HomeMy WebLinkAbout026-1135-12-000 Wwonsi<t "oepartmientotcomirm(ce PRIVATE SEWAGE SYSTEM County-.
Safety and Buildings Division $t. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) 1383851 anitary Permit No.:
Personal infomnawn you pmvioe may be used for secondary purposes [Privacy Law. s.15. (1)(m)).
Permit Holder's Name: ❑ City ❑ VillagK Town of-, State Plan ID No.:
P Collova, Richmond Township
CST SM Elev.: Insp. BM E ev.: BM Description: 4- Parcel Tax No.:
tm.v I I I L _D 1 :11.v* , C'e - riam 1 1 026-1135-12-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark `�; 3 D L60 cm
I
Dosing w eAl A It. BM
Aeration Bldg. ewer 8.6(o S , (o t ( !
Holding St /Ht Inlet `� •35 �(,`)
TANK SETBACK INFORMATION '/ Ht Outlet , Cl � IfI
q
TANK TO P/L WELL BLDG. vent to Air Intake ROAD Ot Inlet
Septic * -2o, NA Dt Bottom 7. `t9 9nn1. 31
Do 28 / Z.Sg� NA HeaderlMan. L - tv►S C[�h
Aeration NA Dist. Pipe • I 1 f
� c
Holding Bot. System 95
PUMP/ SIPHON INFORMATION Final Grade ISO 11
Manufacturer ( Demand S1 Cover
Model Number GPM
S TDH Lift ,a Friction System— TDH Ft
Forcemain Length I Dia. Zu Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length t No Of Trenches PIT No. Pits Inside Dia. Liquid Depth
D IMENSIONS 3 `� ;• IMEN I N
LEACHING Manu actur
SETBACK SYSTEM TO P/L i WELL LAKE /STREA CHAMBER t°
INFORMATION Type a f er ^
//�� �� �—"" OR UNIT r�y
System: LowVllr _X—'
DISTRIBUTION S STEM 5—Aq, p/P
ader / Manif ( Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length &M` Dia. � length Dia. in
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 Q No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present jnt+t(lection #1: O f / V /a (inspection #2: — 7 '`
Location: 1418 144th Street, New Richmond, WI 54017 (SE 1/4 SW 1/4 24 T30N R18W) - 243018942
Evergreen Overlook -Lot 12
1.) Alt BM Description = 6+41\ � 60-0. S tk ; � S
2.) Bldg sewer length = 2' c/ Q U
3
-amount of cove s l � G •.rmkkA+ lal - � - 4rww1v.S
�.r-
Plan revision required? ❑ Yes 10 No
Use other side for additional information.
$BD -6710 (R.3/97)
Date inspector's Signature Cert No
` %3FaZ
HIS 'S Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application Box 7302
1 4 4 cohsin Personal information you provide may be used for secondary purposes Madison, WI 1 5 53707 -7302
Department of Commerce (Submit completed form to county if not
[Privacy Law, s. 15.04(1)(m)]
state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County s State Sanit Permit Number ❑ Co Pr sous application State Plan I. D. Number
'3939-S
I. Application Information - Please Print all Information \ ' ' W Location:
Prop e Owner Name ;' PropertyLotion
J
-"l�� -tS�, 1 �L-*F• ' J � 1!4 � 114, Qq T 36,N, (&or) W
Property Owner's Mailing Address r. p Lot Number Block Number
Za s
City, State Zip Code Phon e4UWffide Subdivision Name or CSM Number
?ON4N6 Or1 < y_. \
II., Type of Building: (check one) ��� __ ❑ city
1 or 2 Family Dwelling - No. of Bedrooms : r""` "` I"~+S . t ❑ Village
❑ Public /Commercial (describe use):_
Town of
❑ State -Owned ✓ — •"z `iYu
Neazest Ro���
i
e'1 esl !
2 \ C a s Parcel Tax Number(s)
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. rl y;,z 6. ❑ Addition to
stem System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Un d ❑ Reci culatmg ❑ Other:
30 17
V. Dispersal/Treatment Area Information: ✓ �,� - �,
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 1 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS show n the attached plans.
Plumber's Name (print) Plumber igna re (no P' PRS No. Business Phone Number
i -drys
lumber's Address (Street, City, State, Zip Code) C L
IX. ounty/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu'ng Agent Signature (No stamps)
'A Approved ❑ Owner Given Initial Adverse Strigharge Fee) t[ r
Determination 22 S 2 %
X. Conditions of Approval /Reasons for Disapproval:
4LJ
`nerx Z. \ 6
SBD -6398 (R. 07/00)
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I L -Wnsin Department of Commerce SOIL AND SITE EVALUATION
Division of safety and Buildings Page .L of
Bureau of Integrated Services in accordance with Comm 83.09 , Ws. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and ®)
percent slope, scale or dimensions, north arrow, and location nce to nearest road. Parcel I. D. #
APPLICANT INFORMATION - Please P�ntrw infog ation. Re iewed by Date
Personal information you provide may be used for sec o " .,ry ¢urpose py/ . , s. 15.04 (1 j \(m)). M w & 2
Property Owner t Property Location
Govt. Lot 1/4Sk/1/4,SZ q T_ ,N,R E(or)(0
Property Owner's Mailing Address ( 5� raCH;< Lot -#",, Block# Subd. Name or CSM#
City State Zip Code a tyflone um er ` '11 City ❑ Villa e K-Town Nearest Road
\ r'
New Construction use: EerResidential / Number of bedroom Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: /"
Code derived daily flow & Q 0 gpd Recommended design loading rate bed, gpd/f? —/ - _ trench, gpd/ft
Absorption area required UU bed, ft / 6 0 0 trench, ft Maximum design loading rate bed, gpd/ff - trench, gpd/ft
Recommended infiltration surface elevation(s) �� • It (as referred to site plan benchmark)
Additional design/site considerations // ��•�5�
Parent material 41 U Ic'- a S v) Flood plain elevation, if applicable
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system V s ❑ u KF s El R s ❑ u El [- u ❑ s u
SOIL DESCRIPTION REPORT N, Cj, w 1 2cst3o
Boring Horizon Depth Dominant Color Mottles Structure GPD/ft
g in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots
Gr. Sz. Sh. Bed , Trench
m
Ground 5 Lo �S Z.�,:-, rn C-S J
elev.
c/ 9,46 - ft.
Depth to
limiting
factor
RS in.
Remarks:
Boring # I _
I Z rYbr > 1
2` Z /! 2 1Y k m c
( - cs S <o
Ground
elev.
9 ft.
Depth to
limiting
fa c�tt or
")I in. Remarks:
CST Name (Please Print) ignature Telephone No.
/- CC m Soh J =am ) 2-q7 o�g
Address Date CST Number
W1 5g 3 b
r
A
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.# a f I Z
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
nor
..::: 2
Zfflab m4� c.S
Gro 3 -%9 3 1 LrJ r CS L S W
/oc ft ,
Depth to
limiting S
fa r
in. 4G•a 82,E
Remarks:
Boring #
1 V4
h Z i -- Sr' ( 2 err (�
Ground �—
elev.
9 '
Depth to Z
limiting
factor
gLin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # CS
Z
`l0 CP L S Z F r rn c s to
Ground
elev.
9�LS ft.
Depth to
limiting ,
factor
V in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R.9/98)
PAGE_,�01'_-3
NAME C6 l rnrr>. LOT# 2 LEGAL DESCRIPTIONSE ' 45w'/ �g k ,N,R f gE (orjsy)
SCALE: I "= uo
BM 1 ELEVATION wc • J
BM 1 DESCRIPTION -Joe p '�� ep't �
BM 2 ELEVATION (00 .0 S
BM 2 DESCRIPTION o iT c P,'� ,,J! Ja 1'►ti
SYSTEM ELEVATION q(, I S
ALTERNATE ELEVATION 6 16 .1 §-
CONTOUR ELEVATION /ll/A '
� s IdPe-
SIGNATURE DATE (O _ ��_ C"C)
r
w'
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms 3
Design Flow - Peak (gpd) $'
Estimated Flow - Average (gpd) ao
Septic Tank Capacity (gal) 1 MID �
Soil Absorption Component Size (ft
Type of Wastewater DorYiestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) S z_ a&.
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank ,
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, See Beds S it Trenches, Privies or Portable
Seepage Seepage ePs Seepage eTr
P a P9 p9 � P9 ,
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
I
�. Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
r
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
-27 -01 09:43A P_O2
PAGE 4
Lk
ALTERNATE SYSTEM AREA AS S H HOWEN ON SOIL TEST, MUST BE LE FT UNDISTINRBED.
cQi
IF ALTERNATE AREA IS REPLACEMENT AREA MAY NOT BE FOUND.
ANY QUESTIONS PLEASE CALL
BRADY UTGARD ......... ..................(715)268 -6995
OR
ST. CROIX COUNTY ZONING .......... (715)386-4680
S T CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer IJ. H 0 V
Mailing Address — 70 1 5 00. C-
5 1 ,
9 C�
Properly Address L �{
5;�- A/" Rl 'c-fli►to,-j b w-r s o l
(Verification required from Planning Department for new construction)
City /Slate Parcel Identification Number
LEGAL DESCRIPTION
Property Location i14 ' /,, Sec. TQN_R 1 0 W, 'Town of 414tow
Subdivision VER e o Lot it 1
Certified Survey Map /E Volume Page It
Warranty Decd It 3 3 ,6-4- Volumc �S /o2 . Page //
Spec house ❑ yes ❑ tto Lot lilies identifiableXyes ❑ no
SYSTEM MAIN TENANCE
Improper use and maintenance of your septic syslcm could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic iank every three years or sooner, if needed by a licensed pumper. Wliat you put into the system
can affect the function of the septic tank as a treatment stage in ilia waste disposal system.
Tlra properly owner agrees to submit to St. Croix Zoning Department a ccrtificalion form, signed by the owner and by a
mraslerplunrber, journeyman plumrber, restricted plumber or a licensed pumper vcrifyimg dial (t) the on - site wastcwaterdisposal system
is in proper operating condition and/or (2) Oiler inspection and pumping (if necessary), lire septic tank is less than 1/3 full of sludge.
I/wc, (lie undersigned have read Ilrc above requirements and agree to maintain the private sewage disposal system widlr [(re standards
Ed forth, herein, as set by lire Department of Commerce and [lie Department of Natural Resources, State of Wisconsin. Ccrli(ication
stating that your septic system has been maintained must be completed and retuned to [lie St. Croix County Zoning Office w
da rc a year expiration date, illnin 30
GNATUI Or APPLICANT 41 /%/ v /
DATE
OWNER CI!.RT1rI
I (we) ccrlify that till statements o this forth arc true to the best of lily (our) knowledgd. I (we) our (arc) lire owncr(s) of
the opuly cribed above y virtue of a warranty decd recorded in Regislcr of Deeds Office,
IGNAIURE, OP AP LICANT
DATE,
* * * * ** Any information that is iris- representedmay result in the sanitary permit being revoked by the Zoning Dcparinren[. +• + + +•
** Include tulip ibis applicntlon: a slnmpcd warrant decd from he
Y t Regislcr of Deeds office
a copy of tine certified survey mop if reference is made in the warranty dced
I
it
08, ;00 TUE 11:35 FA1 715 366 4667 REGISTER OF DEEDS 0 001
4 i: 151 ti - ja2 42
STATE BAlt OF WISCONGIH FOMSa 2.. 19;q !
DoctuoentNunocf WA.RRANrYDEEJ) C0.►�1
off! k'(ai
This Dead, made Wman Steven d Derrick y f px
_
' Grantor. and P Collova Bui!dtrs, Inc., a Minacsota c- rP 0r 1 1Cn
—
Grantor, fcr a valuable considmilod, convoys to Grantee the
following dascrlWd teal cstata in $I, Croix Counly,
sw or W coosin (If more space)t n eeded, plake aweh addendwn);
Reo 111 Ates
Name d Rayuln
The 9outhrxst Quut:r of the Swtdtwrst quarter (SE' /{ at SW It.) of section g �
24 end that iwrt of the N h of Baction 25, lyiag Nordxrly of 140th Avenge
ALL in 7bwnsh W� ! 1
0N, Rana 18 Wds6 tit. Cr oix JOIh-
lP 3 g County, Wis consin, 00 µ,ms g� � s rt/ t) (ia
6XCEVT Pact of N K of Section 23 described as foll ows; Commencing at N � { XT - 0 � I y Q 93
ur corner of usdd SeWou 25; thsoos North 89 degrees 06 tylrwlda West on
North lint of acid 6a.tion 25;60 foci, lhaaoa South 01 degree 23 minutes
Walt 1353 (eet; ihattoe South 89 degress 06 minutes East 1290 feet; thence 26. 1071.40000 dt 24- 1072.70 - o00
North I delpe 23 minutes E 1351 foot to acid Noah Hat; them Notch d9 Paral ldmillicalon Nombet (PIN)
de3raw D6 minatas West on said N lino 687 feu to Py of Beginaing. st T►liI is out hoimb" wttFea7.
Crjix County, Wisccnsim 00 (b lot)
ExcVdOns to wumties: Ummcw. reatrictiers and righ4 -of way of rrctml, If any.
Dated this ) s� day of J •:...__., .._ , 2600
' e Strron tbereldt
AUTHENTICATION ACKNOWLEDGMENT
Signatl:fe(S) Scnen A Dorrick STATE OF WISCONSIN )
A „ County )
Rallrenlieat sh•a
IA- of Y_ , 3000
Pereonrtly coma befars me tLb day or
the above asnted
s MuktaOslead -- -° --
TITLE MEMBER STATE BAQ OF WISCONSIN
(ir %A'k to me known io be the person(s) who executed the romguing
euthor;se,s by $ 706.06, W lL St2u.) Instrument and acknowkd led Um earn..
711!1; INSTRUMHNT WAS D;LVI'lil) RY
n _ a � r��6ci �l"� Oelaed Notary P011%, Stale Df WISCUBSID a M r"' 1, l ty Co,„ mimlon is permancnt. (If not, state expiration date:
(SlpMvet al:N bt aP =Healed or wAvootedaul, Bath an not nauaw).) , ')
Nunes er Fermat S► Xg LS soy c4maity mast be typed cr prbuul telow dwk lissanrs, wsr.w trwurrr Gnr nr. s..s e� to wn
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