ~ra~ zw~erwsv~ m w• rris. r~ur~ woes Cot~y .5 r G/Q C7>' ~ p-ttad+ ~ple6e ate P~ on a11t I l'lars rrwst 11 in size ~ . indude• but not> fo: . (BIuE)• won and Paroel I.D. s~~" , / yG `~ ~(l percerdsiope.scatear distar~cetorroad. /'lease print a1! lttfotmatfon• Iteviawea b,- • Dace 1 t'~ersaiM informwtion you p+oviae nwy a uad+or~agery vurpos~ l~r ~. ~ +s.04 (+) cam- N w O s£ sEGT- ( t~ro~erty o~ ,C~ErPNO,v r3i4s T t~rapertytoc~on c•,a~t. Ld ,Vb1 ,ra~~ ,ra /s'~ •Z 9 tr az / 9 tto~ w Or+une~s 1~6ng A cry L • .8r'1'/e (T-~•' ~~ ' Lot # Biodc # Sibd theme or tSIW! Ew IN "' ~c y'o TE ~ 1p6~-E '. ffUOSo~ wi. sy ~ ?!S 3g •-n7 5 °"'~"' ^valase ~z~ tzoaa ftv©so.~ r~,~x,~.~ adz New c.« use:181 +r of bedroorre -=-f-- Code derived ~- rate yS4 •- oz~ ~ D ~ 1 ^ Pub6c or oanrta_~ret - Desorlbe: Paront ~-~a1 7 i /~ 5 o[J,(ti -Si4•UD V ~~ZJAS~.r Fl«ia t'~n eteva~on if aerie ~tJ ft, General oamienes and • ,~~,~ ~-~-s,~v `~~~ ; s sv~ r•~i~ ,~,e ~4,v _. !~ ~ieovcrp G~,vvc~ r-ie.s~ ~•-~-~• • D• tc~ •'t' : s. ~-t n .. .. ~ ~ ., uD ri • u # Hoeracx~ ~ ~ ~p~ \A{~W MAIM FYND ~. ~ I • I ~~~ - J ~r y I //~ y V V~V tlordrrark t~ecbot Oesaiptlon Te~Auie ~uraue ConseOenoe 8o~ndary Roals in. IWx~sef Qu. t3z. Cont. Color t3~: Si. Sh 'E1~1 'Etf#2 / o•~~.. ~o y~e ~3 L ~ ~ s /c SGt ~ . ~ . 8 ; z ~d • /b SiL Shy c / • Z 3 3 3a • so ~o ,~ -------- ~ 5G ~ s cs • y • ~ 0 • 7•S ,Q ~- G /~ GS 7 ! 2 • ~ ~ - !/ /0 ~i2 7~/ ~t~• S D ~ S4 Q ~# ~ t~notutdsurfaceetev. ~° a ' ~.~. ~,~ ' ~~ ~ . t~tt, DorNnent tfiedaac DeaaipYion see bane C~orooe t ~,. tl ~. ~. com color ~ ~. ~,. -~ 0.7 0/~~3 --- L ~s K ~~~ w .3f . S •~ z iL / s ccv ~~ • Z • 3 3 / o o s Ls /~ ~ cs /• Z ~ ~~•T~ ~" • Ef'Auent #1= E30D y 30 _< 2Z0 AIL and TSS >30 _< 150 mgit. • EtRuent #Z = t3oD = 30 rrgA. _ 30 mglL ~~ Nnvate Sewage Consultants 2812 10th Ave. ~/N •S {-~!2 Spring Valley, WI 54767 Zp.lo1.7• 2-D • !01? z.o • ioz-~ ToT.~G of 80 ~ 2.. o • Oa'a 30 - 4'~ yo • o~ ~- ~~- ii +~ ~'~Rtio,v ~~4-5 ~ Go f- ~- 3 z. 3 PAY ~~ Parcel ip # Page of 3 # ^ ®a~t Growtd surface elev. ~7.3 ~ _ r>.~,,n ~.~,,. 7 /!vZ :~ Horimn Oepfh Dortt Redox Description Texture Strtx~une Consistence Boundary Roots t4PDItP in. MtxtseQ Qu. Sz. Coat Cdor Gr. Sz. Sh. •F~1 •Etr#2 / 3 o~~~o ~oyR ~/ ~• S -- L SL 2f~,b~ fs h G, w a, 5 -- • s . s •8 ^ ~ ^ ~~ ^ Pit Grotatd surface ~• ft Depot bo ~9 factor • in. Florirort Depth Dominant Redox Oesoription Texture Struclune ~ ~ Rate Boundary Roofs GPOVtt: in. iWtarsed tlu. Sz Cord. Color tar. Sz. $tt. 'Et8l1 'EtT#2 1 1 ~~ # ° Ground surface elev_ tt rf~.;x, ~4, ~~:.,.. ~.~e.,. z. Florizon Depth Dortsnatd Redox Despip6on Texture _ Stnrct<re Gonsis~toe - -- Bound~y Raots Soil Rabe GPDVty in. Mu>SeN Qu. Sz Cord. Color Gr. Si. Sh. 'Eff#1 'Eff~2 l Efikterd !F'i =BOOT > 30 < ~p mgll. and TSS >30 < 150 mgll ' C-IBtterd #2 = GODS ~ 30 rrtgH. and TSS _< 30 rrtgif_ .~ ~~ .~ ,~ The Department of Commerce is an equal opportunity service provider and employe. If you need assistance to access services or aced material in an alternate format, please contest dte departrrtertt at 608-266-3151 or TTY 608-264-8777. ~ y ~- ~ ~ ~~~~ `~ /~ C~ / ~ ~~ ~ ~ ,vet- -4 ~ o ti 4 ~ ~ G o_ --mow ~'~.. - ~ ~l~ • ~ ~ ~ ~ w ~ • ~ N N ~ ~ O CT ~. ~ ~. ~.. vj ~1 ~ N ~ ~ ~ cL] ~ <D ~ ~ N ~ O ~p C ~ w ~ c~- s m ~ -tom N~ ~ c- ~ o ^-~ -O (p S,o fD U~ ~ ~ ~ N -•! (D n Sv ~ ~ ~ cD ~ ~ c~i~ ~- ~ ~ .-« -~ 9 ~ ~ J ~ -~, / 4 • \~ ~ N ~ ~~ S ~. [1 ~ ~ ~~ 4 ~~ i ~V_. `t - 1~ ' _ 1 V a ~ Q ~ ~ ~ ~~ ~' o ° ~.' D o o ~ ~ 1 .7' ~ o ~ y ~~ .. w ~ o:. Q ~ ~ ~ ~ ,. ~~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of 2 FILE INFORMATION Owner 1 Permit ~~ 3 tl Z ,~. DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units - ^ NA Estimated flow (average) al/da Design flow Ipeakl, (Estimated x 1.5) al/day Soil Application Rate al/day/ftz 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) S30 mg/L Total Suspended Solids (TSS) S30 mg/L ^ NA Fecal Coliform (geometric mean) S10° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. MAINTFNeN[:F C[_HFnI 11 F SYSTEM SPECIFICATIONS Septic Tank Capacity at ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ~ ^ NA Effluent Filter Model ~-' ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Cell(s) ^ In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s- (Maximum 3 years) earls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: Z ^ ea~(sl(s1 (Maximum 3 years) Y ^ NA Clean effluent filter At least once every: ^ month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: month(s- ^ yearls) ^ NA Flush laterals and pressure test At least once every: ' ^ month(s) ^ year(s) ^ NA other: At least once every: ~ yea~(s)(s) ^ NA 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. Tank 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 ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of 2 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 cell(s1. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cellls) 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 o~ierating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby 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 atua ' o ing tank b e ai a ~RDI-f'1817~ ~D~- A/>~ L'ONS"T72(J~'lON ^ 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 INSTALL R Name Phone POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name S C l b ZOhll N Phone ~lS- .3SC0~ (p (7 This document was drafted in compliance with chapter Comm 83.22121(bl(t-(d-&(fl and 83.54(11, 121 & 131, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address City/State Parcel Identification Number oZo - /~ - 03 - t~ao C z83 `~) LEGAL DESCRI~P/TION ,r~ ,~ Property Location'Y ~ '/,, Sr V y,, Ste, ~ ~ , T~N-R ~ I W, Town of -N'y-~'~~ .~- Subdivision Certified Survey Map # Lot # ~ . Volume ,Page # ~~ Warranty Deed # _ ~ ~ b ~ ~ ~/ Volume Page # Spec house I~ yes ^ 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, journeymanplumber, restrictedplumber or a licensedpumperverif}ring 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. Certifitcation stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of a three year expiration date. ~ ~~~- SIGN TUBE F 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 owner(s) of the prope describ ve, by virtue of a warranty deed recorded in Register of Deeds Office. y ~~~, G ATURE OF APPLICANT _ DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** .~ J -~_ ,.~' Verification r ', ( equired from Pl ing Department for new construction) - ** Include with this 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 . U 2487P 118 STATE BAR OF WISCONSIN FORM 2- 2000 Numher ~ WARRANTY DEED THIS DEED, made between Steven L. Bakken and Caye L. Bakken, husband and wife, Grantor, and K r„r,n r Rai married, Grantee.. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area 750939 KATHLEER H. MALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 01/07/2004 12:35PK WARRANTY DEED EXERT IC 17 REC FEE: 13.00 TRAIiS FEE: CUPY FEE: CC FEE: PAGES: 2 Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. This deed is in fulfillment of land contract dated August 16, 2002, recorded August 20,2002 in book 1952, page 549, as document number 687523 Dated this 6th day of January, 2004. B * Steven L. Bakken AUTHENTICATION Signature(s) OW t' authenticated this 6th day of Janu PUbHc Not°a4ry . S~onsin f ~l _"__ Sta ~ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY Name and Return Address: Edina Realty Title, lnc. 400 S. 2'd St. -Suite 11 S Hudson, WI 540(6 412540 20-1027-4G'-000 8c 30-000 &20-00 Parcel Identification Number (PIN) This is not homestead property. B ~ * Ca a L. B en ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CRO[X COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Steven L. Bakken and Caye L. Bakken, husband and wife to me known to be the person(s) who executed the forego' 'nstrtunent and ackn~~ d the same. 1 *Cheri Brown Edina Realty Title -Doug Berg Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 400 South Second Street 11115, Hudson, WI 54016 3/11/2007 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing in any capacity must be typed or printed below their signature ~3 V1'ARRAN7']' DEED STATE BAR OF WISCONSIN FORM No.2-2000 U 2~87P 1.19 EXHIBIT A The NE'/. of the SE'/. and the NW'/, of the SE'/, all in Section I5, Township Z9 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E'h corner of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE'h of said Section, 407.27 feet; thence South 89 degrees 08 minutes 15 seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the azc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North 01 degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume 1, page 217 at the St. Croix-County Register of Deeds Office; thence North 88 degrees 51 minutes 13 seconds East, along said south line, 570.78 feet to the point of beginning. '~~ LOT d ~ ' , 2.18 ACRES ~'~ 94880 SO. FT. ' LB.O. =906.50 ~ ss. ~``~~ t~2 L43 .` LS6 ~ ~ ~ ~ ~, q~, C ~ '. `~+ ~ ` ~ ~' ~. r r I `. i I ~' . `~_~QOP' /' Spoor y'- ~'~ JQ G o -' ~F~~ ,.~ '~' ~' ~'~ LOT 2 C ~ 2.16 ACRES ' , 93905 SD. FT. ~ L.B.O. = 876.00 ~ LOT 4 5~.3Q7CCA~C//R~~ELS~ 233855 VV. r 1 . L.B.O. =906.50 Q LOT 3 . RES 133385 SQ. FT. L.B.O. = 876.00 '-t N Z - ~ N O ~ ~ ~ .- o m W w M = LL 0 W Z a BENCHMARK v ~ TOP OF 3/4" REBAR ELEV. =901.75 - - -' - - °" ~' H.w.L. = a73.ee O 268 _.~ CV N BENCHMARi TOP OF 3/4" REI ELEV. = 877.E LOT 1 3.89 ACRES 169564 SQ. FT.