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HomeMy WebLinkAbout020-1066-10-075Wisconsin Department of Commeme PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal:nfbrmation you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Slavsk ,John & Tan a Hudson, Town of CST BMEI~i~ b Ins~~eY:D BMDescripti~ /, / ~~~• ~• TANS{ INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ ~„U Dosing ~ `~ ~ /_~ p I~ C Aeration Holding TANK SETBACK INFORMATION TANK TO P~ W~ BLDG. Vent to Air Intake ROAD Septic r ~~ ~ k Dosing ~~ Aeration 0 Holding PUMP/SIPHON INFORMATION ~'YAV(~~/ Manufacturer Demand Number GPM Ft n 0'111 ARS~IRPTIf1N SYSTEM W -i ELEVATION DATA County: St. Cf'OIX Sanitary Permit No: 479352 0 State Plan ID No: Parcel Tax No: 020-1066-10-075 Section/Town/Range/Map No: 24.29.19.254A30 STATION BS HI FS ELEV. Benchmark 3 rj ) 0~ •'L l ~ 0~` ~ Alt. BM o ~ ~~• ~/ p. Z i o 3. / Bldg. Sewer ~ . St/Ht Inlet ~~ ~ ~k > • ~3. . 2 ~Z, a SUHt Outlet .. ` ~/~ t- r Dt Inlet it ~_ Dt Bottom /~ ~- Hgader/Man. ~ ~ ( d ~' , ~..L Dist. Pipe ~ ~ ~~ ~ ~. ~Q ~ ~' t~ .~ l Bohm ~~ ~p P ~ ~ (? • ~ ,~ Final Grade '~ ~ 7 b `~'S•7 St Cove r Z ~S 1 ~ 7~ ~~ • ~". D ~ ~-- ~ ~ ~ S c~ b2 VrYoei~ S i~ l v BED/TRENCH DIMENSIONS Width ~ ~ Lengt ~ ~ ~ o. Of Trenches \ J PIT DIMENSIONS ~~ No. Of Pits side Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WEL LAKE/STREA LEACHING CHAMBER OR n~11 h INFORMATION Typ f System: ~ ~1 ~ ~ ,I ~ l UNIT Model Number: n1~71SIR11TInN SYSTEM (rrl nM,liL, . IJih.d~---- Header/ anifyld Distribution Pipe(s) ~, j ~~ ~ / x Hole Size ~ x Hole Spacing ~_ Vent to Air Intake ' Z / Length Dia lengthy Dia Spacing Cl111 P`!1\/FI? ., o-,. ~ c..~.e ~ n.,r.. .... Mnnnri (lr Af_r~radta Svctr?ms Only Depth Over Depth Over xx Depth of xx Seeded/Sodded Bed/Trench Centel Bed/Trench Edges Topsoil ~ _~ Yes r`:] r Cd11AMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: `~_/L~~~/ U~ Inspection #2: / / Location: 845 Wyldwood Lane Hudson, WI 54016 (SE 1/4 SW 1/4^24 T29N R19W) NA Lot 3 1 " ` Parcel No: 24.29.19.254A30// 1.) Alt BM Description = ~v~ ~~~ • ~r d G~ 6~~ J'r*~' ~""~"'"` ~- ~n~~~ `rr"~` ~~~/ ~r/~ ~ 2.) Bldg sewer length = S r J~~, ~ b T ~'~~,C',cD (/YL ~, t.r.T -amount of cover ~ 1 ~ i~~ Gfi~ ~ / ~~ --4 T--; - - ---` --- --~ /- D ~ Plan revision Required? it Yes ~ ' No 1 ~ ~ _~ ~" Use other side for additional information. ~__~-? ~ S_J I,___~_ - - Date Insepctor's ignature Cert. No. SBD-6710 (R.3/97) to ~ ~, xx Mulched No r] Yes ~~ o Saf i Division Comb ` x. ~, ZOl W. Wttshin .Box 7082 ,~, C,Qp/ C ,~~~~/~ Madtsoa y Permit Number (to be filled in by Co.) Oe artment of Commerce (~ ~{-~j 352 Sanitary Permit Applicati Shy ~ LD. Number In accord with Comm 8311. Wis. Adm. Code, personal informsti p p may be used for txcartdary Purposes Privacy Law, st 5.04(t m) J v ~.. GG Projeq dress (if different tbm mailing address) I. Apptipttioa Intortwttion -Please Print AU IafotmaHtm gT, ~f~b~ ZON4N~ p~FIC ~ gt~, j ~ ~ n ~~ / w Y O~rm-~•s Name Parcel k Lot S Bbdt tl k. 5~~~ - Propaty 's Mail' Property Location ~itY. s Zip Cade Phone Number o ~ ~ :- ~~l- ;p1- ~ ~ circle T v / N R~E ~ IL Type oiBuil ng thtxk ail that apply) 5 „~,~,, ; o ,~,1 ~ 2 Family Dwelling - Number of Bedrooms ~~_ S . ~ ! Nsme CSM um~ ^ Public/Canmereial - Descn'be Use ^ State Owned - Deuxr'be Use ^City ^Vilhge Q~7'mvnsltip of SO III. Typt of Permit: (Chock onty one box on une A. Complete Uae B ii appUcable) ` Zi7 - 0 6~ - ~ o - O ~S . Z~'~i~# A' ~NewSystem ^ Replacement System ^ Troatrttendtiolding Torok Rephcernertt Only ^ Otber Modificatiat to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Cltutgt of ^ Permit Transfer to New List Previous Permit Number and Date Issued ~~ ~P Phmber Owner 1V of POW7B S Check all that a Z T Nat -Prea:mixed ht-Ground ^ Monad > 24 in. of suitable soil ^ Mound < 24 in. of suilabk soil ^ At-Gorda ^ Single Pass Swnd Filter ^ Coasmieted Welland ^ Praaaized ^ Holding Tank ^ Peat Fiber ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ' ^ ' Mega Fiber Chamber Lane ^ Gravel-hxs Pipe ^ Other bier ~ / V. Dior reatt nent Area Iatormatioa: Q - /, C Design Design soil Apptirauitut Rata(gpdsf) l Aron Required (at) D' (af) S Ekva6oa V d ~ ~~~ ~ ~ ~ - ~ 9~,c' ~ 63 VI. Teak Info Capataty m Total Number Maatrtactuaer Prefab Stool Fiber Phstic Galbas - Gaibas of Units Concrete Constructed Ghas New Exigiot Tanks Taoka Septic err Itotdi~ Talc 0 v tAS e ~" Aerobic Trearmeat Unit DaiaiQratba VIL Ra tttdbility Statement- I, the R aswwe aNbiHty for ta:talla WTS shmva oa the attat:Yed plans. 's Name f Print) P ~ ~ ~4~ M RS a ~~~ ~ Business Phi nmber ~a~~-99~~ P umber"s Addreac (Sled, Ci , S Zip ) ~6 a d ; D ~'i ' ~ , r , VIII. Conn rttneat Use O A~y~ ^ ~~ Sanitary Peer~it Fa (includes Cuauodwater Date issued :Issuing A Sfgaatrtre (No Stamps) ^ _ _ ___ Reaso for Denial ) ~'- O 3 .~ I Conditions o l Za. b e I ~ ld 0 Fi leer ~~ (~ y ~~. ;11~v'~ d>r s ~'r ~' ~r~~ ~~ ~S 9G , SYSTEM OWNER: a 3 ~h l ~5, ~We~ ~ 1 Septic tank, effluent filter and SYSTEM OWNER:,.;. dispersal cell must all be serviced /maintained 1 Septic tank, effluent filter ~n as per management plan provided by plumber. only) far tke svsrna tta eHaar .oe lea tttaa tivt :11 Ittebes t.' as per applicable code%rdinances. SBD-6398 (R. 08/02) 2 ~~) O~ 's hq I b se iced / '''13s per management plan provided k All setback requirements must be m as per applicable codelordinances. ,, ; l h ~ ZUI W. Washington Ave., P.O. Box 7162 `~~~~~~~~ Madison. WI 53707 - 7162 Sine Address .' De artment of Commerce Sanitary Permit Application ~ ' Permit N»mb" In accord with Comm ffi.Zl, Wis. Adm. Code. persoml infatuation yet provide ^ Check it' Revision ~ be need for Law ai5. i L App&atlast 7nfot7osttttomt - Plttase Print All Intattmatiaan State Plan I.D. Nnmber Property Ottraer'a Name Pattxd Nmnber Property Owner's Mailing Address `~~ . Property Location •'~ 5i• S T N R B (Sty, State - Zip Code Number Lot Number Block Number Subdivision N ~ CSM Number II. Type of Bur7ding (check all aPPu') Deity ^ 1 or Z Family Dwelling - Number of ~ DVt71ag ` ^ Public/Commercial - Descn'be Use ~ ~ ' f ^ State Ow~J t , . ~, • * , ~ ' . ~-~ , .1 ~, ; ~ , Nea st Road III. Type of Permit: (Check only one box on line nnmberIng schem for internal use). late line B ig applicable) A' 1 ^ New Z D Reptaceaiem System 3 ^ of 6 ^ ' lion to' For C use.. .. stem Tank stem B. ^ Check if Sanitary Permit Previously Issued Permit Number Date Issued - ' lV. Type oP Permit: (Check all that apply)(nnmbering scheme is fo to use) .... _ . - _.. 44 D Noa -Pressurized Lt-Ground 21D Mound 47 D S titer SO ^ Consaucted Wetland ZZ ^ Pressurized Iu-(lroumd 41 D Holding Tank 48 D Single 51 D Drip Line 45 D At-Cirada 46 D 1-erobic Treanneat Umt 49 D Reci 30 D Other V. UZYeatntent Area Informat ion: ' 1)esiga Flow (Bpd) Dispersal Atea Dispersal Area Soil a Pe lion Rate System Elevation Final Grade Required Proposed Rate(Gals ys/Sq.FE. (Mh-: ) i:tevadon VL Tank Info Capacity iA .Total Number Manufacturer Prefab Site Stcel •Fiber plastic Gallons Gallons of Tanks Concrete led Glass New >-~g Teaks Tanks Septic or Holding Tank _ > VII. S'tsattxetmt )[, the assm>;e reaps far aLown m the attaeiud plans. Plumber's Name (Print) a Sigmdtro Bnsiaess Phone Number r~ aa~ 7~s'- ~~~~~~d~ Plumber's Address (strr:ec. City. ) ~ ~ ~e ~~s ~' a ~ ~ Apps ~ 3animtli Pezmit Fee (iocMdes Gneandwater Due lamed Taming Ages sigoawee (No Stamps) . Surrbtuge Pee) D ownu Ini~aed Adverse . . IS. Conditions of ApplrovailReasoas fm' DbaPP~1 . AMaeb a l~ ~ t00 ~' + X41 for me 4A~ ao papee sin rm assn sus = u recap to arse SBD-6398 (R. 05!01) T`,~~° ~-~~` . ' - ~~ '.' ';n, \~ ~ ~, "~ s ~~°u i°f., 'ar r~ ~ ~4 e. `^-z°~ ~'frpe ~--- ~zo .~1r~~. .n .~ t.~'!~a S~ i~~y ~. /, 5e,~,~~ ,yam ~~~• ~~. ~ r =~, .~1' ~~h~labs~ ~udso~ ~~s~ , P co~ \ ~ ~~ ff ..~~' ~~ ~, ~ ~ ~~ a~ ~ ~ ~'ren~nes }6 `~,ar- ~~~w a .3 C~ ~ C!1na~. b ens , ~~ r ~ ,~- ,~_m, ~. p,~h y, . t~~, ~ ~ 8 ~ ~a /o o ~ p r-~J ~ ~ H. ~_~ ~~~ a~ ~y 6 9 ~/a~/o s ~~bG /~ ~ T~ ~ _~ r ~~y ~D~lh S ~~US~ /~a dsoh ~ hs~p, s- ~~. ,; ~` ~ ~ ~\ -~ ,~ ~ ~ ?° ~, ~ ~ °?r a~ es ~6 tan ~ae~w ~.-- ,~_a, ~-p~~h ~. y*` ~ ~~ n- ~J a d M. 7'u ~o ~~ P r•~.v P s ~f,.. ~~~ !o~_U G~~ a~~y69 ~~a~/o s wisoonsih Department of Comme ce ~E~E~~~~OI EVALUATION REPORT i ' Division of Safety and Buildings Page ! of O 1 11 1 VVI11 1 VJ~ VVIJ. MUI11. IJVVG ~,,, Attach complete sit n r not less than 8 1/2 x 11 inche in size. Plan must County '~° , C? A , indude, but not limited t . percent slope, scale or di si a on t~e~~point ( M), direction and n nand istance to nearest road. ~~~~ Parse! I.D. o a - tOC~~ ~- Q- C~ Pleas a mformafion. ev wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~ ~ Z Property Owner Property Location ~o~~ "~- ~o-c'~. 0.... ~ iQ.`t ~~ Govt. Lot SE. 114 5~ 1i4 S ~'^S T ~~ N R 1~ -E-(oF W Property Owners Mailing Address " Lot # Block # _°' Subd. Name or CSM# - ° Loa ~ . ©o~ ~ ~ t ~-D .~ ~ ~,I~t...~ .~... ~~ ~ ~ City State ~ '~' Zip Code Phone Number ' ~ ' ' ^ City ^ Village ,Town Nearest Road ~ ~ I l / 5 aS (l S) 5 6/ -y S ~ ~ -~~e.. ~~ = VJ Id ~,Joc> I ,New Construction Use:~Residential /Number of bedrooms ~_ Code derived design flow rate CpU ~ GPD ^ Replacement ^y Public or commercial -Describe: Parent material G~ C.~~+,"t p~jT '~-~a ~~ Flood Plain elevation if applicable N ~ ft. General comments and recommendations: 'J ~~P ~ ~ i ~€ e, ~ i ~._ `~a r C~:ac1 LS 4 ~:°'~--t~C3i^, 4t... ~ ~,j~t o u~ - q t'p ~?(`~~ S t{ 5~..'(Yl Boring # ~ Boring ~. ~, \ ( Pit Ground surface elev. ~ ft. Depth to limiting factor /' ~ ~ in. Soil A tiCc~ion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPC'fti= in. MunseH Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0- a~ R ~~~ .____.. ~~ ~mo.ab' ~~ ~~ ~r -~5 ion .~ -- ~; ~m~~~~ ~, c ~ ~ a ~ ~ i ~.. k i'° 3 Boring # p~p~~ Boring I,LY pit Ground surface elev. ~' ~ ~ ft. Depth fo limiting factor ~ ~ in. Soil ication Rate Horizon Depth Dominant Color Relax Description Texture Structure- Consistence Boundary Roots GPD/ff? in, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 / ~ '~ f 5~- 4 ~ ~ -- ~ -- °- ,1`~ i , f _ . ,_,. ' ~.. ~ Gca R~. ~~ oY~ !D i' C. t'a.'' a't"~ ~'. . . .. ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BOD < 30 mglL and TSS < 30 mglL T Name (Please Prin) ignature CST t~lumber ~--~ ~~~ ~ ~ ~.a~ Address ~ ~ te.Evaluation Conducted Telephone Number. S 4 Property Owner ~ `+ _ Parcel ID # ~ ~"' ~` T~"~ "~d ~ ~7~ '" ~ Boring # fl.^T~tf Boring ^7~~r!^ C. P Pif GrOUnd SLJ I'fafP P.IP.V ~/ f ~ ~ ff rlanfi. ~.. ~~m;f;n.. fn..1n. / ! 1 E n Page oZ of Horizon Depth Dominant Color Redox Description Texture -'~ -- ~ ~ - ' Structure -----~ ~ Consistence '- ~~~~ Boundary Roots Soil A lication Rate GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 _~ ar. ~ O ~~ ~ f E `E~Rt~ ~ ~U ~`~CaC... S' o,'t^i'~~' `~,~. ---~-- `~ 3 Z Boring # ^ Boring . .. - --- - --• ... .....F...~ .v a„„u~~y ~c~.w~ ni. Soil A tication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ^ Boring ~ . n Ground surface elev ff no~~ti r„ rmir~.,n r~,.ti.,~ v Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 `Effluent #T =GODS > 30 < 220 mg/L 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. If you need assistance to access services or 'need material in an alternate format, please contact the. department at~ 608-266-31ST or TTY 608-264-8777. ~z°~ ~l~,rn ~--- M ~, ~, ~ ' ~.. ~ ~, ~ CD %+w~\ 3 i ~zo~ f ~--- ~ f ~r~~ S r~~~' £' ~, ~ ~ ! ~~6 ~~~ ~. '1~ ~~~ ~, ~~ .~ a e ~"~.1 el.~ q~,7 x~ ~''r u~p as e. a~ ~'o,•ze. et; x'`7.5 ~~ eta g~,~ ~:~ ~°~ sd~~~ ~, N \~ J ro a ~ =~~ ~„ ~~ ~, ~ ~ ..g ~' ~ QM ~ ~~-- i~_o~ Eatl• p,"h ~. 4 ti ~ ~ ' ' ~t , rr, $h(~ ~~p°~ p,.~~'~, elm !aD_O / ~-/It2~r`c~~e So .'! F7or.~1t~S ~ ~ ~ '4 g °S~a6'8~ Q~ °37.8,x' 94°s~,o7~' y~,°.~7gs3 ~ 44°sq a6~t j f~: ° 37. f37~. 1 Ct-.,fs - Sept/o~. o~ Distr.'6c,.t,o, Ce~~r rc1- P~ cT • ~ to io ~. Lam. ~'~-c~ ® ~ 4:ti. s~cd~o ~V~ - 1 Q L- ~ ° ~lo~ /P/dti off' ~u.~K 'F ;~ ~/~t,-~i/far- Sysfe.~ l Sysfe,~ `t ~l ~ 7`I-Cn c1CS~ eel c`! cci~G/ ~_ Qu.c./~ ~ G<.r~, 7S ®~ b6sc/c-r~ f.~h p.pens I/ -// pt~/i ~! Haili /./~+iq 6 /~ ~ ~ sC~ ~~'~ t~Gh ~ ~(.Vh / YCh~hts .v, t t~ a nr s ~ a (c ~~~~2 cowh~w--ef- 9u1,.~ LL !_ cd,,,~owrCl~- ~~~1 - ~ b ~ sysfr.-~e(- F Systc~, e / = /C/~ 6G`' ~/, yj ~- 7~p~1/gf z ~~'?, / ~ s~ .~~ 01` ~ ~~h ~'. ~. /e~ 1v~,! v~ Q! ~ ~~~ per,, ~~~ ~-~.~~~r~~~ fi~Y uh, ~s <<y ~{~~~,~ -- ~ z~~ ~ ~- ~' .Z Se. ~p d{ eh of w~ `lS ~ /~ -~` j~/Se ~ ? ll - o POWTS OWNER'S MANUAL 8c MANAGEMENT PLAN Page ~ of ~~~ c ~uGnRMeTION ~~~.. - - Owner ' ,T6~ti r~Jti fwd S~4~S/~ Permit # ~~-~' 3 S~ DESIGN PARAMETERS Number of Bedrooms ~" ~ ^ NA Number of Commercial Units NA Estimated flow (average) ¢G~ aUda Design flow (peak), (Estimated x 1.5) ~OI~ aUda Soil Application Rate a aUda /ftz Influent/Effluent Quality Monthly average' Fats, Oil 8~ Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOOS) 420 mg/L Total Suspended Solids (TSS) 5150 m /L Pretreated Effluent Quality ~~NA Monthly average"* Biochemical Oxygen Demand (HODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Coliform (geometric mean) .510` cfu/100m1 Maximum Effluent Particle Size Y inchdiameter ~T~A\I[~ SYSTEM 5t'tcirwr-~ ~~~.~ Septic Tank Capacity ~ ~, O l7 al ^ NA Septic Tank Manufacturer Gv,'e~. C.~. ~Q ^ NA Effluent Filter Manufacturer d l p . Or?(,I,b NA Effluent Filter Model ,S"` ^ NA Pump Tank Capacity al ~ NA Pump Tank Manufacturer ~ NA .Pump Manufacturer ANA Pump Model NA Pretreatment Unit ~ NA ^ Sand/Grave! Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other. Manufacturer Dispersal Cell(s) In-ground (gravity) ^ In-ground (pressurized) At-grade ^ Mound ^ Dri -line ^ Other: • Values typipl for domestic (non-commerdaQ wastewater and septic tank effluent ' •* Values typical for pretreated wastewater. MAINTEN~'NCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ~ ^ months year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y) of tank volume Inspect dispersal cell(s) At least once every ~ ^ months year(s) (Maximum 3 yrs.) Clean effluent filter At least once every ~ ~ months . ^ year(s) Inspect pump, pump controls & alarm Flush laterals and pressure test At least once every At least once every ^ months ^ months ^ year(s) ~NA ^ year(s) ~NA other. At least once every ^ months ^ year(s) '1~ NA other. At least once every ^~ months ^ year(s) 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 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 (Y) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatipment components, and any other maintenance or monitoring at intervals of 12 months or less shall ?~e performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 'a 0 days of completion of any service event. STARTUP AND OPERATION. 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(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. Page 2 of ~ 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 cell(s) in one large dose, overloading the cell(s) 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. ABANDONk(~~ 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 ch. 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 replat~ment 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 arld 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. O 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. D 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. 1] 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 ERESCUE OF A PER ONOROM THE INTE, IORNOF ~ANK MAY BE D FIF CUILT ORN MPOSS BLE. MAY RESULT. ADDITIONAL COMMENTS onurrc ~Alcret 1 FR .~ .. . Name ~.fi d ~ ~ Xcdvv ~ ~' Phone _ 7~ s~ - ~ ~- 9 9 s ~' POWTS MAINTAINER l~Cs: K hO`~'"' Name Phone SEPTAGE SERVICING OPERATOR PUMPER uti~h~,.. LOCAL REGULATORY AUTHORITY Name ~ R Phone Agency S~ CYa~ jiC Cv4,h ~rh~ Phone 7~r -39 ~ ' ¢ ~ ~ ~ t This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document mee s the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) ST CROIX COUNTY SEPTIC TANK 1~RAII~TENANCE AGRBBMSNT AND OWNERSI~ CBRTIl7ICATION FORM r--- Owner uyer // 9~ ,,) Mailing Address ~ ~ ~ ~ (J~~'4 U Property Address S (Verification required from laaaing Department for new construction) City/State 1` /~(. l SD ~l ~ Parcel Identification Number ~~ ~~6i V ~D r~o LEGAL DESCRIPTION ` Location ~ '/., S ~ '/., Sec. ~ ~ T ~ ~ N-R l ~ W, Town of ~~SO~/I Properly Subdivision .Lot # r' Certified Survey Map # ,Volume Page # v / ~ ~< Volume a / ~ ~ .Page # D J Warranty 1~ # ,,..~ Spec house ^ yes ~ no Lot lines identifiable .~ yes ^ no SYSTEM MAIlVTENANCE Improper use and raaintenanceof 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 is the waste disposal system. The property owner agrees to submit to St. Croix Zoning Departrneat a cert'if'ication form, signed by the owner and by a masterphmiber, jouraoymaaplumber, restrictedplumber or a liccnsetlpumper verifying that (1) the on site wastewaterdisposat system is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the ~mdersigaed have read the above requirements and agree to maintain the private sewage disposal system with the standards sot 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. Cmix County Zoning Office within 30 days of three expire on date. SI TURF OF APPLIC DATE Uh'j~llrilt l.L`itlil+ll.Lil1V1~ I (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 ro rty d a e, by virtue of a warranty deed recorded in Register of Deeds Office. (~ ~J / / /~7 SI TURD OF APPLIC DATE «««*«« Any information that is mis-represented may result in the. sanitary permit being revoked by the Zoning Department. **«««« «« Ipclude with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made is the warranty deed Smote Bar ~f ~i3 onsin Fos 1-2003 WARRANTY DEED Document Number II Document Name THIS DEED, made between Bri Mar, Inc., a Wisconsin Corporation ("Grantor," whether one or more), and John F. Slavsky, Jr. and Tanya L. Siavsky, husband and wife ("Grantee," whether one or more). Grantor for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Part of the NE 1I4 of the SW 1/4 0[ Section 24, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: of 3 Certified Survey Map filed June 10, 2004 in Volume 18, Page 4769, Doc. No. 765505 ? 9 i='. 1 1 4 KATHLEEN H. NALSN REGISTER OF DEEDS ST. cROIx co. , MI RECEIVED Ft7R RECORD 04/13rzees 01:00Pn WARRANTY CtEED REC FEE: 11.0(0 TRAIiS FEE: 350.00 COPY FEE: CC FEE: PAGES: 1 Area Name and ltetum Address River Valley Abstract & Title, Inc. 1200 Hosford Street G (~ Suite 201 ~~ 1 Hudson, WI 54016 020-1066-10-000 Parcel Identification Number (PI1~ This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances except: easements, covenants and restrictions of record, if any. Dated April 12, 2005 Bri-Mar, Inc., a Wiseon n C poration (SEAL) (SEAL) « * Wayn .John n, resident (SEAL} (SEAL) AUTHENTICATION Signature(s) Wayne J. Johnson, President ACKNOWLEDGMENT STATE OF ST. CROIX ) ss. WISCONSIN _ _ COUNTY authenticated , 2005 ~.. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706,06 ) Personally came before me on April 12, 2005 , the above-named Wayne 3. Johnson, President to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Heywood, Cari & Anderson, S.C., 816 Dominion Drive Notary Public, State of ST. CROIX Suite 100, P.O. Box 125, Hudson, WI 54016 My commission (is permanent) (expires: (Sigaatarea may be autbeotlpted or acknowledged. Botb are not aecesaary.) NOTE: TIIIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD SE CLEARLY IDENTIFIED. WARRANTY DEED STATE BAR OF WISCONSIN FORM NO.1-2003 •TyPe name below signatures. ®Stat@ 69r of WISCOnsin 2003 INFO-PRO'"' Legal Farrna • (8001965-2021 • IMoproromu.com 1 ~~ j .~ ti' CERTIFIED SURVEY MAP LOCATED 1N PART OF THE NE 1 /4 OF THE SW 1 /4 AND IN PART OF THE SE 1 /4 OF THE SWl/4 OF SECTION 24, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, PREPARED FOR: W/SCONS/N. sx:ol~aarcour~mx STEVE & LAURA JACOBSON LOT AREA TABLE NORTH 1/4 z 846 BADLANDS ROAD CORNER OF ~ w F HUDSON, WI 54016 Lot # ACRES SO. FT. .SEC. 2a I i o N LOT 1 2.03 88,378 SURVEYOR: LOT 2 2.62 114,139 LOT 3 3.00 130,535 DOUGLAS J. ZAHLER LOT 4 29.98 1,306,040 S & N LAND SURVEYING, INC. 2920 ENLOE STREET 4G~G p~4 OG~ HUDSON. WI 54016 _ _ ~~aao~c~ aoo NW CORNER _-~ ~-- OF THE NEt/4 N89° '33 ~` i OF THE SW1/4 ~ ~ ~ ~^ i ~ OF SECTION 24 N89°27'33"E 13~~20.« ~ _. 787.34' ~ WEST 1/4 CORNER OF SEC. 24 I Oro o to I ~~~ I ~ I ~ I ~o L5 I ~i~ ~i~ i O ~_ Z ~i~ 00 1 I ~v ILL <~ I O ~" I e („j~ ~ I W tw/)I ILLo o~1 ~O `~ w .'- 00 I J (?I o I ; ,,,~ I ~°i~~~ al I \~~ Ojol ~ O ww U i i w zz L l i ~ ~ z I I I ~ / ° I~ I ~~~ ~' ~ [~ ~~ \ ~~ ~~ ~ !97.16' EAST-WEST 1/4 LINES ~I • LOT 1 _„I ?Ea5505 VOL ~ 8 PAGE 4769 KATRGEEK N. REGISTER OF OEEDS ST. CROIX CD.` MI RECEIVED FOR KECORD 06/10/2004 11:15Ai'[ CERTIFIED SURVEY 11AP REC FEE: 17.90 COPY FEE: 5.00 PAGES: 4 s ~ ~I~I ~~~ ~~a~ I I !LQ±T~ UQH N ~ ~~ Z J i --~~ m W ~ ,1 J ', 2657.16' Y v EAST 1/4 CORNER OF SEC. 24 u'Cz]G pdGQ4 OCR ~7L D~MOOO D -------------- ~I r - W :- ~ MMG°?LLa4u'C~D I ~ ~dQ 1 D~3 GjJC~D l~ O ~ I try ~ r~ ~v 7 QU D~L~Ji LS~i°c~ ~ \~\• r `~~ LOT 3 LOT 2 -,1 1Qaiino aw9~PaA1ks'CunmMtee ~ I ' .Y~1~1 1 0 ~ ~ = N Z LL ~ /.~ ~ ~•o+•s.~~ln~n,ar~s~lr r~~~•~w..ou~ulee 3 z r ~- SEESHEET 2 OF 3• ~ SHEETS FOR LOT DIMENSIONS EXISTING GRAVEL DRIVEWAY '--~ LOT 4 HOUSEE SEPTIC VENTS-~! .,p I ~-WELL PROPOSED ROAD PER SOUTH _ _ CSM VOL. 3, PG. 658 j LINE OF i NE1/4 OF WEST LINE OF LOT 3-- _~' _ THE SW1/4 _ EXISTING FENCE `--- OF SEC. 24 -_ 2.5'~ NORTH OF NORTH LINE j PROPERTY LINE _ OF LOT 2- ~} _ ~ SHED d0~¢4(~~/~~1 (~/7 o c~(J7Io Lll'/IJG~o l/ OLlO G5 G°~C~o 4~0 I NOO°00'49"E .' 183 80'~~~ ~(N RTN) r eP N~ ~~t~6;1°V~1,~ p1\ /~ ~ 5~33~ SCRLE IN FEET 1" = 300' 300 O 300 THIS INSTRUMENT DRAFTED BY: BRIANA GEISSINGER JOB NO. 6288-01 DATE: 07/01/2003 REV{SED:06/04l2004 NORTH LINE < ''-" z=~ EXISTING FENCE OF LOT 3, CSM ,~ VOL 3, PG 658 c4i 1" IRON PIPE FOUND ~_EXISTING FENCE ~ S87°59'52"E 15.25' ~ 1'±- SOUTH OF ~ FROM SET t' IRON PIPE :~~PROPERTY LINE i s6' io~~~~~'--_-~~~ N89°24'19"W _ 1~ ~~EXISTING 305.83 • ;~^ FENCE 1'± _ (389°24'E 321.00') WEST OF g~ t PROPERTY ~, ~ ~ LINE `O I ~o ~ o ss' Q~° ~ ~ ~ ~ ~ • ' / SOUTH 1/4 %~ CORNER OF SEC. 24 - LEGEND '~ FOUND ALUMINUM ST. CROIX COUNTY SECTION CORNER MONUMENT • FOUND 1" OUTSIDE DIAMETER IRON PIPE ~ SET 1" OUTSIDE DIAMETER BY 18" LONG IRON PIPE, WEIGHING 1.13 IBS. PER LINEAR FOOT ' • • • • • • ROADWAY SETBACK LINE (50' FROM RIGHT-OF-WAY) - ' - 12' WIDE UTILITY EASEMENT m FOUND 3/4" REROD ® FOUND 2" OUTSIDE DIAMETER IRON PIPE ~ FOUND 1-1/4" OUTSIDE DIAMETER IRON PIPE ( ) PREVIOUSLY RECORDED DATA SHEET 1 OF 4 SHEETS