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HomeMy WebLinkAbout026-1155-27-000 Wisconsin Department cF Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463015 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 Permit Holder's Name: City Village X Township Parcel Tax No: Baumann, Jerome I Richmond Township 026- 1155 -27 -000 CST BM Elev: Insp. BM Elev: BM Description: SectionlTown /Range /Map No: 9. 3 11U -- 3 22.30.18.1190 TA K INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic — Benc rk Dosing Alt. BM Aeration r Bldg p u3 6S 71 q S Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet S �8 TANK TO P/L WELL EBLDG. Ven ROAD Dt Inlet 5�G� Septic / �} t Dt Bottom 1� � Dosing - Header/Man. S 3 Z r �6c� 6 L7 Aeration Dist. Pipe O o Holding Bot. System -7 a� t( VtokoC / Final Grade �.0 I PUMP /SIPHON INFORMATION NA�/l • .-.� 6211 'a CO s ,.5' Manufacturer Demand St Cover ' / 5 3. GPM s Model Number TDH Lift Friction L Head TDH Ft Forcemain ngth Dia. Dist. to Well SOIL ABSORPTION SYSTEM 2 f o ✓ - / BED/TRENCH Width - / Len th / No. Of Trenches PIT DIMEN NS go. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WE LAKE /STREAM LEACHING anu re _ INFORMATION CHAMBER OR Y Type Oys ^ tem ` : ' �� / f l/0 f' u V • \ � 1 � u Mo li!'.` N f7-c.�c -uc DISTRIBUTION SYSTEM 2LJ 4,4- Vc 2,f4- dYl Hea Manifold istributionn II (( x Hole Size x Hole Spacing V it Intak Len th Dia / Length Dia Spacin 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 Bed/Trench Edges Topsoil Yes [] No Yes [ No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1:10/ Inspection #2: Location: 1486 128th Street New Richmond, WI 54017 (NE 1/4 NE 1/4 22 T30N R1 8W) Pondview Meado II Lot 27 Parcel No: 22.30.18.1190 1.) Alt BM Description ��' 1 l,(lCCfG� X4_ 2.) Bldg sewer length = (`� - dtn) YI6 b, � amount of cover 77/J �Plan revision Required? j ] Yes �o JL Use other side for additional information. SBD -6710 (R.3/97) � Date Cart. No. Safety and Buildings Division County r Iv ��W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) ns,n (608) 266 -31,51 Dep artment Of Commerce State Plan I.D. Number Sanita ern App M In accord with Comm 93.2 1, Wis. Adm. Code, person Project Address (if different than mailing address) may be used for secondary purposes Privacy 1 xin i I2 I. Application Information - Please Print All Information �' _ —27 _ app 0 Property Owner's Name T CROIX L Parcel # Lot # Block # ZONING OFFICE -°� Property Owner's Mailing Address 7/ Property Location /'�,3 b 71 Property S *' 10 r__ %., P 4, Section _ City, State Zip Code jPh Number / LU 7s j� ' - 6* T 3 (� N; R /�li W II. Type of Building (check all that apply) S Su tvisio Name CS Number A or 2 Family Dwelling - Number of Bedrooms u ❑ PublkXommercial -Describe Use ❑City Ilige ownship ❑ State Owned - Describe Use III. Type of Permit: (Check only one box on line A. Complete line B if applicable) — 60 A. New System 13 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System List Previous Permit Number and Date Issued B. [I Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner IV. T of POWPS Sys tem: Check all that a l — )(Non - Pressurized_ In- Ground 13 Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At Grade ❑Single Pass Sand Filter O Constnreted Wetland ❑ Pressurized In -Ground ❑ Hotding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter Recirculating Synthetic Media Filter Leaching Chain ❑Drip Lin ❑ vel -I s Pipe ❑ Z er explain) V. Dis rsaLiTreatment Area Information: �L P� tun Elevation r Design Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required (sf) Dispersal Area Pro e d (sf) ys / �' W / VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stee Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 2SQL Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS Shown oa the attached plans Plu Nam (Print) Plum Si lure M PRS Number Business Phone Number U-4-/A 6 3� 7� Plumber's Address (Street, City, State, Zip Cod ) Vlll. Countyl De artment Use Only g o Stam s Approved ❑ Z Sanitary Permit Fee * cludes Groundwater Date Issued PiSSuir Si nature (N P ) PP Surcharge Fee) ❑ iven R n for Denial n IX. Conditions of Approval /Reasons r Disapproval 31 � S eC �V rr SYSTEM OWNER: / 1 Septic tank, effluent filter and dispersal cell must all be serviced j maintained AA /� as per management plan provided by plumber'. �) ! vo 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on not teas than sIR x 11 inches in size SBD -6398 (R. 01/03) 9Y Y s 9y, So' r r e 0, C O� s Y r r G e h< CD wC _ 1 Wisconsin 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 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. ' viewed b Please print in ep ly Date Personal information you provide may be used or secon ar, purposes ( D Law, s 15.04 (1) (m)). Prop" 2 r0 Location C Pro Owner L ` FEB 8 2003 ovt Lot U L- 1 /4,&C 1/4 S Z Z T 3 Q N R J f E (or)Q Property Owner's Mailing Address I of # Block # Subd. Name or CSM# ST. CROIX COUNTY J �6 Ad i 6W At micGAI S City State Zip Code Phum No, be. City ❑ Village (jj Town Nearest Road .tm.j C th#&4 w ( i S161 (7i5 )Z S`2s 0 4 ct 6— New Construction Use: 0 Residential 1 Number of bedrooms _ _Code derived design flow rate _�s� SG.Q �_ GPD ❑ Replacement ** ❑ Public or commercial - Describe: - - -- �� - Parent material L Li' - -� _ Flood Plain elevation if applicable _!G : ` ► _ —_ —___ ft• General comments S y� M and recommendations: �d -� q / L t 0, 77pd/4 / _ 1 d �b�tJ (:Vt QQ F- 1 E] Boring Boring # ® p Pit Ground surface elev. / ?' ? C) _ ft. Depth to limiting factor in. Sod 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 © -12 1 — Sr 2 c ivy 5 2 - r 2-So /p y — Sic / Zrrrl -L c S � o`' Boring # Boring ? Pit Ground surface elev. / po 1 • V ft. Depth to limiting factor _(2 _ in. S ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Efl1#1 "Eff#2 i v i4 r 3%2 — S i 2 C 5 V -' 2 l4- � lv, /'-( — s; i 2- naCc s — 4 Effluent #1 = BOD > 30 220 mg/- and TSS >30 < 150 mg/L " Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) S' ture CST Number z s 330 Address Date Evaluation Conducted Telephone Number Z ll v -mil` Sorr"r S:24 Sya 1 e-" OZ ?� - -Ly7 '00 , L Property Owner _�c V-',-ck - -- Parcel ID # ------------ - - - - -- Page _ - of Y Boring # El Boring f p ® Pit Ground surface elev. _i!' � -__ ft. Depth to limiting factor -12 —_ in. - §o1 - - APpfiw&w Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfP in. Munsel Qu. Sz. Cont Color Gr. Sz. Sh. (1 ( 'Eff#1 I 'Eff#2 Z !Z Iq i ❑ Boring # ❑ Boring - ❑ Pit 'Ground.surface elev. ft. Depth to limiting factor _— in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring F-1 Boring # Ground surface elev. ___ —_ —__ ft. Depth to limiting factor _ — in. F1 pit Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 220 mg/L and TSS >30:s 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 2648777. ssD -8330 (R.07/00) l PAGE_OF TAM P< r LOT# r LEGAL DESCRIPTION N E X QE ,S 2 Z T 3o ,N,R, /8 E(or)� SCALE: V= y0 r — BM 1 ELEVATION /d6. o BM 1 DgSCRIPTION BM 2 ELEVATION BM 2 DESCRIPTION fj4 -sl.a/ eo co ec ' Z Z' I SYSTEM ELEVATION F-7,36 I SYSTEM TYPE ('a A.. c ,4 b n ip. CON OUR ELEVATION K a S4 D-e 00 r J9 SIGNATURE DA� �� z POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity a l [3 NA Permit # 3 �- 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 a l ❑ NA Estimated flow (average) QCr7 g al/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer ❑ NA Soil Application Rate g al/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 kin- 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) [3 NA years) / j ❑ month(s) [3 NA Clean effluent filter At least once every: r years) Inspect pump, pump controls &alarm At least once every: ❑ month(s) [3 NA ❑ year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page y 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 of 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: F1 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 ey alua n t aiva i s o v a ttabW a o ing tank b e ai a '99D441817FA A/$b✓ LONS"TRUC -1 ❑ 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 r Name Q. Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY E e Name S , ( e) ne Phone /S— This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54111. (2) & (3), Wisconsin Administrative Code. J 2 6 4 2° 5 2 1 7-7 a4ss CI STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX GO., WI This Deed, made between Loren D. Derrick, Rase H. Derrick, RECEIVED FOR RECORD Richard L. Derrick. Joan L. Derrick and Robert J. Derrick 09/24/2004 il:550 Grantor, WARRANTY DEED and Jerome D. Baumann EXD PT li Grantee. REC FEE: 11.00 Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 121.58 the following described real estate is 5t. roix County, State of Wisconsin COPY FEE: (• space is needed, please attach addendum): CC FEE: PAGES: i , Pond View Meadows H in the Town of Richmond, St. Croix ounty, Wisconsin. Recording Area Nance and Rep�rttiA�4� VA � CV BMr NA C 255011 .G H 1 a /l nleyy r DROadri1� PO Box 70 Hudson,VA 54098 026 - 1065 -10: 026 - 1065 -30; 0264119 -20 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. d 2004 Dated this day of AugN t Robert J. Derrick en D Derrick * Richard L. Derrick * Rose H. Derrick * Joan L. D errick AUTHENTICATION ACKNOWLEDGMENT Signature(s) L oren D. Derrick, Rose H. Derrick, STATE OF _ ) Richard L. Derrick, Joan L. Derrick and Robert J. Derrick ) ss. County ) authenticated this - !4(0 day of Amt 2004 Personally came before me this day of the above named * Kristin glare _ •_._ - - - -- -- •------- ...__ - -- _.______ _..- _ -__ -- - - -. __. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ _ _ _ _ to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland * - -- - - - - -- --- ------- - - - --- - -- - -- - - -- ... ............ .................. Hudson, WI $4016 Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co.. Fond du Lac, WI STATE BAR OF WISCONSIN 800-655 -2021 WARRANTY DEED FORM No. 2 -1999 i ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND ' . OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address P 3 0 q© Property Address 7 (Verification required from Planning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location 1 /4 , %V ,F '/4 , Sec. T (D N Rf , Town of 54�� )e2,c Subdivision � n d d Lot #. Certified Survey Map # , Volume , Page # Warranty Deed # 2 7 3 V,5 J , Volume , Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. 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 Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Department within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the prope described above, b of a warranty deed recorded in Register of Deeds Office SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. • L D D 4 a (� O U p 6 oU aj .to•sb _ '8L•�LOL. M.gv I 'qL&ft ,06 I .ZL•sa% ,�9 sst j U9 1) a �. ¢ co O Q D I % (� �' a mo � I . I jr u v \ Z °'I cl ° - ►� ............. . I v \ a� - Iq Q9 r "•sd� M. O I - . L3 LL W� �;--- U / oaf Cl �a I Ro Nv TI LL Q ��` I ....... �v WO� ��� / Wt 27 m W ` v c� G' / ¢ a d �4. N CO s•s I 6 CO aatsioolm a � a��r�daw • a W W tr 2 0 3 Q W m i' o W C9 V 3 2 N� Q o o Dom a >- W U o ui z � a _Y IkiOl Q i�W W �a oaW 2• z a z �. r, r, Mn z t o , to