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Home My WebLink About020-1437-01-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ` ~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Nelson, Gar Hudson Townshi ~ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic t-~.:s ;~ mac: 7 ~ Z `~,, Dosing Aeration Holding ~~ ,.mot ~ - ~C-> TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ,~,:~• .~ ~~ ~ '=iC~` -- ._. Dosing ____ Aeration ~"`~~ Hold ng PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Nu er TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dist. to well ''--- SC111 ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: 430658 0 State Plan ID No: Parcel Tax No: D~0 -/~37 ~o/ oDa Section/Town/Range/Map No: 22.29. ~ 9.a70 ELEVAI IUN UA I A STATION BS HI FS ELEV. Benchmark ].~ /c./,~ Jo~,~t~ Alt. BM ^~- Bldg. Sewer L 3c~ ~,5.. + ~~ SUHt Inlet St/Ht Outlet ~ ~,~ ~. 3 ~~~~ Dt Inlet Dt Bottom Header/Man. r- r~ f ~ C ? 7 Dist. Pipe Bot. System ~' E ~ o z iu _Z 4 / . 5 7/. Final Grade ~ ~ ct ~ CSC ~ ~ J St C_oIver y1~ c>~.~. BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~:~ ~ ~ -~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~k { l INFORMATION CHAMBER OR ~ Y ~ 1-`n~ Type Of System: // ~ 1 ~{. C' nc`'~ .ti 7(.' fL 7 " ~ vC> ~ ~ i--\ .UNIT Model Number: ~ ,1 r ~ vu- _I - v r-Y ) 13 ~~-YtZ~. V- l.. DISTRI6UTION SYSTEM L-~ Vz.i,t Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake f :, .. Length 5 ~~ Dia `{ Pipe(s) Length Dia pawn "'-" .- 1 / SOIL COVER Y Prneenra Rvctame C)nly YY Mnund C)r At-Grade Systems Only Depth Over Depth Over xx Depth of_ xx Seeded/Sodded xx Mulched Bed/Trench Center (..~ Z Bed/Trench Edges -~,__ Topsoil ~ Yes No Yes No ~ri COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: '~ / ~ 7/ ~' ~ Inspection #2: / / Location: 800 Ross Road Hudson, WI 54016 (SW 1/4 SE 1/4 22 T29N R19W) Kelly Estates Lot 1 Parcel No: 22.29.19. 1.) Alt BM Description = n~,...,- ~ ; : t c~ ;5 ~1 S : ~~ ~~; he ~~a--;~ t `~ ~<:.~~ G-~, S..w~..~ v' .~ t, 2.) Bldg sewer length = :.~ ~~ "3~ 'f?l ~-.,-J~ -_.''~ o ~-..,-~ ~n~• ~ ~ 1x~: : ~1 S Cat S c.v -amount of cover = ~ -E ~{ w> ~ , i3 '.~ ~ u ray ~ #b ~ d~ S -} :~ Y / ~~~ sJ ~ t'_ ~ Plan revision Required? Yes ; No r -,~- Z -7 L ~~ ----y ,.~' ~,Z _ _ ~l!~,~' Use other side for additional informati n. _ ____ _- / Date ~, Insepctor's Sign lure r~ i Cen SBD-6710 (R.3/97) ~., Stf~ ~j(, {~.cCC..~. J[tl ~~t~ ~ ~ 1~~;`•r~ ~!~ r t ,. RECEIVED ~Ay ety Buildings Division County ` 201 W. Washi on Ave., P.O. Box 7082 C. ~~~O~S ST OIX COUNIpkAdiso WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) . De artment of Comme ce ZON NG OFFICE 8) 261-6546 D / r-,•a Sanitary Permit Application State Plan I.D. Number [n accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used fix secondary purposes Privacy Law, s 15.04(1 xm) Project Address (if different than mailing address) I. Application Information -Please Print All Information ~ ~ e (~ SS ~~ , Property er's Name Lot # 131eck# ,~i ~ Property er's fling Address pe y ~'/ ~~'/ Section ~ ~ City, S Zip Code Phone Number .,,. ., , - ,,, _ ~' %~ C (circle ~~ N; R~E o~ IL.Type of Building (check all that apply) ~ ~ S bdi i i N 1 or 2 Family Dwelling - Number of Bedrooms f . u v s on e ~SAQ ^ PublidCommercial -Describe Use o~ ^ State Owned -Describe Use 2. IC O ~` ~1 ^City_^Villa ownship of III. Type of Permit: (Check only one box on line A. omplete line B if applicable) A. New S tem ys ^ R Iacement S tem ep ys ^ Treatment/FIolding Tank Replacement Only ^ Other Modification to Existing System B • ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a I Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip ine ^ Gravel-less Pipe ^ Othe (ex i ) V. Dis ersaVTreatment Area Information: Design Flow Design Soil Application Rate(gpdsf) Disper qui d (sf) Disperser ~ (s System Elevation < _ Cry . VI. Tank Info Capacity rn Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~ / 7~ Aerobic Treatment Unit Dosing Chamber VII. Resp sibility Statement- I, the undersigned, ass a responslbi 'ty for installation of the POWTS shown on the attached plans. Plum a (P 'nf) Plumber` Si /% r MP/MPRS Number Business Phone Number J _~ '~ i / Plumber s Address (Street, City, State, Zip Code (_ ~ cL ~ 1 l2~ < VIII. Coun /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issui Age ignature (1`1 tamps) ^ Surchazge Fee) ~ S~ //"" ~ Owner Given Reason far Denial - . ~ 1p IX. Conditions of ApprovaUReasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintai d ne as per management plan provided by plumber . 2. All setback requirements must be maintained as per applicable code/ordinances. Attach compkte plans (to the County only) for the system on paper sot less than 81/2 : 11 inches In size SBD-6398 (R. 08/02) ~,-r= - 1. ^~ _ ~ '~_ _ ~_ r 0.~ ~ ~ --~ 3 ~~ h i" ~'1 ~ -- ~~ ~? ,• c ~ ~~~ ;v~_,~ P}. 1~C? ~~ ~~ ? ~' ~ ~~ c,~ ~o , /~ ~~ O~'pY sso ~ I 4t O .~ r \` l I _.. ~, ~ _ ~~. ~ + c~ / ~ ~ \ c _ '~ '~ I ~ x~ ~ r 7 -~ -- - _ ~ ~" I ~ ~ ~ ~~ ~ M ~ ~ ~ `' '~ v ~`~~~ ~~ ~ ~~~ ~ ~ ~ ~ ,~ ~ ~ ~~G; ,~ ~~ ~~ ~ ~~,~ ~ ~` ; ~t ~ ~ ~~ ~~ ?~ ~ ~r 8 oQ~ P~~o1C ssv~ .~ :~ .~ ~~ ~ ~3 ~8 R ~ ~-~__ a I ~ ,~ __ ~~ a = i M ___ ~ ~~ ~ ~~ -~ ~ ~ ~ ;~ ~ , ~~ ~ R ;,, ~~~~ ~ `\^ "1 ;„ ,~, b :S O, -~ Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in ~rrnrri~nro ~.~tl, (".vnm AS \A/ie e.rm (`nr'Ic 1208 Page 1 of 3 Steel Soil Service County Attach complete site plan on paper not less than 8%: x 11 inches in s¢e- Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. . . Pending Please print a-t infonnaSon. By Date Personal information you provide maybe used for secondary proposes (Privacy Law, s. 15.04 (1) (m)}. ~ - ~~ Property Owner Property Location Reliant Devebpers LTD Govt. Lot SW 114 SE 1/4 S 22 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 9900 Valley Creek Rd. Suite 135 1 na Kelly Estates City (~bbLQbtLh~ State Zip Code Phone Number ~"~ City ~ Vltage ~ Town Nearest Road MN 55125 659-731-3174 Hudson Ross Rd_ /_ New Construction Use: ~ Residential /Number of bedr s ~°'~'''~°°' ived design flow rate 600 GPD Replacement Public or commercial - Descri ~;,„ Parent material ouiwash plains and stream terraces ` ~ r,-` V ~~ ~' ? plai elevation, if applicable na General comments and recommendations: System elevation 96.55ft, trenches spa d an~ s~epth,'~o-e'd.50ft ebw grade ~r ~v. Boring # Boring ~ in. Pit Ground Surface elev. 101.05 ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz *Eff#1 *Eff#2 1 0-7 10yr3/3 none sil 2msbk mfr cs 1f .5 .8 2 7-17 10yr4/4 none sicl 2msbk mfr gw 1vf .4 .B 3 178 10yr4/4 none sl 2msbk mfr gw na .5 .9 4 48-96 7.5yr4/6 none ms osg ml na na .7 1.2 `3t'o ~ SS ~ S`~/~j o ^ Borng # 'Boring Pit Ground surface elev. 101.05 ft. pepth to limiting factor 96 ln. Sod Appliation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 *Eff#1 *Eff#2 1 0-8 10yr3/3 none sil 2msbk mfr cs 1f .5 .8 2 8-14 10yr4/4 none sicl 2msbk mfr gw 1vf .4 .6 3 14-25 10yr4/6 c2d 7.5yr5/6 ------- scl 2msbk mfr gw na .4 .6 4 25-96 7.5yr4/6 none ms osg ml na na _7 1.2 /~? o Horizion 3 has noncontiguous mottling spots ' Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent iY2 = BODS< 30 mg/L and TSS <30 mg/L CST Name (Pl~e Print) Signature: CST Number David J. Steel ~ ~~ 248956 Address Steel Sal Service ~ ,~~~~- `~' - Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, W 154017 10/20/2002 715-246-5085 ~3 s ~ Property Owner Reliant Developers LTD Parcel ID # Pending Boring # Boring ' 35 97 Depth to ft limiting factor Pit Groun ~/ d Surtace elev. . . Horizon Depth Dominant Color Redox Description Texture Structure Consisterx~ 1 0-20 10yr3/2 none sil 2msbk mfr 2 20-30 10yr4/4 none sicl 2msbk mfr 3 30-40 7.5yr4/4 none sl 2msbk mfr 4 40-96 7.5yr4/6 none ms asg m4 Rnrinn # ! Boring Page 2 of 3 96 in. Sod Applicatan Rate Boundary Roots GPD/fN "Eff#1 "Eff#2 gw 1 of .5 .8 gw na .4 .6 cs na .5 .9 na na .7 1.2 * Effluent #1 = BOD 5> 30 < 220 mglL and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. ff you need assistance to access services ar Rnrinn # Boring Page 3 of 3 STEEL'S SOIL SERVICE David J. Steel 1564 Cty Rd GG CST-POWTSM Reliant Developers LTD New Richmond, WI 54017 Lic. # 248956 SWl/4,SE1l4,S 20,T29,R19W (715) 246-6200 Town of Hudson, St. Croix Co. (715) 246-5085 Kelly Estates lot 1 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable 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. 100.00Ft op of '/z" pvc pipe ~=Alt Benchmark E1.99.35Ft op of/2" pvc pipe ^ =Borings Rnrinn Flavatinnc (a; V O L k.e va~u ~Jaa~ ISO ski •Jf (~./j F1 I ~ S.C_-l]I-1_-L-GL.-L_1-1~J1----tr-CL1Y-L 1 ic ~ `~ m r.epwaw ~ ~ m ~ ` -0°'~ • ~ E u^'i ° E ti`: ~ ~ ~ E- l i ~ ~ ~ _ • _ lrs.7a amv4'17~w _. 4 SOt'02'17"E=._ ; 2.4 128 ~~' ZONED AG-RES ~. ,.- --' ~ ~ . . . . - _. , yy~~€ _./ 1.0! M ~ ~7 1 }r, \ '.`\ .` 4.. i- ~ 45.21\ `\ 1 .,.. -~ -' ~~ ~ \ i ,4 / ~ ~ . >> - rt- ~ _ yy q y .t ! ~ - I<~~. 1 ~ 1- ~ W ~ ~"' ~ `-t„~ _ _._. _ -. ...r - ,~'\'` .tam / ~ . I__ v~ r ~, I ' 1 :~ ~ g 4 ~ 0 l~ ~ ^ _ _ _ . . IKI Q ~ i ,~1. 4 z 1 ~~ ..... _ _ ~ 1 IC ~ ~~ 1 R r-iw I I ~ m 1 j ~~ I ~: ~; i (' ,,r~. ~= ~ I+ ~:/ k hA~ 1 O - ' I ° I 's L1> i .. ,~~~ -~ ~ {I ;~ ~ y II+;~ t 7 K. I ~ .,. 1-- ~ ~~ ~ II .: ~_~~ 1. ~..~ >• s 4v 1 t- ~> I N ~ -c ri g 1 I- ~ ; 1~ 1 ~, y . ~r'~~I SCLlL1 ~ ~ w ~ /' i -- : - ~ i Z6,~ •` 11 sy,~ l -~' '° ~s~a ' ~ ~:^~~ -/ ~ i-'. o .... _~_ _ ,~_, ... ~` ~ ~. . I ~ ~ \ FL~,o Ill -~~~$ J 7•b~C ~ ;• ~ ~` "cr. '~~\ v , '`~ \ `\ Y~ ~++~N~ ~~ `/n y^~wOJ b' ,` ,. •.44151 _ '~ ~ ~~ .. _ ? + I { ~ •~ ~• ~!~' ~~ ~ j it ~~v . , t ~"-~'-. 6.44 1 \ '~ !0 / ~ 1 /~ ° w277. ..._ .` 431.06\~' 1 1 `'n v,Y. ,•j6, \ \ Z6 ~ / i ' ~'~ 1 +s '1 1 J~ ~ i~~ 1 ,` \ \ , ~ ~ I`5 i'O l ~ t\ •1\ sic I i 1 \• + ; ~ t~ f ! ~~ / ~, ,~sc.,i 70.47 i -.t:.. I ~ '` {`. ' ~'~" 1 ` ~~ 74 ~ ~ 'rte ~ ~ . % X70 OK RLMOVED- '~ _.~~ ~.,,' ` `~.".' - _ _ / ~~ ,~ .., ' J ~, , r \~'~ _~~w~~ ~ °~ ~.$~,'~7°'+~ YTS h: " ~ ~ ~ •,~,~ :~1/~~ _ i +4, i l1U1 ~ ~ ; r • ,+t P u. 1311; .t ~ ~ r / .~'-~ o _ ~~~ ~ ,F~- . : `\ \'~.°'~~~ ~ J' ~'~ f lts7 urf a u~") l ~ ' ~r 'I ' .s t ~; ~ '" ~,1 ~ y of ~~ :- \ ~ ~ ~~'-. ~, j ~ ; N7~u •--( • , 1 ; i^ ~~' 329.18 N03'1T 1'E = ~'+. '= : j ~ , w..y~ 001 EksEYEN)~'i~ ~ . ~~\ \\ N I `, ra ~~ '~~~ NaZO ~ • ` 416.3 N01°0508 ~~, ' ~~ , ~ _. _6 ~~ 1. esric. ~ Q~ J r -• 5 • .~. l1 ~ 18~I4t8 Q( ~ t\ \ 'tl i '•, t I 1lri';'` i t ~ ~ `k• I I ~~ , : 1 ` + r i ~ I POWTS OWNER'S MANUAL & MANAGEMENT PLAN. FILE INFORMATI N Owner Permit ~ ~ nFRIrtN POROMETERS ~ ~ Number of Bedrooms O NA Number of Public Facility Units 18~NA Estimated f{ow laverage- al/da Design flow Ipeakl, (Estimated x 1.5) al/da Sell Application .Rata al/da /ft' Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mglL Biochemical Oxygen Demand (BODb) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent (2uality Monthly average Biochemical Oxygen Demand (BODE) S30 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) S10' cfu/100m1 Maximum Effluent Particle Size Y, in dia. ^ NA Other. ^ NA "Values typical for domestic wastewater and septic tank effluent. Page ~ c I SYSTEM SPECIrIt:A ~ ivna Septic Tank Capacity al ^ NA Septic Tank:Manufaaturer ,: , f~, ~ . ^ NA Effluent Filter Manufacturer `' ~ • ~' ^ NA Effluent Filter Model ^ NA Pump Tank Capacity al ~NA Pump Tank Manufacturer -®'NA :..,; yr, Pump Manufsoturor' ,,,f;s _. ~ ~ N, Pump Model ., ,, .,, r ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland Q Other ~N~, Dispersal Celllsl ~'In-Ground Igravityl ^ At-Grade ^ Drip-Line ^ NA i l7 In-Ground (presWrized) O Mound ^ Other: O.thar: ^ NA Other: ` ~ ~ O NA Other. ^ NA MAINTENANCE SCNEDULt Servlce Event Servlce Frequency Inspect condition of tank(s) At least once every: month(s) ~ , ~ IMaxifnum 3 years( ear a :~ : • O NA Pump out contents of tank(s) When combined sludge and scum equals one-third lT/sl of tank volume ^ NA Inspect dispersal ce(lls) At least once every: O monthlsl ` IMaxfmum. 3 years) ~ ~ earls) ^ NA Clean effluent filter At least once every: .~ p month(s) ~yearls) O NA jls~ 0 ~C NA Inspect pump, pump controls & alarm At least once every:. aa~js O monthlsl.-; ;. ~, .~ st1'i~° 1~NA Flush laterals and pressure test At least once every: ^ earls) other: At Ioast once every:: O month(s) ^ earls) ^ NA Other.. U NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following Iloenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septago Servfoing Operator. Tank lhspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any oraoks or leaks, measure the volume of combined sludge and scum and to chock for any back up or pending of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels fn the observation pipes and to oheck for any pondln; of effluent on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and rayuires tt~: immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-third IYsI or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of In OoCprd7~oe with ohepter NR 113, Wiaoonsin Administratlvo Code. ' - ' ' All other services, inoluding but not limited to the servicing of effluent filters, mechanical or pressurized oomponente, 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. OMW lal01 Page -~ or' START UP AND OPERATION for new construction, prior to use of the POWTS check treatment tankla) for the presence of painting products or otitier chemicals that may impede the treatment process and/or damage the diaparoal celllal. 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. puring power outage: pump tanks may fill above Hormel highwater levels. When power is restored the excess wastewater will be discharged to the dispersal celllal In one large dose, overloading the oellls) and may result in the backup or surfaoe dlsoharge of ©ffluent. To avoid this situation have the contents of the pump tank removed by a Septege Servloing 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 `;Vhen the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is ~~roperly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Adminlstrative 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 Septege 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 faits and cannot be repaired the following measures have beon, 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. O 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 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 INSTAL E ~ POWTS MAINTAINER Name ~ - Name Phone *- -^ ~ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone "his document was drafted In compliance with ohapter Comm 83.22(2)Ib11111d1&Ifl and 83.6411), 12) & 131, Wisconsin Adminlstrative Code. ST CROIX COUNTY g` - SEPTIC 'T'ANK MAINTENANCE AGREEMENT,y AND O~`'NC:I:51-f1!' CERTIF[CATION FORM Owner~Buyer .~ ~ ~ ~ ,~:'. Mailing Address 1'ro ~ert~~ Address ~ ~~ I _. (Vrriilcation rr~luircd burn I'lannin6 Deparnncnt for new construction) t.:ity/State > _ es Purcvl ldentifict-tion Numbor ~ ~ -~%~-,~,~. !~~r" LEGAL DESCRIPTION 1 ropcrty Location~,~~ 'ia,~~_ ~;;~, s~~c., '~=~N-R~,.W, 'Town of Subdivision (:'ertified Survey Map # Lot # ___~.__.._. ------j Volume ~, Page # `Warranty Deed # •S ~ , Volume G~~ ~ Page # -~---~--' Spec house„~ yes O no Lot lines identifiable ~ yes Q no ~Y TE 'I MAINTENANCE ln;~~roper use and maintennnc:cuf your s~•~uir :;ysicin could result in its prentalure failure to handle wastes. Aroper maintct;:~n~c consists u( ~nunpinb put the septic t:utk curry there years ur so~,nrr, tf nrrclcd by a licensed puntpcr, What yvu put lulu tttc systru~ can affect tl~r function of the septic tank as a trcutnrent stubc in the waste disposal system, The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewaterdisposal system is in propc;r operatinb condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge, Uwr, the undersigned have read the above requirrn~tunts and ague to maintain the private sewage disposal system with the standards set forth, heroin, as set by the Dcparmtent of Commerce and the Department of Natural Kcsourcos, 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/on date.. ~'~"` _ _ ~~ t %a~~--- l l SIGN RE F APPLICANT DATE OtiVNER CERTIFICATION • 1 (we) certify that all statements on th,s form are true to the best of my (our) knowlcdg~,, I (wC) am (arc) the owner(s) of the property described above, by virtue of a warranty decd recorded in Registor of Deeds Office. ~~' Slc:~r;A URJ.~: U APPLICANT' DATE **"'** Any information that is mis•rcprrsented may result in thr sanitary permit being revoked by the Zoning Department. **'*•' ~. ** Include with this application: a stamped warranty deed from the Robistor of Deeds office ~' * ..~ ,,' a copy of the certified survey map if roferenco is made in the warranty deed U. 2y87P .608 STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Reliant Developers, LLC, Grantor, and Gary D. Nelson and Jillienne J. Nelson husband and wife, as Survivorship grits rope rantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in'St. Croix County, State of Wisconsin: Lot 1 Plat of Kelly Estates, St. Croix County, Wisconsin. _-.. Recording Area Name and Return Address: Edina Realty Title, Inc. 400 S. 2nd St. -Suite 115 Hudson, WI 54016 417885 Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. 020-1059-90-000 Parcel Identification Number (PIN) This i no homestead property. Dated this 5th day of January, 2004. Relia ev o ers B * Rick Toston, Manager for Reliant Developers, LLC AUTHENTICATION Signature(s) authenticated this 5th day of January, 2004 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 # 1 15, Hudson, W 1540 16 (Signatures may be authenticuted or acknowledged. Both are not necs~sary,) 'Names of persons signing in any capacity must be typed or printed below their signature * State of isco sin * ACKNOWLEDGMENT STATE OF WISCONSIN ST. CROIX COUNTY. 7~1~~3 KATHLEEN N.• NALSH REGISTER OF pEEDS ST. CROIX CO. , MI RECEIVED FOR RECORD 01/08/2004 10:4SAK MARRANTY DEED EXQPT # REC FEE: 11.00 TRANS FEE: 209.70 COPY FEE: CG FEE: PAGES: 1 ss. Personally came. before me this January 2, 2004 the above named Rick Toston, Manager for Reliant Developers, LLC to me wn to be the person(s) who executed the foregoing instrume and acknowledged the same. Notary P blic, State of Wisconsin My co fission is permanent. 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