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HomeMy WebLinkAbout020-1047-60-300z C r~ ,~, o ~ .:, Q. M; C~. O O r` N i Ci ~. h • ~ 0 N ~ ~ • }r~ V O © ~ O G i.r ~ L~ o r l V ~ `Irri +~ A I'. ~' C 7 W 7 3 "' ~ z N ~ Z O ~ ~ ' '~ Oi Z o N ~- w ~' m m a m N M- Z O Z '~ 'p C (r r ~ v z ~ N H c a~ N ~ p~ ~ N ~ d N U N N ~ d z m z M~ ~ .. o ~ w ~ ~ ~ p1 ~ y - d ~- 4 N r ~ tp d ` o o o a = O O O ~, a a a a ~ ~ •• ~ J ! ~ U ~ t ' rn rn ~ ~ ~ i n' O O ' ~ rn C .a ~ 'O d ~ ~ m ~ V1 N O c7 O O N C M Q C 'p O ~ ~ (0 r F- v ' V o C ~ O ~ N _ ,n M O N 'j p O) ik ~ ~-' E ~ ~ d a ~ ~ °' ~ a ~. U C ~ 3 w ' o `m ;4 o U a ~ O V1 U v °o 3 0 O ~ a~ c 0 Q7 E >. c N E U f0 a N L .3 N O N C O N Z ~ c N O ~. TS W O Q rno N L U W Y E ~ o ~ _ y o c ~ .N N Q1 ~~ N ~ .C O a C L O U ~ n ~ Y _~ Q p Z O p o ~ (b Y Q rn C d ~ ro ~ O ~ C C ~ ~ In N N ~ ~ C N N Q1 ~ r sa ~ Z Z -p s E E ~ N N e.. H I- (n C 7 LL C a~ E a~ U l0 ~p a ~ i!! O O a m I .C C 7 o c ~ ~ ~ a~ c N l6 N N ~ O d (~9 o~Q Z ~ Z ~N ~ ` 16 y - d a ~v w N d ~' O O a` 3 3 3 = O O O ~ a a a c I J ~ ~ O O 0 0 ~ N N d N W ~ '- m ~ .0 c ~ m ~ ~ .'6. ~ VI Vl Q N C 'O f6 L _U ~ N - o j Ln p O (n ~ O ~ a m ~• a N w C c y 3 O N U ~ o° 3 0 O ~ c 0 Y C (q ~ 'p N o~ m c.pCN u1 Q N ~ .~ m ~ _ ai E o ~ p N L C to j U ° E m 3 i6 > N U .!~ -p C 4=. ... C O t' ~ f0 C U y N ~ °~ = a~i w N OOOLL ~ ~ O ~ ~ a p ~ 3 ._ Z 3 ~ C y ~ ~ ~tl $ 'o c O X N f9 N N ~ O~ O Q ~ a~ a Y~ m N L 0 E N Y .off E E ~ ~ L ~ ~ } O Z r, ~~ O ~ o NI ~ Q. n O U ~ N ~ C N N C C ~ ~] ~, -` d tJ N N c0 :~ `!' Y a p O O "" O ~ .~ N ~' ~ O °'~- N Z o N E` CLj ~~ ~~ ~ ~ L3 L'~ O C O tU N ap C ~ r ~ I c a~°i \ ~~ ~ r 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 ~. t~~rcl ~ ~ w~'`- residence located at : ~~1/,, ~(/~1/,, Sec . _2D TAN, R_L~ W, Town of ,^~~. ~~3o.~J 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 J/J/ ~~~~- Did flow back occur from absorption system? Yes No~ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: ~~ o!' f- ?~-~ 2,d~•-G~ Construction: Prefab Concrete ~ Steel Other Manufacturer (if known) : 1~~,,,c.,lls Age o f Tank ( i f known) : ~ ~ ~ GPs' (Signature) (Name) Please Print (Titl ) (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 regardi certify that the tank, to the best of requirements of ILHR 83, Wis. Adm. Code outlet baffle). Name l,,.l, lL~~ So~i.-n~-~!/~ v Signature MP/MPRS ng existing septic tank condition, I my knowledge, will conform to the (except for inspection opening over ~--~' ~~7~Qd Wisconsin Department of Commerce t Pt~IVATE 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 Stout, Richard Hudson Townshi CST BM Elev: 0 Insp. BM Elev: BM Descriptiory, ~ ~' / ADO. aD •b / V TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~~ ~ / , 1, f j (~(/~(/~~ ~ 2 Dosing A ,,~ ~~. t.~~ . ~ J% ~ ~ S~ Aeration , -~ ~ // ljij/ f ~~ u ~ ~ / / b~ ~~----00 ~l^ Holding ~ l TANK SETBACK INFORMATION TANK TO P/L ~a d W LL BLDG. ~ Vent to Air Intake ROAD Septic +ng ,~ n 5 ~ I , / n Aer tion - Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift ion Loss System Head H Ft Force ain Length Dia. Dist. to WeII ELEVATION DATA County: $f. CrOiX Sanitary Permit No: 420502 0 State Plan ID No: Parcel Tax No: 020-1047-60-300 STATION BS HI FS ELEV. Benchmark ~os9 tDO•b Alt. BM /0 2. ~ BI .Sewer ~~ St/Ht llet ~,' ~~. 6. ~ 99 3 St/Ht Outlet ~ '~ p~ d !! Dt Inlet ~' Dt Bottom ~~ H er/ ~ 'O~ ~f' -/ Dist. Pipe 0 I " Bot. System ~ ~5~ Final Grade 651 -3 St Cover ~ v 3.Z o~.~ SOIL ABSORPTION SYSTEM ~'/_ /',G®„~,,,, L e ~ .O~_ ~,(,. ~ ~ ~,G. ~ CGS BED/TRENCH Width / ~ Length ( No. Of Tren PIT DIMENSIONS ~ No. Of its Inside Dia. Liquid Depth DIMENSIONS 3 f 1 +' SETBACK SYSTEM TO P/L~` BLDG WELL LAKE/STREA LEACHING Man r ~; /may ~ INFORMATION CHAMBER OR f ~i / ~ ' ~ Typ Of System: f fj / , /O~ UNIT - Model Number: JL' ~ (flf ~(~ ~, DISTRIBUTION SYSTEM HeaderlManifo~ / If I ~ Distribution f PiPe(s) ~j fl ~s ( L h'v~ ~" "S~ ~ x Hole Size ~ x Hole Spacin ~ Vent to Air Int k r ~ ~ f Q Length Dia engt Dia ing_ - SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~"~ ~-~ ~~ Depth Over ,~~t~ ~ ~ ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ? ° J Bed/Trench Edges Topsoil - Yes j No -, Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~'~ / (g / ~~~ Inspection #2: / / Location: 494 Prairie Lane Hu/~d_son, WI 54016 (NE 1/4 NE 1/4 20 T29N R19W) NA Lot 40~~ Py~ar~cel~NLo: 20.29.19.185A3' ~ 1.) Alt BM Description = S~ WY~ -M"' ~/'s~ ~ ~" n ~/ l~U 2.) Bldg sewer length = ~~~~ ~/ ,.~ff~~.. - amount of cover = ~~ qU~ r'`^ Plan revision Required? Yes __ No Use other side for additional information. SBD-6710 (R.3/97) --- ,- 7/ Date Insepctor's Signature Cert. No. 7'+ li ~V/ h Safety and Buildings Division County t' ~ P~ Z Washington Ave., P.O. Sox 7162 201 W ~ dt~ J . . w ~scansln ~~~~, ~ s~~4~ - 7162 Six Addrea: De artment of Commerce ~} o -Ov -- `~ ~~- ~~ Sanitary Permit Applicatio ~'' ~,` ~~ Ia accord with Comm 63.21. Wis. Adm. via ^ Cbeck if Revision tai be tllOd for aeco aeS ~Y m L Applieatioa Iaformatioa -Please Prlat All Iaf tlon Sate Play I.D. Number Property Owner's Name Parcel Number L { d^ T. Ci~l~)IX, CC)~J ~JYY Q20 -lO~i'~-bC -3t7p • IgJ~~'t ~~ ~ ° ~ ~" r 7 , Propany Lotatioa erty Owoer'a Mailing Addraas prop // 1~~~ !~A-~tti ~ -~ T4~' ~ ~i ~f; 5 0 T.2 N. R CuY. Stan Zip Code Ptax Number Lot Numbar ~~ Block Number Subdivision Nate CSM Number ~~ s~~ ~ ~ ~ ~Yf/G s sv~- ~ .~ ~s 7 .~v.36 II. Type of 8ulititag (check till that appiY) ^Ctry ~1 or 2 Family Dweluag -Number of 8odroorns ~ _____-----.--- ^Yillage ^ Pubtic/Comaaercial - Daserlba Use ownshi .S'o~ ^ Stase Owned A~_ Nearaat Road ~ ` c~ l3~SU III. Type of Permit: (Check only one box oa line A (aamberIa; achetae for Internal use). Complete line B Tt applksble) ~ For County use 1 ^ New m System 9 ^ Replacement of b ^ Addition m Task Od m Parmit Number Data Issued $. o ~ if saaiary >~ iousty Issued IV. 'Type of Permit: {Check all that apply)(autnbering scheme is for later'ttal use) ~ ~ -lOD 44~Noa-Praatrized In-Grottad 21^ Mound 47 ^ Sand Filter SO ^ Coasaucted Wetland 22 ^ Pnesatriud Ia-Gmuad 41 ^ Holditt6 Tank 48 ^ SiaglC Paa6 Sl ^ Drip Liae 45 ^ At-C#tade 4b ^ Aarabic TreaCmane Unit 49 ^ Roa~ ~ Q ~r v. n p~ pl~r (~ eat Area Intoralati Dispersal Area aa: Dispersal Area Soil Application Parcoladoa Rste System Hlavation Elevstioa`~e Requirod Proposed ~~ ~ Rate(Gala.maya/Sq.Fc.) (Mia.Mclt) ~ ' o , ~4 ~,:5 ADD. ~p(J Paz ~lv t~-~ ~ ~ ~~ VI. Taafc Info Gpacity in .Total Ntaalxr Manufacturer Prefab Concrete Site t ,oosttttotad Steer Filar Grass Plastic ttallous Gallons of Tasks . Naw Exislini rasa raalcs Sepdc or Ho~ai'~ ~ - ~2Dd o2 ~` G 8 es~ Dwias C~nmbee {~. ill .Stateateat- Ts the »ud aiBtona for Of 86e PUW7J saown Oa tae ana~aea puuw. ~~JJPlJJUmber's Name``(Priaq P/l~u//mbcr's Sigmttue 9 - ~// / RS Number Business Phone Number ~j f'j~J .Q.~Z JG~a ~alY ej" f/~ r C%4~1•~C~.~ a,z799d - ?~~~~~~i~s '~~/ice Plumber's Addtmai (Stfeet, City. Starr. Ztp Coda) /~7d c a ~ lSa~ .~/• ' /~ VIII. Coca /De artmeat Use Oat to 5i turn Approved ^ Disapproved Sanitary Permit Fee (inclndea (3rouadwatar Dam Issued Issttitt6 gna (No Staatpa) Surcharge Pee) ^ Owner Given Initial Adverse Z~~`- . ZZ ?,Up 2 Detorwination IR. Conditions of Approval/Rostsons for Disapproval ~ s /i ~ _ 0.- ~ .~, ~~- ~2 ~,., i ~i u~~ S ~ yn~-e S d.~c~ ~ ~ ~ p tAttael, oom ~ tw _ `self) ro t e ~ en tw~«' sot less tLaa sus 11 haste, la dxe Vl~t.Cd~- ~ ~~ SBD-638 (R. as~oi) _~j , c`~'rcc .~~ !,~ ~,tJ~~ itJ~~ /~~~ ~~'q ~/QGi/ /oGv~ ~~ ~aG`-.~~'a'..fJ t -a ~, Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page ~ of m arxoraance wim wmm oa, vvrs. nun.. a.wa County Plan must hes in size 11 i 8 1/2 h ~ . x nc an Attach complete site plan on paper not less t include, but not limited to: vertical and horizontal reference point (BM), direction and scale or dimensions, north arrow, and location and distance to nearest road. percent slope Parcel f.D. ~,Q - (O~-~{--- d - , P/f?7S@ pr111t Bll I17f0l7lYAt/OR. Reviewed by Date Personal infortnatron you provide may be used for secondary purposes (Privacy Law, s. 15.04 (t) (m)). ~ 2 Z ( Property Owner Property Location ~ .~ Govt. Lot NF 1/4 ,vim 1/4 S T N R E (or)~ ~ Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ity State Zip Code Phone Number C ^ City ^ Village [>~ Town Nearest Road ` ' l~-vd~sov'~ I t,/ l ~ 5`f ~?S (7iS) S Y~/ -~~31 v cQ a ~0] New Construction Use: ® Residential / Number of bedrooms Code deriv rate qQ GPD [j Replacement ^ Public or commeraal -Describe: Parent material d ~ ~~ Flood Plain elevation if appli ble /~/~- ft• General comments Sy _ /e m ~lev, q~ • ~ ®~~ 1 ~ 2002 and recommendations: ~l ~ ZO"~IiNG OFFiG~~ Boring # ^ Boring ~ ® pit Ground surface elev. f~4` ft. Depth to Limiting factor in. Soil Appliption Rate I Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Efi#2 ~. ~ d -1 Z a 3/ z -- s,~/ ~ mab/r ~ ~ s 1 u . S' ~ ~ 3~ -~i i y~~ ~ GAS a s rM I - - ~ / z av~" Rr 8a / 5~'- `~ ~Yo • rf I a~.;~~ tt ^ Boring . ..' ~ ~ ~ Pit Ground surface elev. /f7(~• ~ fL ueptn to nmmng racrorli~ r~• Appligtion Rate Soil Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fi~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'E~ 3ff -1S lo- r y/ ~ tM ~ - ~ ~ 1~ Z .~ • Effluent #1 = BOD_ > 30 < 220 mq/L and TSS >30 < 150 mglL " tnruent sz = tsvus ~ su mgrs ana r as ~ ~u nryr~ CST Name (Please Print) `~~ Signature CST Number ddress / Date Evaluation Conducted Telephone Number ll ~ FSa ~ S~`• ~orvulS~-~, wf , S`yo z s ~-/~' - ° ~ 7~S -zy~ -`~°° $" a Property Owner _~ cJ ~t Parcel ID # Page ~ of Boring # ^ Boring :. . Pil Ground surface elev. ~~ S~ ft. Depth to limiting factor ~ in. • : ~ Soil Application R tforizon Depth Dominant Color Redox Description .. _. Texture Structure Consistence Boundary Roots GPDIfI= ln. Munsell Qu. Sz Cont. Color •• r• Gr. Sz. Sh. ' ~ •Elf#1 •EtfN a Boring # ^ Boring \ ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application R Horizon Depth . Dominant Color Redox DescripUon_ .. .Texture _Swcture Consistence Boundary Roots GPp/ft2 In. Munsell Qu. Sz Cont. Color Gr. Sz. Sh. •Eff#1 'Efffl ^ Boring # ^ Boring _ . ^ Pit • Ground surface elev. ft. Depth to GmiGng factor in. Soii Application R. Horizon Depth Dominant Color Redox Description Texture .Structure Consistence Boundary Roots GPDIft= in. Munsell /hr. Sz. Cont. Color Gr. Sz. Sh. •Effffl •Elffl'. - • Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mglL • Effluent #2 = BODS < 30 mg/l~ and TSS < 30 mc3/t_ .~ , 'flu Department of Commerce is an edrral 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 TI'Y 608-264-8777. S81?-17)0 (R07/00) PAGE 3 oI~ 3 r.~T# yv ~CA1..E:I"= ~U ~ Iib'I 1 E;I,Eti A'T'ION /~ o • ~ M 1 DI:SCRIPTIUN. bra? ~~ ~ ~y~-,~P~- 1~M 2 :I.IVATIC)N f 9, ~~ I3M 2 DI;SCRIPTIUN ~P U~ ~ pyc. ~,'~~ - SYS'I'FM FJ,EVATIUN ~S ~~ SYSTEM TYPE ('o n u t ~ ~- ~ ~ ~ ~ - - -- C(.}N'I'OI7R I;I.EVATION laa ~ ~ a-~~ a o ~` ~~ SICrNA ZO `T Z ~I _,, L _. -_ ~ I i _._._ __. i ~s&~ti ~~ DATE /G-~4 ._a Z _~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pape ~ of ~ RLE MIFORMATION Owner ~L~~ ~ Tzs+~. i Permit ~ ~{'Z05'02 OESION PARAMETERS Number of Bedrooms (p ^ NA Number of Pubi'ic Facii'rty Units ~IA Estimated flow (average) orp al/da Design flow (peak), (Estimated x 1.51 ~'00 aUd Sod Application Rate ©•~' aUda /ft' Standard Influent/Effluent Quality Monthly average ` Fats, Oil & Grease (FOGI 530 mg/L 6'rochemical Oxygen Demand IBODS) 5220 mg/L ANA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (60051 530 mg/L Total Suspended Solids ITSS) 530 mg/L O NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size Ye in dia. ^ NA ~' ^ NA ~Vakies typical for domestic wastewater and septic tank effluent. SYSTEM SPECIHCATIONS Septic Tank Capacity IZpO 14p1•rua ~ O NA Septic Tank Manufacturer z~ ~, ~~ O NA Effluent Filter Manufacturer ~ O NA Effluent Fiber Model --fQ9 ^ NA Pump Tank Capacity ~ ®NA Pump Tank Manufacturer EII,NA Pump Manufacturer 8'NA Pump Model ~ J8 NA Pretreatment Unit O Sand/Gravel Filter ^ Mechanical Aeration O Disinfectron ^ Peat Filter O Wetland O Other: ~l' NA Dispersal Ce(lls) ~J.in-Ground (9ravityl O At-Grade - ^ Orip-Line •• ^ NA O In-Ground (pressurized) O Mound ^ Oth~~ Other: CIA Other. ANA Other. [+~-NA MAINTENANCE SCHEDULE Service Evert Service Frequency Mspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) ear(s) O NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,1 of tank volume ^ NA Inspect dispersal cell(s) At least once every: month(s) (Maximum 3 yews) 3 ~' year(s1 ^ NA Clean effluent filter At least once every: O month(s) -Z l~year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ~ NA Flush laterals and pressure test At least once every: ~ ^ month(s) O year(s) ~-NA pale f; At least once every: ^ month(s) O year(s) ~!9 NA Other: C~ NA MAINTENANCE INSTRUCTIONS Mspectrons 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. Tanl inspections 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 pondin~ 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,) 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. AN other servir:es, including but not limited to the servicing of effluent fibers, mechanical or Pressurized components, pretreatmen 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 k~cai regulatory authority within 10 days of comptetiort of any service event. Page ~ of STAIiiT UP AND oPERATroN For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(sl. If high concentrations are detected have the contents of the tank{s) removed by a septage servicing operator prig to use. System start up shall not occur whet. soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell{sl in one large dose, overloading the cell{sl and may resuk 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 p~ror to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact. the area within 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 pumpl water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; pa'a~ting 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 util'~zed 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. ^ 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. ^ 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 ANO/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name 1 L_C_l ~,~, t}k~ Phone ~ls-- - 31ZI POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name aot C~suL+JT~Y ~ON/N Phone Phone '~lS - ~b - ~fb ~ This document was drafted in compliance with chapter Comm 83.221211b11111d1&Ifl and 83.5M11, i21 & i31, Win Adma~istrative Code. FpOM :, Sch~emak.er Pi~.mhinq PW( N0. 7153863121 Sep. 13 2002 06:46AM Pi S'1' CROIX CQUti'7Y ~FP i C T r.NK MAINTI;NAI~CE R.CiREEME:'ti"T AND . ~2~1'nL•'F.SHIp CERTIFICATIgIti FO~~i pwncrlHti:vPr !I" ~~~~a~-aL S~r,~~~ . Mailing Address ~~s.~ ~,t/~a. ~•e ~ ~~ _ ____.,.~. Prorrerty Adt~rsss ._. _ - (Veri~icgtion:er;uit~? fir: planning Deportment fat new cattsuusrtiur~) Citv,`St to .~~we+~e5'a.J .Parcel ideuti$catiort Number ~..; ~.°`~~" _ 6° ` 38o C• ~~~ -'3~ ~. _ ~r~~F~"r Prate X,acation ~'l., ~ .jl3 Scse. ~ T a9 N-R~•~.'~, T~~ cf ,~ Subdiri~ia~ , ~..._._.1 Lot # ~ Certi~i 9urvcy M8p # _. Yoluma 7 + Frye # ~~-• W:{rl~sm~ Ueod # ~ `~~ ~6 ~,,,,_;, V oltuua ~' `f -~- _ _, paw # 6 ~I Spoc l:oust: p y~ !~'-no Lot lines idontifiablo~yes ^ no ~ol~ ttsa sad nosiatenauce of yotir septic sywtann could result is irs pntsiauuc failure to handle wastat~ Proper aaa~pnteaAaoe cottaiss of'ptut+pin~ Out the septic tsar awry tit{-ac yeua cr sao~:xu~, if iucdt"13y : licensed ptttaper. What you put into the systata can sffoct tlta fttaotioa of tae septic tsaic ss a aeut~eat stage in the waste disposal syytern. Ttie ptopsrty owxr agrees to submit to 3t. G~oix Zoning Deparmaeat s certification form, signed by the owtaer and by s nustezpluu;be:. jottraeytnsn ptusabar. resscsc~adplwrs-~tlr or r ~r~ceJptuap~ votiiy~::~ tsar (1) t~ o~ite taastierdispossl syateta iu is proper operatiaS eoadit3at aadlor (2) after iaspectiott ttad pumping (if ttocxssary~, the eepde tank is lea: than 1/3 fall of sludge. Ifwe, the ttaderaigaad tuve read the above tvquircuxub sad Aptee to aoaiutsin ttu private sewage disposal syatetq with rho standards set forth, bCrCln, as sot by rho Deputmoat of Cooonaerca and the Daparttnent of Nauu~al ltesoutees, State of W'.seonsht. Ctrtif'aration stating that your septic system has been uatint~edmust be eacapleted end mtutaed to the St. Craitc County Zoning Office within 30 y of the tune Pest expiritioa date. .t ....1! /` SIQNAT~E O APPLICANT "pA~ 5~~~C.--A~TYON I (we} eesrily that alt statements on Ibis form are aria to the bast of ray (our) Ja~owladge. I (we) am (ate) rye owner(s) of t msty descn~ed abov by virtue of s wazraaty daod recarded in Register of Reeds 0»iee. / " ~~ SIGNA'[UIt1I OF App'I.ICANT DATE rs.a.. Any iaformatiott that is mis•rapnaaatod maY result in the sanitary permit betag awaked by the Zoning pep~tt-ent. •"•''"• "" 11,cludo with thie applteatLon: a eesmped wa:r$nry deed from the Rogicter of Deeds otI"tcs a ropy of the cttrtified stnvey rasp if refe~stae it r.~a in the wa*nwry deed ~;. . _ _ .. ,.. _~ . S~l:F~V EY 1 NG • ~ iV . __l. A-t~ D HUDSON, WfSCON~LN.....54016 ~~, , C 7 f 5~ 366-2007. _-- 1 . ,. , / Nome First Federal -of LaCrosse `'~ ~; __ Address 201 South second St. Hudson, Wi. 54016 40 of C.S.M. Vol. 7, Page 2036, Town of Hudson, St. Croix Description LOt County. Wi• Stout PLAT DRAWING This is no~i~ a complete Sand Survey N C.N. d iJ R.R. W G ~ N77°-49'-2z"W R=2814.93 177 ~ S C=110.74' 72 ~--~_~ i ~(q~F P~ 3 in 28 ~ 28' t~l I ~ 38' 33' Duplex o~ z 24 ' 24. 19' R=266.0' N89°-02"-25°E - C-14.70' Town Road Proposed ~_ M V 3 ~, M I r i~ ~o 0 }0' utility easement The location of improvements on this drawing ar_e approximate and. are based on a visual inspection of the premises. Z'he lot cl~mei~sions ~_e t :1:.c from „, ~~i,~atior.-', ~:. recorded plats and deeds of county rec~rc_s- Tt~~s c.11:-a~;~%ir~q 15 ~~ _ _,__..~ a mnm ha nor rl AS ~. COP1j~l~~~.C I,anC~ ~~l1iVC`./