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HomeMy WebLinkAbout020-1447-18-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ~a INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Bast, Kernon Hudson, Town of ;ST BM Elev: ~ Insp. BM Elev: ~ BM Description: ~ Q ~•~ ~.~ ~ f~S 8~~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~+ Z2.' ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numbe TDH Lift 'on Loss System Head TDH Ft Forcemain Length Dia. Dist. to weir SOIL RPTION SYSTEM ~p,~,~aps, RENC idth t Length t No. Of rerlChes DIM 3 0 3 J1 SETBACK SYSTEM TO P/L BLDG INFORMATION T e S tem: 11 / 1 ~]ISTRIl3l1TInN SIiCSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 463433 0 State P n ID No: Parcel Tax No: 020-1447-18-000 Section/Town/Range/Map No: 15.29.19.2849 STATION BS HI FS ELEV. Benchmark , ~~ .Z ' ~ O t Alt. BM Bldg. Sewer ` ~.~ ~ . ,~A t SUHt Inlet `.~ ' 20' SUHt Outlet V~ Z~ 9 } ~ 96~ Dt Inlet Dt Bottom Header/Man. ~O~p 9~` Dist. Pipe D•`~D -` 3. 30 t Bot. System ~ ~ p2 ~,! ~ __// `~'~ Final Grade StCov ~.~ .5. ~ \ 3~~ ~ .~~ PIT DIMENSIONS INo. Of Pits Ilnside <E/STREAM LEACHING Man ct ~, y CHAMBER OR {~7~-7~` UNIT Model Nur~r. ~ ~ -~ C~b1-l C. WELL Header/ n of Distribution x Hole Size x Hole Spacing Vent to Air Intake ~ Pipe(s) Length Dia Length Dia Spacing S[lll l?AVFR ,, o.e~~.,.e c..~•em~ nnr., ,.~ Mnnnrl nr A1~~irAfla SVCtP_MS OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center BedlTrench Edges Topsoil 'i j Yes I ` No i Yes ~i No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:..,tJIM.t ~~Z+~.~nspection #2: ~---~-r- Location: 679 Pinetimber Lane HCudson,WI~ 5~40~161(NW 1/4 SW 1/4 15 T29N R19W) Coyote Ridge Loty18 Parcel No: 15.29.19.2849 1.) Alt BM Description = ~~ 7 ~T` '""'~'"'-" ~r• ZJ' J C3, { r~l~s 2.)Bldgsewerlength= 2,Z.O ~ ` iLl n0'~~p_`. ~~~. -amount of cover = '~,~lA ~,; __ ~j~ ~'^ 'L, f ` c•~.. Plan revision Required? .j Yes No ~a'(~' * C"~ ~ ~~~) Use other side for additional information. ~..~r.,~_2't ~ J Date Insepctor's Signature Cert. No SBD-6710 (R.3/97) OD ir.~P /lJ.'~P-J'1 Safety an gBuildings Division County ~ ` 201 W. Washin ton Ave., P.O. Box 7162 I ~~O~~I ~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be tilled in by Co.) Department of Commerce (608)266-3 ~ "Z Sanitary Permit Application ~ State Plan I.D. Number In accord with Comm 83.21, Wis. Adtn. Code, personal information you prov may be used Yor secondary purposes Privacy Law, s15.04(1)(m) O Project Address (if different than mailing address) I. Application Information -Please Print All Information // ~ ~ CD ~ i(i1a~e- Property Owner's Name ~ 0 U ~ ~ 1 2005 Parcel # ~t ~ Block # Property Owner's Mailing Address ST. CRUiX COUNTY n Property Locatio ZONING OFFICE t ' / / N(! { 5~ , < Section '/< a City, State Zip Code Phone Number , , / ~ ~ / t-~/ ) rcle 'T'ype of Building (check all that apply) II . ~" or 2 Family Dwelling - Number of Bedrooms _ Subdivision Name CS Number ^ Public/Commercial -Describe Use ^ State Owned -Describe Use ^City_ Villa e ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System ^ Re lacement S stem p y ^ Treatment/Holdin Tank Re lacement Onl g p Y ^ Other Modification to Existin S stem g Y B. ^ Permit Renew rt Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued , Before Expiration ~~. Plumber Owner ~[ ~ 7 ~J/_ T J , G..w IV. T e of POWTS S stem: Check all that a 1 Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constnucted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamb ip ine G el-I s Pip ^ Other (explain) V. Dis ersal/TreatmentRrea Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Ar Proposed (sf) em Elevation r VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Unit ~/'~ ~ ~ (('Jps Concrete Constructed Glass New Existing ~~ t _T!~~ Tanks Tanks Septic or Holding Tank / `Q ! ~7 ._ /~ /"U / J l~ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for in tallation of the POWTS shown on the attached plans. Plu ~n (Pri1 t) ~2 i~ J[~ Plumber' ignatur MPRS Number ao ~~~ Business Phone Number ~~s ~~ ~ ~~s Alumber's Address (Street, City State, Zip Code) //O ~.~'.~.~ ~ G~-c.~r' s act VIII. Coun /De artment Use Onl Approved ^ Di Sanitary Permit Fee des Groundwater / Date Issued Issuing Agent gnature (N S ps) Surcharge Fee) ~_ (0 ,~2 ~ Owne en on for Denial IX. Conditions o pproval/Reasons or Disapproval 3)'T~~s ~ n _ _ '~~~ J K SYSTEM OWNER: = -"~ 1 Septic tank, effluent filter and t~,,~~-Q.~ S~.~Q~.~ ,fit'`" ~- ~~~ dispersal cell must all be serviced / meintainlgd as per management plan provided by plumber. Q.~Q_l~ v~' ~ o.~. ~ ~ 5` ~ 2. All setback requirements must be maintained ~ as per applicable code/ordinances. Attach complete plans (to the County ontyt for the system on paper nur mss man oii~ x u ~nu~cs ... sou ~/~, ~s SBD-6398 (R. 01/03) ~- ~ N~ ~ Faso ~- ~,,, yD, {dam z°-~-~ ~~ ~g ys q `f 5Y .P-G~ 9~2 s° ~,-( // ~Pu~ -3 B~aX, v v 0 $-r ~~1 ~~~~7 ~ GpP 1 ~ .~ ~y 9~- ~ ' l ~ H"~~' ~ GG~ N Faso ~~-- ~,,~ z~- ~s q `f I .: ~ r~ ~ ~ , /6`/~ ~~,t /8 ,~ ~~~- ~~ r ~ 1 ' ~ ~ ~ ,._---- y U~ r /~ ~ ,~~ $^aX 0 8~ ~~~7 (~ ' - RECE.t~E 4 wsconsin Deparhnentof ~ rpti~ n, /~ ,, $O~,I~~VA ATION REPORT Page ~ of 3 Division at safety and s l ` _ ! l ~~ E~ with t:omm ti5, ream. was 'RI;iX COtaF~ Il CountY ~ ~ , . t f i ~ ~ an mus ze. Attach complete site plan on paper no! s than ~ ~ ~1rs indude, full not tirnfied to; vertical and h fon and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and. distance to nearest road: Please print al! lRformatFal. '"~ ~' ~ Date ~~~ Peraoaai irdomOSGon you provide may be used for secondary purposes(PrkaCy l.aw. a.15.0< (t f (mij. (~- ( Property ONmer Property Location ~ , ~~j ~ Govt;. Lot 114 1/4 S ~ TZ N R ~ E (or~ Propertytr's Mailing Address Lot # Stock # Subd. Name or CSM# d 6 -~ ~ ~-~ U City State 73p Number ^ City ^ Village ~ Town Nearest. yr ~. (LS ~" -/U/ / ~~P . (~ New Cortatrudiors Use: Q Residerttiaf / Number of bedrooms .~..~ Code derived design rade ~5 ~Y( G ~ GPD Q Replacement ^ Pubpc or convnerciai -Describe: r__. _-- - - --.- -- Patent material ~ v~ a ~ ti. Flood Plain elevation Ii appAcabNa rll~~ ft• ter' tatlons: S y 5~ l~^ e~`~ v - `I' Z•, ~v 0 ( # Plt ~~ surface elev. y9 ft. Depth to 6midng factor ~ d ~. g~ ication Rate i~txtzArt Depth Dant6nant Redox Destxiption Texture Structure Consistence Boundary Roots GP in. MunseA t2u. Sz. t,.ont. Odor Gt. S~: Sh. 1 •Eti`#2 l ~ -(s ro. r 3l l S: I S~ ,r v~ r ~ ~ ~ W~-c~5` fo ~ `1/3 ~zP ~-~,rY l 2rns5 vn ~- CS - ~ - s `l~ ~~ ~ t7 ~ z a~ t 2 • S~ a #°~~ to Pit t;rotxtd aurface elev. o tV n. Depth to lirtsting faCOot' ~~ y in. Horizon Depth DartUtartt Color Redox Deacriptlon Texttore Structure Consistence Boundary In. MWtseli Qu. Sz. Cone Calor Cit. Sz. Sh. ~ ~ Roots GPD/tE •Eff1l1 •Ett#2 /~ 3~' r G qtr 3/~ S Zsst S 2~'L-><.,~ ! -- „ (~, ~, G- 53-t ~ ~ ~ - ~ ~ I ~ • f~t~uettt ~1 = BQD > 30 ~ 220 ~ and TSS >30 < 1 50 rngll • Effluent #2 = BOD < 30 mglL and TSS <_ 30 ntgrL C3T Name (FMease Prirtt) Signature ,,... ~ CST Number zr ~ A date Evaluation Conducted !'(~~ 4'~/~C~ >~,o,_, ~-~c..,.~..~~ fit' ~~/LG,r~ (D ~~.5 Telephone 7~S"7l'°-aZ~ 9 G~5 t ~ • 4 .~ Property p~vnar!~ !L C-~~ ~_ Parcel 10 A~ ` Page ,~ d 3 ~~ ~ ^ 13otirrg Pit Ground suctace alev..~s?? tt. depth to limiting taaa / ~ in. SoN ication Rate Horizon Depth DominaM.Color Redox.f?escription Texture Structure Consistence Boundary Roots Gl' Dlf~ ' in. . MunsQq Qu. Sz. Cont. Odor Gr. Sz Sh. •E~#t •Eti#2 ~-s- ~~ SL »~ r l , ~ /. O -i -- Q vh ~ f. I ~1 n~ `~~ u tirc VI{/VIIY OM IYYQ Oq~. ll. VR}l111 W NllllYll~`WN41-.. Af. ~ .-Rate Horizon Dominant' Redox Desaipibn Texture Sfircture Consistence Boundary Roots "GF D/iF in. Munself t]u. Sz. Cont. Cdor Gr. Sz. Sh. "Fff#1 •Eif#2 ~'~ Groundstwfaceelev. R. Depth to Nmitlng-rector - ln. Soil Bonn Rate Horizon Deptlr Dominant Redox Desalption. Texture Strut~une 1Consistenoe &xtr~dar~r Rants C(?Dlf'tr in. MunseB Qu. Sz. Cont. Color Gr. Sz Sh. 'EA;$1 I •~~ ~. .~ .~ r ~2 • T Eflktent (iR ^ 9OD~ > 30 <_ 220 mgrL acrd TSS >30 _< 150 mgrl. • Eflluuer>< 112 =BODE 30 m811. and TS5 c 3f1 mgiL ~, #'Ite Depantnent o~'iCotntaerce's atl equal opppetunity service provider and employer. (fyou need assistance 20 access services or ''aced tttptttal '(n an alternate format, please contact tiro department at 608-26b-3.151 or TTY 608-264-8777. asusswnraroa> ': ' property Oumer ~"rQr~ ~~~~~ Parrsl ID A~ 8~~. f"1 ~~ f`fV < /~~~ Page ~ of L. /J l~.t`' Pit vrw~iuaui~wmer.,,y w _ n. vaFnr~ w ~e~ecny ~auu • -~ - n~. c~ ~~ Rate Horizon Qepth Dominant Redox.Destxiption Texture. Structure Gonsisterx~ Boundary Roots GP DIPf in . MunseN Qu. Sz. Cont. Cdor Gr. Sz. Sh. 'EfliE1 •EtT#2 ~ / [ / ( ~ ~ o [] pn Ground surtace elev, tt. Depth to-amiting'idctca• in. SoN -Rate horizon Cult Dominant` Redox Destxiptiott Texture Sbvcture Consistence Boundary Roots GP D/PE ~. MunseN Chu. Sz Cont. Cobs Gr. Sz Sh. 'EffA~1 'EfF#Z ^ Pit Gnwnt~~faoealev. rt. Depth ro pmiting.fador in. ~~ # ^ ~~ Still ~ ication Rate Flolizon Deptlt Dominant Redox Desaiption. Texture Strtx~ure C.ortsistertce. Boundary Roots - Cai? Dlfl: in. .Hansen Qu. Sz. Cont. Odor Car. Sz Sh. "E!f#1 'Etfrt'2 ~1 ~ 60D~ > 30 <_ 220 mglL and TS5 >30 _< 150 mgtl. ' EfAuant #2 = C3C?De ; ,30 mgll. and TSS < 30 ~'lte 13epartment ot'~ommerce is an equal. opportunity service provider and employer. if you need assistance to access strvices or 'need tnatGr'ral in an alternate foimat, please contact the deparnnent at 608-266-3 l S 1 or TTY 608-264-8777. aao.sa~~c.a+oo- PACs E _~L_O F NAME ~9Me.CA~'~ LOT#~ ~ LEC3AL DESCRIPTION 'la '/a,S ~S~TZq,N,R~J E(OR~ ~~ C SCALE: 1" _ BM i ELEVATION AGO, O BM 1 DESCRIPTION ~ ~~ Fva o~ ~~'~r~~ BM 2 ELEVATION '- BM 2 DESCRIPTION p `' SYSTEM ELEVATION 1 ~ ~ ~ ~ SYSTEM TYPE ,~(~olucn-~ig,.,j ~e SIGNATURE ~°'~ DATE ~ - ~ ~ O 5 SYSTEM 01FVNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / n as per management plan provided b~ 2. All setback requirements must be ma as per applicable codelordinances. RECEIVED . p,pR 2 5 2005 ST. CROIX COUNTY ZONING OFFICE ~, 'fir ~\ f%~ ; L Ul'~ Safety and Buildings Division County ` + ~ 201 W. Washington Ave., P.O. Box 7082 iscons~n Madison, WI 53707 - 7082 (to Sanitary Permit Nttmbu 611e in by Co.) De artment of Commerce (608) 261-6546 2 ~ ~-2 .7 J Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal infotmstioa you provide maY ~ u+ed for secondary purposes Privacy Law, s15.04(Ixm) Project Addrest (if diffu mailing address) I. Application Infortnatloa -Please Print All Information r / ~ P Ownu's me / Parcel S Lot Block N f Pr fling A r Pro ati ~ / t../ f ' ~ Ci ,State Zi ode Phone Number - ~., Sxtion 1 t:ircle ' IL Type of ButldIne (check a at apply) ~ ~ tv., N; R~E t f~V ! or 2 Family Dwelling - Numbu o ms ubdivision N 'CS ttmbu ^ Public%Commucial - Descn'be Use ^ State Owned - Desrn'be Use ^eyty_^ it e o of III. Type of Permit: (Cbeck only one box on II .Complete line B if applicable) O " ~ _ _ O~ r A' New Syuem ^ htcemeat S tem ~P Ys reatmenUFIolding Tank Repl ent Only thu Modification to~IM!!tf B• ^ Permit Renewal ^ Permit Revision ^ of ^ P ransf N rcvious P e issu Before Expiration Plumbu Own IV. T of POWTS S stem: Check all that a 1 Non -Pressurized (n-Ground ^ Mound > 24 in. of suitable soil Mo 24 in. oCsui b ~ t- gle Pau Filtu Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ P t ^ Aerobic Trees ent it ircukting Filtu Recirwlatin S thetic Media Filter Leaching C ^ Dri Li ^ - ess Pipe ^ Isi V. Dis enalrI'reatmentArees Information: Z Design Flow (gpd) Design Soil Application Rate( st) Disper Arcs Required (s Dispersal Area Pro (st) tem levstion r ~a ~ , ~ ~ ~s ~= a , 3. ~ VI. Tank Info Capacity in Total Numbu Manufacture Prefab Site Steel Fibu Plastic Galloru Gallons of Uni Concrete Constructed Glaze New &ictiag Teaks Tanks septic a Holding Tank S~ ~. ~ SCE l Aerobic Treatmen Uait Dosiag Chatober VII. Res otu161Uty Statement- 1, the under: d, a ume reap siblltty for Installation of the POWTS shown on th Cached plans. ' ~ bu s Nam (P t) Plum Sign re /MP Number B ess Phone Nu C -fs?~'1 ' Plumbu s Addr (S Ci State, 'p C ) / VIII. Cozen a artment Use O Approved ^ Disapprov Sanitary Permit Fee (includes Groundwater Date Issued Issuing ent Si re o Stamps) Reason for Denial Surcharge Fee) IX. Co eas for Dis pproval ~ 1 eptic ank, a uen~'~ter and 3) t7v'~ en~~-tom S dispersal cell must all be serviced I maintaintd ~ r ~ as per management plan provided by plumber. ~ Z9~-, 2. All setback requirements must be maintained '~ t =- as per applicable code/ordinances. i / v /~V /~ --/oo ,~a-~-'~ /moo l~~ ~ 1 = goo l ~ 9a~o~ , T~a.. 93.3 ~s- ~' y ya.sy' ~. ~~ GOpV `1,"30/ ~°~/8`~ ~'"'~ vr~~aao3s~ ~~ -N ~'~/ w~- - ~,~~ ~-/oo ~ /ado l~~' 1 = iod ~ = 9a`°~~ Ta= 93,3s, '~ ~s_ q ~ /~. 1~ S~?{~~ ~ ~ ~ ~~~ ~~ ~l ya,~y ~=a y 3, 3S ~o3S~ -,= ~ 30 / ~ ~a`~g~ :ti . ~ t RECEIVED ~~~~ v}~~~,i,s~~ozo~~r,~n poe~Lpar~tme~po,-yc~on.,m~ne - ~ ~ - ~ ~ S01L E1~ALUATfON REPORT 1.~.*~~Ri ~ oatv~7 ~1d wIRn14i~ ~l f n n n n n n n ~ 3 ~ ~ n m ~ rns. ~. ~.ooe County $ T•' C ~ O / ~ Plan rapist t ' i ~ Ntach oomptete site plan on paper inc~de. bcrt not ~: v~erlical ae. n (BMj demon ~d Paoei t.0. ~!~~'. ~ ~t7 (,~ pe~~tsiape, sca<eororpe, dst~noatonearestnrad. Please print all infanma~fon. Re1ie1A/~ ~' ~ Z~, Powvmi tnfom~tton yon a+owae mgr w wee twseoona~ry owvos~ t~+~ ~. ~- tsot (+) t+Nl N W f' s£ SEGT• l properly (fir lC~rPv4,U l3ffS ~ Propartyt.oca6on cwt. ~ Mw i va~w ua ~~ T Z 9 a +z ~9 i{or) w Properly Owner's Mailing ~j1 G~ • ~8rtl ~' ~r"~ 1~f~ • trot # 1 ~ elodc ~ S'ubd tYame or tSIW1 E,V N a Coo yo TE- ~' /p6~,E" •, sale ~ Phana tJi.rrber •'7 a ~y a ®Town t Road ~ ~w ~'~ h~UOSo~ wl ~ s4olh ?I S~ 38h 7~5 ffUDS - ~i o~ r3A thew t:or~uc6an user Resider~si r t~krrrber or trerf~oorrpe 3 ` Code derived desi~r tlow:a~ -yS0 - ~ ego Rrt ^ Pu66c or aomrrrer~iei - Desaibe: rronti ~S .uP~S/ o~TW!}-~... Flooat~nongfe ~v ~. ~ ~ is sv /Ti}-~ ~€" t ore ~4-.~.~ i:v yiE'o v.vfp j ~ " ii ~ ~ ~ ~ ~ ~ ~ ~ ~ c~.bs~os~+-. t~ r.~na _ o , ~- (, Morlaon Depth Darnirarrt Rsdooc OesoripAion Texltxe 8truokre C.ansisEenoe Boundary Rods sw, ~ tn. tlrr. Sz. Cont. Color 13t: Sz. Sh. 't~lY1 "Eifd2 d oM/a /~ ~3 ~ ifshk ~P~s ~ . s o • o SQL /fsh,~ ~ v c ~ ~ • 3 urn q~P•3Z >90 U - ti5t ~t c~a,nd swfaoe ~-. • " n a rn~g t~or trr. Horiaon Depth !)orr~nent Redoac Desa;ption Tep~re Struc~a+e Corerx~e eaaxiay Roots Sd GP! RsAe )A'f ~,. t~+a,nsee c~,. sz carx. caror c~ s~. sh. -~+ '~ ~ p - /0 Y 3l3 ~- Zf5 bl~ S 3 M • S ' 3 • I ~•s Y/~si ~ s ~t 5 c - ~. Z • i ~• s YR S ---- ~ cs -- i• 2. 0 /a ----- ~,,r,n,Q S 4 ~- • t~enc rrt = eoD > as < ~o rrrgrL and TSS ~o ~ s o mgrs. - Effluent ~2 = eoD < ~i mgA. TSS . 3o mgrt. . `~ Rot3 Rr ~ ~b ~~ ct~.~ ._ 2 G s q Oda Eamon TaNphone Nunber ,..~_... - - - ` wog, `~ -~3 7~s•~~a.3~~{i. Private Sewage Consultants 2812 10th Ave. ~iN S f-o~2 TdT•9-G ot~ ~~ ~ Spring Valley, WI 54767 Z p . eo ~.-~ . Z o ~ Da'a 20 • /01.7 • 30 - O'er Z-o • io17 , yo • o~ r ,.. ~~ U Ca yo Tom- ~,~G-~ y owner Parcel ~ # Page a a~~~ ^ g~.o ?8 ®- Pit Ground sur~ce elev. R Oedh do 6rniUna tacker / v, Horiaort Deptlt Dominant R d D Sod Rate ~. o ~ Munsed /D ye ~/ e aa escription ~. ~- Cunt Cdor TexWre Strrxture Gr. Sz Sh. 2fs C.onsistenoe ~~, Boundary ~ Roots ,~, ©P 'Eti#t . s OVft' 'Ett#2 ~~ ~' S v L Z'FS ~ ~ CGS - s < < ~, S j. ~9 # U Boring ~ ~ l ~~- b2_ ~, ~~ ~ Otxre.~d( , Pit Grotmd surfaoee~ev.-- tt. ~ l~fhii~idlsr, ann.. ~„ Floriton Depth ~ Dominant Redmr Descripfion Texture "' Stnrctx~e - Consistence - - Boundary Sol - Rate GPDlff . MrerseN Qu. Sz Cant Cobr Gr. Sz. Sh. 'Efial`1 'Eti#2 X ~'~ ., r. ' w ' ~ ~ r , i . prt Ground Sllrfa0e 61@V. $. ~ De~h tD ~nidnO tarior in ^ / Sod Rate Depfr Dotes Redooc Desptptiort_ ,Texture S6ucture C.or>sistenoe f3otuxia<y Roots GPOfii< in. MunseN Qu. Sz Corti. Color Gr. Sz Sh. `Etf#1 'Eff#2 .~ .2 .p ~~ ' E~Iluent tf'1 = BADS > 30 _< 220 rrgtt. and TSS >30 _< 150 mgit. ` Eflhreat ~ . Bpps < ~ mgll and TSS <_ 30 rr>~ The Department of Commence i ~ an equal opportunity service provider and employer. If you need assistance to access services or aced material in an fortnat, please cAtttact the department at 6013-266-31 S 1 or '1TY 60&?64_8777. sao-e~opeaoot a ~ 7'o w,~ ~~ ____ ~a . ~ ----~...~ ---~ r- ~,;~,~ --,__, For issuance of permits and designing Contact: Ulbricht & Associates Registered private wastewater consultant and plumbers 2812 10th Ave. Spring Valley, WI 54767 715-772-3442 ~, a i ._ fo~,v~; s~n~~,~ G~4f~.e ~ So y ~~~ Pr, yy , P~f~ ~ /a , q~. o s may- ~ io .'~3 ~~ a G r l 7'~ ~ „_ 30 , 5 ~~}le. ; i a~,, a s QZ ~~4 O -~ ' ~'Y ~ Z '! ~~ pi ~7-2~' GL 33~ Z IQ ~~ ff~ ~M . ~' f ~ r ,j~.~~ ,® POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page f of 2 FILE INFORMATION ' Owner Permit # 3 ~~ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units -'-- ^ NA Estimated flow (average) d al/da Design flow (peak), (Estimated x 1.5) Q d al/da Soil Application Rate al/da /ft~ Standard InfluentlEffluent Q!uafity Monthly average* Fats, Oil & Grease IFOGI 530 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 IBODsI S30 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric 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 , j ~} ai ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ~ ~~ ^ NA Pump Tank Capacity al A Pump Tank Manufacturer I~jNA Pump Manufacturer A Pump Model ~ A Pretreatment Unit I;~NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal CeN(s) ^ NA ~In-Ground (gravity) , ^ In-Ground (pressurized) ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE SCHEDULE Service Event ~ Service Frequency Inspect condition of tankls) At least once eve ry' ^ month(s) (Maximum 3 ears) earls) y ^ NA Pump out contents of tank{s- When combined sludge and scum equals one-third IY,1 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month(s) (Maximum 3 years) yearls) ^ NA Clean effluent filter At least once every: ^ month(s) year(s) ^ NA Inspect pump, pump controls & alarm At least once every: month{sl A ^ year{s) Flush laterals and pressure test At least once every: ~ yee~(s11s1 ~NA Other: At least once every: ^ month(s) ^yearls) ~JA Other: ~A 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 fibers, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. 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NOI1Hli3dO aNV do 1li171S 2 ;o ~ a8ed ST CROIX COUNTY 'SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C;:;RTIFICATION FORM OwnerBuyer ,C~/Yp~/ ~~r" Mailing Address ~D Property Address x.~' x (Verification required from Planning Department for new City/State ~ ~/ Parcel Identification Number 6Zo - ~ ~~ - / ~^ t?z~ LEGAL DESCRIPTION , , A l ~ ~~ ~~~ Property Location „~,~1/., ~ l~'~y., Sec. ,~~, T,~N-R~W, Town of ~_ Subdivision ~~~ .~~~ Lot # / ~ Certified Survey Map # Volume _ ,Page # ~~ Warranty Deed # ~ Sb ~/ c3 / Volume ~2 ~ Page # Spec house ^ yes~o Lot Lines identifiable~es ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result is its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if seeded by a licensed pumper: What you put into the system can affect the function of the septic tank as a treatment stage is the waste disposal system. The PropcriY-owner agrees to submit to St Croix Zoning Department a cartification form, signed by the owner and by a masterplumber, journeymanPlumber, restrictedghmsber or a licensedpumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition andlor (2) after inspection and pumping (if necessary), the septic tank is less than 1!3 full of sludge. Uwe, the undersigned Gave read the about requirements and agree to maintain the private sewage disposal system with the ctandartte set forth, herein, as set by the Departrneat 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 three year expirati date. / ! ~~ SIGNATURE LICANT DATE OWNER CERTIFICATION I (we) certify that ail statements on this form are true to the best of my (our) Iarowledge. I (we) am (are) the owner(s) of the property described above, virtue of a warranty deed recorded in Register of Deeds Offiec. a~ / PS I NATURE AP ICANT DATE s*««** 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 deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2y8?P 118 Document Number STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Steven L. Bakken and Caye L. Bakken, husband and wife, Grantor, and Kern____on r ~, marrie Grantee. Grantor, for a valuable consideration, conveys and ant to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area 75939 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 01/07/2004 12:35PlI WARRANTY DEED El(El~T # 17 REC FEE: 13.00 TRANS FEE: COPY FEE: GC FEE: PAGES: 2 Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. This deed is in fulfiilment 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" authenticated this 6th day ofJanua 04 Pub~IC otary N ~~ ~N is~~ns~n * eta TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Edina Realty Title -Doug Berg 400 South Second Street #115, Hudson, WI 54016 (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 Name and Return Address: Edina Realty Title, Inc. 400 S. 2nd St. -Suite 11 S Hudson, WI 54016 4!2540 20-1027-40-000 & 30-000 &20-00 Parcel Identification Number (PIN) This is not homestead property. ,, , B ~ -~ , * Ca a L. B en ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this January b, 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' 'nstrument and ackn~~ d the same. *Cheri Brown Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 3/11/2007 ) 13 WARRANTY DEED STATE BAR OF V1'1SCONSIN FORM No.i-2000 U 2~87P 1.19 EXHIBIT A The NE '/, of the SE'/. and the N W '/, of the SE '/., all in Section 15, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E '/< corner of said Section l5; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE %, 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 O l 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. ~ ~ ' , . ~ . M[n1G°~~44LI N89°08'7 5"E 1644.49' 'Rx x x396.64' x x x / x ~~ x C 1 -RK x j 250.64' ~ TOP OF 314" REBAR~ ' 'S'hy ~, REV, =861.25' ; '.. •~ ! .: ~ N,,.. LOT 11 ..........,,• .p> :',,.. ~,. 2.16 ACRES ~ ~ LOT 1 O `•''•••• .,,, ••'• i 94205 SQ. Ff. ~ 2.03 ACRES ••••~•~•""~~ ' ~ ~ ~ ~ 88597 SD. Ff. ~ '~ 8 L.B.O. =865.50 ~ ~ ~~F $ ~ ~ ~ ~ LOT 9 ~$~ ~ ~ u3 ~ 2.04 ACRES ~ ft 89039 SGI. FT. q~q ~ L.B.O. = 885. ... .. 1. FT. . .-- --~- ~~ 2' __- ,~ - -: ~ / ~ - ~. .. ~~ •~.` ~ /, . •~ ,~ ~.. •. ~~ •~,~ /' ,~ /- ,. ' ~" ' ~ `~~ LOT 18 ~ ~ ~" ~` ,~~ ~''`/ '~ /" ,- ~'ip 99335 SQ. FT. ~" ' x'` •~, ~' / 311.53' ,~ ~`'47.~ N87°40' 1 op' p{.' ~ ~ ~. LOT 21 LE'T' 17 3.30 ACRES w ... ~; 143828 SD. FT. r~- 1 t' 4 i `, ~ ~ ~' ~ ~ ;~ 1 .p _ 1 "/ ~ W . '. .': C3 ~ ` ...~ f ~ tt' kl;_,. 1. .{ ® ; Q