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HomeMy WebLinkAbout026-1149-00-002 Wisconsin P,.pa of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Sa:ety and Building Division INSPECTION REPORT Sanitary Permit No: 499270 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: Lauer, Ken I Richmond, Town of 026- 1149 -00 -002 CST BM Elev: Insp. BM Elev: BM gescription: Section/Town /Range /Map No: gypT r < T 15.30.18.1107 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic rl J J Z 1 660 Benchmar ` Dos ing- /O Alt. ► —Cow— It r 13 11 ZS Aeration Bldg. Sewer L t` Z .'7 /02 - 33 Holding SbHt Inlet ACE ✓ab•2 TANK SETBACK INFORMA TON St/Ht outlet �• 5 ( � TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / % , / /b5 Dt Bottom _ Dosing Header /Man. * fe ' 1 � • 6$ Aeration Dist. Pipe - 0. Holding Bot. System 4 � Ia PUMP /SIPHON INFORMATION Final Grade 3 •� �� Z "�� Manufacturer De and St Cover M ' Model Number -7 b ss • �� TDH Lift Friction Loss System Head TDH 1 - ( �f( • Z Forcemain Leng Dia. t. to Well i %35 N.- /5 SOIL ABSORPTION SYSTEM BED /TRENCH Width INo. Of Trenches PIT DIMENSIONS No. Of Pik Inside Dia. Liquid Depth DIMENSIONS ^� `t , C —t M, `� \ y Y® J SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of System: , CHA OR Model Number: QY DISTRIBUTION SYSTEM Z(o+-Zq + ZZ1 f Z <,/ f LO Header /Manifold it Distribution x Hole Size x Hole Spacing Vent to Air Inta Pipe(s) 7 A �- i Length_ _3 (0_Dia 4 Length � Dia \ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only e Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center vg Bed /Trench Edges N___1 Topsoil `� �es No Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1526 127th Street New Richmond, WI 54017 ( SW 1/4 SE 1/4 15 T30 R180 Knolls Lot 2 Parcel No: 15.30.18.1107 1.) Alt BM Description = ' G bJ2J — : �b c6 WAR_ 2.) Bldg sewer length = �1 ova m') V 60� - amount of cover = ✓ f F�. ± � Plan revision Required? Yes o % / o Use other side for additional information. —� __ (p / 5 Z Z o 1 Date Insefre's gn re Cart. No. SBD -6710 (R.3/97) I I y • Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ,s 1 *i1se,hOnsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 A a 0 Sanitary Permit Application State Plan I.D. Number lJ In accord with Comm 83.21, Wis. Adm. Code, personal information y may be used for secondary purposes Privacy Law, s15.04(1)(m Project Address (i ifferent than mailing address) I. Application Information -Please Print All Info atio / �� Property Owner's Name p E 0 2006 Parcel # Lot # lock r 2 -fry -acs -� Property Owner's Mailing Address p Pro perty ST. CROIX CO Pro a Location ` -7 1 U S"o?(o IoZ S� � S�^+ I /I, ��' V4, SeCtlon City, State - Zip Code Phone Number �Yi 7 (cir or- one) II. Type of Building (check all that apply) / T N; R/�E Y ❑ 1 or 2 Family Dwelling -Number of Bedrooms �/ < Subdivision Name CSM Number El Public /Commercial - Describe Use �. e". 'co a .t' ❑ State Owned- Describe Use ❑City_ ❑Villa i g ownship of /C III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A Of New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. List Previous Permit Number and Date Issued ❑ Permit Renewal El Revision El of El Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl X Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit Recir lating Sand Filtetr, .'❑ Recirculating Synthetic Media Filter ;(Leaching Chamber ❑ Dri ine ❑ Gravel -les Pipe ❑ Othe (explai V. Dispersal/Treat ent Area Information: S Design Flow (gpd) Design Soil Applicatio te(gp sf) Dispersal Area Requ' (sf) Dispersal Area Pro s (sf) em Elevation g(„ 4 g/ o • 2 22� �s 9G. 3 96, VI. Tank Info Capaci in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks sepa or Holding Tank Aerobic Treatment Unit S oy r Dosing Chamber VII. Responsibility Statement - 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Pi Signature umber Business Phone Number Plumber's Address (Street, City, State, Zip Code) 3S'2 /1/0 n S r GvT ,S'YOo VIQ. uu !De artment Use Onl pproved ❑Disapproved Sanitary Permit F (includes Grourljrter l at Issued I mg Age )t Signature p Surcharge Fee) ° U� El Owner Given Reason for Denial O P l) (� � IX. Conditions of Approval/Reasons for Disapproval SYSTEM n / /) 6,_� s 2 d0 y led ,p-h C-A Sp(y, rt 1 eptic tank, effluent filter and dispersal cell must all be se rviced /maintained 0 Z pd /,q z as per management plan provided by plumber. �tGl� 2. All setback requirements must be maintained as per applicable code /ordinances. - ® /C . S �, giv ae.A.:. Attach complete plans (to the Cd6ty only) for the system n paper not less than 81/2 z 11 inches in size SBD -6398 (R. 01/03) 05/22/2007 07:51 7152687080 GILLE TRUCKING . PAGE 02 I . .a , n 1 .... _ . .:... _� ..... �. .... __......... _ .. f I .Y 1 1 � 1 .. , f I _ . ......... ...... _ _ —._ _ .. fin_...— i 1 ,.:.:., �...., ....__._ .�..._. ,w ..... ...... . ...n__ ..__. _._ ....,... w. _._ _ :� VA , A— few 1 r.• , I _ ...._ ._. . . ........... _ .... - . ........ n...,,.. -... -_ Ak - Tl • I ' �..._ ..,.E —.•..— -- -•� -- - —• -� , ,.., - -- -- ... - -.f. .. i .I. w. • S' : &/e 9 /4, 3 _'` ,, - t 7 4 .� s - - � /t - _ - - 11f o. z - ,,�- -� me - i - i i , i i I I � I r I I I 1 I - -- I I. I , I ' 04/04/2001 10 :07 P-AX 7155376847 BARRON CO ZONING 001 SYSTEM SPECIFICATIONS 7n- ground Soil Absorption Component SBD Project Name:, Distrbbution Cell Type Sepdc Tank Aggregate Q Leaching chambere Miry. Septic Tank V ae 8'o gat. Wastewater Quality Septic Tank Volume /O G d g d. Treated n Untreated ® Manufacturer �. Number of Bedrooms 3 Effluent Filter Design Loading Rate PLR) n / Manufacturer _ (Maaaimmn Soil Application Rate) Model 01 "5 - 21s - / Combined wastewater: Number of be&ooms Pump Tank gal /.day /bedroom x 150 Manufacturer .. . Daily Wastewater Flow (DWF) � ysd Volurne Cleat and gtaywarer only; Number of bedrooms Divettet valve Dyes Ono gal. /day /bedroom 1blarsufiLcture - Daily Wastewater Flour (DWF) Model �SCkWatet the � Note : The use of a dime ut valve ahall be indicated on B t ` i when the valve d men T'lar' e. d �� how act Number of bedrooms. _ ___ shall be used. gat /day /bedroom L - 6 - 0 Daay Wastewater Flow (DWI-') Distribution Cell Sizing (Aggregate) bistribution C4 Sizing (leaching chambers) 1xaching Chamber Manufacture 1 Model Adjusted Design Loading Rate gpd/fe Chamber size, bottom area / 9 L f Syseena `suing = D ADLR / Chambt= size 9._. (sq.tt) # of Ch s Page of Number of chambers to be +used = M MO O Ell M In jueIZ ■ ■ JaeE ■ ■ N OOEM N ■ � ■ r = IN IN � w Is � ■ r ■ t r h t . r ■[I_I) w ..�..... ��.■ ■.ter ��r ■ - LIOLM N s.CI9100 _10 M_tlOa.r Nor sir sir ■�■ ► rK , ■ r w h = 7r h1�rr rte■ rte■ rte■ r ) r KIMIM w ■< r �� r ■ ��[ r r �r � ■ �■�� r sCI�LI■ ML70 ILK w M CIOLI■ MLIOLI■ r�r ■fir sue[■ ■fir ■�■ M�`It■ Mir Mme■ ■t'sfA■ ?, ''i■ P. KAMA■ rtI=r11 r ml r �_ ■ M �_ r � r �_ r ■ t ■ ■ t I ■ M_ ■ t = 7 ■ lop ■ t ■t r K�M�A ■fir �'�r rte■ r'�r ■ tI•LI It r t1 • u r N L 1 ■ w t1 0 I ■ ■ �_ ■ M �_ r M �_ M r �_ ■ ■ t 7 w ■ t M 7 r h t= 7 w ■■[ c> f■ r� r M i r ■ �_ ■ r r ■ w ■ t ■ ■ t A r ■ !C •= 7 r I��■ ■ raw■ Nom■ r LI�I1 ■ ■ tI�LI ■ M tI�L1 r s tl�L7 r � ►�■ sue■ r�r■ ■ ■ �[ � i r ■ t r � ■ ■ I� � 7 w r t�7 r �� ■fir r�r r'r r`r r «�■ rK 10 r M i r r� r r ■ ■�■ * T Wisconsin Di of Commerce SOIL EVALUATION REPORT P age 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County St. Croix Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must 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. Please print all Information. Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 6 Property Owner Property Location � Steve Derrick t SW 1/4 SE 1/4 s 15 T 30 N R 18 Q Property Owners Maifing Address Lot # A Block # Subd. Name or CSW 1438 County Road G 2 - Cherry Knolls city State Zip Code Phone Number [3Vftagv = own Nearest Road New Richmond I WI 1 54017 1 ( 7} 5- 246 -3120 County Road G Q New Construction UseE] Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD n Replacement } Public or commerciat - Describe Parent material T . ti Flood Plain elevation if a li E m �" " 1 ` ? a�ess n_ves ll pp - and re t s Site suitable for a conventional below gr and recmmmendatlons: OL F] Boring # ©Boring Q Pit Ground surface elev. _ 98.80 fl. Depth to limiting factor >I()0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 1 0 -6 10yr3 /2 A 2msbk mfr cs 2f .5 .8 2 6 -18 7.5 4/6 - scl lmsbk mfi cs if .3 3 18 -48 7.5yr4/4 sl Om mfi cs - 3 .5 ' 4 48 -100 7.5yr5/8 s Osg ml - - 7 1.2 Q Bing # 100.66 >98 M Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 "Eff#2 1 0 -16 10yr3 /2 sil 2ms mfr cs 2f .5 .8 2 16 -98 7.5 4/6 sl Om mfi - - 3 .5 o. Z " Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 nVL and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, W1 9 -25 -02 715 -246 -2454 nP1T n�•n mn.1Mn\ If - Property Owner Stev De rri c k Parcel ID # Page 2 of 3 Boring — Boring # E] pit Ground surface elev. 98 '� ft. Depth to limiting factor X1 00 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. S.5 *Eff#2 1 0 -6 1Oyr3/2 - sil 2msbk mfr cs 2f .8 2 6-49 7.5 4/4 - 1 mfi cs - ,5 3 49 -100 7.5yr4/6 - s Osg ml - - .7 1.2 ID 0 I F Boring # Boring Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 ❑Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor — in. Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *E1f#1 *Eff#2 " Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD- 8330Test (R.07 /00) I� Y . PAO �� yi �o� �e � SA T3 De li ti y � www.c :phNKh tAt6y�ts ish.CpNr �n- 246 -24x4 C ItE RRY IK W0 LL0 OP LOT Z © 0 io C OP � tm i 100 To of iron 3% Slade. eolq� 14.70 91 98, 8o 69 . ao � n� Thomas Nelson Scale 1 _ � 227387 , r 3// 3 Wiscoosin Department of Commerce SOIL EVALUATION REPORT Page / of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Crp 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. �� /�/q L -&C) Please print all information. y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). M�66, Property Owner Property Location , 4e 'D Govt. Lot 5W 1/4S t 1/4 S 15 T 3 0 N R I E (or)Z Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# Iy3S C± C 2 Che r� I City State Zip Code Phone Number ❑ City ❑ Village U Town Nearest Road 1v�w Rtc1, WI 5 bri I ( 715 ) 2yb- 3t'zo 1 21 C-�, G New Construction Use: ® - Residential / Number of bedrooms 7S /L4 Code derived design flow rate S 60 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material 41 11 s Flood Plain elevation if E ft. General comments I �h- R and recommendations: ��PA IQLU Cdn4aur elev. �-�q �p MAR 1 3 2002 © Boring # ❑ Boring (�] ZONING OFFICE © Pit Ground surface elev. �! 6 ft. Depth to limiting factor Z in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I a -1b 10 3 2 _ 5; Z k C5 I 5 8 Z _Z ___._ 5 ' c rh c — 4, 3 2 l ► F 7.5 r � s L �rr�S b -" - 5 . `I i a Boring # I❑ Boring MM �'1 I!� Pit Ground surface elev. "1'� . ft. Depth to limiting factor Z y in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 l D 31 — 5,' 2rr cZb c v-� .5 . 8 Z /O -Z 10 r y/ S ice/ Zm b k �r c /,0 vr ,31i,. P/ 7 -5 'tAo SL 2m.5bk 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 t h unxxk Address Date Evaluation Conducted Telephone Number Ztl g a 5 YOZ S ( Y7 - -Y408 / SBD -8330 (R07 /00) Y Property Owner 2� (2f i c�k Parcel ID # Page of -� Fs-1 E] Boring Boring # ® 3d Pit Ground surface elev. - 7�1�1c1 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 o- -31Z. — S' I Zm n c 5 14' .5 .8 Z 0 4 - 1 — Si Z r 3 36-50 10 ,;:S j(n F ) - 7. 5 9 I(p 5L ZmSbk ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department'at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) PAGE 3 OF_ NAME D,e r ( ' c ' k " LOT# Z LEGAL DESCRIPTIONSw XSE X ,S 15 T 30,N,R. E(orG ) SCALE: I"= BM I ELEVATION /GG • o BM I DESCRIPTION � P BM 2 ELEVATION t 9 (y 0 sec BM 2 DESCRIPTION he d f- fl SYSTEM ELEVATION /Oo ALTERNATE ELEVATION /V /A- — CONTOUR ELEVATION 57 q. © ( l �R,3o��� 6' g �►Z SIGNATUR DATE /Z _ 3 0 _ cif r I BENCH MARK: POW g9 TOP IRON PIPE ELEVATION 970.49 e C y ,� G S84V7'17"E 4 79.73' ci DS so 379.99' _ I I \ I 99.74' I LOT 9 'Z \ ° I m I I 2.01 ACRES /. 87361 SO. FT. a e 66.99 MIN. 1975.0 '►� \ _ NW—SE \ ,�2� D R A / N A G E1 \v \ SW —SE \ \ / • • S82 �g8 M N1 g� N8_ ?;3rg fl H• o -57*3 37�_w • , ' pR N �.2� 26 \ LOT 10 , 1.83 ACRES N N / • 79704 SO. FT. v. \ MIN. FIFE 975.0 i V 6 N LOT 11 Z i - �" • \ 4 1 5 ACRES \ / N W ��'Z \ \ `' ti MIN F 0 � / /24.76 NO76'17�E� II . ' LOT 3 o _ • 52.64 R O,9 O 1.91 ACRES ` 83363 SO. FT. • . �rl Jrs2 ; /,�( —� \ \ `{� LOT 2 N S� 1.72 ACRES a • . � \ 74711 SO. FT. 41 LOT 1 a ' fo 1.72 ACRES 74806 SO. FT. !n , o • Z - N Cd 33' 33' 4• 26.26' � 98.62' _..___. 2.38.o.3- � N853856 "W 3 36.65' 587'49 31 284.11 3 h R =N85'59040 "W 337.39' UNPLA TTED LANDS � r PARCEL 1D g CSM VOL. 1 PA GE 9 J C8 L I N09 36 �54 I F �G�.94 • >� PART OF PARCEL 1 C C7 N0073'06'W in the conweynnce for the I 65.00 roct in Volume 699, Page I SE 114' It appears this D oc* 6 8 4/ 5 S I by James E. Rusci, C6 ce calls within this center of section' O ` I bund iron pipe. Title to west re said S,;, ! v ccv7t e con tatted regarding this R�� ,p��,_ N1023 1W ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer K.-V416 �J ' 0 Mailing Address f Property Address `7 s+ N 2t,3 R "C-k Mow 9 W :r S fo /7 (Verificat required from Planning & Zoning Department for new construction.) Cit ✓ .� i c�tmjP W -� Parcel Identification Number 6@& - 11 y4 - 00 - 6 o a ri ,der LEGAL DESCRIPTION Prop Location S W t /a t /a Sec. �S T 30 N R /8 W, Town of Zi Lk m o N d, P Y Subdivision Ch E R R�j kN o l i 5 , Lot # a Certified Survey Map # , Volume , Page # Warranty Deed # 'WI 36 ®8 , Volume ?2 3� , Page # j ;IT Spec house yes Lot lines identifiable (ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Itwe, 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. Uwe amlare the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Numbe of rooms 3 S16NATORE OF APPLICANTS) 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) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page - -f•— of 2 :ILE INFORMATION SYSTEM SPECIFICATIONS L Septic Tank Capacity 1 m 0 al I Owner Permit # EL Septic T ank Manufacturer Effluent f=ilter Manufacturer )ESIGN PARAMETERS Number of Bedrooms 3 7 ;e9NA Effluent Filter Model .� Z.� "— "_" r _- -_ — g al 0 NA Number of Public Facility Units Pump Tank Capacity Pump Tank Manufacturer ❑ NA Estimated flow (average) �(S 6 al /da ❑ NA Design flow (peak), ( x 1.5) 4 al /day Pump Manufacturer -� _ ❑ NA al /da /ft' Pump Model ){caj� 9 Sall Application Rata 6 _ NA nthly a erage" Pretreatment Unit Standard InfluentlEffluent Quality F=ats, Oil &Grease (FOG) 530 mg /L ❑Sand /Grave{ Filter ❑Peat Filter Aeration ❑ Wetland Mechanical Biochemical Oxygen Demand (130D 5220 me 1L ❑ NA i•] ❑Other: Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection Pretreated Effluent Quality Monthly average Dis sal C011(s) E3 NA Biochemical oxygen Demand {HOD s30 mglL - Ground (gravity) ❑ In - Ground (pressurized} C3 Mound Total Suspended Solids (TSS) 530 mg /L ❑ NA © At -Grade ❑ Other: Fecal Coliform (geometric mean) 510 cfu /100 ❑Drip -Lino ❑ NA Other: Maximum Effluent Particle Size y in dia. ❑ NA ❑ NA Other: Other: ❑ NA _ ----- ❑ NA Other: *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Frequency Service Event months) (Maximum 3 years) ❑ NA Inspect condition o f tank(s) At least once every. q�'ysar(s) Pump out contents of tank(s) Y When combined sludge and scum equals one -third Jyp of tank volumes 13 NA d month(s) (Maximum 3 years) 13 NA Inspect dispersal cell(s) At least once every: 46 sar(s) � ❑ month(s) � 1 ❑ NA Clean effluent filter At least once every: ,i� years) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) 1:1 month(s) 0 NA Flush laterals and pressure test At least once every: C3 year(s) ❑ mvnth(s) ❑ NA Other: At least once every: p yearls) __^� ❑ NA Other: MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following g lice ring r c tifr n M aster Plumber, Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; an cracks or leaks, ny missing or broken hardware, Inspections must include a visutEla sludge o a scum ident for back up or pond ng of effluent on the ground s urface. of the measure the volume of combined pipes and to )fie dispersal cell(s) shall be visually inspected to the eff g�ouMd surface may indicate a failing condi on and requires the of effluent on the ground surface. The pond g immediate notification of the local regulatory authority. equals one-third When the combined accumulation of sludge and scum in 9 p tan k erator and disposed a more e n t ire the tank volume, the a Se coo dance with chapter NRt 3, contents o f the tank snail be removed by p ta g e Wisconsin Administrative Code. pretreatmen All other services, including but not limited to the servicing of effluent fiiterasCefilednPOWTS Ma ntaznerc ompanerrts. units, and any servicing at intervals of S12 months, shall be performed by A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4101) Page Z of y 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 LAN If the PO r fails and cannot a c ed the foil wing measures h ve bee ust be takerf, to provi a code compliant replace t system: A suitable replacement area has een valuated and may be utilized for th location of a r lacement soil absorption system. The replacement area should be protected from disturbance and compaction and show d 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 s I technology a holding tank may be installed as a last resort to replace the failed POWTS. T i`� aluat a o ing tank be ' e ai . ?R DI- , z iti� fo R- M61^J a 5 �'L 00 ❑ 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 S E� Name Phone - 6— Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name s C ( ( (1 ZOtiIlAI Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page f of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity ga l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal ❑ NA Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gal /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 <_ 220 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 O At -Grade ❑ Mound Fecal Coliform (geometric mean) :510' cfu /100ml ❑ 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 ❑ year(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 ears) ❑ NA ❑ year(s) y Clean effluent filter At least once every: El 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: At least once every: ❑ month(s) ❑ NA 13 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 <_12 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. State Bar of Wisconsin Form 2 -2003 WARRANTY DEED Document Number Document Name THIS DEED, made between Steven J. Derrick and Margaret M. Derrick, husband and wife ( "Grantor," whether one or more), and Kenneth W. Lauer, ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Lot 2, Cherry Knolls. St. Croix County, Wisconsin. 026- 1149 -00 -002 Parcel Identification Number (PIN) This is not homestead property. (is) (is not Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any ,/ Dated ( 0 (SEAL) � 1 (SEAL) * *Steven J. 16e rick (SEAL) � (SEAL) * *Marga et $. " Derrick by: Steven J. Derrick, Attorney in fact AUTHENTICATION ACKNOWLEDGMENT Signature(s) Steven J. Derrick and Margaret M. Derrick by: Steven J. Derrick Attorney in fact STATE OF ) authenticated on,, 24 d, t U ) ss. COUNTY ) *Kristina O land Personally came before me on , TITLE: MEMBER STATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Ogland Notary Public, State of Hudson, WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO -PROT Legal Forms 800- 655 -2021 www.infoproforms.com � v U 2 9 3 9 P 17 8 8 1 3alZa KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI Document Number Document Name RECEIVED FOR RECORD 12/05/2005 03:20PH WARRANTY DEED THIS DEED, made between Steven J. Derrick and Margaret M. Derrick. husband EXDPT t and wife R£C FEE: 11.00 ( "Grantor," whether one or more), TRANS FEE: 140.70 COPY FEE: and Kenneth W. Lauer, CC FEE: PAGES: 1 ("Grantee," whether one or more). Recordir Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Estreen & Qgla Lot 2, Cherry Knolls. St. Croix County, Wisconsin. f 304 Locust Street J3 H udson, Wf 54016 026 - 1149 -00 -002 Parcel Identification Number (PIN) This is not homestead property. (is) (is not Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any Dated ( 4 ( U (SEAL) /_ (SEAL) * *Steven J. a rick (SEAL) (SEAL) * *Marge t . Derrick by: Steven J. Derrick, Attorney in fact AUTHENTICATION ACKNOWLEDGMENT Signature(s) Steven J. Derrick and Margaret M. Derrick by: Steven J. Derrick. Attorney in fact STATE OF ) authenticated one d ) ss. COUNTY ) *Kristine O land Personally came before me on TITLE: MEMBER STATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Oeland Notary Public, State of Hudson. WI 54016 My Commission (is permanent) (expires: 1 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 • Type name below signatures. INFO -PROTM Legal Forms 800. 855 -2021 www.infbproforms.com