HomeMy WebLinkAbout024-1021-20-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
479460 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:
Evans, Chris Pleasant Valley, Town of
CST BM Elev: Insp. BM Elev: ,l BM Description: Section/Town /Range /Map No:
/65 lA Z e- 17.28.17.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � /, 3 Benchmark
/ g . 3 �.Z /e37
7 (� Alt. BM t
4. 1 M Y 1 , 54
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet $ 7g 937 --9
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
C(141 .
Septic ! 7 56 31 0 1 3 o Dt Bottom
Dosing Header /Man. o/ ,.� /a 3(, , tog
Aeration Dist. Pipe y ., 183(o Z9
A ) . a3 ,
Holding Bot. System
0
Final Grade 9 ,3 V 63(6 , 94(
PUMP /SIPHON INFORMATION , 1 Z
Manufacturer Demand St Cover
GPM �� ca 10 • 1 1 5 • a
Model Number /D • (p / 6 4
TD Lift Friction Loss Head H Ft ; I + I •6 /635. L1 I T
Forcemain I Length Dia. Dist. to Well ; II • $ myv
SOIL ABSORPTION SYSTEM 7
BEDITRENCH Width Length No O n ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 vx ,d,- 716 3 1 � eV� '` _ '_
SETBACK SYSTEM TO aU P/L JBLLDG WELL LAKE /STREAM LEACHING Manufacturer. (�
INFORMATION CHAMBER OR - ,R, k
Type �ZSJ�UQ J� o / J 7 > J / UNIT Model Number. ` <A
DISTRIBUTION SYSTEM 4D Q' rHle Header /Manifold �/ Distribution Size x Hole Spacing Vent t it ke
\
Length 12 Dia Length \ Dia ` Spacing
Pipe's) 10
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center ) 1 Bed/Trench Edges ` Topsoil � Yes LJ No as _ No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1665 County �Road
1 N Hammond, WI 54015 (NW 1/4 NE 1/4 17 T28,N�R-1177W) NA Lot / 2 Marcel No: 17.28.17.
1.) Alt BM Description = �, t �`" �O �'�' EL 4 a A� � f r J•A :r;k �0.
2.) Bldg sewer length = 51
amount of cover Q
Z 1
Plan revision Required? ❑ Yes No V
Use other side for additional information. — —� ` _
Date Insep Signat Cert. No.
SBD -6710 (R.3197)
1
VA - Safety and Buildings Division County ce o tf
201 W. Washington Ave., P.O. Box 7162
visconsi Madison/W, 53707 - �� ry er nit Number (to be filled in by Co.)
6 -315 REC q� V)
Dep artment of Commerce Ssa Plan I. . Number
Sanitary Permit Applicati )
In accord with Comm 83.21, Wis. Adm. Code; personal information you Addr s (if different than mailing address)
play be used for secondary purposes Privacy Law, 315.04(1)(m) S1 CROIX - W
FFICE
I. Application Information - Please Print All Information #
Property Owner's Na me Parce N . Lot N Block X
0 Property Owner's M ailing Address Pr �erLocation dAX M'
Q l.( G/R UL LZ //t// �kN b4 ,Section
City, State / Zip Code Phone Number
d�r7 N ri f
/4 5 � J` zs o trcle one)
T �N; R_ or4p
E
II. Type of Building (check all that apply) S
Stibdivisien Harrte CUP N er
* or. 2 Family Dwelling - Number of Bedrooms C�
1) Public /Cotrunercial - Describe Use Vo L P `
❑ State Owned - Describe Use - ❑City_ ❑Village Pownship of
�L
III. Type of Permit: (Check only one box on line A, Complete line B if applicable)
A. I�N System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
1V. TZpe of POWTS Syste (Check all that a 1) 3) - R1 - , .0
* Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single ass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ R circulating Sand Filter
❑ Recirculating Synthetic Media Filter X Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explai 5 Ste"%^ C (A.Aj s „
V. Dispersal/Treatment Area Information: ryMy_. 20.0
Design Flow (gpd) Design Soil pplication Rate(gpdsf) Disp r al Area Required (SO Di sal Area Pro�sed (sf) System Elevafi l / /o s 7
A Z� / Z� 0—v v 3 0° 3S- 2
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallo Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
_ Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plu er's Na me (Print) Plumber's Si gnature MP /bPRR Business Phone Number
Plumber's Ad " ss (Street, City, State, Zip de)
Luz
VIII. Count /De artment Use Onl
,K Approved ❑ Disapproved Sanitary Permit Fencludes Groundwater Date Issued Issuing ent Signature (No Stamps)
p
❑ e Surcharge Fee) en 1 for Denial 300 S Ot) / j� r.
IX. Conditions o prov l
SYSTEM NER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by Plumber.
2. All setback requirements must be maintained ��nR
as per applicable code /ordinances.
" �/P
Attacit complete plans (to tho County only) rm tha syste on paper not less � than 81/2 x 11 inches is size
SBD -6398 (R. 01/03)
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Wiscor►sin Department of rce SOI EVALUATION REPORT Page I of
Division of Safety and Buildings
N dVclonlarxy�j�n 85, Ws. Adm. county
ST. CROIX
-Ntach complete site plan on per not less than 81/2 x 11 in in size. Ian O
utclude, but not limited to: verb I ar r hLTe,point di Parcel I.D. ending)
percent slope, scale or dimen ns, ' UNl on a ad. � " (-
Plea a anformadon. b Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (t) (m)). 5-
Properly Owner Property Location
ROGER EVANS (Buyer: Chris Evans) Govt. Lot — NW 1/4 NE IM S 17 T 28 N R 17 E (or)
Property Owner's Mailing Address Lot # Block # Surd. Name or CSM#
1667 C.T.H. N 2 - (Pending)
City State Zip Code Phone Number ❑�liltege own Nearest Road
Hammond, WI 54015 ( 715 796 - 8885 C.T.H. N
n New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement ❑ Public or commercial - Describe:
Parent material gracial drift Flood Plain elevation if applicable NA ft.
General comments Conventional In -ground T renches - to be designed by installed - 0.4 loading rate
and recommendations:
Pumping may be required.
(Amoy- Cromwell sandy loams)
Bori
Boring # ❑ng
Q Pit Ground surface elev. 1037.20 ft. Depth to limiting factor 58 in.
Sod ApOcation Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 '01#2
1 0-5 10YR2/2 - A 3f -mgr mvfr cb 3vf-co 0.6 1.0
2 5 -13 - sl 3f -msbk mvfr cs 2vf-co 0.6 1.0
3 13 -29 10YR4 /4 - sil 3fabk mfr aw 2vf-co 0.6 0.8
4 29-48 10YR3 /4 - s & gr Osg ml cw 2vf-f 0.7 1.6
5 48 -58 IOY4/6 - s & gr Osg ml as lvf-f 0.7 1.6
6 58 -65 10YR4 /6 f2d 10YR3 /6 Is 1 fsbk ds _ __ 0.7 1.6
Some cobbles and few stones.)
❑ 2 Boring # Bourg 1035.0 56
0 pit Ground surface elev. ft. Depth to limiting factor in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'Eff#1 'Effi#2
1 0-4 10YR2/2 - A 2fgr mvfr cb 3vf co 0.6 1.0
2 4-16 10YR2/2 - sl vfr cs 2vf-m 0.4 0.7
3 16-25 10YR2/2 - Is if - -msbk mvfr cs 2vf-m 0.7 1.6
4 25 -33 10YR3 /3 - sl If -msbk mfr cw lvf-m 0.4 0.7
5 33 -56 10 - s Osg dl as lvf-f 0.7 1.6
6 56-62 10YR5 /6 fed 1OYR4/6 s Osg dl - - 0.7 1.6
Some gr in all horizons.
' Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 ng/L and TSS < 30 mg/l_
CST Name (Pty Print) - - Signature CST Number
Mary Jo Hollister 224832
Address Date Evaluation Conducted Telephone Number
W9875 690th Avenue, River Falls, WI 54022 11-09-04 (715) 426 - 1775
Property Owner _ EVANS, Roger Panel ID # (Pending) Page 2 of 3
Boring # Boring
Ground surface elev. 1 035.20 ft
0 Pit Depth to limfirg factor 58 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHF
in. Munsell Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 I 'Eff#2
1 0-6 1OYR3/3 — sl 3fabk mvfr cb 3vf-co 0.6 1.0
2 6-20 1OYR3 /4 — sl 2fabk mfr as 2vf-co 0.6 1.0
3 20-26 7.5YR4/6 — Is l fsbk mvfr aw
2vf-m 0.7 1.6
4 26-58 10YR5 /8 -- fs Osg dl — Ivf-f 0.5 1.0
Some gr in all horizons; horizon 4 has some pockets of I OYR3 /6 s.
Boring # Boring
H Pit Ground surface elev. ft. Depth to lim" factor in. 1
Sa Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIFF
in. Munsefl Qu. Sz. Cont Color Gr. Sz. Sh. 'Eft #1 *Etf#2
F-1 Boring # Boring
❑ Pit Ground surface elev. ft. Depth to Igniting factor in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. *E1f#1 I *Etf#2
* Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 30
_ 5 _ mg/- and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266-3151 or TTY 608 -264 -8777.
s1311- 9330ren (e 07100)
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Parcel #: 024- 1021 -20 -000 01/05/2005 03:53 PM
PAGE 1 OF 1
Alt. Parcel #: 17.28.17.114A 024 - TOWN OF PLEASANT VALLEY
Current ❑X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
ROGER H & JUDY C EVANS ` EVANS, ROGER H & JUDY C
1667 CTY RD N
HAMMOND WI 54015
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 1667 CTY RD N
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 20.000 Plat: N/A -NOT AVAILABLE
SEC 17 T28N R17W E1/2 NW NE TOWNSHIP Block/Condo Bldg:
PLEASANT VALLEY.
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
17- 28N -17W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 950/184
07/23/1997 784/26
07/23/1997 767/595
2004 SUMMARY Bill #: Fair Market Value: Assessed with:
25181 Use Value Assessment
Valuations: Last Changed: 05/21/2004
Description Class Acres Land Improve tate Reason
RESIDENTIAL G1 2.000 28,200 96,700 124,900 O
AGRICULTURAL G4 6.000 800 0 NO
UNDEVELOPED G5 9.000 9,800 0 9,800 NO
PRODUCTIVE FORST LANC G6 3.000 4,500 0 4,500 NO
Totals for 2004:
General Property 20.000 43,300 96,700 140,000
Woodland 0.000 0 0
Totals for 2003:
General Property 20.000 53,000 96,700 149,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 117
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
1
Q.`,c ff / Cv r-UA-A4,51"
TW
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3E Q
STANDARD CHAMBER
52"
Quick4 Standard Chamber 48 "
(EFFECTIVE LENGTH)
e
12" Z 5 a
a i �� l€
6„ °$� _ Emu
34" SIDE VIEW
SECTION VIEW
MultiPort End Cap
Q ; t
16"
12"
34" SIDEVIEW TOP VIEW
FRONT VIEW
1 r�r
-24
"
INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY
(a) The structural integrity of each chamber, and plate, wedge and other accessory manufactured by Infiltrator ( "Un tsj, when installed and operated
n a leachfield of an onslte septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ('Holder") against detective
materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however,
that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences.
To exemise its warranty rights, Holder must notify Infiltrator In writing at its Corporate Headquarters in Old Saybrook, Connecticut within fifteen If 5) - • .
days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty.
Infiltrator's facility specifxalty excludes the cost of removal and/or installation of the Units.
THE LIMITED WARRANTY AND REMEDIES IN H (a) ARE . THERE ARE A WARRANTIES WITH RESPECT
T SYSTEMS INC
TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES N'f1ES O O EXC
MERCHANTABILITY OR OR FITNESS FOR A PARTICULAR ICULCULAR R PURPOSE.
(c) This Limited Warranty shall be void ff arry part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does
not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of Environmental Onsite
Wastewater Solutions'
production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third parry. Specifically
excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of
the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the 6 Business Park
Road " P O. Box 768
minimum ground covers set forth in the installation instructions; the placement of improper materials Into the system containing the Units; failure of
the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or Old Saybrook, CT 06475
any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the terms set forth in this Limited
Warranty. 860- 577 -7000 " FAX 860- 577 -7001
Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third party resulting from installation or ship- 800_221 _4436
meet, or from any product liability claims of Holder or any third party. For this United Warranty to apply,, the Units must be installed in accordance
with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's installation instructions.
(d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any parry other than the ongi-
nal Holder.
The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty require-
ments. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a
copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units.
U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844
Canadian Patents: 1,329,959; 2,004,564 Other patents pending.
Infiltrator, Equalizer and SideWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. nECrceevvavea
is a registered trademark in Mexico. Contour, Contour Swivel Connection, Microl-eaching, PolyTuff, SnapLock, ChamberSpacer, PosiLock, QuickCut, QuickPlay
and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed in U.S.A. Q011203HP -0
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page L of Z
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner `s' � j' Septic Tank Capacity �e al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS 10 Effluent Filter Manufacturer 7.4ec L ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model D ❑ NA
Number of Public Facility Units - ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) g al/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA
Soil Application Rate gal/day/ft' 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 /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑ ear(s)
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) (Maximum 3 years) ❑ NA
❑ year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
® year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA
❑ year(s)
Other: [3 month(s) At least once every: ❑ year(s) ❑ NA
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)
+ Page Z 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
E me �s Name
ne — Z Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name Cle X Z a
Phone Phone Q
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
08/29/2005 10:49 FAX 715 273 0444 NELSON - PLUMBING fboo1 /001
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer C A✓'t � �t` � Ila t�► � � -
Mailing Address ��f�. T QGt ea ; I CIre_ f -� So+1 �. S I /
Property Address r CouN tit JQ /V Hkotot onot �
II II (verification required from Planning & Zoning Department for new construction.)
City /State doLmoo ,1 w _ .__ Parcel Identification Number Par'• a W 0 ; 1-A0-DO O
LEGAL DESMPTION
Property Location W r/4 , leg y , Sec. 17 , T 28 N R t 7 W, Town of He4.6amt V a ilG &A .
Subdivision , Lot # :�
Certified Survey Map # —$ Volume , Page #
Warranty Deed # 7 " l! Z , Volume 79K, .Page # /�_
Spec house yes no Lot lines identifiable yes no
SYSTEN 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 rank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certillcation 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 18 full of sludge.
Vwe. the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
swndards 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.
I1we certify tha 11 statements on this form are true to the best of my /our knowledge. I/w•e am/are the owner(s) of the
property desori b e, by v e of a warranty deed recorded in Register of Deeds Office.
Number be ooms
SIGNATYRkOF F ANT(S) DATE
s * *Any inforrnatiou thatt is misrepresented may result in the sanitary permit being revoked by the Planning & Zorring 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, 08105)
li 2796 P 6 1 7'94102
STATE BAR OF WISCONSIN FORM 1 - 1998
WARRANTY DEED R EGIST ER H. DEEDS
Document Number
ST. CROIX CO., WI
_ _ ................ .......- ........::.:..___. _�_. ___..�-- .- -.....= ::......:_: —. - -..
-:= _ RECEIVED FOR RECORD
This Deed, made between 05/04/2005 04:15PH
i WARRANTY DEED
EXEWT # 8
and C S ,p a P ire L c cantor, REC FEE: 11.00
,. TRANS FEE:
COPY FEE:
CC FEE:
� Grantee i
PAGES: 1
Grantor, for a valuable consideration, conveys to Grantee the following
described real estate in C^a/ w epGeiy County, State of Wisconsin
(the "Property "): ( Recording Area
i Name and Return Address
C° 5 M V I q P 4g5q L 01 .2 r g8ejr �JLL Evans
(0(0 7 C 1yoa.j N
5 Cro Cou Y) i y Ida. corn oy) d
0 'F � "� iy
o - � d /0-2 — �Do2�- o fD�UOD 1 i
Parcel Identification Number (PIN)
This / S 170 homestead property.
(is) (is not)
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Together with all appurtenant rights, title and Interests.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except II
I
Dated this day of
I
St. Croix County Map Output Page Page 1 of 1
St. Croix County Ma pin
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1101 Carmichael Road cervye d .3fvey Map
Hudson, WI 54016 0 Mar Qlr
Phone: (715) 386 -4674 0 R °'O`'
RJroad
Orai rlage
DISCLAIMER : The information contained on this map is advisory. Map !Streams
accuracy is limited by the quality of the public records from which it was Dam
prepared. It is not intended as a substitute for an accurate field survey. Rerl*wval beam
nlelrnl Ilpnl :Kam
AERIAL PHOTOS : Aerial photography is date - sensitive. Features that exist
presently in the County may not be present in the photos.
http://72.21.23 0.178 /servlet/com.esri.esrimap. Esrimap ?ServiceName= StCroixOV &ClientV ... 9/8/2005
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VOL19 PAGE 4959
KATMEEA H. WWLSA - ---
REGISTER OF DEEDS
ST. CROIX CO.. VI
RECEIVED FOR RECORD
03/31/2005 08:00AN
CERTIFIED SURVEY MAP
- - CIiRT-TRILID 1 MAP
LOCATED IN THE NW 1/4 OF THE NE 1/4 OF SECTION 17 T28N REC FEE: 15.00
R17W, TOWN OF PLEASANT VALLEY, ST/ CRO COUNTY. WISCONSIN COPY FEE:
PAGES: 3
UNPL A T TED L AND 1
N 1/4 CORNER
SECTION 17 iq 1 NE CORNER
T28N, R17W I NORTH LAV OF ThIF AIE 114 i� 1 SECTION 17
(1" IRON PIPE) '� 1 "� I T28N, R17W
_N 88.54' S0" W 2648.17' (MAGNET NAIL)
662.04' �i. T H N .. O$
662' _
T 66.02' 400003'
100' HIGHWA
SETBACK LINE S
n 1
"SI M 3 W
15.0 1 T ES 654 s POINT OF
• INCLUDING C.T H]�
I Nw 114 OF 7W AE 114 t �8 RIGHT -OF -WAY BEGINNING
I 14.549 ACRES CENTER OF
66' WIDE N 633,749 S.F. DRAINAGE SWALE
Q ACCESS EXCLUDING C.T.H . N N
EASEMENT I RIGHT -OF -WAY .X
N 87 9 00" E
- N 90 00" E O I
`--�� 92.14' v Z
LQ
`! oS 87.30' 00" W C3
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43.19
CENTERLA C .SEPTAC VENTS W
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AR/VEWAY N 90.00' 00" W 9 c -
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LOT 2 His His B2 ® 5.008 Ac SCALE IN FEET
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• �— '� —•�- �- O 100 200 400
6 5'
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SOUTH LAID OF THE
NW 114 OF THE AV 1/4 I
SW 114 OF 7AE ALE 114
UNPLA T TED I LAND
4 - --
LEGEND
COUNTY SECTION CORNER
MONUMENT FOUND,(TYPE NOTED).
0 1 1 /4 11 x 18" IRON PIPE JAME$ 0. FILKIN3 S -2246 JOB #04 -2716
WEIGHING 1.68#/LINEAR R G WE
LAND SURVEYOR
FOOT, SET. O N ENGINEERING COMPANY
1234 S. WASSON LANE
- X - -X EXISTING FENCE. RIVER FALLS. WISCONSIN 54022
B1 ® SOIL BORING PERFORMED BY MARY JO DATE: OCTOBER 21. 2004
HOLLISTER ON NOVEMBER 9, 2004. REVISED: NOVEMBER 4. 2004
REVISED: NOVEMBER 15. 2004
THIS INSTRUMENT DRAFTED BY JEROD A. FINK PAGE 1 OF 3
Vol 19 Page 4959