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HomeMy WebLinkAbout020-1047-60-200 < C ~ <r ~ ; f~ O O N ~~ N G 6.: v , C i 3 LL 3 M ~r ~ Z N ~ z " ~ ~ ~ + •~ O Z ~ y y o ~°'„ w a m N H Z c C9 O Z ~ c p ~ ~ G i Z d' 'i ~ C 'd J~ ~ N N N O 1~.1~(Vl ~ ~ N (6 d U • *v a cn Z m Z O N M ~ ' CO 1 Gl ., ' O V 0 h m ~ ~ d - ~ d ~ w f~ ~: > N d ~ o I: C C a Q ~ o c Z M > ~ ~ = a a a • R ~ a ~ ~ .. ~ o ~ w ~ ~ o 00 N F U rn rn a o 0 C1 N ~ ~ ' -~,~ O 1 ~ ~ c ~ ~ ~ ~1 ~ °~ ~ o .' w O _ U Q f V! C ~.+ CC O N N Q C 3 ~ ~ ~ 0 N L ^ F- U w ~ ~ c ~ i.r O' N 'O 7 O ~ • L; O NO p 2 (n ~- O O :C c c ~'i ~ .^. ~ ~ w . - .. !r E .r a~ ~ d ~ ~ a "' a ' i o. w . ~ . ~ , .~ ~ :3 c ~-1 A U a ~ I' O N U ~~ o yo n' o mho 0 31 0 U ~ C7 ~ I ~ ~ Y C (0 ~ C ~ '~ m N 'C ~~O . N C ~ .~. N N N 7 ~ ~ ~ ~ O ~ C X y N t/> ~ ° ~ p- E ti ~, C C ~ ~ O ~ N C U N _pp U ~ d C >`O 4-- C ~ ~ U N~ y ~ U y ~ r U Y N~"p i 6 a o c 3 a~ ~ C O ~' LL C .Q vi N E N . d O N C ~ O ~ > p~ + + ~ .E U ~_ ~ ~ N ~ ~ 'C3 N~ U i Q ~ E Q ~~s3n U ~ O a a~ ~ 1/1 ' O O d d a m c ~ ~ N N a O (V N ii c ~ E ! ~ ~ I .~ (6 ~ ~ 7 v CL Q 7 ~ v ~ ' ~ N i (p C O~ L p7 ~ O a m .C O ~I ~" n `o ~ O. ~ N Z ~ Z ~ ~ o i E .. ~ (D •• ~ _ ~ O l6 L ~ ~ ~ .. d - {0 d ` N N ~ G w H d i N Y ~ ~ D D a rl E ~ x p N V1 M E ' U a cn ~ ~- r- f- ~ ~ a a a ~ ~ c m ~~ o ~ No o ~ ~ Z •~ N o O} ' I O N O ~ m C ~ I~ m 0 ~? n- '~ v, Q c ~ ~;. m ~ ~ I ~ 'a ~ d ~ Q r~ n o`~ m p ~~ _ 1O ~ C o E O N p ~ ~ V N C C p ~ p~ O ~ U N p ~ Q O O N N N y`'7j ~ L U N.~ C ~ ,C ~ N ~ o } ~ '~ ~' O 1- O I- U !n O ~ N v o ~n `~; N c6 Y d ca CI1 .~ E a d ~ i e ~ O N v Wisc sin Department of Commerce PRIVATE SEWAGE SYSTEM Sty 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 Stout, Richard Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: ~ (3 a ~~ ~ U b ~ D -'j~'1 ~,(l 6 -~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing 7'tlLl,.) ~---~1 ~+ v Aeration t--.~~ Holding ~ U~ TANK SETBACK INFORMATION TANK TO P/L 1~/~"S?. WELL BLDG. Vent to Air Intake ROAD Septic 1.STI~~ ~ >~ ~ S` D g ~~5~ r ` ~ G~ ~ ~ Sr Aeration Holding PUMP/SIPHON INFORMATION Manufacturer __-- . --_ Demand - -_ --- GPM Model N TDFi Lift Friction Loss System Head DH Ft Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM Dom /. ._ /_ -_ ELEVATION DAYA county: St. Croix Sanitary Permit No: 420501 0 State Plan ID No: Parcel Tax No: 020-1047-60-200 STATION BS HI FS ELEV. Benchmark ~. ,3 goy ~ laa'~ ~ Alt. BM S ~ /d/• 3?j Bldg. Sewer t ~ ~ 5~ SUHt Inlet i,. 9~ ~~ St/Ht Outlet Dt Inlet !~ ~~ Dt Bottom ~~ /~ He er/Man. -~, ~ c~` . (~ Dist. Pipe ~ ~ : B~ '.s~ Bot. System I ~• Qq 9 Final Grade _ ~j `' ~/ P . 0 St Cove ~ p~ 33 !.l ~ -~C...~ BED/TRENCH Width / Length No. Of Trenches ~ PIT DIM S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS + ~{ ~1 'Y 1,y SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHING CHAMBER O Ma ~r.~-~ /~ f /V, `2<~ f~+'t'f"1 T e Of System: , ~~ r ~~/~ ` ( ~/~ / / D Model Number: G DISTRIBUTION SYSTEM / ~h ~~~ s~....-d'~ Header/Manif ~d p Distribution ~.~ /- r Pipe(s) ~~ ~ /Lh (.G-Y ~ •~ x Hole Siz~ x Hole Spacing Ve ?r t t~ ~ Length Dia_ Length Dia ~ -Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At-Grade Svstems Only 7.rw ~ n n ./ ~ ~ ~ L Depth Over / Depth Over xx Depth of xx Seeded/Sodded xx Mulched ~ Bed/Trench Center ~ I I ' Bed/Trench Ed es g To soil p Yes ~' No ~,? Yes [~~ No COMMENTS: (Include Lade discrepencies, persons present, etc.) Inspection #1: ~~ / ~ ~/ U v Inspection #2: / / Location: 492 Prairie Lane Hudson, WI 54016 (NE 1l4 NE 1/4 20 T29N R19W) NA Lot 39~ Parcel No: 20.29.19.185A2 1.) Alt BM Description = S'~ C°vL~ 2.) Bldg sewer length = -amount of cover = I, ~ I I ~ ~ ~ Z~ II ~ Use others de for additional information. o ' ~ ~ _ ~ __ -- - - __ ~~~!Yli__~ ~~ ~ ~___._. SBD-6710 (R.3/97) Date Insepctor's Signa ure Cert. No. r i ~ $dfaty 8!1(1 t3~uWngS i~arwwaa _~_... ~ 20i w, Washia8ton Ave.. P.O. Box 71b2 ~~~~~~~ I Madison, WI i37a7 - 71E2 R~ ertment of Carnmert:e - o -D ~~~ ~ Sanitary Permit Appiicat~an la aoaord wWt coeaat 53,x1. Wis. Ades. code, personal iaformsdea ya>s provide y,~ ~ Ptiv 4aw 15. 1 m f. Applityitlatt iatoems- - l~ttse Pry ~ lafonaaeino ~ ~~~ ~,~ property Owoer's Name ~ LQ~2 /P.~ a~-d S~?ou~` C~~ 1 Ad<Irree c; QTY pr~asey Wwner s Sj. G• ,, ;~X ~ C~E 135,3 ~~ GJa~u c'. ~~,` ~ ~ cr,,i~a~~r, ..,... ~«... Ztp coda as Number ~ownry S'TcrQ P' ~ 5itc Addsnss Sanitary perialc Nuazber ~~qZ Pr~,~vze. ~0 5~ ( ~ Q tick if Revision 5tste Dian T.D. Number dzo- ~o~~--bo - Zoo(• 18S~h-z~ ~{~a~sDN ~ " ~J ~Q~~ ~~3'~ s~! -~ 7,~r ~/~1~~3~' ~/ . - ~ ,2036 fl. `1y'Pe of Btiallt44ng ( 041 that opglY) pia or 2 Pasa4iy Dwelliab -Number of Bedrooms ~ - ^Village CI PubllolCoamnsrciai - Deferfbe Use awas>tii r~ D Q Sts OvVned Nosmsr Read 2)3~ ~cf3~•s~ --' Ds. 'type t+i (CStedc otu box on tree A (nuucbsrlns scheme for ltrterntti sue}. ~Co~uplate line 8 if 0pp1tc0ble) ~' 1 ^ New 2 Replsamastt System 3 ^ Replecemeae of b ^ Addition m Teak Oat t B. ^ teak ff Ssalari pastels previously Tsuad Perout Ntuaber ~. 0ppty)(numberin~ scbettu lC for ir-tarna4 use) 4a Nott- a ~~ 211.7 Monad 17 ^ Sand Flier ?Z~ Fretsuriud Io~Ground 4l {~ Hoidin5 Twit a8 ^ Stogle pass .~ n ..~. ae [~ Aerobic Treotrrsaot U~sic a9 0 Recucuisdae errs 30 ^ eyed Wetland 51 Q Drip Line ,Aron DlepersalArea'" sou,*piulcsaaa ~,~•~~-.-- _,------ ---- `~ 1?bx l~ Ro ~p~ 13~ l~(Asis./I)ays/Sq.Pt.) (Mics.iincb} ffievadon ~J ~~ ~~ ~~ r~ T ~~ g~~ ~~ yq. ~ prefab Sits 5teai Fiber T013k ftrto Captcit}' is .Taal Ntimber 1il~ Caxrata Car~tcustad Glass Mons Cistloas of Tstilrs Sepda ac HoiditK'~ic Od •~ r G' e s~ - - ~ 0o~c cxo>b.r laoD VIY. lrEli Btstmttent- I, tM and. , assume tw ter of t4u pOVVTS shown mt the ttttarbed pluprbar's AUmo (pe40t) p~ber'r $i5asnua Number reusiaass phone Number ' j,`o- n~ -~~~ m phtmbet's Address (Stt~est, City, Saste, ZIP Code) II ~ sue- ` t G - ---- ~-~-- •-•••~••~••!•~ - $BAit~ peltfllt f'ae lurGtuaes {jrpugpwiaca ~-•• .~•.•~ -- ' - - I~..Appeoved 0 Diasppaovad > ^ owner arnn taidal adverse ~~~~e~'/~" ~ . ZZ ZdOZ. `~,. .,_._ Detorsttirtietica DL, Cottdtt4oo0 of Appraro01tAe0sons for D4strpprovel ~ ~ ^"`~°~- ---~ ~ti-~.. 5.e~aPic- ~~- ~ l~ o~ Pte' ~-`'` ~ . - , oa paper not leer rises iili x ~r ~G~a y.E Spa u-P~ , ~~%Y.~r~`% sdd T~ iP~Q tJ ,(0 ~'3 ~ G ~'~n ~6ii.~ A~ ~~dsa..~/ .,~,~ ~`i<r~,~S' /~Oeix TD Gt.,~G Gt- S'1.L ~c ~ pdC~ '~$ CD / G l ~ ~ = YO ~ '~ " d e- ~'~ 6D /~ ~ '~ v` `lS,TD `a~e a.r~ J''~ u- ~ G° ~ ~% said T~ ~(Q C•~ ,(o ~'"3 ~ Sin ~ ~d ~~ ~fiar~ iS' iF'aarir TD use c~ s~6fi~~ odcv ~Sc~~~ l" ~ YO ` %~r r v b v x M t ~ ~~ 8/~Z d,Sm~ f'` L~' 1 i ~,, t f~d'~ S rP • k S03L EVALUATION REPORT Wisconsin Department at Commerce Division of Safety and Buildings in accordance with Comm 85, vYis. Adm. Code County Attach complete site Plan on paper not less than 8112 x 11 inches in size. Plan must inducts, but not limited to: vertical and horizontal reference point (BM), direction and Parent I.D. percent slope, scale or dimensions, north arrow, and location and distapce to nearest road. Reviewed by Please prim! a!! information. _ Personal information you provide may he used for secondary purposes (Privacy Law, a. 15.04 (1) (m)). Property Owner Property Location 1 ~ 1 s ! GOVt. Lot ,U - 114,0 1I4 S property Owner's Mail~g Address Lot # Block # Subd. Name or t State 'p Code hone Number ^ City [] Village ®Town u cQ 5o w `~!o (CP (7~S'j s Y 9 - l~ ~ ~ sty Q New Construction Use: ® Residential !Number of bedrooms __.~2.__--. Code derived design flow rate _ [] Replacement [} Public or commercial -Describe: Parent material ©~i-~^1~ s ~ F1ood Plain elevation it appli ble ,,,~ General comments S y~e y/t ~ { v . 9:~, ~' ~ and recommendations: Page ~ of .~.~._-- r Date ~.~ r... - ZO T Z g N R ~~ E (or) ~ :SM# Nearest Road p~ 0 ~, GpD tt. ~ ~ j 1 "1 2002 ST. CROIX,~c~ CEY } Boring # ^ Boring l ~ Pit Ground surface elev. ~q~ . n- Depth to timitinp factor l ~ ~,,,^ in. Soil iiption Rai i Horizon Depth Dominant Color Redox Description Texture Structure Consisience Boundary Roots •E~GPD/ft Eff#Z ~ in. Munsell Qu. Sz. Cont. Color ' Gr~ Sz. Sh. ~ ~ 5 • ~ i a -/ ~l rb 3 z ._ I S ~ ~ rn~ ~- c Z ly - 3 yr y~ S L m b~ ~- 5 - , S , ~ 33-ICY Iniir `~~~D ~ ~ O iM ~ - ,~ J 3°~ -~ Boring # ^ Boring j0 _ ~ in. ^ Pit Ground surface elev. ~Q~ ~ ~ n Depth to limiting factor. Soli Application Rate Horizon Depth Dominant Color Redox Description Texture SWcture Consistence Boundary Roots GPDlfI? Gr. Sz. Sh. ~Ef<#1 ~EN#2 in. Munsell Qu. Sz. Cont. Color ' Z 1 ~-~ ~o ~/ - ~S /r~s m l cs ~ ~ ~-»~ >,~.,~ yip - m os m - , ~- , z 39 ~~~ ~. 'Effluent #1 =BODE > 30 < 220 mglt_ and TSS >30 _< 150 mg/L iT Name (Please Print) atui .~` /tins 7. ~ S~~?(y~0..~Y - ~~ I1 ~ s ~'~~ 5~ , Sa mJ;T~-~'~ W 1. ,S `COL ,S • Effluent #2 = 80D6 < 30 mglL and TSS < 30 ntglL Date Evaluation Conducted ~`Zv-U~ ~isy~-yo~g Property Owner ,g,~ J ParcellD # i ~ Page ~ ~ of t3oring # ^ Boring '~ ' ~ ~ Pit Ground surface elev. s<~~ 8 ft., . Depth to limiting factor In. ; ~ Soil AppllcaG`a,~ tlorixon Depth Oominanl Color Redox pescription Texture Swchue Consistence Boundary Roots GPDflt' in. Mansell fall. Sz. Cont. Cdor ~~ r"~ Gr. Sz. Sh. ' ' 'Etfltt •Eftif2 .1 a-ii o. ,- 3iZ - ~~'. mahL f ~ S Jl ~ S . ~ z ~ ~. U. 5 ~ m vr~-~-~ G S - . ~ . ~' .~ ' ~ sr•~ ~.~ Boring # ^ Boring pit Ground surface elev. ft. Depth tolimlting factor in. cAb A ligation Rut horizon Depth . Dominant Color Rt:dox DesaipUon , i'exture _Structure Consistence Boundary Roots GPDlllr In. Mansell C±tr. Sz. Coral. Color Gr. Sz. Sh. 'Effp1 'Eff#2 Boring # ^ Boring . [] Pii ~ Ground surface eiev.,_,"__ R beplh to limlling factor In. Soil AppUgtion Ral Hortzon Depth pominani Color Redox Despiption Texture Sirudure Consistence Boundary Roots GPD/ltt in. Mansell tht. Sz. Cont. Color Gr. Sz. Sh. 'Effgt 'Effl12 - ' Effluent #1 = BODE > 30 ~ 220 mJ11-and TSS >30 < 150 mglL • Effluent #2 = BODs < 30 mcyl~ and TSS < 3U mall. Tl~e De~sattment of Commerce is an ecptal opportunity service provider and employer. If yott need assistance to access services ~~r need material in an alternate format, please contact the department at 608-266-3151 or TI'Y 608-254-8777. sunsno (R oTlOOy ,. ~. PAGE~C)F~ i SCAI:E:I"= ~/~ (~ ELEVATION /GV • ~ 814 Z DFsSCftIPTION~ n r~ ~ ~ D v ~- ®~~-2- 13M "1,IVATION ~~~Ct ~ BM 2 DE5CRIPTIUN~__p_a-~ l ', Dv~,D~`~.~ SYS'T'EM FJ.EVATION ~I~ ~ ~ SYSTEM TYPE ~C> ~ U -e ~+_~ ~ a_ ~ C;()N'I'OTTR ELF,VA'I'ION 9~~~ ~ 100-d 1 I v~ ~°~ ~~p`' f ~`~ ~ ~ ~J ~ ~L SIGNATURE ~\ '~ ~~ .~ ~V' DA1"E -Z~ -~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ! of ~ FILE fElFO1i11AAT10N owner (L Irc.tk+~ZaD ~ t~.1 Permit #~ ~~ OESIQN PARAMETERS Number of Bedrooms (Q ^ NA Number of Public Facility Units ~IA Estanated flow leverage) p•O al/da Design flow (peak), iEstimated x 1.5) q00 al/da Sod Application Rate ©•~' aUda /hZ Standard Influent/Effluent Quality Monthly average • Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOOS) 5220 mg/L ANA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Oemand (BODE) 530 mg/L Total Suspended Solids (1'SS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size Ye in die. ^ NA ~~ ^ NA 'Vahies typical for domestic wastewater and septic tank effluent. ruretrurFruewr_F ScNFnruF SYSTEM SPECIFiICATIONS Septic Tank Capacity 1200 e~ IOD!*~ ~ O NA Septic Tank Manufacturer =? ~~ ~~ ^ NA Effluent Filter Manufacturer y2 ^ NA Effluent Filter Model -!c!0 ^ NA Pump Tank Capacity al ®NA Pump Tank Manufacturer I~NA Pump Manufacturer 8'NA Pump Model ~ ~ NA Pretreatment Unit ^ SandlGravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~ NA Dispersal Cell(s) ~I.In-Ground (gravity) O At-Grade - ^ Orip-Line '. ^ NA ^ ln-Ground (pressurized) ^ Mound O Other: other: t~NA Other: 0' NA Other: ~(q Service Event Service Frequency h~spect condition of tankls) At least once every: ^ monthls) (Maximum 3 years) ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA {nspect dispersal cell(s) At least once every: -3 monthls) (Maximum 3 years) year(s) ^ NA Clean effluent filter At least once every: ^ month(s) --Z lil9-yearls) ^ NA ^ monthls) 1~ NA Inspect pump, pump controls & alarm At least once every: ^ yearls) ' ^ month(s) @~NA Rush laterals and pressure test At least once every: ^yearls) Other' At least once every: ^ month(s) ^ year(s) {9 NA Other: [# NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or cert'rfications: 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 IY31 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. Atl other services, including but not limited to the servicing of effluent filters, mechanical or pressu~~zed 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. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~ gltE INFORMATION owner 2iL~,~ ~ j't9~.1 Pemtit ~ DESIGN PARAMETERS Number of Bedrooms (Q O NA Number of Public Facility Units ~IA Estimated flow (average) ~p al/da Oesign flow (peak(, (Estimated x 1.5) q00 al/da SoN Application Rate ©• ~" al/da /ft' Standard Influent/Effluent Quality Monthly average ' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand IBOD51 5220 mg/L I ANA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Oemand (8005) 530 mg/l. Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Othsr: ^ NA "Values typical for domestic wastewater and septic tank effluent. SYSTEM SPEdFICATIONS Septic Tank Capacity IZarO e~ I~rol~ al O NA Septic Tank Manufacturer =? hs~~ ~~- O NA Effluent Filter M~ufacturer ~ O NA Effluent Filter Model -I QO O NA Pump Tank Capacity al ~ NA Pump Tank Manufacturer O,NA Pump Manufacturer 8'NA Pump Model J8 NA Pretreatment Unit ^ SandlGravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter O Wetland ^ Other: ~ NA Dispersal Cellist ~In-Ground (gravity) O At-Grade - ^ Drip-Line t ^ NA O In-Ground (pressurized) O Mound O Other: Other: gy-NA Other: M'NA Other. f~-NA MAINTENANCE SCHEDULE Service Event Service Frequency Mapect condition of tank(s) At least once every: O month(s) (Maximum 3 years) ear(s) O NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY51 of tank volume O NA Inspect dispersal ce(lls) At least once every: month(s) (Maximum 3 years) ~j ~yearlsl O NA fi t once eve : A l O monthlsl ~'Z O NA Clean effluent her ry eas t ~yearlsl O monthlsl 19 NA Inspect pump, pump controls & alarm At least once every: ^ year(s) ^ month(s) I~NA Rush laterals and pressure test At least once every: O year(s) Ocher: At least once every: ^ month(s) ^ yearlsl ~ 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 etspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal 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 IY,1 or more of the tank volume, the entire cattents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. AN other services, including but not limited to the servicing of effluent filters, mechanical or pressurzed components, pretreatmem 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. FROM ;, Sch~aar>akcr P.~:anbtnq PWS N0. :7153863121 SeF~, 13 2002 06:46AM P1 S'1' CRO1X COU1'TY SFPTC r ~.NK MAINTENANCE ArREEME:~"I' AND ' CsV1'r`LF.SHIp CERTIFICATIQIti FOI~~I OwnaWr/E?tluer ~7 .:~zE,i ~ ~~ ~' w7~ _~....~ Mailing AQdress ~ ~G/a.f~e=Ty „_, Prottarty AaiC~lt'865 a ~u CJ ~~ ~ (Verification :e~,airs~? frorx! F'Iaanin6 Depattaieat for new constFUetaur,} ~^. ~ ~~x.~C. so~.cl Parcel tdoaiaflcation Number D ZO ` i 0~~ ^ b c - 2cU l.• ~~ ^Z~ .~ 1 ' Prtr X~xatiaa tl/,,,1C, Y., ~1,, Sec. ~~ . T~Q N-R/ ~ 'W, T~~ cf ~~a../ Su'Jydir~~ia~ _,__ ,. ~_..___.~ Lot # ,,~. Certtii~d 9urvay Map # ~ ~:~ ~ _. Volume ~ , Pule # ~,7/13.~,,.,._: Warxaet~ I~ad ~ ~_._.~ ., ,.._: Yoltuae ~...,_:-., P-aka # , 3_, Spue Y:ottse D you ~no Lot lines iclontifiable c~ yes ^ uo ~o~ use sad maintouaaccof your Coptic system oould result is iu pt~amaturc failureto hsadie watatos, Proper aa~nttaaace cod5in~ oE' p>ur+ping oa3t the soptlc tank dY+1ty th~-ayc yeup or sooy:~u~, ff i~.edr1 by x Hcensed parapet. What you put iirto the system can at~iect the flmotioa of tiu sepiic csak as s rrasat+~reat stage in the waste disposal tyltana. The prope.*ty owxr gees m sulanit to St. G~oix Zoning pepat~rment rt certiAcation f4rw, signed by the owner snd by a naastoYplumbe><, jouraeyaun Plumber. reacr~a~trdplual~sr ear Y ~rutedpunypgr ti~titya»g mat (!) ~ orr~it~?vawtawsoardlsposat aysteru iA !a proper opentingcondition and/or (2) attar inspection a~ pumping (if noeossary~, the septio tank is lass thaw 1J3 Hill of sludge. I(we, the aanderaigaed have read the above rcga:ireurcnts and agree to >in the prlarate sewage disposal system with tine standards eat forth, berclu, ss sot by the Dcpermaont of trorttmeme sad the Depatttnent of Natuiaa! Resottrees, State of W~aonsin. Certification saxtir>g that your septic syatom bras bees matinmined:uttst be aaxapieta:d and retiuaetl to the St. Croix Cocuaty Zoning t7tilce within 30 da the threo year expisstioa date. ~° SIQNAT[7Yt8 OF LICANT ~ .,AA'Pa AWN C~RTYON . 1(vw) oratitay that all stata:ments oa this foan are trtu to the bast of ray (Darr) loroa'IedEo. I (we) am (are) the owner(') of the mrty des s 0, by virtue of a watraary deed rcxarded ii! Register of Aeed9 (?J~ioe. Jd ! /~ a3 DATE SICiNATURH OF Al'1?LICANT +m«•~• Any information that is mis•repzeaentodmny resaslt izti the sanitary permit being awaked by the Zoaia$ pdparbaient. •"''r`'' '" 1ac1ud0 wttb thin 4pplteation: a cta:aped wa:rattry deed from the ltegicter of Deeds office sE raspy of the calif ad atuvey map if refeseuos is rude in die waRanty det:d DOCUMENT NO. ' , 448469 STATE 8AR OF WISCONSIN FORM 2-19A4 WARRANTY DEED Wo! . ~~ r~ct ~~ :~ ~ ~~ .. ., . ~. I conveys and warrants to ` '" `~' C~ . :, 'G1' ' 3r:,i _ ': i_. :~'": EI)'L4BAPY) ANm WIFE AS JOIIVT Z~ViS the following described real estate in ` ? ' t 0'' r County, State Of Wisconsin: T-nS SPACE RESERVED FOR nECOROINO DATA (~ REGISTER'S OFFICE ST. CROIX CO., WI Recd for Record ~ JUNo 451989 V l,~s -'uru(,,QQ Rsphfer of Deeds RETURN TO Tax Parcel No:_ ~~l lY' .,~':'_~'.LC?i ~~~~ ~7i ~'.^.j.t. '~ ~.Oi±~~f -.:2'~~~P_ ~'~~ ':e.'T _~]_~_= `. ~ lti'__ ••~~ ~~^.~~ li! ;C~ Hen ..,~ -t- ^~~J~~• f c~ -,r iY'.. `. ;..Yl .~C'. ',a~ ~ Tali ..1 a _, .T;~~, U ~n fi__ E MP'!k This ~ : homestead property. (is) (is not) Exception to Warranties: Dated, this e / ~/ dayof_ r jZ'Z ccL7 ~Y • r~~L~t I' \ (SEAL) t9 EAL) (SEAL) AUTHENTICATION Signature{s) authenticated this day of , 19 TITLE: MEMBER STATE 8AR OF WISCONSIN pf not, authorized by § 7('16.116, Wis. Stats. ) THIS INSTRUMENT WAS GRAFTED BV (Sisnatures may be authenticated or acknowledged Both are not necQSSary.) ACKNOWLcU3MEMT STATE OF WISCONSIN ss. County. - . Personally came before me this day of , 19 the above named to me known to be the R~ fnfQOOinO instrument and Notary Pub ic~_ 1L My Commission is germane `v~"),... ? P~ ' ~41~'Ax~uted the sAnn 1 d a~mn ~. _y F --~__ ~r-r. ~~~--_.~_~ounty4 Wis. t'•.~pt!~f+gf, staib a cation l~l,~ r`~ i ~~~ ~. ~.Q - I f'. J Certified Survey Map in Vol. 3 Pg. 725 ~~," ~~ /`'` ~~ S00°49' 40"~ 5 0 4' w1 z-~ ~.. `• a~ ~r 5 4 4. 2 0 ~ 15 . Q 4 ~ _. -r cal r~- ~ ~ I u w .- ~ I ~ r I • W •J tU W ~ ~- I C1 W ~'-> ' -+i S+ ~.1 ~~' ~ ,,, o~ ~~ 6 ~ ~ n ~~ o n> ~z ~ ti ~ ' ~ i I ~T; ,vA ~ r hr 'n ~ :.. I ~ , ~~ ~~; n // I ~ ~ ~ ~ i~ _- --., ~U ~'~~`'~ ~ / Ga I 5 0 ~ ~y 1 t i -I I i w ~i UJ ~ ~ ~ 7 ~-~ l _~ I' 1 0 z` N(k0°57~35~~IJ ~ ~~~ n~ - Q ~' ~ 1 4 9 5 .., ~' ;..J - .P ~, ~~ ~ _ I , t ~_~, -, ~ v> ,'~ 1 ~ r ~" ~- ~- i ~ ~ ', ~ w 1. ~ <~ i Y- ~ ~ ~ ~, ~ ~-, w i CJ ~~ _ ~ Y~ I -J i ~ V tv JD ~ - '_, I__ r~ i:; -.cam I C::. T ~ ~_ i .. I ( j~ al ~ _~ --~J ~ ~. I I ~j N ~ _ .n r_, Y\J ,r. J tv Ln _- u -rJ J O !v l ,,~ i, ~~ 13 to ~~ .i /~ ~ 0 6 ~ ~ ~ ~~ '1 ~ -, , ~ ~ ~ Y ~ ~ -~._ - ,~ ~n r~ Y~ ; <-~- NC0o57" C W ;~- ~; ~~ _---East line of tide NGz of Section 20 ~ ~ • ~, ~, ~ n, - ,~ -, Unplatted !.ands _ . w ~ ~ °f f /-~ r Cn ~ l1 -. 1< _ O ~ l I r~ ~ ~~~ FF-..~1 H v ~r _, '~ ~ o' F, C=j c `}~ I I-i ~~, - r, _ Va I ~ -t f ~~1 M 7 Y-. ~pYYiI -~ ~-.. TJ v -p -) rr ._ - ___ ~~1 (D Y ~~ ~ ,~ -t, ~ I - ~?~' F3ea^in~s are s,eferencec .,, e :,st • ~ ~> ~ .-, ~ `~i lire oP the NEz of Sect'_cn _ rD c>, c u, x ~ ~ aSSU~ned t0 he2r ~lu~~Y ~~ 2~-~~~~ ~ . ~~ t`.^ l C> y F ri .. Y D U O (J ~ ~ ~ ~~ ;~ ~~ ti ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ~'.`Gti~ S ~~.~ residence located at: ~%, ~%, Sec . aQ T 2~ N, R~W, Town of ~a~sd.~ St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced LJ//~j/J~ Did flow back occur from absorption system? Yes Nom( (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: _ /o~DO ,~ ~sdci-a~~l-e~ Construction: Prefab Concrete ~ Steel Other Manufacturer ( if known) : Lt/e cs~'s Age o f Tank ( i f known) : _~ y- s (Signature) (Name) Please Print 1~nJo ~ ~~ ~1?4 (Title) (License Number) (Date Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . Name ~J,11 ~,r.~ ~~~~ ~-~~ S ignature L/~.~'----~~~~ MP/MPRS ~ 2 ?~Gj~J