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' t� + + a a p - I — - I 11 , ���'�Zt''a e� sro � s a �_., �" �. � z_ 11 s � u „+ r �; , . p a,< s r ,.c, t•x F U, t. =� ' a E € x, A sK , ,� m r p 'V- 3 s - x.. � t 1 PE `Iti 7 c t r l � C i I, } r� fti' 'x,�y „ , a - '. . l X� . - PROPOSAL Wang Excavating, Inc. Proposal No. Thomas Wang, Owner � W9672 770th Ave (� Sheet No. River Falls, WI 54022 715- 425 -9958; Fax No. 715 - 425 -5344 MPRS 3231 Date: PROPOSAL SUBMITTED TO WORK TO BE PREFORMED AT-- f Street r city State Date of plans Architect Telephone Number , Fax Number We hereby propose to fumish all the labor necessary for the completion of r r - " The above work to be completed in a substantial workmanlike manner for the sum of $ with payments to be made as follows: This estimate is for completing the job as described above. It is based on our evaluation and does not include material price increases or additional labor and materials which may be required Respectfully Submitted should unforeseen problems or adverse weather conditions arise after the work has started. Any alteration or deviation from above specifications involving extra costs will be executed upon request and will become an extra charge over and above the estimate. Per ^ - NOTE- This proposal may be withdrawn by us if not accepted within days. ----------------------- - ----------------------------------------------------- ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. w, i Accepted Signature Date r Signature r Wisconsin of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 514885 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)]. Permit Holder's Name: City Village X Township Parcel Tax No: Knox, Michael J. I Kinnickinnic, Town of 022 - 1060 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: i 0 1 /vD - p (�o?l(�h 21.28.18.P329B TANK INFORMATION ELEV TION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. p / OD Oaa Se �` �` 1664 ? Benchmark W; c , �^ 100 b$ Alt. d Z . d 7 Q Aeration Bldg. Sewe Dwv a &tQ / SUHt Inlet i/ St/Ht Outlet TANK SETBACK INFORMATION TANK TO WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / t t / Dt Bottom c 1/ , 3 / / , /L3 I 5'7 Header /Man. 2 15 97 25 Aeration Dist. Pipe 2.15 417 -15 Holding B t. Syst m a 2. 7 1 ' D PUMP /SIPHON INFORMATION Final Grade 1116 Manufacturer Demand St Cover q GPM , 2 Model Number TDH L , u Fricti Syste ei5 TDH Ft Forcemain / Length / Dia. Z // Dist. to Well , 7 �Z3 SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length ` / No. Of pth DIMENSIONS a 7 J V1z— Sf \ SETBACK SYSTEM TO P/L BLDG WELL INFORMATION ( / n Ty e Of System: ( / � � Z� ' .na�CV V rJ G OOOU ( Z 1 �1Z 2 �- DISTRIBUTION SYSTEM � - , p, or , / J Header /Manifold Distribution �i V (Jd wit` �ntke Pipe(s) 5 \ L _ Length � Dia Z Spacing ` SOIL COVER x Pressure Systems Only xx Mot Depth Over Depth Over xx Dept Bed /Trench Center / O Bed/Trench Edges Topsoil Yes E] No U COMMENTS: (Include code discrepencies, persons present, etc.)'�I� Location: 1134 River Drive River Falls, WI 54022 (NE 114 SW 1/4 21 28N R16 / � 18.P329B P o t / cc. a� � ~ 1.) Alt BM Description = �`^� if6d _ �,�,��4 � 2.) Bldg sewer length - amount of cover - J v i�l2T,tlG- S a Use other l side for additional information. No I � L - .1 � I I fS ignature ,J SBD -6710 (R.3/97) Date Insepct Cert. No. CommerCe.Wi.gov Safety and Buildings Divis Counry ,, ' ,rg w 201 W. Washington Ave., P.O. 162 ro 1 )c Q C '! 1 n Q' n Madison, WI 5370 7162 Sanitary Permit Number (to be filled in by Co.) I t iepartmeryt VV of Commerce N 1 Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate gove enta X r 0 � O unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POW are Project Address (if different than mailing address) n t submitted to the Department of Commerce. Personal information you provide may be used for secon p urposes in accordance with the Privacy Law, s. I5.04(1)(m), Stats. . J � 1. Application Information - Please Print All Informatio Property Own - a e Parcel # e le Avdx C�9D -- eta0 -41 "dm Property Owner's Mailing Address Property Location / Z� Govt. Lot City. S `te Zip Code Ph FFICE � ' /., S W v., Section tJ P r w ) circle one G T _N; RE Ill. Type of Building (check all that apply) of # Subdivision Name �[ t nr 2_F�mit; T) walling _, Nnnlher of RPdmnms Block # ❑ Public /Commercial - Describe Use ❑ City of ❑State Owned - Describe Use � - )� CSM Number ❑ Village of Town of l/A n 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System g p y g Y (explain) ❑ TreatmentlHoldin Tank Replacement Onl Other Modification to Existing System y B. ❑Permit Renewal El Permit Revision ❑Change of Plumber ❑ List Previous Permit Number and Date Issued Permit Transfer to New � Before Expiration Owner IV. Type of POWTS Svstem /Com onent/Device: Check all that apply) �' ❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground 'R At -Grade ❑ Mound? 24 in. of suitable soil ❑ Mound < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rat (gpdst) Dispersal Area Required (� f) Dispersal Area Pro (st) System Elevation � � 0 Vl. Tank Info Capacity in Total # of / J"a `r Gallons Gallons Units /,/d � a v u New Tanks Existing Tanks f f, w y 5 . �a m X UV 6 ioo6 (�( c v v H rn i� C7 a Septic or Holding Tank 'r J Otto 1 d t'rl Dosing Chamber V11. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. PI u tier's Name (Prim Plum ignature MP /MP S Number Business be Plum r s A4d /f re s eel, City, t ,Zip Cod t r-- A 117 e) Vill. County /De artmenUse Only Approved ❑ .sa d Permit Fee D sued Issuing A Signature $ M D0 DDS El vner n Reason enial l(�.v IX. CondiIMteasons for Disapproval \ n t 1 64 - t 1. Septic tank, effluent filter and 3 J 44 6> \ a►�5 � .�.y dispersal cell must all be services'/ maintained ��--J 6Q� as per management plan provided by plumber. Z AN setback requirements must be maintoi ed t�0 PW tt9ch to complete p ans or the system and submit to the Coun • only on paper not less than 8 vi x t t inches in size SBD -6398 (R. 01/07) Valid thnm 01/09 M e ke y S_ n. C � d � v 4 � v 1� v v rr ti r f Q S 3 ul o �L) d N v o r 0 - ro a j I I 3 w -!- S v R I ORs a 9n�:, tb t :butyl si ._.�U. /z Hsi. rd P7n,- Rd. I �l Co- O r, 1 0 11 - rd lc,,� t.w, }4 °x3.7/1 4f j 7i.;. 4f �� °�4..zsc ECOPY M% lie _r /t ho y kiHniC Tvv,► / � ' S �` Cre,x Y iv d '�. 46- tA t 'H x J C"A oj- „ Cal L Rol u 3 J " u CY- s� R IVER ORivE L:6er7yRaL �— ►-- b.1] 1+,i. r Pine i"ra� red. 1 Co - d, o�tes v n/ ' f4 ° ,x'3.7 // 4 71A If "x3.71 Safety and Buildings PO BOX 7162 commercem.gov MADISON WI 53707 -7162 TDD #: (608) 264 -8777 , tilepartment of Commerce s c o n s i n www•commerce. o www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary May 12, 2008 CUST ID No. 220673 ATTN: POWTS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER SOIL TESTING & DESIGN ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/12/2010 Identification Numbers Transaction ID No. 1534862 SITE: Site ID No. 737146 Mike & Jenny Knox - Dwelling Please refer to both identification numbers, 1134 River Drive I above, in all correspondence with the agency. Town of Kinnickinnic, 54022 St Croix County NEIA, SW1 /4, S21, T28N, R18W FOR: Description: At -Grade Object Type: POWTS Component Manual Regulated Object ID No.: 1181634 Maintenance required; Replacement system; 450 GPD Flow rate; 42 in Soil minimum depth to limiting factor from original grade; System(s): At -grade Component Manual, SBD- 10570 -P (R.6/99), Pressure Distribution Component Manual, SBD - 10573 -P (R.6/99) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located _in accordance with the enclosed approved plans and with the component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. P.I No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, 00114 stats. AP I A copy of the approved plans, specifications and this letter shall be on -site during construction and open to DEP T inspection by authorized representatives of the Department, which may include local inspectors. All permits DIVISf required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. SEE CpRR In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. CHARLES L WEBSTER Page 2 5/12/2008 I Sincerel Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 P ter ag &Plaeviewer, Private Sew Integrated Services WiSMART coder 7633 (608)266-2889, M - F, 0630 - 1500 Hrs pete.pagel@wisconsin.gov cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544, Friday, 7:00 A.M. To 3:30 P.M. 5 a M14Y 7 ZOO�s Webster Soit Testing ft Sewer ,fe�i ' & n Chartie Ft lKris Webster, Owners N5815 770"' Street, Ettsworth, WI 54011 Teteptone: (715) 273 -3430 Fax: (715) 273 -4181 WI Licenses: MP220673, ST220673, ST 261669, PE18803 POWTS Index Sheet Page 1 of 8 At -Grade System Desizned for a 3 Bedroom Residence Property Owner/Project Name: Mike and Jenny Knox 1134 River Drive NE 1/4 SW 1/4 S21 T28 N R18 W Town of Kinnickinnic, St Croix County, WI CO. nt ents Page 1 of 8 Index Sheet Page 2 of 8 Plot Plan Page 3 of 8 Plan View Cross Section Page 4 of 8 Distribution Pipe Layout Page 5 of 8 Pumping Chamber Layout Page 6 of 8 Pump Performance Curve Page 7 &8 of 8 Management Plan `` 11111rar4� 1-mm- ,`. WEBSTER s HARLES L N don E•18803 [C O : LLSWORTH + AL .,, �• ,� err M Component manual_ used: lco;N s Name: At -Grade Component Manual for POWTS Version: SBD 10570- P(R6/99) LZ SP °No c E Date: 6/99 Name: Pressure Distn'bution Manual for POWTS Version SBD 10573 P (86/99) f ld� -r L �,�� -b #E --�-8 � 66se�• wed /S �6 � �1 r � 2: hc, 4 p0j.c'e Mat in. Alm 10 Feet �= 7S Feet L= (9 Linear Load�.s3g Rate== GPD /LN FT Feet DesJgn Loading Rate= � GpD /SQ'FT W= Feet • 'Fabric •= D rstribution -Late al Observation -- , ,,� v . z"nv.�� -�-� El= 17 7 Well 12 19 . % X 1 k1 t ` \ I / 1 % ''T.� ve C/ w , 0 s _ c 84. cc d e _ P7- kn6x lecatc � bat*°'"' � �r'•� eg k,d� spa�l �- 6 3 P 7 S — F t N Z - X .Z,•eA Ce3� Tk�.4�s �cVCt M 2i4 !Ji } "'s�t'i � ..�1►CJiGS - rtive�T���w.dt;ah aP4j 1s 9 7 7 Ft Pld T iIS�T� lZe+�G .�! +ke4iu rt l'#6CzaT 0 '4., 5 c�ece a •1. hdle'r + ;It C4 ,4. .*wdlS_ 4.9 s7` /e td loe • � jk eh Cs 7�i�vr., a.. � �7�' er.+:t �r.':5' se,J�i <iyr a C, jf � 1 i ✓1. f, d le C' • d sst,e A A • ✓ �`' ' /fit., t' t � � {'� � :3 4r �t - 6"�d �� f �d�, ►- H1 Khox Pa of C l CA dt Sc,6,e d 4 O (No Scale) Pi -'sri� re.i? Approved Locking Manhole Covers � P`i'ei /opt With Warning Labels Attached � �'•ti�k or f''�� Weatherproof Approved _ d 7r x " 77 0 Junction Box Vent Cap —� �grfi•1���� ✓e 12" Minimum 4" Minimum i Quick 18" Minimum Disconnect 1 /4" �ra< Csvv4 Weep d�„dk ¢. Baffle i Hole e Pp &e,�F h e� A Alarm 6J B On t 'F I C u„'A-. t a, *APPROVED Off 6' F 1 90• /,.5 coy --r re JOINTS WITH { y s APPROVED PIPE r - h 3' ONTO 1 D SOLID SOIL ` Cone. B I i 3" of Bedding Under Tank - ,�w#- {swamp �c��•� 0�1 �e.� alrt�t� ci %'^�ia.�`�3 Number of Doses: / Per Day Gallons Per Day /Doses: 36= S` GaIIons Volume of Back fI ow• - .<tD 64 GaI s Tank Manufacturer: w.'ese, /?v 41- C. Total Dose Volume: ........ =Gallons Tank Size-Septic/Pump: loov /rs--y Gallons Alarm Manufacturer LeYe /.t /a ry Model Number: D LV Capacities: A .? 3 inches or 3 ?0 Ga j Ions Switch Type: + B Z inches or 2+ Pump Manufac Gnw / d + Chinches or y S— Gall Ions Model Number: E fv .f. + D = inches or ons Minimum Discharge ate: M Total ..... = inches or Co + Gailons vertical Difference BetKeen Pump Off and Distribu tion R ipe: ZSS, eet Minimum Required Supply Pressure: ..... At4 ':. C J..���... + 2, ; -4,0 Feet of Force Main x 1-3 Friction Factor /100 Feet: -t eet Inch Diameter Force Main Total Dynamic Head: ... = //.,3 Feet Internal Tank Dimensions: Length / /Y,, ; Width ?3;h - ; Liquid Depth d �s�c� ��Pdc. �4 P��,�, C4�/.,�e,. r C✓e �l �'�► Jl'li "1� Shy,, l�t, a f t� o� Goo/& Eff u a *e 13871 EPO4 EP05 APPLICATIONS * Fasteners. 300 series Fully submerged in high ■ Motor Housing: Cast iron" Specifically designed for the stainless steel: grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. r Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas- Homes components. Available for automatic and tic cover with integral handle o Motor. and float switch attachment • Farms manual operation. Automatic • EPO4 Single phase. 0.4 HP; • Heavy duty sump - � 115 or 230 V 60 Hz, 1550 models lnchrde Mechanical points. oWater transfer': , assembled Float Switch mbled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload -wifh rated oil and water resistant automatic reset. P aIf the factory. • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower SPECIFICATIONS 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 built in overload with k EPO4 Impeller: Thermo- construction. • Solids handling capability; automatic reset. plastic Semi -open design 3 /4" maximum.. • Power cord: 10 foot AGENCY LISTING with pump out vanes for • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. �. Ca ngtand�s ion • Total heads: up to 24 feet with three prong grounding • Discharge size: IIle NPT. plug. Optional 20 foot end i ot . m EPA Impeller. Thermo - g length, l6/3 SJTW with plastic enclosed design for listed model numbers • Mechanical -seal: carbon- improved performance. end n "P or "AC".) rotary/ceramic - stationary, three prong grounding plug BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (4.0 °C) continuous superior strength and 140 °F (60 0C) intermittent corrosion resistance. • Fasteners: 300 series - METERS FEET stainless steel. 10 • Capable of running dry.without damage to s 30 l components. Pump: EM a l ,­,� Al • Solids handling capability: C 7 W maximum. W • Capacities: up to 60 GPM. X s 20 ' l • Total heads: up to 31 feet. R f + • Discharge size: 1Ih NPT. z 5 • Mechanical seal: carbon- >. 15 I rotary/ceramic - stationary, a 4 BUNA -N elastomers. c • Temperature: 3 10 104 °F (40 °C) continuous l 140 °F (6VC) intermittent 2 s ' `�' rZ _ '�tl 1 • ,3t 0 00 10 20 30 40 5o GPM 0 2 4 6 a 10 12 m CAPACITY ®1995 Goulds Pumps, Inc. Effective May: 1995 POWTS OWNER'S MANUAL & MANAGEMENT T PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Cry , j `, Septic Tank Capacity / ©O O a l 13 NA Permit# Septic Tank Manufacturer ejl, e e. C' NA DESIGN PARAMETERS Effluent Filter Manufacturer P / /� ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model J _ ❑ NA Number of Commensal Units ' ANA Pump Tank Capacity a l ❑ NA Estimated flow (average) 3 0 03 g al/day Pump Tank Manufacturer c::;,, c, 01Q 13 NA Design flow (peak), (Estimated x 1.5) 4 $ c? gaYday Pump Manufacturer y l ❑ NA Soil Application Rate C;. 6 al/da /ftz Pump Model ❑ NA Influent/Effluent Quality Monthly average' Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand/Qravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD x220 mg/L ❑Mechanical Aeration ❑Wetland SS ❑Disinfection [3 Other Solids Total Suspended (T SS) 5150 m L Manufacturer Pretreated Effluent Quality , KNA Monthly average** Dispersal Cells) Biochemical Oxygen Demand (BOD 530 mg/L 13 In- ground (gravity) E3 In-ground (pressurized) Total Suspended Solids (TSS) 530 mg/L At -grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu/100m1 1 ❑ Drip-line ❑ Other Maximum Effluent Particle Size Y. inch diameter Values typical for domestic (non - commercial) wastewater and septic tank effluent •+ Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months *ear(s) (Maximum 3 ym.) Pump out contents of tanks) When combined sludge and scum equals one -third (Y,) of tank volume Inspect dispersal cell(s) At least once every ❑ months year(s) (Maximum 3 yrs.) Clean effluent filter * At least once every 3 ❑ months )Kyear(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA 11ee de_oe Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA Ar N8e Q / t „ r✓ Other At least once every ❑ months ❑ year(s) X NA Other At least once every ❑months ❑ year(s) XNA M�' eee7sar A, rT / h'r ohce ver 3 y ro Lve`ecoM^'a of f MAINTENANCE INSTRUCTIONS you.• c /ej+� rt / err every �'•+!/ ! , V• J a �y P"•� /•+•� d'^ -r•tii� +be w1h3eA^ Inspections of tanks and dispersal cells shall be made by an individual carrying one of tlfe 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 (X) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreattment components, and any other maintenance or monitoring at intervals of 12 months or less 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 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 ent p rocess and/or dam the dispersal cell . If high concentrations are chemicals that may impede the treatm ' � t (s ) detected have the contents of the tank(s) removed by a septage servicing operator prior to use. • • "la CFY/G..YA / p/d4 Pe A( 6` �- t!c Po. , L/lf �+' .J C�f�v A - - Page F Qf C� System start up shall not occur when soil conditions are frozen at the infiltrative surface.. During power outages pump tanks may till 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 . 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 property and safely abandoned in compliance with ch. Comm 83:33, Wisconsin 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 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: CI 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. O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 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. )I( 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 C.L., aw Name a� Ex�� Name Phone Phone S EPTAGE SERVICING OPERATOR PUMPER LCh LOCAL REGULATORY AUTHORITY Name Agency .$`�- �°y;X C C 'A Phone Phone 7tS^ _ t This document was dratted by the staffs of the Green tabs, Marquette and Waushars County Zoning and sanitation agencies. This document meets the minimum requirements of ch. Comm 83M(2)(b)(i)(d) &M and 83.54(j),(2) & (3), Wisconsin Administrative Code. Use of this document doqs not guarantee the performance of the POWTS. GMW (2/01) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code �r� Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County St include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Z —/060 - Qp — ©Q O Please print all information. Re ewed by Date Personal information you provide may be used for se ry puiVres AivacyTalh s. 15.04 (1) (m)). � Q� Property Owner - Property Location / e 6 h h I O Govt. Lot N E 1 /4 S W 1 /4 S .Z T ,� N R E(ar W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# !l3 River- r.'ve _ — — City State Zip Code Phone Number Cl city ❑Village own Nearest Road ❑ New Construction User Residential / Number f bedr@s rived design flow rate S C7 GPD W Repiacement El Public or commercial Descnbe: Parentmaterial G �dc; �� �: Flood Plain levationifapplicable General comments MAY 7 2008 and recommendations: ST. CROIX COUNTY ZONING OFFICE F/I ❑ Boring Boring # Pit Ground surface elev. 7b ff ` 7 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I - Eff#2 < — l;?- 1of°A3 s ps rn cw C %7 ' Af 0 s m s o. i q 10 -- o-F e Q s c, - 7 !- 6 4a - so ioY g 6 Po z S YAL l, s C, 5' q, A,, c w l ?O 0-7 l � so 'o Eo - 6l4 7- s S s a s — 0- 1-6 ` l r h.. L 5- it T r e y YV C,+ El Boring Boring # ,Y ® N Pit Ground surface elev. 9 4 X / ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 "Eff#2 0,7 1- a t3 /oY R313 X r o s Q . q s ,n 0- �. 6 of 1- ' v / 6 Ig fA(' / v it' 0. /• ' Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number ch s J. e- e P. -�� as b 673 Address Date Evaluation Conducted Telephone Number lu.Sv /S 77at4 st. Ells- ortti �F J'40// l2 /0 F3 7/S-- 173 -343 0 Property owner XAF64)( Parcc 0-2 2, — 106 0 - 0 0 El Boring # [I Boring 3 ❑ pit Ground surface elev. '71!�13 ft . De;t :)� ll Horizon Depth Dominant Color Redox D— in escnptton I Texture • Munsell Qu- Sz. Cont Color S-- S.", 0-13 10-9 40 0-7 S o8 0 0-7 0.r 071/.6 a>-7 /-e;' C> X o-7 J- z' ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor Application 2t,- n. Horizon Depth Dominant c Reclox Description Texture Structure Consistence Boundary Roots Soil GPD/fF R in, Munsell Qu. Sz. Cont Color Gr. Sz. Sh. - Eff#I - Eff#2 'ale 21 L ; Boring # Boring ❑ ❑ p Ground surface elev. ft Depth to limiting factor in. Texture Structure Application ate 7 H®rizon Depth Dominant Color Redox Description Consistence Boundary Soil R Roots GPD/W in. Munsell Qu. Sz. Cont Col Gr. Sz. Sh. *Eff#1 'EfIQ21 I Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mgIL Effluent #2 = BOD,:5 30 mg& and TSS:s 30 mg& 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, P contact the department at 608-266-3151 or 77Y 608-264-8777. SBD•8330 (8.07M) �- K I M "* K i hh IC TWti�q - •1 t �Lc.'x Y P� .r Q!. i d a t� t 4, 4. �s L y lb 4 r 1 k w 7 o rt l UN 1� 1 � ` `ND W l b ri ,� I �t I ► s � Y u f2 �vER DRivE o• 4 M : t. c ; be r7y fact •�-- - F--- -� G tee,: res PTn T • C Rd. PS Co - 0 Ly l ie o tC S C, �c e ! GYa f4.el �`i cJ. �`� :r ��• °S /l I 4f's 3.7/x.. 4f 75'3 - 716 l ° 3�. �T6 I f d� � 'f. �4.i e �s �.� �.2✓� t C s r' ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify ghat I have inspected the septic tank presently serving the n Yl OX residence located at: 11 F '/4, t '/4, Secti n a ( , Town N, Range W, Town of C �i ; �� , 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 service Aez. ' J 6 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: Lo Construction: Prefab Concrete X, Steel Other Manufacturer Pf-kaQw n ): Age of Tank (f known : th 1 � •�e w �� , fir' x % ak (Licensed Plumber Signature) (Print Name) owe (Title) (License Number) /MPRS � � a (Dat Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer k O mn P hhx Mailing Address y , �U'� �" 'DI L l U e Property Address /1 3 T OC 1i - e r b Pip lam' em eh ,Q (Verification required from Planning & Zoning Department for new construction.) City /State it c �' tGZI. ) , Parcel Identification Number 00 LEGAL DESCRIPTION Q Q ' t / Property Location Al , S ' /4 , Sec. , T 0 N R Alf Town of /6/ h 1 ' & 4 t� 4 l ' Subdivision , Lot # Certified Survey Map p # , Volume , Page # Warranty Deed # Q 6 , Volume , Page # Spec house yes no Lot lines identifiable es' 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 §Gomm. 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. 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 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 am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. NL er of bedrooms PA,4:X 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) ' 8303 4 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX Co., MI STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 07/24/2006 01: 30PN WARRANTY DEED THIS DEED, made between Dale Andrea and Rae Ann Andrea, f/k/a EXERT # Rae Ann Lindeke, husband and wife, Grantor, and Michael J. Knox and REC FEE: 11.00 Jenny R. Knox, husband and wife, as Survivorship Marital Property, TRANS FEE: 735.00 COPY FEE: Grantee. CC FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee PAGES: 1 the following described real estate in St. Croix County, State of Wisconsin: The East 671 feet of the south 365.6 feet of the Northeast Quarter of the Southwest Quarter (NEI /4 of SW %), Section 21, Township 28 North, Range 18 West, Town of Kinnickinnic, St. Croix County, Wisconsin. Wisconsin Assured Title, LLC 1810 Crest View Drive, #1 B Exceptions to warranties: Hudson, WI 54016 i Easements, restrictions and rights -of -way of record, if any. �T C— 1 ` 022 -1060- 90-000 Parcel Identification Number (PIN) This is homestead property. Dated this 21 st day of July, 2006. * Date Andrea * Rae Ann Andrea, f/k/a Rae Ann Lindeke * * AjWKMW?GOULET ACKNOWLEDGMENT Signature(s) NOTARY PUBLIC STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. authenticated this 2 u y, Personally came before me this July 21, 2006 the above named Dale Andrea and Rae Ann Andrea, f/k/a Rae Ann * Lindeke, husband and wife to me known to be the person(s) TITLE: MEMBER STATE BAR OF WISCONSIN who executed the foregoing instrument and acknowledged the (If not, s e. authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY 8eaz� *Pamela J. Goulet Peterson, Fram & Bergman – Steven H. Bruns Notary Public, State of Wisconsin 50 East Fifth Street, St. Paul, MN 55101 My commission is permanent. (If not, state expiration date: 10/11/2009 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000 I of I