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HomeMy WebLinkAbout020-1417-40-000Wisconsin Department of Commerce Safety and Building Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) 'ersotrL'~ infoFination you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Abla, Armando & Tami Hudson, Town of :ST BM ~lev: ~ Insp, BM Elev: BM Description: r'A 411! IdICA~11AAT1/'1 d1 ., CI C\/ATIlIAI r1nTA TYPE MANUFACTURER CAPACITY Septic ~/ _ _ ,_ Dosing r' ~, Aeration ,~ Holding ... TANK SETBACK INFORMATION en o it na e " ,fir ~ ep is R ,~._~ osmg era ion ` , o Ing PUMP/SIPHON INFORMATION anu ac urer eman GPM o e u er i nc I oss ys em e or mm g i _ ,VIL HDJVRr' I IVIV J T J 1 GIYI otMENSrr3Ns ~ < ' e ~` s ', -` ~ ,yrv . j INFORMATION CHAMBER OR ~'~ ~ UNIT r N F , ~- r UIJ 1 RI~U 1 IVIV J T J I GIYI .- __ ~. _ -.. . _.... _ - _ __ .~ ~. Length, Dia ~ -_' Spacin Length-- - g S 7 \JIL vV V V~~ )< fICSSUIG .7yal.cuw vn.y ..• . .............. r...... ...~- - ------- --- -~ - 3ed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No ~OJIAMENTS: (Include cod di~gre ncies, persons present, etc,) Inspection #1:~~/. ~. /j,_i,/~..~ Inspection #2: --1..-- - -~ w ei ~ - - ~,( ,3,,, Ir `-., I e ~ ~C~!X..• ~- 4 : _ 1 1 v.,e?t `';': ~ iCS~(_u.a .,•~. _.. _ _ __ - __ _ _ Location: 432 Wren Lane Hudson, WI 54016 (SE 1,~4 NW 1/4 20 T29N R19W) The Glen to( 48 - ~ Parce o. 21l0.29.19.2642 ~ (, , J _ 1.) Alt BM Description - `~. , ~•1-~ a,r,. v+~' .~._ r ~`~~-~-r <; ', =k t i ~y ~ C;'i r-. S /V d 2.) Bldg sewer length = ~ , t . ; c1 -(r~ :y; ~.i r :~,~" i c~+G •~3L. ~ -amount of cover= `..~ ~ ~ ~~ •r" ~.~ ~~.?.~~t ~ i~.~q.~~;.r ~ 1'~ .~ { r _ _? ~ ~ r..y~ ( i!~ ,~ ~.~~,._,. _ ~ ~~~. Plan revision Required? Yes 1~Ci No ~ ' °._.._ ~ns~ ctor~s-~ ~riainre ~'"`-° ~ f Use other side for additional information. { LDate f~ -t F I ~ •~ p g ' Ce~~1o~ r' SQQ-6710 (R 3/97) ' ~ f ~ • - f ~~ •~..? ~~:_ t.L`_c;'~ d..~t a,•.:a tif.. ~•~„ ,.~.+:.1.>-«.,`..,,1~..:1v __ '4U_*-x,'~t1 ; r...^."t~'~_,.;~.. `::> `5tt:c.s~.,, ~.t.•,•.(k. '~~'~if~.. • county: St. Croix Sanitary Permit No: 488276 0 State Plan ID No: ~ ~/ ___... Parcel Tax No: 020-1417-40-000 SectioNTown/Range/Map No: 20.29.19.2642 STATION BS HI FS ELEV. Benchmark ~'~~. - i Alt. B - ~. , -- r. ~ Bldg. ewer I ~r ,-- (• 5 `^ r ' ; 5 u a ~Clj• ~r ~ i i t/ t nlet - ~ a c ,(cr r (02•~t, 'tr t ut et G~ pr I' /L' C}.Z.E~ n et i '" _- 0 om ea er an. / ;f is . ipe %" o . ys em ~ ~ `~ 'ty~ ma ra a t .. -~ •ti% v L O ~ ~ ( -:?~ y~: ~ •~ ,/~r ~C J `(' ff, G' ~ .. s . ~.~ ;~ r Safety and Buildings Division ~~h' ~r 201 W. Washington Ave., P.O. Box 7162 ~~J/ c •,^~ ` ` A ~~ ~~~ ~ Madison, WI 53707 - 7162 Sanitary Permit bar (to be Slled in by Co.) /~ (608) 266-3151 ~ S ~2 Department of Commerce U V ' Sanitary Permit Application State Plan I.D. Nu/m~ber ~/ personal information you provide Code 21 Wis Adm In accord with Comm 83 " ' , , . . . may be used for secondary purposes Privacy Law, s15.04(lxm) jeer Address (if different tbatt mailing address} # I. AppHcatfon Information -Please Print All Information ,?1o~Z {` ~, :~`~~ ~1~v1~ ~ t J -- Pr^'~v owner's N ~ i : ,~ ~"tYlq~~' w ~~ Nip ~,~~~~ a Block # Parcel # -/tll7 ~~' ,~.. laroperry vwLLGl J 1N1a111'"~ AA.in.cc _ - -_ _ a ' 3 ~ 3~ ~c ~ ~ '' LOCahon i ~ ~i:J 1V ~,~., ly~~., s~ti~ ~~ rtv. State ~;++ ~'^a° Phone Number (~~ ' unle one) midi T II (check ail that a l ) pp y ype o . // ~A.L t T~~C ~ ~ s Subdivision Name CSM Number µ. (~ 1 or 2 Family Dwelling - Number of Bedrooms ~ / 5 • r?+ i l ibe U ^ P li /C `~ '~ facr nmtntxc a - se ub c ^ State Owned -Describe Use ^City_^Village Township o IU. Type of Permit: (Check onty one boa on Iene A. Complete line B if applicable) A' New System ^ Replacement System ^ Treatment/Holding Tatrk Replacement Only ^ Other Modific~tiUOn to F,xisting System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expirntion Plumber Owner rv. T of POWTS S rem: check all that a 1 „Non -Pressurized In-Ground ^ Mound ? 24 in. of suitable soil ^ Moues < 24 in. of suitable soil ^ At-C,rade ^ Single Pass Sand Filter ^ Constructed Wetland ^ pressurized In-Crroimd ©Holding Tank ^ Peat Filter ^ Aerobic Treatment U:lit ^ Recircatlating Sam Fiber ^ Recirtxrlating Synthetic Media Filter ping ^ Line ^ Gravel-less Pipe ^ Other (explain) V. Di ersaUTreatment Area Informs on: C4 L 2SD Q°' Design Flow (gpd) Design Soil Application Ra f) Dispersal Area Required af) Dispersal Area Proposed (af) System lev 'on S1U -7 p ~r b~'~ 97- 99 -la! VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Units Wr~~ ~ ~~ 1 Concrete Constr»cted Glass New Existing ~ EF~ ~ ~~ J Tanks Tanks Septic a Holding Took X ' Aerobic Treatment Unit DosingC f LOo'd l ~~ VII. Respoosi Statement- 1, the aadenigaed, a~ame respo tor' tlatlon of the POWTS shows on the sHached pleas. PI s ~~ Plumber' /MFRS Number ~ Business Phone Number 71S 351-1 ?d ~t ~et~ ~- ~ S ~ Pluc~mber's Address (S~trjee/t, City, State, Zip/-~ ~) VIII. Coun rtment Use O ved ^ Disa ve Sanitary Permit Fee (' hrdes Gramdwater Date Issued Is ing t Signature o Stamps) A ppro Surcharge Fee) ~(J~ `- ~ ~~ ^ Ow u Rtzsou for Denial ~/ Ix. Conditions Ap o~ R C E IV ED SYSTEM OWNER: 1 Septic tank, effluent filter and ' dispersal cell must all be serviced /maintained JUL 1 3 2006 as per management plan provided by plumber. 2. All setback requirements must be maintained ST. CftOix COUNTY as per applicable code/ordinances. Attacl+ esmpkte pleas (ter ne (Coaaty ody) rar tae system oa paper aner less wo arrc x ^t ncaes a sue 3 • s S~~nn~.- Cati~t~ ~ w ; ~u~,.~ cl~,n~-~-~nol$2 A-~.-~X t~~i ~~12.(3J.Q,(a.o~cc%~I .~ SBD-6398 (R. 01/03) ~ ~~ Q,Q~$;~ t r Gam'" ~• ~~ ~~ ~ T ~ e' t, f 6', ~ . 1 ` i ~ ~ 1 ~ ~ ,~ ~ , ~ ~ ~~ 1 1 ~ ~~ ~ ` 1 G~-- ~} i ~ f~ ~ ! , ~ ~ ~ ,,;y, ._ . 29.0 .r 4. I 2` ~ ' 1; ~~ h 1 i 1 i ~ YY__~,,~ w ~ ~ ~ g', ~ ~ w~ ~' I , I Houma ~ r ~. I ~°` ~~ ~~ ~ ~~ ~ ( _ ----~1 ~~ ~t~'~ ~' ~ ~~ ~ ~ ~ 1 _. __~.~.~.m.,....~F.~,..:~~~_..r .._ ~r. _.,_ ..~~. -4rv- °~ ,'r. ~ LOT ~~BL ~ SUB ~h ~ G ~. .,tie ~~~~ y . ~ ~ `4ytiM.. ~ R 9 .. ... _...... ..,~.._:.. .~.......... .~u~.._.... ........._......_.. .., _ 9t ~2 C ~ e-w IN r~- L.. C~. ~ c I ~~...., t 1 D~ NTMA(,E~~p~ 1 1 1 ~,~ ~ E . }, 3 ,~ 1~ t e~ 1 1 T ~. 1 1 k _ 4 ,~ , 1 1 -" ~ , ~ l,~G ~ ~ ~ iC w ~, ~N - ~. - 1 ~ ,~,/,~ ~, ~ 1 ` ~ r S,, ~~°`I' s Z~`~ R~ ;~ B 2-' .. /-~L inv. ~~;- 1 s 2~` 1'~'L, ~~ `~' s ;~ .r ~~. - _ ` 29.0 .. , ~. i ~~ _ Proposed ~ Houae i~ ~ ~ ~_ ~ ~ ~1 ~ , ~ g. _ _- ~ Sir',/4 /S~w,/4,S ZvT 2 7N,R ! 9~ a LOT ~yBL ~ SUB ~~-~ Gam. C ^ V ^ T ~' d~--fin-- ~~1- ~~~ Z 1146 Wisconsin Department of Commerce SOIL EVALt~ATION REPORT pie 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel Soil Service Courrty ' Attach complete site plan on paper not less than 8%: x 11 inches in s¢e. Plan must St_ Croot include, but not limited to: vertical and hor¢ontal refererx~ point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. pending Please print all information. e ' ~ Date Personal information you provide may be y Law, s 15.04 (1) (m)). (i(.liYt/k~ ~ y Property Owner Property Location Sienna Corporation vt. lot SE 1/4 NW 1/4 S 20 T 29 N R 19 W Property Owner's Mailing Address ~ ~~ ~ ~ 2 Q 0 G of # Block # Subd. Name or CSM# 4940 Viking Dr, Suite 608 . 48 na The Glen City t ~:riy State ~ p Co~T F#rbrle ~, ~` , ~i -~ Cily Village ~ Town Nearest Road . ' MN a Hudson Carmichael Rd. New Construction Use: iV' Residential / Number ~ bedrooms 4 Code derived design flow rate 600 GPD _ Replacement Public or carrmercial -Describe: Parent material Pitted outwash Flood plain elevation, ff applicable na General comments and recommendations: System elevation 105.OOft, trenches spaced and depth to code 3.50ft below grade ~ s .s-~r~, a~r~'ue 83 ->5'se~-f~lz 6.~-a~ 2~~ ~~ S c~~ 0. 7s6;is 1 Boring # Boring !! Pit Ground Surface elev. 108 50 ft pe th t itin facts ~ in li S d A li ti R t . . p g - o m o pp ca on a e Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ftZ *Eff#1 `Eff#2 1 0-6 10yr3/3 none sl 2msbk mfr cs 2f .5 .9 2 6-19 10yr4/4 none scl 2msbk mfr gw 1f .4 .6 3 1 29 9 7.5yr4/4 none Is osg mvfr cs 1f ~ 1.2 4 29-96 7.5yr4/6 none ms osg ml na na .7 1.2 ~~ /i Boring # Borng ~ Pit Ground Surtace elev. 108.50 ft. Depth to limiting factor in. Sod Applicatan Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz 'Eff#1 `Eff#2 1 0-8 10yr3/3 none sl 2msbk mfr gw 1f .5 .9 2 ~2 10yr4/4 none s= 2msbk mfr cs na .4_ .6 3 12-9 7.5yr4/6 none ms osg ml na na ~ 1.2 ~2 ~~ 7~' `" ~30'~ ~~ y ~ .~-~ sy~s~r .~~ - t=rrruem ~ r = rsw 5> su < ~~u mg~~ ana t 55 >su < ~ ~ mgiL 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Phse Print) Signature: CST Number David J. Steel ~ ~~ 248956 Address Steel Soil Service Date Evaluation Conducts Telephone Number 1564 CR GG, New Richmond, WI 17 9/19/2002 715-246-5085 ` property Owner Sienna Corporation Parcel ID # Pending a Borin # Boring Page 2 of 3 ' g /, Pit Ground Surtace elev. 100.00 ft. Depth to limiting facts 96 in. ~ Application Rate Horizon Depth Dominant C~or Redox Description Texture Structure Consistence Boundary Roots GPD/ftz 1 0-11 10yr314 none 2 1124 7.5yr4/4 none 3 24-96 7.5yr4/6 none ~r I ;ea,~~ ~r sys~ .~v~~--- (~o`' Boring # Bonng *Etf#1 *Eff#2 sl 1 csbk mvFr cs 2f .5 .9 cos 2msbk mfr cs na .7 1.6 ms osg ml na na .7 1.2 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/L and TSS <~0 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or Boring # 'Boring _. _ ... .. ... _ . Page 3 of 3 STEEL'S SOIL SERVICE G ~~ David J. Steel CST-POWTSM Lic. # 248956 Sienna Corporation SE1/4,NW1/4,S 20,T29,R19W Town of Hudson, St. Goix Co. The Glen lot # 48 1564 Cty Rd GG New Richmond, WI 54017 (715)246-6200 (715)246-5085 This soil evaluation was conducted to satisfy a zoning requirement, it ~ or may net be suitahle for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the soil-test was conducted. Legend 1" = 40' • =Benchmark El. 100.OOFt Top of %" pvc pipe ~=Alt Benchmark E1.100.20Ft Top of %" pvc pipe E} = BOFingS Boring Elevations B1 =108.SOFt B2 =108.SOFt B3 =100.00Ft B4 =00.OOFt s-a~ ~~ ~.,,~ q-" 5Tv ~u r a. / ' ,. r 57~ it " q / ;~' ~• 1 !/ :.~, r,~ ,ta :r \,.a /~~ ,.I ./ y ~~`4/i __._. _ 417 _, .~ •~~~~_,_-'_'-_ '_.--yJ''-I'~~yl - •. Q ~ ~ 1 a a ,,,-~. 2\. ; ~ -, - '` _ ' 85 .. .i ~ `~`b $1 ~\ Ste. ; ..- -~3•'. I 87' 86 ~ " - /t~ ;, ,. ,~ ~ gg1 `, , ,~ _ /p~ - _ ~ _;y I '1! '-~~081 ,~_ _ ~Y7 129 a1tB ~ .7 - 1 1 y-- ~.., ~ ~ _ y ~ ~, 1 ...,~ _ _ a . _._ 1 \ ~ / .. . ., ~' t t w4o ._ .r ~+ ! NUJ ~~ ~ 1 _i 1't1 ~ 1'.,I + ~ .It a1 _ •I n / ~~//yy~ v ~~ a W `: I r I ~ ' i i ~ a1 .>, ~'i / : - 1 _ 4 - - - . 345 ~ ~ -t _.., I 1 ._... ` 1 ` ~ ~ x s `1., .`r as m \ ~ 1 1. .. Y ~.I 1 1 _ I E. '-. . ' t a a t . ~ `i 7 _ _ 3441 _ _ %~ / \ ` i _ .~ F - t i I ._. - ~7 'ems" .. ~ ". ,a~ ~ ~ ~ e 1~~1 ~ ~ . \. '~1 + ...3 - .. 96 '. _ ~, p \` fir! l ~ 1 l -- / 1 - ~ - a • '. 40q~ ' '- .-' - \ J i 'I -.. t 1 .'i all r~ ~ l hi t i 1 + ~ 1 / @ l a a _y .` a` ~ ~ ~ '.. ~. 'L t t . -a~+/sit _'____ _- ~_._ __' i .`~ < .. e~ ~- t v a ~h. a ~ N ~ ;1 1 .79 ~ - - ••. , -' - ~., ,~~. t ..~ ~ f : -. . ~'~ _ ~ ,1. 1 r 'i. ~ . 1 - !: / ~: 293 ' r _ 138 ~-' 3]2 r ;33 f y , ~ ,~_, ~, , 111 , ?~ ~ ... aA/ . 1. ~`~` 1 ~ I I. ~ I ~ ~ 1 ~ N a - I \a 1 ~ , / ~ ~ f W .• ( \ ~ . 1b : ` / r \ -- { ~ f I ~ F r. 111 1 i ' y' ~~ ~ '~ y. 1 ;• t a , I ~~i I rr ; ~7 ~ ~ i ~~ ~ I' ~ ' ... ' ~ ~ , ~ ~ N I ~' I ~ ww f -- 26 ~~ ~ V . ~ 1O \ ' ' I ~ ~ I a 'Ek` , • . .. ' ' ~ I' -. ~ ~~V- • , ~ j~ ~ f ___ -l , l ~ a I`~, ~ ~4 . _ ~ 1 . I ' I i i ... ' ~ '% ~ ' . •' ' I ~ ~ ~ rte-_ a ( I. _ + 1 1 + a r . 1, , `~;~ /„~1 ;~ ~ a .. , i ~ 1 ~t a. 1, ~ N 11 R II 1 a tla l : a a 'a 1 I l • `l 1 a _ 1i11\ l .\ ~ i 1 I1~ l II ~•:... \ 11t 1 I A a + 1 1 ... a.. r ' a \~ 1 / ,l , t ~ 1 I r ~ r 1t ~ ` 1. 1 / R / a ,' a \ a \ \ a t a / . 14 ~~~ a \ „' 1:, f f a 111 1 , i. .1 , ~ ~ ~ 1. 1 / 1 1~ I' I 1 • Y :, .~ ~t \ i \ '~~` , / 1 1 ~ I hf 111 ~ -_' ~~~~ ~~~ . ~ ! ' 1 ~ I, + 1 , ' 1~ t l~• ~ / \ _ ..-~ ;; __ ~~~~.~~ ~, ~. _.. 1 G7 ~~, a I I ', a 21 - .. ~ : : 1 =- 1.-~f~- ~ , / ~- 3 ' ~ ~ ~ 22 \ A .nt - 1 -- -'-- -_~~_.~. _.- .~. o / S- c~u .-~ /~.~ o 1:~~~ ,® O ~7s, G 0 ~~ / ~. c / ~/ «,t~ ° I LOT ~8L SUB ~~ ~~-~- CD VD T~ ~~t /~~~a~raSw 2a~1a ` /~ ® 7J ~ Cam' ~~ / !d/ `' ~ ~ y 870.Ox Existing Elevation rtes Iron (870.0) Proposed Elevation Scale: 1 "=30' ument f=ound rtes Iron BENCHMARK: NW corner of Lot 47, Block 6. ument Set Elevation = 865.44 3tes Wood Hub - NOTE: Driveway proposed to come off road at 881.8 elevation per builder. ~+ ~~° 16 R-2914 ~9 ,182.26 ~4 ~- ,182 • , 41 E ~"d':N~S'~4 ~ crd. e`g' ~ +~6~ 6;A ~ ' `\ ~ ~ O DRAINAGE AND `\ 1 z UTILITY EASEMENT ~ \~ ' ~ ~°, O \~ ' ~ ~ ~ ~~ ~ z ~ +~~ ~ + ~ N. ~ o,+ \ ~j~ S ~ o ,~ +~~ ' cNo.. ~ , 1_5.0 (881_3)- - - i .a3 N - - -~-- 15.0 35'~ r~ (p a- - 29.0 d= 24.08 _ ~ rn '~ ~ '~ . . ' ~ '18.18 ~~ Proposed 2.+~1 37.4' 2 N House ~ / o °' /\ ~ 00 16.0 °• N 0 4.08 ~ 100 a 8 6 (882.3) ~ 13.83 0 ~ 1~ k 1 2a.o 8 1 ' ` ~ 15.0_,x.___-F----~+(882.3) _a~+l(882•~) 9~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~'' FILE INFORMATION Owner. ~~ ~ 0 Q _ QE1'E S Permit # p2 DESIGN PARAMETERS Number of Bedrooms ,~ ^ NA Number of Public Facility Units ~NA Estimated flow laverage) , j ~D gal/day Design flow (peak), (Estimated x 1.5) ~-~ gal/day Soil Application Rate Q , ~ gal/day/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand 160D5) <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBODS- _<30 mg/L Total Suspended Solids (TSS) <_30 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~~ (o ,S gal ^ NA Septic Tank Manufacturer W 1L ~ ^ NA Effluent Filter Manufacturer Z~q-QEL ^ NA Effluent Filter Model ~ --/dU ^ NA Pump Tank Capacity 67Jp gal ^ NA Pump Tank Manufacturer w~~-S~ ^ NA Pump Manufacturer ? ^ NA Pump Model ~ ~ ^ NA Pretreatment Unit I~NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal Cellls) ^ NA ~,In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: A Other: A Other: A MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tankls) At least once every: 3 ^ month(s) (Maximum 3 years) yearls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal ce(lls) At least once every: ?J ^ monthls) (Maximum 3 years) ITd yearls) ^ NA Clean effluent filter At least once every: ' _~ ^monthls) I~.yearls) ^ NA Inspect pump, pump controls & alarm At least once every: 3 ^ month(s) ~ yearls) '^ NA Flush laterals and pressure test At least once every: ~ ^ month(s) ^ yearls) ~] NA Other: At least once every: ^monthls) ^yearls) ~'°' Other: L~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 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. 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 <_12 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 ~~ 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 celllsl. If high concentrations are detected have the Contents of the tanklsl 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 celllsl in one large dose, overloading the celllsl 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 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 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. aluat a o ing ank 1`r ~ T be ' e ai a ~RD}~181'fEI~ ~~ !c/$~ COIVS7KClG'TI.D~ ^ ~ 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 INSTALLER Name C p ~~ Phone 38', '~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ST, ~~Q ( d U 20/Jl ~Cl Phone ~/S- 3g'(A_ (~ (~ This document was drafted in compliance with chapter Comm 83.2212i1b-1111d)&If- and 83.54111, (21 & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK. MAINTENANCE AC AND OWNERSHIP CERTIFICATION OwnerBuyer ~~ Mailing Address RECEIVED JUL 1. ~ 20U ~3 nL~ ti~ Property Address _ - ('Verification requir from Planning $c Zoning Departrnent for new construction.) City/State ~C1~n ~ k ~ Parcel Identification Number ~ ZU ^ ! Y/ l - ~G- o c~ LEGAL DESCRIPT/ION Property Location J~'/4 , ~''~/. ,Sec. 2y T 2 Y N R ~ `~ W, Town of Subdivision Certified Survey Map # Lot # ~~ . ~L~ (, Volume ~ Z ,Page # 3 3 G Z. Warranty Deed # ~' 2 ~f ~ `~ ,Volume ,Page # Spec house yes ~ Lot lines identifiable es no SYSTEM MAINTENANCE AND bWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52{i}and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted phmlber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. Iiwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. L/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 property desen`bed above, by virtue of a warranty deed recorded in Register of Deeds Office. Number edrooms ___~ ..>-t - SIGNATURE O APPLICANT(S) ~7 i®7~ a~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. ~c/~5~1 (REV. O8/OS} 07/07/2006 FRI 15:24 FAX 715 386 6687 6T CROIX CO RE6 OF DEEDS Document No. I~ STATE BAR OF WISCONSIN FORM 2 - 1882 " WARRANTY DEED 5 a Mjp corpora nveys and warrants bo AR ANDO ABI.A-REYE AN TAMI J. WOHLFE Ingle persons as Joint Tenant, the following 4esCrlbed real estate In St- Croix County, $taLe of Wisconsin. KATHLEEN H. NALSH REGIST>~R OF DEEDS ST. CROIK CO. , MI RECEIVED FOR RECORb 05/10/2006 01:55PIf NARRANTY bE6P EkE1AP'i i xEC PSI;: 12,00 TRANS F6E: 2$8,~p COPY FEE: CC FE15: PAGi~ s 1 ®002/042 Sienna Suite 0 grfve MN 6t348~6a1e Vietro I.eyal Scrviccs :DIRET 4)6298 A 170727 Wt7 S1UUbl This is not homestead property. kFTURN T0: k1C1RO LEGAL SERVICES, ING 330 SOUTH 21~~P AYFNII; , S(/1~ I50 MIf~10iAPOf.fS, Mry 55401-2217 Tax Parcel NO: ,120-141j•40-000 Lot 48 Block 6 Plat of The Glen in the Town Of HucSEOn~ -~t. Cro x oun consln Exceptions t0 Warranties: Easements, re5ervaNOns, dnd reStrtCtions of record. Gated this ~ Q day of ~_ .2006, AUTHl:NT1CA'f'ION (SEAL) SIENNA CORPORATION, a~Ai(+nesota corporatbn sy ~c~-..t s~~ C] 1~t~.a.~~ (SEAL) Marsha A. Pierce Assistant Secretary Signature(s) authentigted this tley of 20 f TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06 Wis, slats.) This in8tlyment was drafted by: sienna Corporation ACKNOWLEDGMENT STATE OF MINNESOTA } )ss. Hennepin County } Pe/rsonal(y me before me this _:~,~ day of , 2006, the above named Mefrha A. Pie ,the Assistant Secretary of Sienna Corporation, a Minnesota corporation, on behalf of Ute corporation, to me known to be the person who executed the toregOing iri1strumeM and acknowledge tea same. f 1 ~.~,-~_ _ Y1. ~. 1.... C i a o Catherine M. ThoMhill, Notary public 4940 Viking Drive, Suite 608 Notary Public of Hennepin County, Minnesota. Edina, MN 55435 My Commission expires January 31, 2010 5ignetturea may be authenticated or acknowledged. t3oth are not ~~~ ~ ~~ necessary. ea~ovr,~IC--e~NEsoTA -•- t!'ammisot~0ew~e~r, lot , ~ _ Names of persons signing in arty capacity should be typed or printed be their gnatu- ' LOT ~~L 12. SUB ~~ ~~- ,.. ,. 1~F'S?n,ftw j^ 07/07/2006 FRI 14:51 FAx 715 386 6687 Sz CxOix CO REG OF DEEI)5 ®002/002 ~L' -_ __ LOT.~BL~ SU6.~~. THE GLEN WwbO w M Netltre! pirW N w lYpwlt fir, N M Pr~rwt Ot~M N tW Gtlllnwt Walt. 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