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HomeMy WebLinkAbout032-2190-01-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 605006 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Brent & Jill Mason TOWN OF SOMERSET 032-2045-60-001 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 61. L)'.1 " 12.30.19.657A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV. Septic Benchmark A,4 /CC) Alt. BM~'' i 5L C T' Aeration Bldg. Sewer -7, ue Holding St/Ht Inlet 1.-7 cr ih TANK SETBACK INFORMATION St/Ht Outlet TZ 13 i TANK TO P/L WELL BLDG. ent Air Intake ROAD Dt Inlet Septic e ) /Vf "TL > d/5 Dt Bottom Dosing I Header/Man. Aeration r" Dist. Pipe >~t Holding Bot. System q PUMP/SIPHON INFORMATION Final Grade 7• Manufacturer GPImNand St Coverer-` Model Number t / TDH Li Friction Loss System He TDH Ft Forcemain Te_~ Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width j Length f No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Li uid Depth DIMENSIONS 3 1V i'eI 'LL '~J ,}tt Ic_ SETBACK SYSTEM TO P/L BLDG WE LAKE/STREAM LEACHING Manufacturer: INFORMATION / CHAMBER OR 61 Type O~f System: 7 34; UNIT Model Number: DISTRIBUTION SYSTEM ( ywzkk Header/Manifold i( Distribution Ix Hole S le Ix Hole Spacing Vent Jo Air Intake i~ ` Pipe(s) ` LLength Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 1-) 1195 / G Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched ,L Bed/Trench Center if w l BedrTrench Edges Topsoil _7~_I ❑ s- No ~S No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1604 85TH ST, 1.) Alt BM Description 2.) Bldg sewer length = ~ f - amount of cover Plan revision Required? C Yes ;<No: Use other side for additional information. / ! ! t!✓V r SBD-6710 (R.3197) Date #Siture Cert. No. © 10 County Safety and Buildings Division St rroax 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) ~ P$• P~ Madison, WI 53707 7 IN, - Co~X e~oP~ ~E' ary Permit Application Stater a~A°n Number l /I✓1rLlI.~ In accordance with,S Q1(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary L O ' purposes in accordance with the Privacy Law, s. 15.04(1)(m , Slats. Ldp 1. Application Information - PI si-MtRrint All Information Property Owner's Name ' Parcel # Brent & Jill Mason 032-2045-60-001 Property Owner's Mailing Address Property Location Z 33y A` Govt. Lot n/a City, State Zip Code Phone Number SE y,, SW V4, Section 12 [A ~.u%.~ -L s~109 T 30 N. R 1circle oone) II. Ty a of Building (check all that apply) Lot # ( 1 or 2 Family Dwelling - Number of Bedrooms 4 n/a Subdivision Name au Block # n/a ❑ Public/Commercial - Describe Use ❑ CiTy of El State Owned - Describe Use CSM Number ❑ Village of Somerset Z n V it L.~ 4-9 C-Z ❑ Town of III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) &Q_ A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner -;az4kr%A IV. Type of POWTS System/Component/Device: Check all that apply) < on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil El Holding Tank Other Dispersal Component (explain) El Pretreatment Device (explain) V. Dis ersal/Tre ent Area Information: Design Flow (gpd Design Soil Application Rate f) Dispersal Area Required (sf) Dispersal Area Propose sf) Sys Elevation 600 .7 858 900 `.~.i .Z VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o a New Tanks Existing Tanks o PolyLock 525 U yr is. 3 0. Septic or Holding Tank 1250 Wieser 1250 xx Dosing Chamber VII. Responsibility Statement- 1, 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' Address s (Street, City, State, Zip Code) VIII. un /De artment Us, Only pproved rsapprove Permit Fee Date Issued Issuing A Signature ,tg5 • s y5 /g caner Given Reason for Denia IX. Condi asons for INsapproval 1 ' r 'r•Ie, ~tTlt:'c»: IUte* e~is~# ~ ~C.e..~„ CL~~. Ipt. p~~•~ '61-% efuui toll must all be S*Iy giros 1 t a nfti tL r ft per rrplr gameM plan pro ridea by piuiribet. 2 A#,rllre ev e ► s truAbe r.,siWir it a PW tWAGM2! 00W / CMiii1 mcf. Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Brent & Jill Mason Owner's Name: Brent & Jill Mason Owner's Address: 1604 85th street Somerset WI Legal Description: SE 1/4 SW 1/4 sec 12 T30N R19W Township: Somerset County: St Croix Subdivision Name: n/a Lot Number: n/z Parcel ID Number: 032-2045-60-001 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: Soil Test & House Plans Designer/Plumber: Countryside Plumbing License Number: 664713 Date: 05/09/2018 Phone Number (715) 246-2660 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page of Project Name: Brent & Jill Mason 2 No. of Cells 9 Per Cell 3 ft Cell width 18 Total No of EZ Fl 90 ft Cell Length 300 sq ft EISA Per Cell 3 ft Cell Spacing 50 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Infilitror Gravelless Leaching Unit Model: EZ 12031-1-10 Typical Cross Section Finished Grade 100 ft ' Observation Pipe with approved cap or vent ■<>:< Soil Backftll 2 y . Geotextile Fabric 103 ft Infiltrative Surface 12 in___ 106 n Limiting Factor AEX, . - in Slotted and Anchored Vent/ Observation Pipe with Cap Plumber/Designer Signature: Countryside Plumbing and Heating I License 664713 Date: 5/10/18 i k4a-s purl "s saiccaosR/kwucrj•Y Y Mdld lno7iViS 3SnOH . „(f h•.i 10]i'.)".':1n'!`O~`"O":1>'_3~2'~W i~~O *L.1C_'','6C~!Gi:_:I 77lr:3c ^ lsnai W3a NOSVW a° S3NOH WOlSnD NOIM30 ~ F ZZ o ° w x z o 0 Z a m w J Z W w Z o S d Y OZ W¢ O wli W ¢ Od UpC F m O x _ o Z0 m LL m¢ J w r. a 2r UiLL In °r °rN \ \ \ m¢ Z O O w E Z o o I - - a \ \ b Qm 3 3omooo / N SS \ W W y ~ Q O > O U d Q N z W 2 o X® 6 0 G 2 O = I I \ ¢ m O ' \ W ¢ _ ¢ ! w E + m~ o LU W W % LLJ \ g<o -orf i \ SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page_of Project Name: Brent & Jill Mason 2 No. of Cells 9 Per Cell 3 t Cell Width 18 Total No of EZ Flow 90 tt Cell Length 300 sq ft EISA Per Cell 3 it Cell Spacing 50 sq ft Total EISA Manufacturer Model Laying Length EISA Rahn Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Infllitror Gravelless Leaching Unit Model: EZ 12031-1-10 Typical Cross Section Finished Grade 100 ft Observation Pipe with approved cap or vent Soil Backfill Geotextile Fabric 103 ft Infiltrative Surface 12 in 0 Jy6 ft Limiting Factor in Slotted and Anchored Vent/ Observation Pipe with Cap ■■■■■ars ■r aa■■■■r■■■■■~~!i■r■rr■■■■r u■■r■■■■■■■r■r■■■r■■■■rr■rra■rr u■■■ Plumber/Designer Signature: Countryside Plumbing and Heating License 664713 Date: 5/10/18 '0X Inc. PI)LYAk Innovations in Precast, Drainage "I Zabel' PL-525 Effluent Filter & Wastewater Products A Division of Polylok Inc. PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: 1/16" Filtration Slots Alarm Switch • Rated for 10,000 GPD (gallons per day). (10,000 GPD (optional) • 525 linear feet of 1/16" filtration. Accepts 1" PVC • Accepts 4" and 6" SCHD 40 pipe. Extension Handle • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. R 10,000 ated Gfor PD • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 525 Linear Ft. 10,000 gallons per day (GPD). of 1/16" Filtration Slots 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" 3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. Certified to 5. Replace and secure the septic tank cover. NSF/ANSI Standard 46 PL-525 Maintenance: w The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring t cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter Gas Deflector needs servicing. Servicing should be done by a certified I septic tank pumper or installer. VAut.matic 1. Locate the outlet of the septic tank. Shut-Off Ball 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. j ' 5. Hose off filter over the septic tank. Make sure all r„~r r a solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making . sure the filter is properly aligned and completely inserted. I Outdoor SmartFilterC Alarm Extend & LokTM Polylok, Zabel & Best filters accept Easily installs 7. Replace and secure septic tank cover. the SmartFilter® switch and alarm. into existing tanks. 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N 1 I I o w ^r+ U N Q H W z Z ~ W Q 98 ciiano38 Sd V) Y Z Q H POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Brent & Jill Mason Septic al Tank Capacity / 0 ❑ NA Permit # Septic Tank Manufacturer Wieser ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Pol lock 525 ❑ NA Number of Bedrooms 4 ❑ NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units Q NA Pump Tank Capacity al qNA Estimated flow (average) 600 gal/day Pump Tank Manufacturer Ia NA Design flow (peak), (Estimated x 1.5) $5$ al/day Pump Manufacturer qNA i Soil Application Rate 7 al/day /ft2 Pump Model q NA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit CkNA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODs) 5220 mg/L IX NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) D(NA Biochemical Oxygen Demand (BOD6) 530 mg/L In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L a NA At-Grade ❑ Mound Fecal Coliform (geometric mean) 510" cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ye in dia. Q NA Other: ❑ NA Other: Q 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: 3 ~ ❑ month( yearlsr(s) ► (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) 3 tB year(s) (Maximum 3 years) El NA ❑ month(s) Clean effluent filter At least once every: 1.1 ❑cyear(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: 11 month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ 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 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. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Brent & Jill Mason Mailing Addres N4t-.1 '5S 10 1 Pro ertAddres's 1804 85th street p y _ (Verification required from Plannin & Zoning Department for new construction.) City/State Somerset Parcel Identification Number 032`2045"50-001 LEGAL DESCRIPTION Property Location SE 1/4 , SW IA , Sec. 12 , T 30 N R 19 VII, Town of Somerset Subdivision Plat: N/A , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # '01' 3~Z'G (before 2007)Volume , Page # Spec house Oyes lno Lot lines identifiable 0+ yesono 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 §SPS, 383.52(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. I/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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification staring that our septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department wi m 30 days of the three year expiration date. I/we certify that all statements n 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 warranty deed recorded in Register of Deeds Office. Number edrooms 4 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. 04/12) Page Z of 7/ 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 63.33, 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: ~c 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. dflaul a o ing tank T alua ' be' a failed . ?R Dv 115 TIC V.-D~ A!$w ~'ArVSTRt1G?l0 ❑ 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 Countryside Plumbing & Heating Name Countryside Plumbing % Heating Phone 715-246-2660 Phone 715-246-2660 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Powers Name sue(-', C l V N ~D~t Phone 715-246-5738 Phone 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. ftrltllil II III II1 E(( I(1I~t#!Il1t1f ICI _ DOCUMENT NO. STATE BAR OF WISCONSIN FojW 11 ft{ E I f~ tfAflEfl , Ifl WARPANTX VELD 0 4 1 7 t 3 0 Tx:4350035 THIS DEED, made betweea'Michael D..Flandrick, a married person 1041320 VG.rantoel whether one or more) conveys and warra»ts.to. BreatC. MasBETF1 PABST lff M. Mason, husband a»d wife, survivorship marital property (`GranteREGISTER OF DEED S whedhes ont or more), the following aesmbcd.mW estate in ST CRU1X ST. _CROIX CO,; Wt State-of Wisconsin: 01/03/2817 20:37 AM. The SE% of the SW34 of. Section 12, Township 30 North, Range.19 Wegt !n the RECFFE: 30.00 C .FEE: Town of Somtrset, St. Croix Coux4yViscoutin EXCEPT part to Certified Survey Map Cited In .Vol. 26 of C.S M~. ~ 61110 as Document Number TRANS FEE: 651.00 1010262. PAGES: 1 [New TURN TO Alf A Croix County Abstract: & Title Co. Inc. M'ifhaei Ftanciyl_V. . S..KnawfnAvenue Richmwud, WI 5401:7 This is not homestead property Exception to warnntits:.easements, restrictions and covenants of rt cord; highway and kmef rightsof war.. and Municipal and zoning ordiriancs.an agreemeuis entered under. theta; and furtttcr except real estate tax". accruing in thc.year of tbis.conveyance. Dated this 34th day of December 2016. P Ichae! 1?. Elandric c" AUTHENTICATION ACKNOWLEDGMENT Signatures authenticAted this day of STATE OF WISCONSIN 20 . ss. COUNTY OF ST_ CROIX TITLE: MEMBER_STATEBAR OF WISCONSIN (if not, FctsoiWly carne before me this 30th day of December, 2016, the aufhorizcil b 706.06; Wis. Scats.). above named Michael D. FiandrIck, it married person to me y known to be the.person(sj who executed the foregoing. instrument and;acamowledge the same, THIS INSTRUMENT WAS DRAFTED BY Robert L. LoberR / 1. oberp Law Office Lt, e . 1'12. ` v 1 y 1630967 / !tn Not.. public S.t. Croix:: County, ft. ! t My Commission.is permanent. (If not, state exp' (Signatrrec may be authenticated or acknowledged. Both are a f~ not necessary) ) a •t✓cr C.•~'Okd`p' "TAIR `Names of txisoas.si(nitng In atry ap~iity diouid ba 7pod arptiotcd Detow their tt¢iututel. , ~ ~ , . ~ WARRANTY DEED • _,,.id.._.~tdiw7~io..!-zoos t i t I t ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Brent J11[ Mason Owner/Buyer Mailing Addres _ ' - V-1 r t c.s 'a °~d 3 NA 4-1 t 09 Property Address 604 5th street (Verification required from Plannin & Zoning Department for new construction.) City/State Somerset Parcel Identification Number ®32-2045-60-®®1 LEGAL DESCRIPTION: Property Location 1/4 . 114 Sec. 1 2 , T 30 N R W, Town of Somerset Subdivision Plat: N!A Lot Certified Survey Map # Volume Page # Warranty Deed # (before 2007)Volume , Page # Spec house DyesE3no Lot lines identifiable[D yes❑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 stag: in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(l) 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. I/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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that our septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department wi in 30 days of the three year expiration date. Vwe certify that at; statcments ri this form are true to the best of my/our knowledge. I/we ani/are the owner(s) of the property described above, by virtue ofp warranty deed recorded in Register of Deeds Office, v Number edr•ooms 4/1 e I;e A-4 SIGNATURE OF APPLICANT(S) DATE w"Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department, KY° 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. 04/12) Wis. Dept. of Safety rand Pt6fessional Services SOIL EVALU/ - Page 1 of 2 Division of Safety and Buildmg.i !~a Y in accordance with SPS 385, Wis. Adm. Code County ST CROIX 30 1~• 7~ :F. AttatskWW i~lA e plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 032-2045-60-001 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by 2/5"h Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location MICHAEL FLANDRICK Govt. Lot SE 1/4 S 114 S 2T 30N R 19E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or SM# 1823 WINDING TRL RD 26-6100 City State Zip Code Phone Number ity ❑village ■ own Nearest Road NEW RICHMOND WI 54017 ( ) NA SOMERSET 7 L-! 71.1 S f, e r New Construction User Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: Parent material OUTWASH Flood Plain elevation if applicable NA ft. General comments GOOD FOR CONVENTIONAL NICE SAND and recommendations: Zd FT] ❑ Boring Boring # gq+ El Pit Ground surface elev. LI ~ LS ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 1 0-14 5YR3/1 SCL 2mbk mfr CS 217 0.4 0.6 2 14-24 7.5YR 5/6 COS -m- mfr gs 0.7 1.6 3 24-89 7.5YR 6/6 S -m- mfl• 0.7 1.6 rc / Z~ Boring # ~ Boring 79+ Pit Ground surface elev. L! 1 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 1 0-16 5YR 311 SCL 2mbk mfr CS 2f 0.4 0.6 2 16-28 7.5YR 5/6 COS -m- mfr gs 0.7 1.6 3 28-78 7.5YR 6/6 S -m- mfr 0.7 1.6 Z tf ~2 . * Effluent #1 = BOD > 30:< 220 mg/L and TSS >30 < 150 mg/L * E ent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature.- CST Number PETER ERICKSON1293207 Address Date Evaluation Conducted Telephone Number 1291170TH STREET ST CRIOX FALLS W154024 952-261-1100 SBD-8330 (R71 /11) Property Owner MICHAEL FLANDRICK Parcel ID # 032-2045-60-001 Page 2 of 2 Boring # Boring 94+ 0 pit Ground surface elev. (1 i : ~ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 1 0-14 5YR 3/1 SCL 2mbk mfr cs 2f 0.4 0.6 2 14-29 7.5YR 5/6 COS -m- mfr as 0.7 1.6 3 29-94 7.5YR 6/6 S -fit- mfr 0.7 1.6 I ❑ Boring # 4_I Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F-1 Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 *Ifff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD s < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330'1w (RI 1/11) +ca IV, on C~D 04 3 4 1 ` Fdytey.„~t a .,o Y"'i♦ i 't. e z ~ .4?R' ..cF c x 't 40 i { d g~.~ 3 S i r c w *)to ^ ~s rat t , 'A"D Q "Milk L r , bra w,' , l O Uf) / b I ~ J t~ s J ~ f s r s r t f tA„B .I ~l 7f~ O W ~ r~ ~ o C v+ a' C