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HomeMy WebLinkAbout030-1011-30-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safe g ilding Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) W 3 1719, GENERAL INFORMATION State Plan ID No: A) A - i � 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: G W E 9CX, tig. 01 Q Q a S+- 3 � �-� 1 -- 1611- - ?O CST BM Elev: Ins BM�EI�: BM D iption: ��_ S� tioZown /� n ap No: / Ob - 6 W J r / ` TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM t S71 ati 2 Bldg. Sewer �° 6.R ��r �R� 9.33 - lit Hol Ting St/Ht Inle 261 - 7 L 5� G?i TANK SETBACK INFORMATION St/Ht outlet q _ U TANK TO P/L WELL BLDG. Ve t t ��tnnake ROAD Dt Inlet / / 7 KJ� — Septic Dt Bottom Dosing Header /Man. A n / Dist. Pipe Holding Bot. System PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand S 3 / e E5 Model Number S4k6 - 3,SD 79. - b TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Di a Length 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 Topsoil ® Yes 0 No 0 Yes AN. COMMENTS (Include code discrepencies persons present, etc.) Inspection #1: 13 1 1 7- 1 � Inspection #2: / / Location: T ? - �,,,f, _/�,/ Parcel No: 1.) Alt BM Description = '" ' _ Kurvv / 7�-t �0 f�X'^ �� : f r S Vf /yt W 2.) Bldg sewer length = ;3 2 1 — - amount of cover = >I g n f r' KIAJ Aeta .! r� j Plan revision Required? ❑ Yes o rr Use other side for additional information. SBD -8710 (R.3/97) Date Insepctor's ft na ure Cert. No. ` commerce .Wl.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix ' W isconsin Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) epartmmrt of Commerce Sanitary Permit Application NaeTransactionNumber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary purp oses in accordance with the Privacy 1 Law, s. 15.04 m), Slats. Same ^ + °' ' � 1 I. Application Information — Please Print All Information Property Owner's Name Parcel # 030 - 1011 -30 -000 CRC Wisconsin RD, LLC - Burkwood Treatment Center Property Owner's Mailing Address Property Location C� 55 615 Old Mill Road SEP 2 3 2010 Govt. Lot City, State Zip Code Phon SW' /.,SW' /s, Section 3 Hudson, WI 54016 ING OFFICE (circle one) U. Type of Building (check all that apply) Lot # T 29 N; R 19 W 1 or 2 Family Dwelling — Number of Bedrooms 0 Subdivision Name D Na Na lock # ® Public /Commercial — Describe Use Accessory Office A �� ' // a City of ❑ State Owned — Describe Use f 1a &,.I CSM Number ❑ Village of Na ® Town of St. Joseph III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) System Addition of Septic tank B. F] Permit El Permit Revision ❑ Change of Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner Expiration IV. Type of POWTS System/Component/Device: Check all that appl ❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) " �jf(�; n ,yr1, � PoJ �J V. Dispersal/Treat ent Area Information: Design Flow (bpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (s0 Dispersal Area Proposed (sf) System Elevation 59 0.00 t}? VI. Tank Info Capacity in Total # of Manufacturer w a Gallons Gallons Units U a VI P / , w v' New Tanks Existing Tanks a / L " F F a a Septic or Holding Tank 261 261 1 Weeks C ncrete Dosing Chamber VII. Responsibility Statement- I, the and rsigned, as ume responsibili tallation of the POWTS shown on the attached plans. Plumber's Name (Print) VI.— s Sign MPlMPRS Number Business Phone Number James K. Thompson 5 - --- 30021 (715) 248 - 7767 Plumber's Address (Street, City, State, Zip Code 340 Paulson Lake Lane, Osceola, WI 54020 -5413 VI Coun /De artment Use Onl Approved Denial _ Permit Fee Date sued Issuature _Owner a for $ Z c • c o Q 2 ing ent Sign DL Conditions of A%V#R easous for Disapproval f . Septic tank, eftluant filter and dispersal cell must all be services / maintained n �Q,•,�,' as per management plan provided by plumber. A6 Z All sotback regWements must be maintained Attach to complete plans for the system and submit to the County only on pWer not less than 8 m a 11 inches in size SBD -6398 (R 01/07) Valid thru 01/09 l 43 CCLSSOf y OF4r Ce�b ruCt�ur� 4 "•3 03� P.��• la ce.; I d; rn4 .54tLAJ 0 Pcopo sad c v ea,(�s a FO L 6Cndo. , e d im --4— :2 (ya.P. S 6-" 303q �d.e. sscc�e dlst(;b oh . _ 1 Y, /22 ef'� /ue �i e�Fluen� line � C S�sE a."e c�/°r°X /rnc e�•c G`.Y�- s�i'no� G /n�C i SJ ESE,•.na,fed /00.0 e Io C • cf7 (/ gi� aP 0104 o �;y���l� f }�� �3� rode• ,PeSi c%.,��e � E4�fer•�a : 1 6 ��J� o d's�ocls�c% sir. // •�P4� 'GD�+YKS � // �� Sit /fed �cJasz�e�q •, ,Poa CL P 3o�0 Index & Tilte Sheet - Existing Septic Tank Replacement Project Name: Burkwood Treatment Center Septic Tank I nstallation Owners Name: CRC Wisconsin RD, LLC Owner's adress: 615 Old Mill Road, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Na Legal Description: SWv4SWv4, Sec. 3, T.29N., R. 19W., Town of St. Joseph, St. Croix Co., WI Parcel ID #: 030- 1011 -30 -000 Page 1 Index and Title Sheet Page 2 Sanitary Permit Application Page 3 Site Plan Page 4 Daily Flow Calculations Page 5 Treatment & /or Filter Tank Cross Section Page 6 Filter Specifications Page 7 Septic Tank Maintenance Agreement Page 8 Existing Dispersal Cell Evaluation Page 9 POWTS Service Contract/Management Plan Page 10 Waranty Deed Attachments: None Mater umber Restri ted Service: James om son, Dept. of Comm. Credential #30021 Signature: Date: — =� 'ZO / D Page 1 Of 10 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01) gcce.ssory oF4ice, SE�uCEure y ",3OY P''•e• kicu I d.; n9 Se,u)f✓ 0 ASP r °X l oea ' 0 w�s / ! 5ca /e propObto/ c��e �';q.5, F aba n do., e,� � �. 2� 1 �a1 Sepfi� -fin 303 1 j°J. F tsSccre Cott; a oh �_ O �/l c ; a / / /au•�'c•� s e � e�lu�� line arCao�o�oxlrr�a�c�•o /�alyLa('/ /22 e /u � S -Ltm SA � EX�SEIn� �e� 6s At C& CICL; c 9.44' (/ gieR sc aF P ` 0 f>O d CIO-OWL v � eSi c%G e o E'a en wash -e d, 3Pe�sa / C i � s � - / /e�✓ q -,'/ � �c OQ Burkwood Treatment Center Daily Flow Calculations JOB DESCRIPTION Accessory office structure to be added to existing Community Based Residential Facility. Structure to serve as office space for three (3) existing employee's - no increase in wastewater flow will be generated. WASTEWATER FLOW ASSOCIATED WITH ACCESSORY OFFICE STRUCTURE: Estimated wastewater Flow 39.00 Gad (3 employees all shifts) (13 gal. /employee) DESIGN WASTEWATER FLOW: Design Wastewater Flow 58.50.00 GO (39.00 Gpd)(150 %) ABSORPTION AREA SIZING: Not applicable as no increase in daily effluent flow will be generated by the placement of the new office facility. SEPTIC TANK CAPACITY CALCULATIONS: 1. Design wastewater flow = 58.50 gpd 2. Minimum required capacity: 122.15 Gallons (58.50) + (11.61 x 3* x 0.78) + (46.77 x 0.78) = 122.15 *(Requires a three year maintenance cycle) 58.50 gpd/ 75 gpd = 0.78 gpd person equivalency 3. Proposed Septic Tank Capacity & Manufacturer: 261 gallon Weeks Concrete 4. PolyLok PL -122 effluent filter installed at outlet of proposed septic tank. P �o��o Aol;c� WA L eoN 119i; V, Rio a5a As acl� ah / O S S _' x a lo S cN�� c�1'tZ {i�tt /g i eoAni4;w,&z .. 0 /4 t ) i t ) r t I i - ; I t ; I t a�It - ----------------- i �^ o u t t it t. 1 r� $� 3� rr fi�)t s q .� tt , i ,3a WEED GUNCRE RAY L WEEKS 3 1832 215th St. X17 eW RIChmond, ' S a� /� PL -122 Effluent Filter - Effluent Filters.: Polylok Inc. Page 1 of 1 PL -122 Effluent Filter Description .. The PL -122 was the first filter developed by Polylok. The biggest advantage of this filter is that it has an automatic shut off ball built into every filter. When the filter is removed for regular cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. To this day, no other manufacturer can make that claim. It is also rated for 1,500 GPD (Gallons Per Day) and is NSF approved. Ordering Information © Request a Quote © Related Products i Features j • Offers over 122 linear feet of 1116th inch filter slots tX' Has a flow control ball that shuts off the flow of effluent when the filter is removed for cleanings • Has its own gas deflector ball which deflects solids away • Installs easily in new tanks, or retrofits in existing systems • Comes complete with its own housing; no gluing of tees or pipe i Enlarge for details Rated for 1,500 GPD • Has a modular design allowing for increased filtration • Accepts 3" and 4" SCHD 40 and SDR 35 Pipe The PL -122 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning It is recommended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should "— be done by a certified septic tank pumper or installer. - _ Maintenance Instructions: 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when cleaning filter. 4. Pull PL -122 out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace septic tank cover. PL -122 Installation: Ideal for residential and commercial waste flows up to 1,500 Gallons Per Day (GPD). http://www.polylok.com/products 9/23/2010 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner / O "L ( �DrI S•� /� �� — �tcxt2�/ / [ � C.t., Mailing Address (o /$ a,6 &" Sf O16 J Property Address 15 a..72 (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location S14) t /a , -S t /a , Sec. –d_, T ZE N R Town of • �f�StiOl� Subdivision 4Q , Lot # A Certified Survey Map # /�a , Volume Il , Page # no Warranty Deed # 49815 , Volume , Page # Spec house no Lot lines identifiabl yes SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 Planning & 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedroom _4 4&4 0 SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 7o�io September 23, 2010 Burkwood Treatment Center - Existing Septic System Evaluation Location: 615 Old Mill Road, Hudson, WI., SWl /4SE1 /4, Sec. 3, Tn. of St. Joseph, St. Croix Co., WI., Pcl. #030- 1011 -30 -000 1 have conducted an inspection of the existing dose - conventional septic system that serves the facility at the above address. This inspection was completed September 15, 2010. Records obtained form the St. Croix County Zoning Office indicate that the system was installed May 27, 1983 under permit #383936, and indicate that the system was installed as per codes in force at the time of the installation. An inspection of the observation pipes show signs of effluent ponding within the system dispersal cells. There were no indications or evidence of effluent discharge to the surface of the system nor to the surrounding area. This indicates that the system is functioning and is marginally able to absorb and dispose of the wastewater that enters it. Because the failure of a septic system is a progressive process, it cannot be predicted how long the drainfield will continue to dispose of sewage effluent before it fails. The inspection was based on a surface evaluation, so there may be hidden defects within the system that were not discovered. James K. Thompson Dep't of Commerce Credential #30021 Cc: file POWTS SERVICE CONTRACT The proper operation and maintenance of the components listed below will significantly influence the performance and life expectancy of the POWTS (Private Onsite Wastewater Treatment System). This agreement authorizes A.C.E. Soil & Site Evaluations, L.L.C. personnel (Service Provider) or their representative access to the POWTS components during regular business hours to perform regular inspections and routine maintenance of those components. It is herby agreed by and between Owner and Service Provider that in consideration of the payments provided for herein, Service Provider will provide a manufacturer trained and State licensed inspector to perform periodic inspections of the POWTS components as set forth below. Service Provider will prepare a written inspection report after each inspection containing any recommendations for the operation, maintenance, and or repair of the POWTS deemed appropriate by the Service Provider. A copy of the report will be provided to Owner and the appropriate Governmental Unit. Service Provider will supply additional services, parts, or labor only after authorization by purchaser. This agreement does not assume any responsibilities or obligations that are normally the responsibilities and obligations of the Owner and does not cover any costs associated with operation, maintenance and or repair of the POWTS. In no event shall Service Provider be responsible for any special or consequential damages, including but not limited to, loss of time, injury to person or property, or incidental economic loss due to equipment failure for any reason whatsoever. This agreement will be automatically renewed each year unless amended or cancelled by either party with 30 days written notice. This agreement may be cancelled by Purchaser only if replaced by a service contract with another service provider authorized to inspect and maintain the specific POWTS components in question. Purchaser agrees to pay Service Provider the sum of 1175.00 per inspection. Two (2) inspections will be completed per calendar year with inspection fees billed at the time of inspection. Any additional fees for effluent quality testing (if needed) will be approved by POWTS owner prior to sample collection and submittal to lab. POWTS DESCRIPTION: Two existing Conventional POWTS serving the "Burkwood Residence ". POWTS LOCATION: 615 Old Mill Road, SW' /4 SW' /4, Sec. 3, Tn. of St. Joseph, St. Croix Co., WI. Parcel # 030 - 1011 -30 -000 Owner name and address: CRC Health Corporation 204000 Stevens Creek Blvd. Cuperti , CA 950 er signa ) (Date) - - - - - "- Service Provider: A.C.E Site Evaluations, L.L.C. J s K. Th mpson 40 Paulso aka Road sceola, 5 ice Provider signature) (Date) Instrument Drafted By: James K. Thompson P� 90-00 . 11111!1 NIlI Nlfl IIIII IIIII NIlI Ilfl IINfI IIII IIII * 8 8 1 5 1 1 1 STATE BAR OF WISCONSIN FORM 2 - 2000 gg 1511 Document Number WARRANTY DEED KATHLEEN H. WALSH This Deed, made between Herbert E. Blaisdell and Lisetta M. REGISTER OF DEEDS Blaisdell, husband and wife ST. CROIX CO., WI RECEIVED FOR RECORD 09/17/2008 10:15AM Grantor, and CRC Wisconsin RD, LLC WARRANTY DEED EXEMPT I REC FEE: 11.00 TRANS FEE: 1296.00 Grantee. f PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: PART OF THE SOUTHWEST QUARTER OF THE SOUTHEAST QUARTER (SW 114 OF SE 1/4) OF SECTION THREE (3), Recording Area 11 TOWNSHIP TWENTY NINE (29) NORTH, RANGE NINETEEN (19) Name and Return Address WEST, TOWN OF ST. JOSEPH, DESCRIBED AS FOLLOWS: 14Tt1AN;Lt, Wt iNCI( Commencing at the Southeast corner of said Southwest Quarter of the Southeast Quarter; thence West on the South line 478.37 feet (recorded �e N�htrLLti co, =� as 486.5 feet); thence N30 1 40'00 "W 633.00 feet to the point of o Hop , _.Ve�13 C:I"ee_k e :"ji 0000 beginning; thence continuing N30 0 40'00 "W 264.80 feet; thence L CJ– LPE QTh40 CA 96(D / N59 "E 283.50 feet; thence S30 1 40'00 "E 264.80 feet; thence C,b_ 2a S59 0 20'00 "W 283.50 feet to the point of beginning. 030 -1011- 30-000 Parcel Identification Number (PIN) This is not homestead property. 4M (is not) Exceptions to warranties: easements, restrictions, and rights of way of record, if any. Dated this 15 +11 day of _ September 2008 � • ae� + Herbert E. Blaisdell s . Lisetta M. Blaisdell AUTHENTICATION ACKNOWLEDGMENT Signature(s)_ STATE OF WISCONSIN ) ) ss. PIERCE County } authenflc i h Ni day of Personally came before me this I 5 4 1 day of C i , Sepotember 1 2008 the above named �'. Herbert E. Blaisdell and Lisetta M. Blaisdell TITLE: WM$!KR -gtATE BAR OF WISCONSIN — (Ifitvt ' CHARLENE A. LARSON to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) e 2ty instrume 4kROwigdged j)te s � State of Wisconsin _ �,� ��.^ THIS INSTRUMENT WAS DRAFTED BY Joseph D. Boles - Attorney at Law Notary Public, State of N� River Falls, WI 54022 My Commission is p ent. (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. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 2000 INFO -PRO ( 800 )855 -2021 www.infoproforms.com 101 ST* CROIX COUNTY PLANNING & ZONING September 22, 2010 Burkwood Treatment Center ATTN: Candace Clausen 615 Old Mill Road Hudson, WI 54016 RE: Site Plan Proposal for Modular Code Administra 715 - 386 -4680 Dear Ms. Clausen, Land Information I have reviewed the plans that you submitted to this department on September 20, Planning 715- 386 -4674 2010 regarding the removal of the existing modular unit used for office space and the addition of a new, larger modular unit for additional office space. The proposal Real Prop e indicates that the new modular will be placed at a setback from the property lines of 715 -3 677 at least 15 feet on the east property line and more than 15 feet from the north property line. This placement will satisfy the County's setback requirements. The Re Ming modular will also be placed more than 10 feet from all other buildings on the site as - 386 -4675 required by the Ordinance. The project will not increase the number of staff or residents. As you recall, there is a limit of the number of staff and residents due to the size of the existing septic system. You have also contracted with licensed plumber (MPRS) Jim Thompson, A.C.E. Soil & Site Evaluations, to connect the new modular unit to the septic system. A Sanitary Permit will be required for connecting to the existing septic system. Any increase in wastewater generation may require the system to be redesigned, enlarged or modified to adequately treat an increase in wastewater load. The St. Croix County Planning and Zoning Department has determined that the project as presented will meet the requirements of the County Sanitary and General Zoning Ordinances. Please contact the Town of St. Joseph to obtain any required Town permits. inc ely, K vin Grabau Code Administrator Cc: Clerk, Town of St. Joseph, via email ST. CRO1x COUNTY GOVERNMENT CENTER 1 10 1 CARMICHAEL ROAD, HUDSON, W/ 5.4016 715386-4686 FAx PZ @CO. SAINT W1. US W W W. C O. SAI NT-C ROIX. W W S