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020-1395-38-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 556392 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village X Township Parcel Tax No: Lundeen, Matthew & Jennifer Hudson, Town of 020-1395-38-000 CST BM Elev: Insp. BM Elev: BM Descripti Section/Town/Range/Map No: * 0 l9U b m'v / 25.29.19.2432 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION f B35v II HI~ FS ELEV. Septic , jT j _ Ai1 f t ~ 12 ~ ~ Benchmark .2, Dosing Alt. BM /0D v Aeration Bldg. Sewer Holding + St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outl S we :A I, TANK TO P/L I ELL BLD Vent to Air Intake ROAD Dt Inle / 41 . I - SeUXI ~i 6- 100 f DtBoo 4ni X~t~~1CQrN 13,13-f ~ b D;jL Head /Man Lk > 5~s lob l ob 1o v ~s-y 1 a~. s Aeration Dist. Pipe . O Z 7 f o 3- Holding Bot. stem i [1 l S ,"a~ S s D 5 ` /d ~ PUMP/SIPHON INFORMATION Fin-- Manufacturer Demand St Cover I S M \ S GPM I`1 Model Number - ,1~~y -T- 1 S l 0 5 91 TDH Lift Fric 'on Lo Sys em ea I TDH Ft f ~~f Forcemain Length IDia. Dist. to Well SOIL ABSORPTION SYSTEM ,5 BED/TRENCH Width / Length No Of Tregch s r PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO 7J P/L BLDG WEL LAKE/STREAM L CH G Man rer: INFORMATION CHA R OR Ty Of System: LW / 1>100, Model Number: DISTRIBUTION SYSTEM VI~G~t + Heade anif ~ Distribution i p / x Hole Sizp x Hole S ing Vent to Pir I tae f Pipe(s) Length Dia Length D Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges ) Topsoil 4/_ 2- Yes H No [j] Yes Ed No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 0 ( 2- - Inspection Inspection #2: Location: 801 Highlander Trail Hudson, WI 54016 (NW 1/4 SW 1/4 25 T2 R19W) Scenic Hills Lot 38 Par&el No: 25 .29.19.2432 1.) Alt BM Description 2.) Bldg sewer length "U - amount of cover = Z FNI Plan revision Required? Yes No L-y Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Sign ure Cert. No. x. 4 ? r. r V' % t It~ y •r s Ti- u ! _J 5 h 14 .e. y \ 'fit 4 k ~ y~7 Y r County 57 C R Q ,,Safety and Buildings Division 8 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) m ' , S PH Madison, Wl 53707-7162 3? O~sax"` _ - State Transaction Number ° it Nq. in it Application ental unit In accordance with SPS 383.21(2 Code, submtssion of this form to theaed POWT 3 are omitted to Project Address (if different than mailing address) is required prior to obtaini4t3~ary permit. Note: Application foams for state 1 aM n _ "P7~ the Department of Safety'Q Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privac Law, s. 15.04 1 (m , Stats. d✓~•~ 1 I. Application Information - Please Print All Information Parcel # Property Owner's Name _ p p 0 ~ l 3 g S 3g M fq Tr, t/ w J~Sr-NAli---e g &.N PE 61V o 20 Location Property Owner's Mailing Address Property Z3Z. 8 D` f G Nj_ lqA! ER 7'R -LL Govt. Lot City, State Zip Code Phone Number N W v~, :5 E-1 '4, Section A cucle one) H lU. IJ ©N $ 4 C, l ~v T N; R I E o>~ II. Type of Building (check all that apply) Lot # 3 © Subdivision Name 1 or 2 Family Dwelling -Number of Bedrooms Block ❑ Public/Commercial - Describe Use A ❑ City of CSMNumber ❑ Village of L1 ❑ State Owned Des be Use . Town of rl C z A; X6 M t, w 5 x $S' czj III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A Other Modification to Existing System (explain) ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only List Previous Perm Number and Date Issued + B. El Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New '1~~~~ r Before Expiration Owner '7 (O A, 3 IV. Type of POWTS System/Component/Device: Check all that apply) KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < of suitabv soil / 15 El Holding Tank El Other Dispersal Component (explain) El Pretreatment Device (explai 10 V. Dis ersaVrreatment Area Information: Design Flow (gpd) Design Soil Application te(gpdsf) Dispersal Area Required Disper al Area Propo d (sf) S~ Elevation (p O0 fov,`{o VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units A t _ AQ U ; y New Tanks Existing Tanks • ( S cl~ U y k p ,r ✓ Septic or Holding Tank ` 240 040 g Dosin i000 j 00 o I L_3 t.n~ o/ Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) qG'2 14 uY7 k- 5 ~ mkre ZZ4 L>) / S'>i 0,23 VIII. Coun /Department Use Only Permit Fee Date Is ed Issuing t Signatur PProved rov $ #26- Given Reason Denial CondiSy66Tff~ Reasons for Disapproval DL 1. Septic tank, effluent fllW and dispersal cell must all be services t mom" as per management plan provided by plus W-, 2. Al setback requirements must.be, as per apple tilde-/ wooricei, Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: d/►,t - S s wl Owner's Name: Owner's Address: -Evo-J, % `J N R 1 4 Legal Description: C+J y'S~ S rl~ S,te_ Township: County: S jr, Cne-~. Subdivision Name: Lot Number: 3 Parcel ID Number: 04,o Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Designer/Plumber: gQ License Number: oz-7 "7 I O Date: Phone Number 7 l S - -7 Y Q - 3 3d Signature \ ~.3 9 Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 f r a}~j S ^~4 F 3 440 S ~ f~ ~ 2 i ~ 7-S IZZ~ sf 3p$ ~ ~ g p „ a~ t 144 l-k t~J V'h 13 y i V ~ i ' x ! E ZJ1 i t ~ ~ ~ 1 ''+a, s t 3 { 3 ~ ~ ~ ~ t~ ~ a j s ss } ; { 03 N ! i 4 Sa s ~4 Y s ~ so ! -47 r ~ l i 1@ i ~ r ~ 5 '3 ~ 4 S ~ f ~ ~ ~ 3 ~ ~ ~ t~. I # Ila f N r Ada l a yx s ; F'rt ~ f $ ~ ~ t t} i w o T . I'~ 3 1 j 1 s f° VEN T C A.P t-- wEAT HEn ROOF IUNCe C7$t S(X. ---T i APPROVED LOCKING PIPE MANHOLE COVER AND WARNING LABEL 25 FROM DOOR if, MIN. } ° ifflDt W QR FRYES : 3 g GRADE Ai R, i=V ikKE ~ 4.o f1R:~#. I jtt.~~..✓"'' i,r. ~1~~.~!/1.~~'~',~ i~...L.ti ISM mlN. PROVi'0E y ICI LRS J _ - AIRTIG?T SEAL _ J E"~ i i I ¢i! R'~d AP-g0VED 10I 1TS Ct 1. c iA: 2 ~a,i WITHPil.C. 4PJ-°v(YYEC~ 044T ' ALARM i EX R EHIOING SOIL ffIII H AN%*piip ~°4 ONTO SOU D A., i fi kr.>, PUMP 9 CG NCRE'. i E ilb.OCY ""~'a''''q:: ~.•1 (J'j .-4, " ` a k'6 --..~.r..~~•~: :.o : 9. . •w a'~ • " li d , ! r aef ;,Q. ? RISER EW FERMITTED ONLY IF TANK I+eAKUFAC"k-URER HAS SUCH APPROVAL Yn , l - vu rr,,k f 6p 8M-000 d-M:31IJ Nte- JN -002 90OZ *NVr 'n38 veooz k,,vnNvfl :11.Ho 0(;LYS M 'NJOL) NN~301V N 04.*H Sf? !)LLCM Z w o 31313003 V3531M 3b'(iNbW OI1d3S W alb'f1 ON A36 _ S = „b/l 3`iV10S 2i6N-000 LdIM w ~ W Z Z W W K K LJ cn` w v K 0 J O O O W a U w ~ J CY 2 K L.j J K J w O F- > O w f~ C7 Q -d a v) V) w O z V) ti 'y'y O O w W O Z t,~ s Z O ' O W O O O Q W c~ 0 LL t; p` K CL O r) tr O ¢ a It F--" a r: m o ac z a rLD > 7- a r- C> ) J Z J 2 \ N Q O W z 7 v) LLj U) C <C O O W Q O .c"JL C) C > <I. L'i a....~ 0 Gl C ~A (Y1 Q q LL C (!3 -D > ' N LJ rr -(2'0 O , .f ~.r) J W I d LiJ V) C~ LJ W Q X 4~ h- L 1 - L V) h m ICJ W n (J Z> Cj U., OD < LaJ NCL N c OjL -1 r- wa< W- < N w~ O z w O 2 Lo z CV -t J L. W Co L W li') 6- Z 0_ U Y x U Q J \ L) W af_. - O<w OOL, Q Z1-~ V) = w C) 0 Qt Li s LLJ OJt- >~C~ z -OZ UQ Z~F Q ~i-F- C V)~C Z W Un 0 U :D N< C) C7 'T lil w n W (3' LJ Q B U Y 2 Z Q (A Z Z J 7's GI C) .J?mJ~ C] COQ Z d-''~ U z w W L~j Q Y ~ o CV Z Z O O Z z O Y K J r J < N G F C) O U) Q v (y tl_ > d O w F- U > W V) 1 Y 0 ~ 1 dw O d v „6~ J W LL U r( J a r= o° I 0-0 w o - i LJ 0- LiJ J <L I > m I. I ff Ld I ~ ' „~5b L7 U)l F- N „L9 P. ~ Q a ~vMODEL 98 s ! PUMP PERFORMANCE CURVE M06EL 98 R207.1 eters Liters 3718 9114 1.5 273 4 518 25 3.0 61 231 4.6 45 '170 "1& zc 25 95 u ad: 23 ft. 7.0m) 4 > 4 p 1112x11-1r<"aT j O 009971 i 2 1 ~ I- 1211,6 10 20 30 40 50 60 70 80 CALL-NS - I j i h rl L11 -RS - 1 42N32 0 80 160 240 j FLOW PER MINUTE SK1102 CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and Variable level float switches are available for controlling single supplied with an alarm and three phase systems • Mechanical alternators, for duplex systems, are available Double piggyback variable level float switches are available for with or without alarm switches variable level long cycle controls • Refer to FM1922 and FM0806 for temperatures above 130T 98 Series -v Control Selection Model t Volts-Ph Mode Amps Simplex Duplex I Jt98 115 1 Auto 9.4 1 4 11198 111 1 Non 9A__ 2 or 3 4 _ D98"--" 30 1 Auto 4.71 a _ "Easy assembly" E98i 230 s Non T 41 2 or 3 4 ( \ (pump 8 discharge pipe not included.) SELECTION GLIDE 1. Integral float operated mechanical switch, no external control required. 4. For automatic use single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 3. See FM1228 for correct model of simplex control panel. 4. Sae FM0712 for correct model of duplex control panel or FM1663 for a residential alternator system. OPTIONAL PUMP STAND PIN 10-2421 • Reduces potential clogging by debris. For information on additional Zoeller products refer to catalog on Piggyback Variable Level Replaces rocks or bricks under the pump. Switches, FM0477; Electrical Alternator, FM0486; Mechanical Alternator, FM0495; Sump/ • Made of durable, noncorrosive ABS. Sewage Basins, FM0487; Single Phase Simplex Pump Control, FM1596; Alarm Systems, Raises pump 2" off bottom of basin. FM0732 Provides the ability to raise intake by adding sections of 1Tz" A CAUTION or 2" PVC piping. • Attaches securely to pump. All installation of controls, protection devices and wiring should be done by a • Accommodates sump, dewatering and effluent applications. quaiified licensed elcctrician. All electrical and safety codes should be followed NOTE: Make sure float is free from obstruction. including the most recent National Electrical Code (NEC) and the Occupational Safety and Health Act (OSHA). gA~ RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX 16347 Losrsvllle, KY 40256-0347 Manufacturers of.. SHtP T0: 3649 Cane Run Road W Lam.`"' Louisville, KY 40211-1961 ,DU19P9 51mc.- ff& (502) 778-2731. 1 (800) 928-PUMP QUatirr avw,v.zoeller.com FAX (502) 774.3624 © Copyright 2010 Zoeller Co. All rights reserved. ~ . "NHCLE COVER r wrrp. L4cok4G, DEVICE Y F-ENIS-l"ED GRADE .._......-a---"'y 1 FF,1.E ; MTER,w-13t3FF . - 4CLEA.ZCNE. SL 1t c, L~tYt = 5~T:C TAN SEP 11C TANK p u:w : ; . yw l si:e-p~~s ; ueatir~-v asi~watei o~+ pso ri,. seivia and low r~ K ~2Ct~P,a~.t lt~BSeii3~ x7.i, $O"i1C1$ a[:C:StQr3~`z cvfr,_ t . r so ns. Typicaf. riasj o4s,:.greasesare ;fighter segos, vlnit may .ema=n 'ion or e sme Wwe.qgge.&d.sia'':rpto, to lower zones. $,ve; ctax71:R..dcz,r"Wed O loe:,Wasi:.`P13F r,.!P.1746~R~ X16 'tai. Dk asa'._'`~ ~i3~'~""'~~"sea..wrtic~t t:3ve ~ii8~e~ ;~Saiec3 ;i9-ttse,$op or sunk.io the ~~rr:s: ° ~l y, i ie2~ir~~ ~a`tY,SE!]LC_ta"1F snusi a rrr8 tro r ;%a laar" oree tared e, carry =_-artd: . :l e.: S+ :aal". -c sp, ~-1.5. uhW 3i'e., and have become, e o: -e der'Se :ti~1 w"c i n ancg. Wm rsapc s.r uFred Yu. maxxirre zs sysie Eiia hA&ny . vc .:ins r?C . v.y.. x " v . Q~e tvao Al iFeez year4 to-doWMMP if }wmr PRS ~s ne essary=_ maue rea, rnct^e sc aTe cldsludge"yep s.vaLl resin L us ac x~=: sss :vole g_ T iss stSs{ce-s,. eten;ian ws to sa :seining 00cu s ,'~.v :t ~:,R3 ~ .pct' ~tiahes i:l:ssaspen+ls~.so]id~. -fre.suspercedso=cv;s ev:tr~tu~~y ~E3n?' ti o:S iit.li lltcLVr ~teT LLtuch:G.Il ls;AA O jr~trYl QtS;ei S21S1CL' 3.~:'tw`sY1e; 8? li V F UL PRODUCTS A u-",3:ay5 a-m > C' 957i'tP$Pi: c:c.7Y" C!1 ,Dot.s'.v' i=D.'+bi2StE. 4Ft;~%'Lr?,~ , fCX3 .:a.'lwl L%i„CEui. Vdt ' o'4 add W ['m sc dw -M; tar. ic Vie: dig teb Y =.:t~a^tes The {tip l ism"living em4ronment that eels k, ?"J cn cra te ...i-s arm *art".to a:reic ]c lrn~ the t9ac4aria *4th. harsh x*err ice!& arc + rugs. a:!: ;a.ps i ury:ex~utssrs Le'-t over lti ~~are ~e sa tt::y ~:~csiucts,.cs;'~rris.,.t~a~: YrEz~s= c"~%~' ; iaci;~ issue, tovrsurg S*e5ts, pag-i% pair g c~, g easa~.i . 00 $uM oil ree: e" :gas, - os> pfcducts t wI d 9t °-orcrlw- my cxF' a .'',"E nl:X-HMG!- PIPE VATER to Vi ti nn; ef::Uert7 (1K-0 d) to a :tf~,hes iaieva71w 0to pfuvide a :s~~rs ~Y ~~:ur~ y u~sL~ouhcrr;>:~rtg. ixov des a Wamegxoof araa ?or purpp c:anuol.& and ai rm- e is Cal e J:?z iL Cw.^S. Lam" V'w 'tes. c nuds iI e pump cyde. Set I" spe6fc, dose -votumnes. ''.,.a,,: wi" ent : „.9sad, saws an $b6it:1E.23 skWt£Y to can t^ali$m and rmtfisu awner f e -nigh ma er carer Alam to:. ;maybe rk uVed at µ:s nk, a§ong the structurs sareed or ~Y~5 t* burn. G: er a<e-, an a:r Rw s4nat, isuai skeiW or bete. Pw EVENT-IV MU T; E14ANCE s s sv: -71a d6s:; x'13; sn&ttf.s to gi:r pep :<.t*n fire se3iic, zagx is pt:nI . he a 4'x:1 Ss`SieETe, 'pS.m: p owarois .:tit Cti.1' p b9' oiki be teslad r im G: 3ce and the padodym aj. t ocKr;R dw--- s3awid rena 06,E,;:G It in t3¢5 tOi1k Visuaagy inspected ',tais debes o -t ,.d.^. ..csr✓::;4stic:r. zLFa'"~: Mw-y i%' YC'uiw wt ii°.r`.,"C 5.^'guid nw^t be W. into 3 --6*: ~.ank WJl ;T,pass a to e;.nd ssrd a*-, wax ir}tc the uosa tvk T -W-se items caq,:,a a pure fa;iura Poe 4 i rgmgt eSstrk:Mat, swo ch 7rov nee- w be p4.amp r: into the so', z:,*o area and Cause ~,i: ~r~~ arrr', ~css:b4.e ;,ratrat;;rz~ :2k~ze. ' I.PY'~.3 ' G~-]tJb-+'v%v."' .-es-,~.OC X .,,a.ti3t►~~-'c. 4~'--'~~^...a L.Qrv~!'kr=s~-~.-a.'* n6 p tXW mot - , , o `a..' ~."'✓v~3 ' .t•-r-., ,,,,~~LVti'\,sh.dr~-_1 _ `~-.~'a'"c~S~,r~-~, 1~. ~.,~L}~~ `1 Cs~3'~.?L^-cx c~...~y"•`,s~y~"TT ~`b f`c~ 1+~ J -cs~•~. , ~~}v"'R++-'Y~s ~A 4~ " jj POWTS OW'NER'S MANUAL & MANAGEMENT PLAN Page4oA of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity (0 6 al ❑ NA -yq Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 4 ❑ NA Effluent Filter Model P_ /00 ❑ NA Number of Public Facility Units NA Pump Tank Capacity / o ©6 gal ❑ NA Estimated flow (average) / o o "/(X al/day Pump Tank Manufacturer W LZAA- • ❑ NA Design flow (peak), (Estimated x 1.5) Pump Manufacturer 1!50 /VOgat/day ❑ NA Soil Application Rate . 7 gal/day/ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit 0( NA Fats, Oil & Grease (FOG) _<30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD,) <220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispe~rrs~alCeAfs) - ❑ NA Biochemical Oxygen Demand (BOD5) . 530 mg/L In round igravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS).. 530 mg/L W NA ❑ At-Grade ❑ Mound i Fecai Coliform (geometric mean) _<10° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y3 in dia. ❑ NA Other: _ ❑ NA Other: M NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other. _ ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA. _ g year(s) ? Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 0 month(s) (Maximum 3 years) ❑ N IK year(s) Clean effluent filter: ❑ month(s) ❑ NA ,At least once every: )$year(s) Inspect pump, pump controls ontrols & alarm At least once every ❑ month(s) 11 NA p`~P; p ❑ year(s) ❑ month(s) NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersed 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 i,ispection 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 an 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 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 S12 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. GMW (4/01) Page a& of START UP 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. 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. 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: 0 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. El 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. l~ 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 POWTS MAINTAINER Name W ' Name Phone -7L5 - 7 '1 Phone -71 5'- -7'1 Q - 33~;L SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name an-d- Name s Phone 715-- - q - 0 153 Phone 7 /S' S8(. - J4 !o QD This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(7), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY p' SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer v Mailing Address Property Address 4"~ L.-s (Verification required from Planning & Zoning Department for new construction.) City/State ~,,,~.b2,,a..o,., LD . / Parcel Identification Number ca ~Ze - 137,5- LEGAL DESCRIPTION Property Location AILO /4 , Sec. 0-T , T 7-1 N R_L3 _W, Town of Subdivision Plat: Is C ~ Pte. La_ Lot # 8 . Certified Survey Map # /4 pf. , Volume , Page # Warranty Deed # ? a) 1 a . (before 2007)Volume Aq 81 , Page # (0 8 Spec house 1 yes ikCno Lot lines identifiable !)yes i no SYSTEM MAINTENANCE AND OWNER 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(1) 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 plumber 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 1/3 full of sludge. 1/we, 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we arn/are the owner(s) of the property described above, by virtue of a ~~varranty deed recorded in Register of Deeds Office. Number of bedrooms J/ 11 /1:3/ l "'SIGNATURE -OF APPLICANT(S) 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. (REV. 08/05) U. 29 89P 268 7S1`1--- ~ KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 1 - 1998 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number 01112/2004 08:30AN This Deed, made between Grande Desion. Inc.. a Corporation Grantor, and Matthew J. Lundeen and Jennifer L. Lundeen, husband WARRANTY DEED and wife , Grantee. EXEMPT # Grantor, for a valuable consideration conveys to Grantee the following REC FEE: 11.00 described real estate in St. Croix County State of TRANS FF E E• 1095.00 Wisconsin (the "Property"): COPY CC FEE: PAGES: 1 Recording Area Name and Return AddJ~ess MetlheMr.f. Luwtleen K 7, r &4 - 1 g an rail sot Hrs mN 020 1395 38 000 Parcel Identification Number (PIN) This Is not homestead property. (Is) (is not) Lot 38, Scenic Hills, Town of Hudson, St. Croix County, Wisconsin. Together with all appurtenant rights, title and Interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this day of November, 2003. (SEAL) (SEAL) Grande Deli , Inc. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT WENDY SWATZINA Signature(s) NOTARY PUBLIC State of Wisconsin, STATE OF WISCONSIN ) S8 authenticated this day of St. Croix County Ah Personally came before me this day of November, 2003 the above named Daniel Ni t re i o of rands Desions. Inc. to me kno to be person -Tia o executed the foregoing TITLE: MEMBER STATE BAR OF WISCONSIN inst m an acknowledge the me. (If not, [An authorized by §706.06, Wis. Stats) (t, l.x) THIS INSTRUMENT WAS DRAFTED BY Notary Public. Stat of Wisconsin Coldwell Banker Burnet 1301 Coulee Road My commission s pe nent. (If not, state expiration date: Hudson, WI 54016 3-64849 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) r*N es o f rsons s' ni in an ca ci must be typed or rinted below their si nature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. RANTY DEED FORM No. 1 - 1998 Milwaukee, Wis. ~I 3 ~ LL LL m R& W ~ w ~ Ye ~ b b • 61 tat; w W~ -o ilk ~w ' ~ ,.~yema.~es~r ~mam~eaocc~s asnrrWn^m-~ ~ -.J! rw f Y o. ( m >i-= t i Y ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) S o 1 /4,'located at: Ai W 1/4, ~5 " 1/4, Section a 5' , Town,:1 q N, Range / W, Town of /4.,,,~ , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service / - 4 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: / A<.o Construction: Prefab Concrete ✓ Steel Other Manufacturer (if known): 0"Jo.,,, Age of Tank (if known): q o o 3 Permit number (if known) q,3 00 `f (Licensed Plumber Signature) (Print Name) -,Oq P k- S cl:Z"t -7 t o (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430041 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)I. Permit Holder's Name: City Village X Township Parcel Tax No: Grande Design Hudson Township 020-1395-38-000 CST BM Elev: Insp. BM Elev: BM Description: Section(rown/Range/Map No: (J6 .0 lot. Q ~ 1/h 25.29.19.2432 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~ .ez.~J a o $rn ~1 I ~a 6 Dosing / Alt. BM v Aeration Bldg. Sewer -.52W /00-7 Holding F St/Ht Inlet o% ~ TANK SETBACK INFORMATION SUHt Outlet TANK TO WELL BLDG. Vent to Air Intake ROAD Dt nlet P_ / N V-2. -3 V Septic ~ 1t Bottom s 01fl Dosing Header/Mar>, H 13., ! 0 / s , 3 to Aeration Dist. Pip 1-7 '77 al Holding Bot. System b j PUMP/SIPHON INFORMATION Final Grade v/~/°~'t'S 7 q /D - Manufacturer Demand St Cover / GPM o! 2. ; 10(a- L> Model ber TDH Lift icti ss System Head TDH Ft S , Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length S, No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L S BLDG WELL LAKE/STREA LEACHING Manu rer: INFORMATION CHAMBER OR 1 Type, Of System: , L~ ! > I / ~L UNIT Model Number: DISTRIBUTION SYSTEM ! ! / v fS Header/Manifold Distribution ix Hole Size x Hole Spacing nt to Air Intake 1 h Pipe(s) g I ~ , i ! Length~_ Dia Length b t Dia_~_ ~Lir1g~_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over / Depth Over TTDepth of xx Seeded/Sodded xx Mulched Bed/Trench Center Q Bed/Trench Edges Topsoil U i Yes I No Yes. No COMMENTS: (incl~fd'e co disc encies, persons present, etc.) Inspection #1: / /0_3 Inspection #2: i i Location: 801 Highlander Tr Hudson, WI 54016 (NW 1/4 SW 1/4 25 T 9N R19W) Scenic Hills Lot 38 / Parcel No: 25.29.19.2432 1.) Alt BM Description =~I lCO v6~ 2.) Bldg sewer length amount of cover Plan revision Required? I ' Yes , No ~ ~ r, 0_1' - ~ /rnature ~~Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Cert. No. Safety and Buildings Division County Visconsin 201 W. Washington Ave., P.O. Box 7082 T r Roix Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (608)261-6546 300 Sanitary Permit App ica - EiVED State Plan I.D. Number in accord with Comm 83.2 1, Wis. Adm. Code, infortnation you provide maybe used for secondary purposes Privacy w, s! S.l?4(I xm) Project Address (if different than mailing address) ,;{Uwe 0 5 2003 ° 1. Application Information - Please Print All Information S T, # ?V1 j+1 W+UAPJpEXZ_ TR Property Owner's Name d N C' C F ~ ; C C Parcel # CE~Et Block q _ AGES74-Al - o e 213~ Property Owner's Mailing Address Property Location s City, State Zip Code Phone Number ~/W Y., , S-W Y,, section 2,5- 00 S~! (circle o T N; R_ j_LE o II. IWx of Building (check all that apply) pBgg_ Of 1 or 2 Family Dwelling -Number of Bedrooms KV 5,4.V-4 S Subdivision Name CSM Number ❑ Public/Commercial - Describe Use C ❑ State Owned - Describe use 2 r, SO L~ 'ty_❑Village W wnship of~L/QSOn/ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding 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. Type of POWTS System: Check all that apply) it 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 Line ❑ Gravel-less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (so System Elevation F20. 96. z VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank i-loo .2O P Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) P 's Signature M um Business Phone Humber r- - - - 41;~~ 1 9.2 17 1/ Plumber's Address (Street, City, State, Zip Code) L _ VIII. Coun epartmeni Use-Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater to issued Is i gent Signature o Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial IR. Conditions of Approval/Reasons for Disapproval n /~/j~ rt^ti~~(,fvL( .,t:t... W. L . ~dU.CWv~0.Q,e cQ[L ~f^`~ 9^ J&A-f i 'I'V Attack a as a oa y the system on paper less ban 81/2 x it inches in size SBD-6398 (R. 08102) yvvc uew;r ~,vsoc-cT~~N PINS SCALE ~ yo ~ A Ro G~-- /Ov' _T_.P A641L L..nT .38 Sc FN!c _ f-li 4 cS i3ro /iiu 5 ysTcr'i c~. 94"2 ' . ' i o f - 7/4- 89 NO 70 83 _ 1 So. p,l LT 8 j GRANDE VeSIGN - CARR/_AGE. -A&es : - nOw`" - - - - - - - GGC ! I 291 zasijr -~i7 y/ • r, 1158 W Wisconsin department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 8 , is. Ton, Schmitt Attach complete site plan on paper not less than 8%: x 11 inches in size. Plan ustSt. Croix include, but not limited to: vertical and horizontal reference point (BM), di n and parcel I. . percent slope, scale or dimernsions, north arrow, and location and distance neares~ 020-1395-38-000 Please print all information. L vie y D Personal information you provide may be used for secondary purposes (Privacy s. 15.0(1.) M) O 3 IUAA. 1'2~ ~ I wr _ Property Owner RICE Grande Designs Govt. Lot SW 1/4 S 25 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 781 Crestview Drive So. 38 Scenic Hills City State Zip Code Phone Number City Village ✓ Town Nearest Road Saint Paul MN 55119 Hudson Highlander Trail ✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Plain Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd/sgft rating. Possible system elevation for Area I is 96.2'. Boring # Boring ✓ Pit Ground Surface elev. 102.59 ft. Depth to limiting factor 115+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2 1 0-15 10yr3/2 none sl 2fsbk mfr 9w 2f .5 .9 2 15-32 1 Oyr4/4 none sl 2fsbk mfr 9w 1 f .5 .9 3 32-42 1Oyr4/3 none sl 2msbk mfr cw 1f .5 .9 4 42-50 7.5yr4/6 none ms Osg ml 9w .7 1.2 5 50-115 10yr5/4 none ms Osg ml - .7 1.2 -7%•to 8 112- 8 ❑ Boring # Boring ✓ Pit Ground Surfaceelev. 101.99 ft. Depth to limiting factor 116+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 1Oyr3/2 none I 2mgr mfr cs 2f .5 .8 2 12-25 1Oyr4/4 none scl 3fsbk mfr gW if .4 .6 3 25-34 1Oyr4/6 none Is 1msbk mvfr gW 1f .7 1.2 4 34-116 10yr5/6 none ms Osg ml - .7 1.2 o 9 rr " Effluent #1 = SOD 5> 30 < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD S30 mg/L and TSS <-30 mg/- CST Name (Please Print) Signature: CST (dumber Thomas J. Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 5/24/03 715-247-2941 Property Owner Grande Designs Parcel ID # 020-1395-38-000 Page 2 of 3 • F Boring # Boring ✓ Pft Ground Surface elev. 6D. O ft. Depth to limiting factor >114 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounds Roots GPDM in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr312 none I 2fsbk mfr Cs 2f .5 .8 2 9-27 10yr5/3 none sl 2fsbk mfr 9w 1f .5 .9 3 27-34 7.5yr4/4 none Is 1msbk mvfr gw 1f .7 1.2 4 34-114 10yr514 none ms Osg ml .7 1.2 6~ gZ. tab 4] Boring # Boring ✓ Pit Ground Surface elev. 102.69 ft. Depth to limiting factor 116+ in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD& in. Munsell Qu. Sz. Cord. Coke Gr. Sz. Sh *Eff#1 *Eff#2 1 0-11 10yr3/2 none sil 2fsbk mfr CS 2f .5 .8 2 11-20 10yr4/3 none sil 2fsbk mfr gw 1f .5 .8 3 20-29 10yr4/4 none sil 2fsbk mfr 9w if .4 .6 4 29-40 10yr4/4 none sil Osg Ml Cw .5 .8 5 40-116 10yr5/4 none ms Osg mi .7 1.2 ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKe In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 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 -A .,,ots+,;u) ;n - oIt-+ f-t -1-- r-+.,t +1- .lA.~~rtmant ar fAR_IfA-2117 - I" r'V O;nR_7AA-2777 38 j /au ~ l Aj A;; I J `fi r L f I I B 93( ~ l tsro• 3J S, ~Qr 73, ALil /¢d" xa-las Y, S c.•~~, `7 P Cresbuye,) jQrJ GS Z R.2 Q,% A-e z zI4 •w~, 4,47 4 -P-oi7 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of / FILE INFORMATION SYSTEM SPECIFICATIONS Owner _ _ Septic Tank Capacity Q al ❑ NA Permit # Tw Septic Tank Manufacturer ❑ NA -A 4 1- DESIGN PARAMETERS Effluent Filter Manufacturer z ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units jIrNA Pump Tank Capacity al 0 NA Estimated flow (average) gal/day Pump Tank Manufacturer ® NA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer 6 NA Soil Application Rate al/da /ft2 Pump Model ■ NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit ■ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODE) 530 mg/L ■ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L M NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ys in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA . "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: earls) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: El monthls) E3 NA ! year(s) Inspect pump, pump controls & ,alarm At least once every: ❑ month(s) M NA ❑ year(s) Flush laterals and pressure test At least once every: month(s) ® NA ❑ year(s) Other: At least once every: ❑ month(s) M NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank 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 (Y3) 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 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. Page of START UP 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. 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. 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. ❑ 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 INSTALLER POWTS MAINTAINER Name Name - - Phone S9,2 _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name - Name I- C Phone Phone 8'Q This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM xiQ~ l. Gi1-h`D/`'i~ S Owner/Buyer C Mailing Address _Z& ~~~sT(forw ~i? , ~a ~il~.l~:CL'nnD /`74( S^/5/i9 Property Address D ✓ (Verification required from Planning Department for new construction)- City/State AV11,s~a a !Z Parcel Identification Number 11,16 -1,3 Z 2 Dvd LEGAL DESCRIPTION Property Location A(a2- V4, 5W- V4, Sec. a-<'a T-g_N-R1 _W, Town of ~u►.✓ Subdivision .2 2Ci1<iC f7/'L s , Lot # 36 Certified Survey Map # , Volume ..Page # Warranty Deed # 46 = 6,11 , Volume /lam % 9- , Page # Spec house A yes ❑ no Lot lines identifiable 1' yes ❑ no SV~TFM ~NANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastCrplumber, jouraeymanplumber, restricted plumber 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 1/3 full of sludge. Uwe, 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 Zoning Office within 30 days of the three year expiration date. SIGNA OF APPLICANT DATE OWNER CERTIFICATION 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. abo .3IGNATUR F APPLICANT DATE Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I,~ 1662FAGE 289 r,. - ` 648604 KATHLEEN H. WALSH Document Number Documeatlitle REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06-18-2001 12:45 PM j- WARRANTY DEED EXEMPT N CERT COPY FEE: COPY FEE: TRANSFER FEE: 9900.00 RECORDING FEE: 14.00 ' PAGES: 3 Recording Area Name and Retnra Address T14 I m e- . • l goo 5'~ lv c r Lake Zo~d AJc~ tJr7q"t^~l~ MN SSII z 0Z0 - 106'f - -7O - oo (D Parcel Identification Number (PRO ~Z 0- f d ~1? - Q V C) Q. Z v- 10-70 - 00 -CaOO 020- 1070 " 10 "004 02-0 j 0 _70 - Zo "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" 'Innis information tn" I" completed by submiaer: document tide, mmne do renrnn address, and f_lJV (,l rcgrdred). odur Wonnarion etch as du g-tdng dauser, k:d daaipdon, erg may be placed on dis fate paje of the doeronaar or"be placed on addAmd Pa;es of dK doe mu a Hole: Use of dds eowr paac addr one page to your docwncru and x'2.00 to the reeorfing fce. Wisc vin SranrrcJ, 59.S17. WRDA 2/96 i 11 DOCUMENT NO. WAlIILANTY DGh:D I STATE OF WISCONSIN-FORM 9 L ~ THIS SPACE RESERVED FOR RECORDING DATA 1662PAU THIS INDENTURE, Made by......RICHARD N. PEARSO.. and JEAN M. PEARSON, husband and wife, i grantors.. of.... St. Croix Count , Wisconsin,j~ it CARRIAGE HOMES XXI, IN a -•-•-•••-••-••-'I hgreb conveys and warrants to MinNsota corporation, ..................................................1. . - . - - ~I Mi: rautee........ of, Washington County, mi 4 142t~ or the,4 sum of ( T. Qne-• Dollar.-•and - no1100 (1:00).._and other good end valuabl...._Ii RETURN To L _j ' o S, (✓er Lul(~ 1 rS(v'3(I 7 i D o .;.gaa egation III sf /Y1 IL) t _ Ne~J y~s1l Z the following tract of land in------ t. QrOi.X................................................ County Wisconsin: .F11-l..of..the.•.Northwest.-Quarter••-j~1WA)_••.and-N(?rth,-Half (N 2) of the Southwest Quarter (sWq) of Section Twenty-Five (25), Township Twenty'-Nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin, except Lot One of Certified Survey Map filed June 29, 1994, recorded in volume 10, Page 2782, St. Croix County Register of Deeds, as Document No. 518444. See Attached Exhibit A Parcel Identification Number i is I jI • I This is not homestead property In Witness Whereof the said grantorsL haVe...... hereunto set.......... their hands... and seals.... this day of... M...........--•-•••...................., A. D., XYL..ZQQI .....(SEAL) SIGNED AND SEALED IN PRESENCE OF ) P tSON (SEAL) StAte, of W9 Z to 2001 Washington ____County. I Personally came before me, this." day off; fp._...... A. D., { . • ~ ~ voi.lbb?PAC.?Uj ~ EXHIBIT A Parcel Identification Numbers 020-1069-70-000 020-1069-80-000 020-1069-90-000 020-1070-00-000 020-1070-10-000 020-1070-20-000 pp, r w Z ~ LO o L Cl) w _ . Illing 8 R U) WW CL wo 00 wN- ;N w ; SC1N L1.006 = ~M W 3e ~ CO) F W leis" Z 4q ~ w . ~ W o 16 ~ _ CO) ~Iu N tat t lit WW ` 1 4 r , f QL« ~LQOOf • _ 39~10,A0S 4-0 I -~i 8 g I I 1 ~ iK I I 1 1 I 1 \ • I 1 I wa 1 @I ~ 1 P; 1 Z_, 3NI I I! 1 1 1 Wisconsin Department of Commerce " - SOIL EVALUATION REPORT Page I of Division of Safety and Buildings in accordance with Comm a85, %ft Adm. Code s Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Plan must County c ro include, but not limited to: vertical and horizontal direction and Pwcd I.D. percent slope, scale or dimensions, north arrow, a to nearest road. 02 0 13 q ~ -W -Q&O Please Print au aNon. fr by Date Law~;„I5. Uri)). G~2G / l2 Q Personal information you provide may be used for ry PLPM Property Owner Pr9Pe Location ? ?001 c.~ of ,V,v 1/4 SuJ 114 S 7,T T Z Q N R E (or) 410 Property Owner's Mailing Address ST ~,a)( L Block # Subd. Name or CSM# CO Z O S-1 i wc~-I r^' ~N S e City State zip Code _ , : t4City ❑ Village Town Nearest Road ~S7i Ilw«~-cr VNA. ® New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate AVSQ l (o O O GPD ❑ Replacement Q Public or commercial - Describe- Parent material Ov fu~1a S Flood Plain elevation if It General comments S yyL er ( e- r1Gl.- n - fo P 9 / Gow a / G and recommendations: U e i e,~ 0. . d r~ --10P 9Z SO LO`'" ~2z G J 13 2 ~3 9 F Boring # Boring Pit Ground surface elev. 3.5~ Q fL Depth to limiting factor Z~ in. Soti Awk0on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PDW in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •011#2 b-~ f . I 2-n-ahk rn C- I v 5 8 Z-I ►n. L1I3 Scf c 5 ~f Ili-I~l] )c" 9~ rn5 ~3.~SUC~ Z h 5 Zy 60 Boring # Boring ® Pit Ground surface elev. 2 O ft. Depth to limiting factor ) in. Sol Rate Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. -Efr#1 'Efr#2 i C-1o b Iz Sf l 2 b k . ..rn r c---s lye )111 11S IL r\n 2- sal - 2o ~f ' Effluent #1 = BOD > 3( < 22o rng/L and TSS >30 < 150 mg/L ' Efn nt #2 = BOD 130 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number e r 25 3 3,~g Address Date Evaluation Cuxrduded Telephone Number /-rv -115) Zq 7-` o6g Property Owner Parcel ID# Page z of a Boring # ❑ Boring ® Pit Ground surlawelev gla•(9 ft. Depth to limiting factor, in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sr- Sh. *EW *Eff#2 2,-, ,csbk 4- c 5 Ij 9. W. 1/) L416 (1 b S r ~ cufy q,3, 0 r 0( ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. icxation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 Tff#2 a Boring # Boring El Pit Ground surface elev. -ft Depth fio limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Efr#1 *Eff#2 • Effluent #1 = BODE > 30 < 220 mg/L and TSS >30:5 150 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 608-266-3151 or TTY 608-2648777. SBD4330 (8.07/00) f w PAGE 3 OF~ NAME 14 y, K LOT# 3 8 LEGAL DESCRIPTION,vw '/4-caN,S 25-Tzq N R[ Q E (or) SCALE: BM 1 ELEVATION /00 C) " BM I DESCRIPTION I, e 1z Jc~ '0 e BM 2 ELEVATION g S' q s Sec•ZS BM 2 DESCRIPTION i jeo~ 1 z '(2 J c Ot SYSTEM ELEVATION +P q l•So I-ow cr 9/,pC~ x- - ALTERNATE ELEVATION + ? QZ. Sy Law e r 97• o ° I CONTOUR ELEVATION -J&,5-0, gS•SO I LLt /Zoo ~•-Qo~ lam. 1 ~ ~ ~a4 <Tll w~ g_l it m1~u SIGNATURE - DATE G - U / / X ( 7 .4 9 .6 i ' r.4 I X X I O Q / / 1 1110 \ 4t2 4 s.1 x 980.0 982.1 X X f 981.9 99 970 J# X \ X X 971. I , 981.0 9 1 x1.'Lr ; 1 1 A, x 99 X979. !i / / II SW CORNER SECTION 25