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HomeMy WebLinkAbout026-1135-14-000 Wisconsin Department of Commerce County: PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 383854 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: P.C. Collova Builders, Inc. I Richmond Township 026 - 1135 -14 -000 CST BM Elev: Insp. BM Elev; BM Description: / Section/Town /Range /Map No: CCU :co c� .� ! ( PUG 24.30.18.944 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ADS 10b-o Dosing Alt. BM e -S � 5.31 IC) /•2� Aeration Bldg. Sewer to •ro 1 34 - sS Holding St/Ht Inlet , TANK SETBACK INFORMATION St/Ht Outlet 2,2. `lS •�43 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet r J/.zS `1ST Septic , I Dt Bottom Dosing / , Header /Man. i b 20 q•o� 4�•io'� Aeration Dist. Pipe B)' 1 �F Holding Bot. System r PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length I Dia. rf Dist. to Well SOIL ABSORPTION SYSTEM (IS) Q„ BM41BMCD Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 I 93 � C2 ) SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer. INFORMATION 4 CHAMBER OR Type Of System: I G r > 1 CA I — UNIT Model N u 6bgr: V. 19 7 anQ� DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size Ix Hole Spacing 7to if Air Intake !( Pipe(s) Length�e �. Dia C L Dia Spacing 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 To soil 0 �ti g p Yes No E] Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ya / 3I / O ( Inspection #2: i -- -- Location: 1438 141st Avenue New Richmond, WI 54017 (SE 1/4 SE 1/4 24 T30N R1 8W) Evergreen Overlook Lot 14 Parcel No: 24.30.18.944 1.) Alt BM Description = _� d "Q, AOWT �Be✓�t2rU t� a^ V*rY C�i `Q ) 2.) Bldg sewer length = 26 I V n � amount of cover = 24 t s« I cpoiz, 7 o Ll I I ; ' � cQii•. IVl �t4D NHS PI n visequired? a ''" No Use other for additional in ormation. L D to Insepctors Signature Cert. No. SBD -6710 (R.3/97) l,a � d SAe4iik tAAAW— 5t- U ' q,3 Pa 7 3 �c� �'— 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 PO Box 7302 isconsin Personal information ma ou p rovide be used for second p ur p oses Madison, WI 53707 -7302 Department of Commerce y p y p rP [Privacy Law, s. 15.04(009].__„ (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) fgr,4he`system on paper ndt.)ess than 8 - 1/2 x 11 inches in size. County States Sa�ni Number 4 eek if revisior to previous Nication State Plan I. D. Number ,� �' Lev --��.. J O J O � �• ,,,� -�. I. Application Information - Please Print all Information �L-T•._ Location: Property Owner Name I Property Location 7.(11 j 1/4 5tV(1/4, S3 T. IN, iV (or) Property Owner's Mailing Address, ­.J Lot Number Block Number City, State Zip Code Phghi Number , Subdivision Name or CSM Number Hu- 11. Type of Building: (check one) --> ❑ city 1 or 2 Family Dwelling -No. of Bedrooms: ❑ Village ❑ (Town of Public /Commercial (describe use):_ ❑ State -Owned �w Nearest Road ( I - C Parcel Tax Number(s) C✓ III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) C) - - % .5 U Ea 0 A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. '/ 6. ❑ Addition to System System Tank Only of T Existing System $) C3 Permit Number Date Issued A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) KNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit Rectr lating 11 Other: :3f�� 17' I V. Dispersal/Treatment Area Information: — Cs 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Ra (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 S ICC _� /Cc' / c �.i w�< ❑ ❑ ❑ ❑ VIIL Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS sh wil on the attached plans. Plumb 's Name (print) Plum is Si g ture (nos s ): P PRS No. Business Phone Number SAW Plumber's Address (Street, City, Sta Z'p Code) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surch ge Fee) do t Determination X. Conditions of Approval /Rea ons for Disapprov 1: - s r % — !� s� ce rvu t c . ►Ma�� 1 s c�� � n�-arh e� c��, �. vw►,.�,µ.Qo►.�;�nf -•�s r e.�a,nn �e� t�.5. SBD -6398 (R. 07/00) r jCGC� 57 - Ol 7 c/ l.3lu _ / 00,05 T l I //~ - 1 5 T )CO / sa ~-- / � - � � � Wisconsin Department of Commerce SOIL AND SITE EVALUATION 4 vision of Safety and Buildings Page of oureau of Integrated Services in accordance with Comm 83.09, Wis. 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 C percent slope, scale or dimensions, north arrow, and location nce to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please 604)1 info nation. Reviewed by Date Personal information you provide may be used for seco darySurposerf s. 15.04 (1) (m)). ' --- K Property Owner Property Location ?c:,+ (o11c� �i' a4 Govt. Lot S ,E 1/4 cJ 1/4,S,;'4(' ' T ? ,N,R (� E (or) (g Property Owner's Mailing Address a y�i j Lot.# ;' Block# Subd. Name or CSM# � d „OUNTY E�:�,' Ever ,rem (per -look City State Zip Code � um er City ❑ Village Town Nearest Road ti vi a wcl GtJri /o �i [ff New Construction Use: Residential / Number of bedrooms 3 - Y Addition to existing building ❑ Replacement �.-� ED Public or commercial - Describe: � Code derived daily flow L C) gpd Recommended design loading rate - bed, gpd/ft trench, gpd/ft Absorption area required ZZO d bed, ft / ttrench, ft Maximum design loading rate - bed, gpd/ft2 " ( �,, trench, gpd/ft Recommended infiltration surface elevation(s) / li• 1 � ft (as referred to site plan benchmark) Additional design/site considerations v Parent material e3 U +t,_ Gk S t\ 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 �S ❑ U S [] U S El S El El E] S P" 11 SOIL DESCRIPTION REPORT tj Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots Gr. Sz. Sh. Bed , Trench i Z 1413 e__5 (� s Ground 3 30 l l� `� ` elev. ]S3 ft. Depth to limiting yZ, g(, Q . 3 factor _aQin. Remarks: Boring # , b -12 i 0 ZmabL 64, 31- d LAILI L Ground elev. . Ca a ft. Depth to limiting fa n _ in. Remarks: CST Name (Please Print) nature Telephone No. A6Gm Address Date CST Number - Zt�s 5�0 C�-1 - zSI>361 SOIL DESCRIPTION REPORT PROPERTY OWNER 1 ® Page, of PARCEL I.D.# D 1 T Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench tb r 31z 5;1 Zn - m�c ! J 15-40 I' Ground c i ( ��� �� �—S 2 tJ�� CS ✓ 7 , . elev. � •�3 e ft. �" , Depth to limiting QG factor `1 I in. x{2.36 �8 • �. Remarks: Boring # a �Y � :> a i a —� � icy r J � _---• � l Zmo� fir c=5 i v -� . 5 ' (� 3 q8 r �5 I �Se� m1 C5 — S Ground elev. Depth to 47- limiting factor �in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # J t5 Z 511 ZlnabL ff�ff C5 VIC Ground elev. Depth to 2'O / - limiting ; M f t fa for in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) PAGE__ OF NAME CO l (0 UCH LOT# . 14 LEGAL DESCRIPTION.5F- ' /t.� /4,af T ,N,RlR E (or)�D , ' - SCALE: F'= U 0 BM I ELEVATION /00 ' BM 1 DESCRIPTION .,eoa 1 i p Vc- e Pe 647 /ok r BM 2 ELEVATION lOU • BM 2 DESCRIPTION t J/ /,* 1 SYSTEM ELEVATION q6. 3 y 3d ALTERNATE ELEVATION g6, � CONTOUR ELEVATION j �fL4 � F61 7 �� SIGNATURE - DATE lO I f 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 S Number of Bedrooms 3 Design Flow - Peak (gpd) `/ Estimated Flow - Average (gpd) S&..) Septic Tank Capacity (gal) Oc) Soil Absorption Component Size (ft2) r % Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absor tion Component Design Flow - Peak (gpd) 4� Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 7777 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, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable 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 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 i r , • o 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 in t intrusion into the com component may component should be avoided since roo Y obstruct wastewater p P flow. 3 Apr -27 -01 09:43A P 02 PAGE 4 ALTERNATE SYSTEM AREA AS SHOWEN ON SOIL TEST, MUST BE LE FT UNOISTI�RBED. als� IF ALTERNATE AREA ISOMTE ED, REPLACEMENT AREA MAY NOT BE FOUND. ANY QUESTIONS PLEASE CALL BRADY UTGARD ........ ...................(715)268 -6995 OR ST. CROIX COUNTY ZONING .......... (715)386-4680 ST CROIX COUNTY SP_1''I'iC TANK MAINTENANCE AGREEMENT AND AND OWNERSIIIP CERTIFICATION CORM Owner /Buyer 11 -VA 8 1,1 r1 S X-1 c_ Mailing Address - 7 06 w . Al C— 1 u -v L V Z Properly Address ! ►!`Q �(/ R f j dux s Q/ (Verification required from Planning Department for new conslruction) City /Slate Parcel IdentiGcatio►t Number LEGAL DESCRIPTION Property Location y + , SW y,, Sec. r 0 p ©� N -R �0 W, Town of �[-1W4%OAld Subdivision E VE:tq (I , CEP— V o t/ 'CA. 10 0k Lot It 1-4' CertiRed Survey Mal) !s' Volume , Page It Warranty Deed It &A 3 3 S"4- ' V01111110 1512 Page ll Spec !louse ❑ yes ❑ no Lot lines iticntiffableXes ❑ no SYSTEM MAINI ENAP C 1 Improper use and nnainlcualnccof your scpte syslcm could result in its premature failure la 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 tic syslcm can affect (lie function of the septic lank as a treatincnt stage in the waste disposal syslcm. 1 11C properly owner Agrees to submit to St. Croix Z oning Dcparllllcllt a cettification fault, signed by the owner slid by a maslerplumber, jountcynla11 pluutber, restricted plumber or a licensed pumper verifying lhat (l) the on -site wastewater disposal sysicul Is in proper operating condition and/or (2) after inspection and puulping (if necessary), the scplic lank is less than 1/3 fitll of sludge. Uwe, file undersigned have read the above rc uirenr q cuts and act to maintain the private sewage disposal system with the standards set forth, herein, as set by the Dcpartnteilt of Commerce and the Department of Natural Resources, State of Wisconsin. Cerliflcatio 1 staling that your scplic syslcm has bccu maintaincd must be completed and returned to file St. Croix County Zoning Office within 3 days 1c c yea ion dale. o GNATURL� OP APPLNT' DATE OWNER CE UrWICA'I'rON I (we) cctiify that all slalements on this form arc (rue to (lie best of my (our) knowledge. I (we) pill (arc) the owr►cr(s) of the perky scribed ab ve, by virtue of a warranty decd ►ecorded in Register of Deeds Office. GNAIURII. OF APPLICAN'r DATE * * * * ** Any information that is Luis -t presentednnay result In ante sanilliry permit being revoked by the Zoning Department. *•• +•• Include walla tills applicallou: a stamped watianty dccd from the Rc istcr of Deeds office f(icc a copy of the certified survey map if tefcrence is made in the walrauty (Iced 09,'05r00 TLIE 11:33 FAT 713 38d 4687 REGISTER OF DEEDS C( 001 1 51;► w E2 42 ' SPATE OAK OF WIStbNGtyl FOkk 2.104 Z344 COY DoaweraNunoer �y' T'YDgE1S c o w1 Itcuil T6ia Decd. made buman Stev d Derrick lad Ah r'e j Grantor, and P Collov� a Builders, Inc., a Miaaecou CorpoNtiva . X1'0, .. j Gnmuao. Grantor, ftr a valuablo coasidc 11011. cWvuys to Grantee the followlr,tl dcscr(bad mid estate in $1. Croix county. Sotto of witcoasin of moue spice is need , pieaer altaeb addendum); Rona 44 Axe e d A4411 The 9outheasr Quarter cf the $outitwcst Qtmrtar (SE '4 of SW '!.) Of 5ectitm Nam s;+�° !� 24 and that twr( of the N A of Section 25, lyiag Northerly of 140th Avenue ` I O 1 Ct ( tF f ( f ALL in Township SON, Rangy 18 Wort, 5t. Croix CDtmty, Wisconsin, �,, g n v 0 ( to EXCEPT Part of N 4i of Section 23 dcacnbcd as follows; Commcnoing at N ' 4�r tF ; q y V# cony Of eaid Section 2S; thence North 99 degrees 06 mhules West on Nord( sine of acid 644tion U.603 foci, Ihenas South 01 dogreo 23 minutes West 1353 fact; tj eonpe South $9 degrees 06 minute, East 1290 feet; thence 26- 1071.4MW di 26- Io72- 70 Nor*: t degmo 23 minutes E 1359 foot to laid Not* linty. ibenoo Nor* d9 Nand )de umadlml Namba RIN) dogrtwaf 06 minutes West on laid N lino 687 feat to Pilot of Beginning. St Tlds to not haaataad p t t7, Cnix County. Witcc=in. 01) (blot; Exceptions m wuraatIcs Saaemwta, reetriedcra sndrig4U -u: way ofrocant.Ifany. Dated this day of hL •; 21W ti '.._. ... ..••• s Stevan .Ikrelck AIJTHCNTICATION ACKNOWLEDGMENT Signatg.re(s) Strtien A Derrick STATE OF WISCONSIN ) �... - ... _..__. _ ) as. A „ County ) avlhentioatad thh; day of &LY_ 3000 rerlarAny cwt+e betas me 116 day of ... , the above Waned r Itrlat4u Gslaud -- TITLE, MEMBER STATE BAR OF WISCONSIN (I U4141 to me known to be the gem, who ettetuted the io,xau;ng autborasrd by d 706.06, WIL Stau.) instrument and aokaowlcd*ad the name. 71I4 INSTRUMENT WAS D)I-A rkiD BY Atearovt_t KrUUUz O taaA nil ito — l Ti �fFti -. Navy Ncblic, Stale Df Wiaconsiu - --- * 124mmimlon (3 Demtsncnt, qt not, state expigation due: (StPwacet nl:ry bs atxn endcaed of ackaow(rdLed ®olh tae not ntCMW)) 1 rNunes capacity musk typal below awksiatann. are.wwr+w.ran.a . r.t■+a f WARRANTY u6CD STATRaAtt0ttW1 MN6lM FORM Na 2. 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