HomeMy WebLinkAbout026-1127-45-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Cou
Sgfety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 383837
Permit Holder's Name: 0 City ❑ Village ❑ T#wn of: State Plan ID No.:
Peterson, John Richmond Township
CST BM Elev.. Insp. BM Elev.: BM Descr'ption: P rcel Tax No.:
cQQSk cQ C 0"_ Ell '1 -- YS
TANK INFORMATION ELEVATION DATA o2a = 30, ca
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �J�`l�,, Benchmark
Dosing
Aeration Bldg. Sewer & y" ) q4 gcel .62r
Holding St/ Ht Inlet �, qo citf, os
TANK SETBACK INFORMATION St/ Ht Outlet q3. 4.9
TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet - �---
ir
Septic I 3$' ---, NA Dt Bottom
Dosing NA Header /Man.
Aeration NA Dist. Pipe
Holding Bot. System
O.Z
PUMP/ SIPHON INFORMATION Final Grade , e C ec ")
Man4facturer Dem � d CaJGrL X33 . 62
Model N ber G M
TDH Lift ion System TDH Ft
H ead
Force Length DI
SOIL PTION SYSTEM
TRENC TRENC Width ( Length N . Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
IME 3 •�S DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manua ure
SETBACK
INFORMATION Type Of CHAMBER M e Number:
System: ) t � OR UNIT r
DISTRIBUTION SYSTEM
Header anifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
11 w f
Length Dia. Length Dia. Spa '�Q
SOIL COVER x Pressure Systems Only - xx Mound Or At -Grade Systems Only
Depth Over � " u Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center l — Bed /Tr dges Topsoil ❑ Yes ❑ No []Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc. Xnspection #1: 011 l'?161 Inspection #2: --� t — �
Location: 1315 144th S ew Richmond, / W ' I 5401 (SE 1/4 SW 1/4 25 T30N RI 8W) - Richmond Hills -Lot 45
1.) Alt BM Description= � &_ �eu (u best �u,tl�
2.) Bldg sewer length= 4 0
-amount of cover
�✓�`D U t1e +n , inN Cft �Q�
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Plan " i on requIrh es No �eT�\
U r, - o de f r addition al inform tion. �Z O I O 117
q - 1 S 2
S�671� 4 6 • Date Inspector's Signature Cert. No.
13 Sanitary Permit Applirap 1 `\ Safety & Buildings Division
y J __ _,? r 201 W. Washington Ave.
i
In accord with Comm 83.21, W a "' ..:! r PO Box 7302
N*h See reverse side for instructions for co this ap cation Madison, WI 53707 -7302
DeparYmentsoE earttmerce Personal information you provide may b for se oses �� ubmit completed form to county if not
[Privacy Law, s. 15 O i/j(m)] state owned.
_,
Attach complete plans to the county cop only) for th `s em, qq paperao le4fihmm 8 -1 x 1 inches in size.
Coun `
State Permit Number ❑ Chec i sion pl apX _Ian 1. D. N umber
ty 5T rte;, 33s 3 " ,-� z CROIX
I. Application Information - Please Print all Information O COUNT o ' tion:
Property Qwn�,Name ^ 1/ 4 Location
J • {rJ ri
1/�4J 1/4, T.30,N, R L r W
Property Owner s Mailin Address umber Block Number
N __ City, State Zip Code Phone Number Sub vision Name or CSM Number
5 0 l `rC5 a (0 7 d
I Type of Building: (check one) ❑ City
a ❑Village n c
1 or 2 Family Dwelling - No. of Bedrooms : �— � Town of 1��CT�o 17�
Public /Commercial (describe use):_
❑ State -Owned
t Nearest Road 1 /1
Parce Nu
III. T e of Permit: Check only one box on line A. Check box on line B if applicable)
❑Addition to
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5
System System Tank Only Existing System
Date Issued
B) Permit Number
❑ 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 Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information: I.2 t�
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation �rAdc
Required Proposed Rate (GalsJday /sq. ft.) (MinJinch) 377 j9 A fl ��. 5 S
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Gallons Gallons Tanks Con- Con- glass
Information
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersi ed, assume responsibility for ins on of the POWTS shown on the attached plans. Business Phone Number
:mbees Name nt) �s - d Plumber's Si tature o stamps): MP/MPRS No. w•� r to S'
Plumbees Address (Street, City, State, Zip Code)
IX. County /Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
A Approved ❑ Owner Given Initial Adverse rcharge Fee) Vol JLA AA
Determination a�S OD �Z��'- Z�'D
X. Conditions of Approval /Reasons for Disapproval:
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 _ of 3
Divipn of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must St. C r O 1 X
include, but not limited to: vertical and horizontal referetice,point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, andJocation and distance to nearest road. endiri
Please print alllw'*b matfon.A•- Reviewed by Date p
Personal information you provide may be used fofs4condary p-OOC Ofa4 Law s 75.04(1) (m)). t 11 7 — M
Property Owner Property `Location
": Gout SE 1/4 SW 114 S T N R 18 fir) W
RJCDeelomn Inc.
Property Owners Mailing Address `Y Lod # ` Block # Subd. Name or CSM#
1868 Ct . Rd. C E na Richmond Hills
City State Zip Code Phohd-NLffnber
I s ity [I Village K) Town Nearest Road
�
New
Richm ondi WI 1 54017 1 (71 4574 Richmond I 130
�] New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material 1 ac i a 1 d r i f f - Flood Plain elevation if applicable _na tt•
General comments
and recommendations:
trenches spaced to code, 3.50' below grade
❑ Borin g # F] Boring 1 ® pit Ground surface elev. 10 0 . 9 Depth to limiting factor + in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 I - Eff#2
1 0 -10 10 r 3/3 none sl 2m r mfr cs if
2 na na
Boring # Q Boring
2 Ed Pit Ground surface elev. 100 . 3 Depth to limiting factor + 8 4 in, Sal ftNication 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
1 0 -8 10 r 3 non
.7 1.2
3 26 -31 7.5 r 4 none is _ .7 1.2
4 31 -84 7.5 r 4 none Ms 0sa ml na n 1.2
. V .2
f T
• Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg /L uent #2 = BO < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature //J CST Number
Gary L. Steel 02298
Address Date valuatio nducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 10 -18 -2000 715- 246 -6200
Property Owner R J C Developmen Inc. Parcel ID # Pndincl Page 2 —
3 1 Boring # ❑ Boring
® pit Ground surface elev. 1 01 ' 5 5 ft Depth to limiting factor + 8 6 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
sl 2
2
ye 6 ,f
Boring #❑ Borin 100.75 + 8 8
F 4 ] ® pit Ground surface elev. ft. Depth to limiting factor in.
— !go — ilApplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -10 10 r 4 if .5 .9
2 10-19 is Os
3 19- ml na na
39
F-1 Boring # ❑ ring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soit 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 = BOO, > 30 5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 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.
SBD4330 (R.6M)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
RJC Development, Inc. New Richmond, WI 54017
MP SW -3254 SE 4 s25- T30N -R18w (715) 246 -6200
town of Richmond
lot #45- Richond Hills
1 i ' 40' ✓
BM. =top of 1" pvc pipe @ el. 100.00'
Alt. BM.= top of 1" pvc pipe @ el. 101.35'
sA
2
Gary L. Steel
10 -18 -2000
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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 $3 �-
Number of Bedrooms 3
Design Flow - Peak (gpd) 5
Estimated Flow - Average (gpd) 17 M
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft') S< < C,kDMberS
Type of Wastewater Jomestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) I typ 3 �^
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, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of tW se k and outlet filter shall be assessed at least
once every 3 years by inspection. outlet filte shall be cleaned as necessary to ensure
p roper operati The filter cartridge shou 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
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
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
f I OWNERSHIP CERTIFICATION FORM
Owner/Buyer �.J try Plq�io r5 O r-11
Mailing Address `7�,Sn � a r t� Q ,,,�Q, I y•2,�.� RA'MC)4
Property Address t/v
nn ,, (Verification required from Planning Department for new construction)
IV
City /State Y T�(A_ V "cL (Ak Parcel Identification Number It 73 '-109 - 0 0 07
LEGAL DESCRIPTION
Property Locations ' /,, Sw ' /4, Sec. - J%5, T�N -R &W, Town of RL AQ
` �t
Subdivision l f � k � r lnw,o An 1L 1� , Lot # .
Certified Survey Map # , Volume , Page #
Warranty Deed , Volume S , Page #
Spec house ❑ yes Pq no Lot lines identifiable 00 yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanccof 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.
The property owner agrees to submit to St. Croix 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
e fo rth, he as Resources, State of Wisconsin. Certification
.
set fo re set by the Department of Commerce and the Department of Natural R ,
stating that yWyea 'm has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
day of a tion date. G I / ap
ATU RE OF APPLICANT DATE
WNER CERTIFICATION
I (we) c 'fy that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the rop de c ' ed a ve, by virtue of a warranty deed recorded in Register of Deeds Office.
Jd a.(/ 0 1.E
G ATURE OF APPLICANT DATE
* * ** Any information that is mis- represented 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
a copy of the certified survey map if reference is made in the warranty deed
Vil.1565PAGE268
STATE BAR OF WISCONSIN FORM 2 -1999 634841
Document Number WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between RJC Developm Inc., a Wisconsin
Corpo ration, RECEIVED FOR REGARD
- I2 - 07 -2000 9:30 AM
- -' — � —_ —_
WARRANTY DEED
Grantor, and John A. P and Melissa L. Peterso hu sband and EY.EMPT A
wife, CERT COPY FEE:
-- -- — -- - - -- COPY FEE:
TRANSFER FEE: 85.50
-- - RECORDING FEE: 10.00
Grantee. -- —_ PAGES: I
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Wisconsin.
Lot 45, Plat of Richmond Hil ls in the Town of Richmond, St. Croix County, Name and Return Address
ba.�) 1 e L'U le K f�" k
aqua -at �? 5 + nos x , �0
, 56Cr III Ix IsWl - 6 1 { 0a9
Pt 026-1073-30-000, 026-1073-40-000 &
026. 1073 - 60.000
Parcel Identification Number (PIN)
This is not homestead property.
Exceptions to warranties! Easements, restrictions and rights -of -way of record, if any. Q() (is not)
Dated this i day of December 2000
RJC Develo m9a t. In
?ems
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) RJC Development, Inc., a Wisconsin Corporation STATE OF WISCONSIN
b y ) ss.
ll j County )
authetbtia�q day of December 2000
�O ✓� i �' f. Personally came before me this _ day of
the above named
r� BAR OF WISCONSIN -- —_ -
s,, '�'4Griizl'�__ to me known to be the person(s) who executed the foregoing
authorized b 706.06, W is, Slats,) instrument and acknowledged the same.
YS
THIS INSTRUMENT WAS DRAFTED BY r —
Attorney Kristin Oglan -- —
Notary Public, State of Wisconsin
Hudson, W 1 54016 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) _ ____ )
Names orpersons signing in any capacity must be typed or printed below their signature imormabon Frorrrrsbnels Company. Fmddu Lw, N7
WARRANTY DEED STATE BAR OF WISCONSIN eoo�ss - zaz:
FORM No. 2 - 1999
DEC -11-2000 MON 03:25 PM FAX NO. P. 03
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