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020-1374-04-000
Wisc, nsif Depa+tment of Commerce Count PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 499299 0 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 X Township Parcel Tax No: Storch, Edward & Sarah Hudson, Town of 020- 1374 -04 -000 CST BM Elev: Insp. BM Elev: BM i Description: Section/Town /Range /Map No: l Cam' O / 61 p m 12.29.20.2237 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchm - 7. o5 /o ?. /00.0 Dosing Alt. Aeration Bldg. Sewer St/ t Inlet Holding / o TANK SETBACK INFORMATION S Ht Outl O TANK TO P/L WEB BLDG. Vent to Air Intake ROAD Dt Inlet Septic > � ) J /2, Dt Bottom Dosing �/ Header /Man. g Aeration / Dist. Pipe Holding _ Bot. System 73 gU - - - -- / 1 3 Final Gr d e G c, PUMP /SIPHON INFORMATION iw�Q S S i% y Manufacturer Demand St Cov p �+� -7 6 Model Num TDH Lift Frictio s em Head TDH Ft G f 1u d Forcemain Length Dia. SOIL ABSORPTION SYSTEM j BEDITRENCH Width / Length INo. Of;renches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREA LEACHING Man INFORMATION CHAMBE R Yt Tr Type ystem: r IT 1 12 Model Number: >iOb 1 DISTRIBUTION SYSTEM Header /Manif Id Distribution / x Hole Size x Hole Spa t to it Intake l f 7 9 + Pi �_ S / Length Di Length Dia Spacing ��f SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only a, zro Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed /Trench Edges Topsoil Yes No Yes rt No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1:__ Inspection #2: Location: 196 Stan Hudson, WI 54016 (NE 1/4 SW 1/4 12 T29N R20W) Starr Wood Lot 4TH Parcel No: 12.29.20.2237 1.) Alt BM Description = O �'CC✓n 2.) Bldg sewer length = 12 r SG/-' q9 - amount of cover = > 3 t L1,7 _A4V,V_J_r f vv"ry � Plan revision Required? Yes �� c Use other side for additional information. Z;; Date 4sepctorr gnature Cert. No. SBD -6710 (R.3/97) cortlfYmGPce Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 f , 1 Q co n s / n Madison, WI 537 162 Sanitary Permits Number (to be filled in by Co.) QqaZx Department of Comma ■ roe ■ g / z7 c l Sanitary Permit Application to Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate I AA unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are roject Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary , J1y6 .f}�q/?/t p urposes in accordance with the Privacy Law, s. 15.04(i)(m ), Stats. 1. Application Information - Please Print AUrW formation D� Property Owner's Name f Parcel # _ A r RECEIVED n _ _ Property Owner's Mailing Address Property Location / Z MAR 0 5 7.007 t Govt. Lot City, State Zip Code Phone Number ��_ y. _r k/ y., Section T. CROIX COUNTY (circle o % — T AY N; R _96 Eo4W 11. Type of Budding (check all that apply) 19'1 or 2 Family Dwethng- Numberof Bedrooms Subdivision Nam OTC Gb Stll i ock # , ., El Public /Commercial - Describe Use At�9iZ tti_ ❑ Ciry of ❑State Owned - Describe Use CSM Number ❑ Village of 8` / f' 1!5 44C ®Town of � /n_rn../ Ill. Type of Permit: (Checli only one box on line A. Complete line B if applicable) A • ® New System p y g p Y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explaModification B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 1/I IV. Type of POWTS S stem /Com onent/Device: Check all that appl ® Non - Pressurized In -Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVrreatment Area Information: YLI ca4. Design Flow (gpd) Design Soil Applicatio ate(gpdst) Dispersal Area Required (sf) / Dispersal Area Proposed (s System Ele tion ,6 0 cps? / y ,/ 191?- RO Vt. Tank Info Capacity in Total # of Manufacturer y Gallons Gallons Units � v New Tanks Existing Tanks c a iz A v,t7 a Septic or Holding Tank Aso s o /✓G _ 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 ignature MP /MPRS Number Business Phone Number 2 - ? Plumber' Address (Street, City, State, Zip Code) .r N. S V11I. nt /De artment Use Onl Approved isappro Permit Fee Date !s ued Issuing nt Signature Ow iven Reaso rDenial ne 5D 3 IX. Conditis .easons for Disapproval 1. Septic tank, effluent filter and dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All $90mck requirements must be maintained DWIQSn= Attach to complete plans for the system and submit to the County only on paper not less than 8 ra x I] inches in size SBD -6398 (R. 01/07) Valid thru 01/09 ZAM *PAW Y OVCA /sv To /f/oitrN 15L rY 4z•v 1NrT •. - E • 'OECK P rCT WE.S7 �/tOioE/�'Y LZivE !�"aEQ4o0°7 ,?A=O&VCE awu46E Zo �s' y Svc JrOwFa /�/toPaaEo l✓ c. TAMX tAOW • , � F.ASr J�r�'Y Lr� y EfFL�E Z rAdr • E' � ?0 /oo' /�ito�rn GLrsP�ua� �4�tEyv – -- _ - -- - -. _ .- _ 6s W +1 X8 10 0 �'TiOI?R w000 A-V Id I'M f ��� P1 0 �/Y G.4rx TjLEE _ .Fot.�79r / /1/ .SCA ?aZC K %' ,J Tit 4 (..I PVIWIW/! v� GvP -- �s�■r� u OBSfPi/ATZav���En�.hACkTO T,6?I�.oTE /d�iPLPovE CaZvDE FinatsN `�ZvOf ti —z– DATE: �T o7 rivxr���r 96 ' Co vER �1 Pvc J'NEL fo /°�E --• bt' _ — 4V _._....._. •qL TdSTl1�N iY: tEPPECIIVE �iN6T11) r .02© awe vw w .ELE rAXrviv /JER Multiport End Cap fpor� wavy v Sari 7Err copv e r 1 _ _. I ..Z�YF.,ILTi�TGV2 .jxsr�il sivc • ..P SeCTION PLANS PLOT & §WA1f 111�iA Wo OVER /SO ' To MoArlle / "itvPE,CrY .LINE 1!Idi1rMM1O UNT .DECK pfwj T /oi4.ao -- - ..S'C/iEEivF4 /�'ortcfr ' WEST i$tOmlw Zz vB • I . tsr S.CLKad+7 11f�ENCE LWti9GE yaio GAL. k4axFAJ 7AVW 49W 2AAOW. A - f?oo dUhAr AA40 XA AAr AAA" • t f y - &Sr AMIVY &Ae- y Ac EZrzwr. w Ls �imoar�o BOO � .�Roi►I &UAL. eftOf — - - -- - - - ... N . 'k , , �i1o� ,diet• ✓ E`rA Y " w E ,ai LO sr tilboO AV. S .(QA1 J'PZkE.Zi✓lY�ovr� 7/LEE . Q usC I< 4' Tn4o C iW "4M - Q,d"Apl#i9TioN raw ...... Wwr G40 uMNU: D.QSF� ✓Al2ui✓��En7..hACa To T,�i�OT,t /d �To►� C�OE FsivZSN C�Zvor' -- x-. DATE: /7.4xz�r.�► 96 " Co vER * Avc lrwez yo /fie — w �EPFkC11 E tino�T►+� Oft TUTMN BY: ST `a• AIL > vwEw rlgzyCN .riov� .ELE V.grsviv /Jr'R Sarc 7Err M End Cap Iw voiw I � � c r i .Iiv�xtrn.•vra2 ,1"rsr�r, ..Iiv r Wiscon ' Department of Commerce Di viaiorpof Safety and Buildings SOIL AND SITE EVALUATION Page / of ,, Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code I _ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and C i percent slope, scale or dimensions, north arrow, and loc distance to nearest road. Parcel I. D. # 02 0 APPLICANT INFORMATION - Ples grant all for �Qn� , Rev we y Date Personal information you provide may be used fo ary pule y Law X15: (1) (m)). t Property Owner roperty Location govt. Lot 141C 1/ ,,)1/4,S t'Z TZ� ,N,R E (or) W Property Owner's Mai mg Address L vRO; Block# I Subd. Name or CSM# City State Zip Cod e Phone Nu er Nearest Road ((, I" ❑City ��Il W Town �T New Construction Use: ® Residential / Number of bedrooms -� Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow 46 0 gpd Recommended design loading rate 40 1 2 bed, gpd/ft ©, cL trench, gpd /ftz Absorption area required <RS'aO bed, ft 7SO trench, ft Maximum design loading rate a ; bed, gpd /ft D_ �L trench, gpd/ft Recommended infiltration surface elevation(s) 9 2 9a ft (as referred to site plan benchmark) Additional design /site considerations VA n r /per h60 E 7-0 = A PPi' a y - 11 - Parent material a i_A<_i Az_ / T L-L Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U K S El W s El CX S❑ U S❑ U El S U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 16v zh L l m c'r cs 6.9:6 Ground Depth to limiting factor 7 in. Remarks: Boring # 6-1�; MN IQ i — L l i-n <r �Ground 1 7 , e1 ft. Depth to limiting r ? in. Remarks: CST N me (Please Print) i nature Telephone No. �y Ja�Nsoky A ro �X�x G t rl L1 �SaiJ S� l _ `_,,Date C ST Z zz S7 i SOIL DESCRIPTION REPORT -2 1 PROPERTY OWNER Page df 3 " " PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench A 6-7 f Ob23 / — L 1 A c Al cS 0 A:6 Ground v Lft. >o S6 rn-� /lit Depth to limiting r �! 4in. Remarks: Boring # 5 o�� 4 3 -- SG rns rn cs ,'7 63 02 Q Ground -O /6� 3 "' 5 G in S /►'! ;7 ;6 elev. / OO�ft. Depth to limiting fr 9 � in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Boring # /Q -S 16 VP �- m t - /h C 5 o A b, 7 iA k4 M:5 M I cs Ground Jr� "" Depth to limiting factor > in. Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) nn f'&L S�eF I �D r rJo�u -C� I � X IV a g 3 FL(v - 919 AO -5 ELCV 166 - BEn) -Sflrc� �N nol , gENGur , w�,ti. S,�� �N Iq�o�K C L.E J - 91E. 3� LE T C&k. L —s �nvv Parcel #: 020 - 1374 -04 -000 01/12/2005 08:17 AM PAGE 1 OF 1 Alt. Parcel #: 12.29.20.2237 020 - TOWN OF HUDSON Current 1X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): ' = Current Owner ERICKSON, DEAN M TRUST DEAN M TRUST ERICKSON 1221 MCKINLEY DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 196 STARR WOOD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.609 Plat: 2506 - STARR WOOD LOTS 1/25'00 SEC 12 T29N R20W PT NE SW STARR WOOD LOT Block/Condo Bldg: LOT 04 4 1.609AC Tract(s): (Sec- Twn -Rng 401/4 1601/4) 12- 29N -20W NE SW Notes: Parcel History: Date Doc # Vol /Page Type 09/13/2002 690200 1975/266 WD 09/13/2002 690199 1975/265 WD 09/13/2000 629835 1542/324 WD 08/18/2000 628460 8/5 PLAT 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 50136 193,900 Valuations Last Changed: 10/30/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.609 150,000 0 150,000 NO I � Totals for 2004: General Property 1.609 150,000 0 150,000 Woodland 0.000 0 0 Totals for 2003: General Property 1.609 150,000 0 150,000 Woodland 0.000 0 0 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1 FROM :Zappa Brothers Inc. FAX NO. :715- 386 -0323 Mar. 06 2007 09:30AM P1 Wisconsin Department of Commerce SOIL AND SITE EVALUATION 649on OPS46W and Buildings P u lp. of 1 < �f eroo serik� in•a=ordariw with Comm 83.09, Wis. Adm. Come AaekAbomolete site plop dn paper not low ntnan 8 418 x 11 inches in sae. Plan must raw include, but not limited to: vertical and hoiizornal reference point (BMA, direction and i x percent W.". sraie,or dimensono, nom wrow� and location and distance -to hearast road. Parcel I.d: 8 OPP AN_T INF�RIVAATIQN: P.Ar�a�a.R.a�[Jetlo�enat>�.:.. _. _ . _ _ ay , = . Pwmmal mkanwm You pnNW@ may be uaad forsaonndwy purposes (P&WY Law a. IS.oa (1) (m))• Tj �/D pal", 11AW rppetty Locatiorq i J a xZ'i Govt. Lot 1 411/4 / T11 ,N,R Zd E (or) w , gPei+ V 0 W TYW W .1teg:A 1100. Blod►* $ubd;:Nsma f39Md ... � _9tif4 a Code Phone Number Nearest fload p ❑ City 13 village Town 3 ,� (,Ci /�uaScb✓ � }� . r.V .4. +Yl.► - w4T.�•►•h- +� -- . .M1.�- .+f +.�. Y L ._ \.:L V � w - • },i _ •.� New Construction Use- ® Relsfdential / Number of bedrooms _ Addition to existing building Replacement 0 Public or commercial - Describe: Code derived dally flow ! d.2 gpd Recommwnded design loading rate A2—jwd, gpd0* A F . health. 9Pi* Abeor nlonarea required t ed, e ° trer ,. ft Maxltewm designing rate .t ea: ePd+r��a�B�. '• .. f •...- P,..,. -.. i Recommended infiltration surface elevation(s) rt ( as referred to si te plat benchmark) Addfioner desigrdsite conslderatiarrs EV* L (i A 7'I p �L &8 jr lVLOA JR A e f vw. 4L Pareni inaterlatl' L LAG 1 'L Flood plain elution, it appliicawe biA $ • ; Conventional . Mound . In- C3round Pressure AT -Grade System in RM HOW* TW* u Unsuizable for system �Q s 0 u 14 O u U s Q u M s (O u Xs 0 u U SOIL DESCRIPTIONtREPORT Boring # Horizon Depth Dominant Color Monies Texture ire CPnsisw" Boundary Roots GPDKA in_ Munseil Du, Sz Cont Color or. 6z. Sh. Bed Y Trench Amle Gs 01:0 - WT l y ev Depth to limiting I .�..i :• i.. .�s1Aa,�u °r "�'�!�i ^ Boring # th -z G fa t • 4 �- ( ms J'l+l S it : • ; � . rns MT J Grote n. - • . _ ►p,. Remarks: { CST • . (Please pmo . 1 nature Telephone No. r A&CY SauA - r*4 v � o O Z /�_/�/`Date CST�umbe�' FROM :Zappa Brothers Inc. FAX NO. :715- 386 -0323 Mar. 06 2007 09:31AM P2 SOIL, DESCRIPTION REPORT PRIOPERTY.OWNEFI -- ' PARCEL 1.0. tt ' Boring # Horizon Depth DortdnantCob" Mottles Texture Structure Conaiatsixe ft urwary Rood in. Munsall 0u. sz. Cant Color Or, Sz. 3h. Bed . Trench s - 3Z SG Grgtand -S .S S�r n+S es - :o:St O 3- .� ! 64 rh5 M 7 p .� I Depth to t limiting oor n. R �. Jdorin9. iavk 03 •• 5 • Z rA� � �4 rns � cs .� dg. Ground S o�rt f Depth 03 limithlg l i in. Remarks: Horizon Depth Dominant Color Mottles Texture lure Consistance , Boundary Roots GPD/ftz in.. Muneell au. Sz. Cont. Color Car- Sz. Sh. Bed . T"etwh ! E3oring - /� -- t r M e5 m 5 m Cs. 1 04`7 o.g ; t rd t 6 ms 6 .7 t� Ground 54 Depth to limiting � factorr "' Remarks: Boring # } Ground ' slay, Depth to limiting factor --J "' Remarks: OWN fte— ti FROM :Zappa Brothers Inc. FAX NO. :715 -386 -0323 Mar. 06 2007 09:31AM P3 f i > Poz.£. a� 3 L° y J QR!rU / E LSV - 'SLa LE Eav - 97 9 qq . 1O E' gA F-Lry -106.7 ELC V- � 9 ao� . �Ena�nn+�YLK �+.► Dbl� o Lut %%wkC V • S,rm► 4p r i N / O &LEJ $EN S�- ac, °x.. '+;� ..+u�.b >,- .. ��•�� s r�."k -.�. ... ., a �,�.. .. , r n , 3 J ; - r '?as 2d1. iF � 44 r, W12WWWO wclaw FOR ftlE*.,1XE9a+ld9 NllthlS.. t00Y1eaSt i , OUTLOT 1 +�fh fiJrtilYi L4N /, R �r P r F. -1 j iIRt�1AgMIEf10IDIF9�lr8UTp � l F �...V �CAYJFA 1� KNFF�@'8Ai7 ,x, k j I.— 'r�sa.sr��eorrw:rr��rvaanr � l .xtua.rEnwe +rrC ucTb is iswt3r� r 5 7 sl OfdfiOT2 V � S E 6 M " �aee 2 K i9re� kaev yi "cei ' Omq 7 f i N ^ MJ�SW�7f� eY0b74t � erJ s 9d^usa f 1( r f �ateer `+,' - �� � `�' � ° � � � Q e;, ^1 Y'� ......rte � ••'-.°-`,!�.. ` � . g "' �. A id3a191�AplR G / R y vavmtr xra�rFapesocaPr+artvi -+,N � \ � e ✓ aaNKawan ry,{ � w'A�;:rl � r s'i ,, & rwmt' .'� +awn •- "'� j i t jj J� y q r 22 ' nrtWer Ago iatrf� � ow VMS lo � asn QFl W11f i Fsg •�.� � � r ��r . r TM'4y +�k � k P � p f , 1 �- gr k C `� +ate" L to $'A 8R v wM a F { � d: yl Ea 0 � ,n C14 (N o i I Js LE II4W2 N ` \ N ' :4k / I -4k. O � ~ X 11 J 1 �� W n 1 g6n . OZ2� � 0 \•`\ q pZ \\ 1.)-WZ \ O s IL I i a h ph,qi ? �.. W m a a eA I UU "` a W a a,riai ` � J On. '\ Q Z v. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page —/— of FILE INFORMATION SYSTEM SPECIFICATIONS Owner — - Septic Tank Capacity a l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 1,9 p ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal ® NA Estimated flow (average) pJ al /day Pump Tank Manufacturer ® NA Design flow (peak), (Estimated x 1.5) 0 � al /day Pump Manufacturer ® NA Soil Application Rate al /day/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 (BOD 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 (BOD 530 mg /L ® In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA other: ® NA Other: 10 NA Other: ® NA * Values typical for domestic wastewater and septic tank effluent. Other: IN NA MAINTENANCE SCHEDULE Service Event Service Frequency q Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA GC IN year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: ® year(s) ❑ month(s) ❑ NA Clean effluent filter At least once every: ® year(s) ❑ month(s) IN NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ® NA Flush laterals and pressure test At least once every: ❑ year(s) ❑ month(s) ® NA Other: At least once every: ❑ 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 (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 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. GMW (4/01) i 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; de ntal floss; diapers; p , 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 04 ) Name T _ o Phone '?& _ Phone - _ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Zz i z Name Phone _ O Phone This document was drafted in compliance with chapter Comm 83.22(2)lb)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 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 _ c G Name Z - i✓ v Phone �ds� _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name T /iz _ _ Name Phone v rve _ Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411►, (2) & (3), Wisconsin Administrative Code. I/ 84528 HATHLEEH H. WALSH State Bar of Wisconsin Form 7 -2003 REGISTER OF DEEDS ST. CROI?I CO.. MI TRUSTEE'S DEED RECEIVED FOR RECORD Document Number Document Name 02/23/2007 09:30A11 TRUSTEES DEED EXOPT # THIS DEED, made between Steven E. Erickson as Trustee of Dean M. Erickson Irrevocable Trust TRANS FEE: 11.00 TRA FEE: 824.70 ("Grantor," whether one or more), COPY FEE: and Edward A. Storch and Sarah J. Storch, husband and wife CC FEE: PAGES: 1 ("Grantee," whether one or more). Grantor conveys to Grantee, without warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in Recording Area St. Croix County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Name and Return Address River Valley Abstract & Tide 1200 Hosford Street, Suite 201 Lot 4, Plat of Starr Wood in the Town of Hudson, St. Croix County, Wisconsin Hudson, WI 5016 File Number 2693155 020- 137 4-04 -000 Parcel Identification Number (PIN) Dated February of 2007 (SEAL ) (SEAL) * * Steven E. Erickson - Trustee (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signatures) STATE OF WISCONSIN ) authenticateQltA ) )Ss. INUU II St. Croix COUNTY ) * Personally came befor on February �� , 2007 TITLE: MEMBER STATE BAR OF WISCONSIN the above (If not, to known to a the pe ) who executed the foregoing authorized by Wis. Stat. § 706.06) i ment a ackno the same. THIS INSTRUMENT DRAFTED BY: * No ..Public, State of Wisconsin M Commission (is permanent) (expires: �' ��'' ) (Signatures may be authenticated aclmo�vled=ed. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIF ATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. TRUSTEE'S DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 7-2003 Type name below signatures. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address /9 / f zi �y� Property Address (Verification required from Planning Department for new construction.) City /State tJGIcS Parcel Identification Number 37`"f LEGAL DESCRIPTION Property Location S ' /a , Sec. 12 , T _;�_JN R 2 O W, Town of t G1 6�1✓ Subdivision , -a {r r Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # S2 6 ] , Volume , Page # Spec house ❑ yes ® no Lot lines identifiable byes ❑ no SYSTEM MAINTENANCE 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 County 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. 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 Pp,partment within 30 days of the three year expiration date. SIGNAT OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the gerty desc ' ed above, by virtue of a warranty deed recorded in Register of Deeds Office. V\ 6 � / a�l,1_9 2 SIGN URE OF APPLICANT DATE * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed.