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HomeMy WebLinkAbout026-1149-00-009 0 CO) oI 3 'a n t7 c sr f ° Im ° eD cn 3 'v z W U1 N ? d. 3 y .°+ c o Z <W ICI A m �° y 0 3° C c C 0 O A N a df cn a �° CO ; CD 0� (p N i S 3 = y rn 4 o o. v s* A - S W lr d 0 v ID a (D (o y a �o O `° O i 7h CD o m p o ° w v_� A W F 3 CL CD 3 M Z 0 O cn a =r ti en to � 1 7 a of 0 3 ° d o x CA C O = a o' < , ° m O N N 9 d y 7 a .. G — N C _ + (D W z D) a a (D 3 7 _ Z CD 1 N cn O A Z n v n a A �?� o N CD d W V m W cn m C o x a Z ° m ao v y z x CD A I D a'a y _ a a 'o o 3 CD a A N _ c o -• a) CA a N C 1 W (D W v c 3 (D N N O CL < ay CL a b CD =r ti v m EL p ?a b CD aro v A C.A O w Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ' INSPECTION REPORT Sanitary Permit No: 430571 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: Derrick, Steve I Richmond Township 026 - 1149 -00 -009 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: I QD r6 0 (7 I �VvG 15.30.18.1114 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing _ ( Alt. BM DT. Aeration Bldg. Sewer 92. 35 Holding _ SbHt hlerr� rS 0. ,f -7D - R St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELD BLDG. Vent to Air Intake ROAD Dt Inlet — Septic / t / S Dt Bottom Dosing / Header /Man. V7 S Aeration Dist. Pipe Holding Bot. System ' g7 Fin I Gra e PUMP /SIPHON INFORMATION 0220( 1 JOY Sldt 5 - - 1 `j G• Y Manufacturer / I�( GP and Cover � / q S Model Number TDH Li / Friction Loss SystemZap T DH Ft Forcemain Leng Dia Dist. to Well I SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ' / 2 SETBACK SYSTEM TO P/L W BLDG IWELL LAKE /STREAM LEACHING Manufact INFORMATION HAMBER OR TO ✓ J �l Ty Of System: , / Model Number: DISTRIBUTION SYSTEM ICJ �� ' Header /Manifold Distribution x Hole Size x Hole Spacing Vent t o Air Intake 5 j L4 % jPi � � Length,j Dia Length Dia Spacin � 70 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only r Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center t Bed/Trench Edges Topsoil ( Yes ( J No Yes 1. No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_/� Inspection #2: Location: 1531 127th Street New Richmond, WI 54017 (SE 1/4 SE 1/4 15 T30N R1 8W) Cherry Knolls Lot 9 Parcel No: 15.30.18.1114 1.) Alt BM Description = !✓� 2.) Bldg sewer length - amount of cover = / / p C�Q -dJ1— "7�„�'" � �1��,�✓4�- Ci��"`J � I1,[.�lr� /�� %��0'n / Plan revision Required? ' IV Fil No Use other de for additional information. s L 1 SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division County FN *I 201 W. Washington Ave., P.O. Box 7162 sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) Sanitary Permit Applieati n S e Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informal n you r,Qytde may be used for secondary purposes Privacy Law, s15.0 (1)(m)IV U V 2 4 2003 pr 'ect Address (if different than address) I. Application Information - Please Print All Information ST. CROIX COUNTY f ` ZONING OFFICE IZ` Property Owner's Na me arcel # Lot # Block # Property Owner's M ailing Address Property Location City, State s Zip Code Phone Number �- tk k,Set non A GtJ ,`Gln �✓L4 .!/� �lJ ! Q' 7l S ' y �`�l -2 (/ T �.r , R cE ole�e) N II. Type of Building (check all that apply) J� 60 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ❑ Public /Commercial - Describe Use State Owned - Describe Use 2 'S K V ❑City , ki ownship of III. Type of Permit: (Check only one box on line A Complete line B if applicable )y 7fo _ ( _ ab _ 0 A. New 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 IV. Type of POWTS System: (Check ali that appl _ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil i_'i Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland D Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter j ❑ Recir culating Synthetic Media Filter VLeaching Chamber ❑ Drip Line ❑ Gravel -les ❑ plain) V. D i_ sper /Treatment Area Information: Design Flow (gpd} esign Soil Application Rate(gpds0 Dispe.sal Area Required (sY) Dispersal �RroSystem Elevation VI. Tank Info Capacity in Total Number Manufacturer Site Steel Fiber Plastic Gallons Gallons k of Units ( Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank t 2 su 6- t S(✓t� - - Aerobic Treatment Unit -- Dosing Chamber VII. Responsibility Statement- 1, the unde rsigned, assume re sponsibility for of the POWTS shown on the attached plans. Plumber's Na me (Print) AA�� '' Plumber's Si gnature PRS Numb Business Phone Number Plumber's Addre ss (Street, City, state, Zip Code) 161,7 67 VIII. Count /De artment U Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwarer Date Issued Iss ing Lentsignature (N Stamps) Surcharge Fee) ❑Owner Gi Rea son for Denial . � GJ IX. Conditions of Approval /Reasons for Disapproval , SYSTEM OWNER: 3 � O — 1 Septic tank, effluent filter and ` � �� ,•.,,, _ � `� � � dispersal cell must all be serviced / maintained Q 1 v " C j J 1 as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. ` Attach complete plans (to the County only) for the system on per tot Less tban 8111 It in0e size SBD -6398 (R. 01/03) � e a P'c Ao. b ey :T 7s / ,4j 7x X44 o� l Cop r oZ�'' c�.�6eys To7'e/ ,� = Tie ✓cd��� �✓ 11, 25V-44 �N Sr � 1 L Wisconsin Department of Commerce SOIL EVALUATION REPORT Page -Z— of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County r Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ` include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please prin ED R 'awed by Date Personal information you provide may be use or purposes (Privacy Law, 15.04 (1) (m)). Z,S Properly Owner party Location - 1 - 1 NOV 17 2003 T vt.Lot 1/4 1/4 S T N R E (or) W Property Owner's Mailing Address L t # Block # Subd. Name or CSM# ST. CROIX COUNTY ING OFFICE - city State Zip Code ❑ City ❑ Village ® Town Nearest Road New Construction Use: 9 Residential / Number of bedrooms — Code derived design flow rate 6 0 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Ov 4, u S Flood Plain elevation if applicable 14 ft. General con iniiii �,- 2 Z u and recommendations: v` E Boring # [] Boring ® pit Ground surface elev. 9lv 0 . ft. Depth to limiting factor //S in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fiz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 in-)Z I o -j(3 1z — SL msbL G S l u - 1e r'1 — S L ) ,n sb k 92.0 Z Boring # Boring pit Ground surface elev. ft. Depth to limiting factor in. FI cat lon 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 I o v a to r 3 Yy\�— e Effluent #1 = BOO > 30 220 mg/L and TSS >30 150 mgA- ' Effluent #2 = BOD < 30 mg& and TSS 1 30 mg1L CST Name (Please ) Signature CST Number ZS 3 G Address Date Evaluation Conducted Telephone Number 1 54 1' S / / - /r- 7/ Property Owner �`�` `^ 5 c'^ Parcel ID # Page z of _ F731 Boring # ❑ Boring /� Pit Ground surface elev. Ili , 30 ft. Depth to limiting factor 16 (a 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 6 0 /Z SL z /c, Z ►-3 6 /f/ 1 S , S - 3° F -1 Boring ° Ong ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F Ong # ❑ Ong ❑ Pit Ground surface elev. ft. Depth to WnWig factor in. Sal 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 Effluent #1 = BOD > 30 1220 mg/L and TSS >30 1150 mgA- • Effluent #2 = BOD, < 30 mg& and TSS 130 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. seo.9330OL6r00) f Prop" Owner �c� h vi S c v� Parcel ID # Page Z of F 3 ] Boring # ❑ Ong Pit Ground surface elev. G , 30 ft. Depth to limiting factor 1 4 (a in. �ication 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 6 -11 Z I -3 6 /f� — S L /e E # ❑ Bonne ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 a pit Boring # Boring Ground surface elev. ft. Depth to Uniting factor 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 Effluent #1 = BOD > 30 < 220 mg& and TSS >30 < 150 mglL ' Effluent #2 = BOD, < 30 mg& and TSS 130 rng1L 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. 3ND4 otRAMt PAGE 3 -OF-�- NAME: S yh n r` LOT# LEGAL DESCRIPTION :_1 /4_I / ^T_ , N , R , ,_ E(or)W SCALE: i ,, = �� r ..L. ELEVATION: too BM 1 DESCRIPTION: BM 2 ELEVATION: BM 2 DESCRIPTION: 1; . Ff SYSTEM ELEVATION: SYSTEM TYPE: (w✓��<rt��� q�'� 0 sib �c� DATE: SIGNA / -/� -� 3 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner s pE Q 1 L Septic Tank Capacity ZS'Q gal ❑ NA Permit # Z Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer I: ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A. --(OD ❑ NA Number of Public Facility Units )dNA Pump Tank Capacity al 2T A Estimated flow (average) jcm g al/day Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) C� gal/day Pump Manufacturer A Soil Application Rate al /da /ftz Pump Model A Standard Influent /Effluent Quality Monthly average* Pretreatment Unit E�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 I'Dn- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: y 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 QF-year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA 2 year(s) Inspect pump, pump controls & alarm At least once every: ❑ y A ' ❑ month(s) NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) PFNA At least once every: ❑ year(s) Other: 1e-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. Page of 2 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 tanks) 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. T aluat' g W191 . a o in ank be ' e ai a FfZD}418 � �Oi Al Co N STXcI Cat ❑ 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 W ( LU 4,v,&- 5C+4l Name Phone �(s, 312- Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name f5t c ( (7 Phone Phone � f — 3W( (0 C7 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54111, (2) & (3), Wisconsin Administrative Code. I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS E wner .5— C-0 e- be � 1 L Septic Tank Capacity 2SQ al 13 NA ;ff Z 6 Q 57 Septic Tank Manufacturer welsbf- ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer L ,` AO& L_ ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A --IUD ❑ NA Number of Public Facility Units )KNA Pump Tank Capacity al 2 TA Estimated flow (average) ov gal/day Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) 6em g al/day Pump Manufacturer A Soil Application Rate al /da /ft2 Pump Model O MA Standard Influent/Effluent Quality Monthly average` Pretreatment Unit 53 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 (BODJ 530 mg/L t 0on- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100mi ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Oder: ❑ 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 earls) 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: ❑ year(s11s) (Maximum 3 years) 13 NA Clean effluent filter At least once every: r ❑ month(s) ❑ NA 2 year(s) month(s) A Inspect pump, pump controls & alarm At least once every: ❑ year(s) ' ❑ month(s) NA Rush laterals and pressure test At least once every: ❑ year(s) Other. ❑ month(s) PFNA At least once every: ❑ year(s) Other I?-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 dispo$ed of in accordance with chapter NR 113, Wisconsin Administrative Code. AN 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. Page Z of ?� START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) 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: l _ 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. Iv alua ' a o ing ank b e ai �RD(d rl�a. ��- �� Co N S"TRU�D� ❑ 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 W t_L4 Avv,_ e✓{44lWl.JkKk-Q_ Name Phone �S, 5Rn . 317-1 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S G ( '20AIIN Phone Phone - 71 S— 3R40- 4o 0 This document was drafted in compliance with chapter Comm 83.22(2)(b)0)4d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. ~ ST CROIX COUIN SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer�� Address � S `� vi Mailing Property Address Ki (Verification required from Planning Department for new construction) T L "' ✓ °F ��ccJ �••� Parcel Identification Number City /State tr .xrr DESCRIPTION Property Location " 11� t /4, 5 6 - t /4, Sec. 1J . T ? e - N -RAW, Town of • • ,�, a L� S Lot # Subdivision Doc R- (0 8 q-9 SS" , Volume , Page # Certified Survey Map # Warranty Deed # 6 - V4 Z �, Volume 1$S g ,P # 3S} Spec house 2-yes ❑ no Lot. Imes identifiable 2-yes ❑ no SYSTEM MAM06BCE I use snd mainzenanoe of your septic system could result in its premature failure to ha wastes- �P m n YB m into cor>sist: of pumping out the septic tank every three years or sooner, if needed by a licensed pumper What can affect the function of the septic tank as a treatmew stage in the waste disposal system. no property owner agrees to submit to St. Croix Zoning, Department a certification form, signed by the owner and by a mastcrplumber, j0Vmu*manpiumber, restrietedplumber or a licensedpUaVerYed** that (1) the on site wastewatexdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fish of sludge. I/we, the undersigned have road the a requirtm=ts and &Stec to maintain the private sewage disposal system with the standards set forth, herein, as se the nt of Commerce and the Department of Natural Resources, State of Wisconsin. Certification thyg ur c ter has ma' ta d must be completed and returned to the St. Croix County Zoning Office within 30 days of ar �. _ DATE Si A OF 1 'UCANT I (we) certify that all statements on this form are true to the m be st of R e gi ster of Deeds OftTid e. I (we) am (are) the owmcr(s) of the property descr above, by virtue of a warranty deed rec ` DATE SIGNATURL OF APPLICANT + * ++*+ Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departme include w10 011 appltestion: a stamped wamaty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the war=ty deed Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 �YD co /���� Madison, WI 53707 - 7162 Sim Address �■ Dep artment of Commerce Sanitary Permit Number Sanitary Per '� NEB In accord with Comm 83.21. Wis. Adm. $10 provide ❑ Check if Revision may be used for aeco s 1 m State plan I.D. Number I. Application Information - Pieria Print All Informatio 3 1 parcel Number Pm owner's Name Property '� c� � 0 0 `� - 00 - co 71;? e e c N Property Owner's Mailing Address o OO2 Property Location td �6 V4: S T N. R lS ��✓ ✓ Lot N Block Number Zip Code r�, City, State � �� . � � , , � � ._ Subdivision Name CSM Number II: Type of BuUding (check all that apply) OCity X1 or 2 Family Dwelling - Number of Bedrooms 4 ❑Village ❑ PubWCommercial - Describe Use ❑Townshi rG v? Nearest Road ❑ State Owned r � � 3 t JG applicable) M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). For Count ount e. t a if app A. I gNeW 2 ❑ Replacemient System 3 C1 Replacement of 6 ❑ Addition to stem Tank Onl Exis ' S stem Date Issued B. ❑ Check if Sam Permit Previously Issued Permit Number IV. 'Type of Permit: (Ghee that apply) (numbering scheme is for internal use) 5o C1 Constructed Wedanci 44 Non - pressurized In- round 2111 Mound 47 ❑Sand Ftlt e 48 El Single S 51 ❑ Drip Line Holding Tank g 22 ❑Pressurized I n -Gmund g 46 ❑ bic Treatmen Unit 49 11 R elating 30 C1 Other 45 11 At -Grade V. Dis erasillTireatment Area Information: ,�Z 7a�/ s' Design Plow (bpd) Dispersal Area Dispersal Soil Appli on Perc dOn System El on Final Grade vation Required Proposed Rate(G ays/Sq.Ft.) 7 / �U Si Fiber plastic VI. Tank Info Capacity in Total Number OF M anuTANW3 Co etc Glass Gallons Gallows of T New Existing Tanks I Tanks a Septic or Holding Tank I - Q. OF `G Dosing Cttamb" assume res ndbllity for n a POWTS shown d the tmdersi im VII. Responsibility Statement I, s Number . RS Num a Nam t Plumber tgnature P Pitunber' (Pr1n ) 3 G 3 Plumber's Address (Street. City, State, Zip C e) VIII. Co 1Do ent Use O Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) El Approved ❑ Disapproved Surebarge Fee) ❑ Owner Given Initial Adverse . Determiaadoa r , ` n IX. Con of ApprovaURaasos>g for Disapproval �— vw� 1� 4'�' ad I to tha coca od7) tar tie s7rtens as Papa' Ins um x 11 laeha >4 size Attach eanplata &W ( t7 SBD -6398 UL 05101) �, t ti- '; 4 �" ��#. � • � �, � � „� �� �+ At.. ��` = � F -�� � , �,, � �� Y 4 y .. °` �`: .116f /-j c- pe D� 1 d 1 • Dl ,j f i I • i , �,,7Z 1 n Ago Wisconsin Department of Commerce SOIL EVALUATION REPORT Page i of 3— Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County L^,� Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot SF 1/4 h /4 S �� T N R E (or) Property Owner's ailing Address Lot # Block # Sub 'ame or CSM# City w t ate Zip Code Phone Number ❑City ❑ V ge [ Town Nearest Road �Jrcv S�fo� (�• S ) z y� 3izo * New Construction Use: [� idential / Number of bedrooms 3 iv - Code ed design flow rate a O � GPD ❑ Replacement 1 El or commercial - Describe: Parent material t d (� Flood In elevation if appli 7REC ft. General comments S'�/ 5/t vr\, \--u 93, So IVED and recommendations: 14 - 3 2002 As UHO IX COUN M T' Boring # ❑ Boring Q ZONING OFFICE Pit Ground surface elev. ft DepthQ limiting factor + in. A ca ate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary in. Munsell Qu. Sz. Cont. ColorAk Gr. Sz. Sh. ff#2 2 1 -`18 16 31' — S L 2 b -- TZ a Boring # ❑ Boring O Pit Groun urface elev. [ 90 ft. Depth to limiting factor E in. Soi ppf n Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenc Boundary s z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff# I a--IZ 10 14r 3 5L Z c- 2 1 --8 id SL Zm-s c -S IN4b 3 -yg 10 Ica -- m5 c — .2- N$ -I 16vil-liho S r I -- Z * 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 Ct N'� G w G 3 O Address Date Evaluation Conducted Telephone Number SBD -8330 (R07 /00) Property Owner >mc-k, Parcel ID # Page Z of 3 3 Z Boring # ❑ Boring G ® pit Ground surface elev. / r yy ft. Depth to limiting factor �0 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 o -12 3 3 sL 2-ms mP- c- i v-' . 5 2 12 3D I -- S L Ztns r c 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 1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 '7M F-1 Boring # ❑ Boring G ❑ Pit r and 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 w R, `n * 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) * 4 PAGE 3 OF 3 NAME �� r � - LOT# 1 LEGAL DESCRIPTION 5E XS� X ,S) S T 3,N. . / E(or SCALE: I"= - BM I ELEVATION BM 1 DESCRIPTION {S o BM 2 ELEVATION T9 Z 0 BM 2 DESCRIPTION - /a0 o -f- / t-- SYSTEM ELEVATION 7-3.5 � ALTERNATE ELEVATION I3 ,-d — -I CONTOUR ELEVATION 98, O 9 $. O O a) � 0 0- Z Z 076 &3 � (1 SIGN TUBE DATE /2- 3 O L . Z.■ � < ! .� . ■ �� _ .P f - ©f �° ■ ^` � � U 1858P 387 6 - 7 , 4 2 1 9 WARRANTY DEED KATHLEEN H. YALSH Document Number REGISTER OF DEEDS ST. CROI CO., M1 This Deed, made between CRAIG R WARREN and LUCILLE R RECEIVED FOR RECORD WARREN 03-21 -2002 1:15 PH husband and wife Grantor, EXE)PT I DEED 1fElPT t AND STEVEN 1 DERRICK REC FEE: 15.00 TRANS FEE: 60.00 G COPY FEE: Grantee, CERT COPY FEE: PAGES: 3 Witnesseth, That the said Grantor, for a valuable consideration of one Recordin Area dollar and other valuable consideration, conveys to Grantee the following Name and Return Address described real estate in St. Croix County, State of Wisconsin: This is not homestead property. ROBERT F WALL Together with all and singular the heredilaments and appurtenances 522 SECOND STREET thereunto belonging; And Grantor warrants that the title is good, HUDSON WI 54016 indefeasible in fee simple and free and clear of all encumbrances except easements, covenants, and restrictions of record, and will warrant and defend the same. (Parcel Identification Number) 026- 1046 -20 -000 SEE ATTACHED DESCRIPTION aced this day of __, =? 20_C CRAP WA EN ILLS R WARREN AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF COUNTY OF ST. CROIX Personally came before me this a authenticated this _ day of the above named CRAIG R _R WARREN to me known to be the person(s) }i0 eiKcuted th4 foregoing Signature inst ent and ino, I dge the L .v+ ifil type or print name a+ nature I 14OWy Pub a Ot W� SI Mfpgitt55< R 200 type or print name TITLE: MEMBER STATE BAR OF WISCONSIN trtrl5�f ... (If not Notary Public ST. CROIX County — authorized by §706.06. Wis. Stats.) My commission is permanent. (If not, state expiration date. THIS INSTRUMENT WAS DRAFTED BY __ ) Robert E. Wall 'Names of persons signing in any capacity should be typed or printed below their signatures. U 1858P 389 A parcel of land located in the NW' /. SE%, NE' /. SE' /., SE' /. SE'/., and the SW %. SE' /. of Section 15, T3ON, RI 8W, Town of Richmond, St. Croix County, Wisconsin, described as follows: Commencing at the S % corner of said Section 15; thence NO* 14'36 "W (assumed bearings referenced to the monumented East line of said SE'/. of Section 15, bearing NO °37'40 "W) 707.67' along the monumented N -S A Section line (previously recorded as NO* 14'30 "W) to the point of beginning; thence continuing NO °14'36 "W along said line 1922.33' to the monumented center of said Section 15; thence N89 °56'20 "E 1872.44' along the monumented E -W %, Section line to the West line of that Certified Survey Map recorded in Volume 4, page 927; thence SO °37'E 430.00; thence N89 °56'20 "E 60.00'; thence SO °37'E 1378.45'; thence S89 °47'W 372.25'; thence SO °37'40 "E 175.00': thence N85 °59'40 "W 900.39'; thence S89 °47'06 "W 675.57' (previously recorded as S 8947'W 675.71') to the point of beginning, subject to all easements and restrictions of record. The parcel conveyed is added to Derrick's existing parcel to create a single parcel. Warnn DerrkkDeedDesc -07 SA T �2�E g11.2 Y2 o� 139• � 3 0 � w N I N 6 L C4 C4 id � I � se• i� s - - — �19str / � I � � • �l - .�n tZi Ave, Z I ol ^ / CL a MOVE / ♦ o C4 1_ Nn i ce/ I / � �// •'