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Home My WebLink About030-1084-10-000Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j, Permit Holder's Name: City Village Township Brandon & Kim Searle TOWN OF SAINT JOSEPH CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 617846 State Plan ID No: Parcel Tax No: 030-1084-10-000 Section/Town/Range/Map No: 291M319.307C STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer St/Ht Inlet St/Ht Outlet Dt Inlet Dt Bottom Header/Man, I. Pipe Bot. System Final Grade St Cover BED/TRENCH BED/TRENCH Width Length No. Of Trenches DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 1:1 Yes COMMENTS: (Include code discrepencies, persons present, etc.) Location: 488 PERCH LAKE RD 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Inspection #1: Inspection #2: Plan revision Required? Use other side for additional information. Date SBD-6710 (R.3/97) Insepctor's Signature Cert. No. %Njamy an® Buticiings [division 201 W. Washington Ave., P.C. Box 7182 Sanitary PerntitNumber Ito be MW in by Co) Madison, Wl 537()74162 Sanitary Permit Application State Transaction Number a Aao�wnv* with SPS 383.21(2), Wk Adm. Code, submission of this farm to the appropriate governmental unit i required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS.are su miffed to Project Address (if different that mailing addres he Department of Safety and Professional Servies. Personal information you prov of ndary mmoses in accordance with the Priyac Law, s. M l m Stars. W= LiQ (�E�C� `IA K� p . Application Information — Please Print All Informatio O t�l ) Iroperty Owner's Name Panel # M)porty Owner's Meiling Address County t Property Locstlon 3 St. Cr \,Xoe\IeloPR'en Qom Lot i City, Stets Zip Code C umber 'Ko '/, Section 1 2 U �'Sl�`' \1I JS`1• T mil` N; R/fit( (circleone) IL Type of Building (check all that apply) Lot # M or 2 Family Dwelling- Number of Bedrooms Subdivision Name S • Hioclr # • ❑ Public/Commercial — Describe Use ❑City o ❑ State Owned— Describe Use CSM Number ❑ Village of 9LTown of S I` I O .SE 01 ldd. Tvue of Permit: (Check only one ban on lien A. ConupteU line $ 3f gpptlorrlsle) A. r dery System Rept110entent System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (expw B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Is=ued Before Expiration Owner �fon-Pressarized lnfi3tound �i Pressuriaxd in-Gronnd Holding Tank U Other Dispersal Component (explain ►us Ststtement` t, rho � At�Grade � Mound >_ 24 in. ofsuitable soil ®Mound < 24 in. of suitable sail ❑ Pretreatment Device (explain) assume v� t:lallons f Units Approved ❑Disapproved Per'r"t Fee cn/1 ❑ Owner Ciiven Kea9on for Dealal ;�w'�• V• Ct t 50myallRessons for Disapproval 1. Septic tank, effluent filter and dispersal cell must be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained � 1 u 1 �o $'d� 9•s' 3 Manufacttuer V 40 VJ V on of the POWTS shown o the attachtd lens. ThM RS umber Business Phone Number Z2329 Z 115 111 .3y�; • � i i, • ;,, � . , .- ,,, � - � r -- Project Name: � 1�(��1�01.> v� �� Owner's Name: _ �f� M C Owner's Address: legal Description: �� ,� � �, township: �`I--�c��l� 3ubdivisian Name; _ot Number: sarcel ID Number. �� > %d8�� . � � ._ � �L� Page � index and Title Page � Plot Plea Page 3 System Sizin 8� Cross-5ecfion Page 4 Fi{ter Specs Page 5 Maintenance Information Page � Ma�ement P{an Page 7 St, Croix G Se tic Tank IVfaintenance Form Page � Warranfy Deed page 9 CSM or Plate' Attachments: Soil Test &House Plans esignerlPlumber: �,F'F" �� license Dumber: i�l1�S ��Zy � ate: � j (� � Phone Number ignature r / v �si9tied Pursuant to the In-0raund Soif Absorption Component Manual fur FOUNTS Version 2.0 5BD �10705-P (N.Oi/01), Page 1 Mar.12.2020 10:59 AM _, 'N\ 'l_. ;-� i ..,1c1.Sr:',.y�.�.i ...I'��;'.��' .. ...S��i Ci�'C�ly. c�.i'.:l,�i�;''T'i ;' N1�1'� / r� r�• ,� .� L1 . , PAGE. 2/ 2 R , �� MAR 12 2020 ISt. Croix County Community pevelopment ;! / `-4/ �'�, :lam-.hx�11 N\��.\(_ ��I.-T"c�r' � � • l a ��.(' it L I? (:�'..� 1� I._�� i ,� , ••. i �� r.:.c`.�11 1.��c�. � �� Leaching Chamber Sall Absorption SYS"am ClOss Secilon 4° Schedule qD p /C Vent Pipe Gj 4 �:5g With Vent Cap ft ft Soil Abso Lion stem Plan �`ieff ft F[nal Grade �— System Elevation 3der Leaching Chambee SP�ificafions Manufacturer And Model - Njl -I Soil A rication Rate � gpolsq It EISA Rating l sq ft per chamber pp c� 11 Chambers Soil Application Rate _ f EISA = gpd Design Flow 3 rows of chambers each. t 't POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of Z FILE INFORMATION SYSTEM SPECIFICATIONS Owner Q (kao . Permit # !� ! DESIGN PARAMETERS Number of Bedrooms ❑ NA Number of Public Facility Units 01NA Estimated flow (average) QC' gal/day Design flow (peak), (Estimated x 1.5) gal/day Soil Application Rate a gal/day/ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) <30 mg/L Biochemical Oxygen Demand (BODO <220 mg/L ❑ NA Total Suspended Solids (TSS) <150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODO <30 mg/L Total Suspended Solids (TSS) <30 mg/L ,^NA Fecal Coliform (geometric mean) <104 cfu/100ml Maximum Effluent Particle Size %8 in dia. ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Septic Tank Capacity SVC5� gal ❑ NA Septic Tank Manufacturer (&FS( (L ❑ NA Effluent Filter Manufacturer Po lu to L ElNA Effluent Filter Model L Fj ❑ NA Pump Tank Capacity gal ❑ NA Pump Tank Manufacturer ❑ NA Pump Manufacturer ❑ NA Pump Model ❑ NA Pretreatment Unit �2tlA ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal Cell(s) ❑ NA �ln-Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other: ❑ NA Other: ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tank(s) p At least once ever y' ❑ month(s) year(s) (Maximum 3 ears) y ❑ NA 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) 3 VVyear(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) ear(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) J@ year(s) ❑ NA Flush laterals and pressure test At least once every: ' ❑ month(s)A ❑ year(s) Other: At least once ever y' ❑ month(s) ❑ year(s) Other: 'V A 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 (%3) 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 <12 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. Mar.12.2020 10:58 AM PAGE Dose Tank Cross Sectiion And Pump Performance Speci�"xca�ions Tank Manufacturer � W �£� C-� Tank Modal Number l�Jl-(� 5�.�, `j5'0 Total Tank Capacity j �, 3� Max, $ury Depth Pum Manufacturer Z. v G C Y Pum Model Number ,Q j 5 ,Alarm Manufacturer U Y� Alarm Model Number �,T .G�G� Switch Type �V�Cta Minimum Pump Performance Required GPM )?t TDH Total Dynamic Head (TDI� -Feet Elevation Head Distal Pressure Neiwark Pressure Doss . Force Main Pressure Loss ,3 Total ..��..__. � � � Vent M{n, 12" Feather -proof Above Grad® Junction Box With Cap --� ^' Finished Grade — — •" �' ""' � -� Depth of Cover Ft s � � �� f �. � r- :.; , i• '; ��;; �� I`�'' ��I �r ��+r.�{.trc.�rc.�.c.+.,.�. c'�-�, �-�-�: �. �, c: c; �: �: �; {, lac �`< (`�`�`cc�`t c� � � � Switch Settin sand Reserve Ca acity 'Tank Voluxrwe = Gp1 Dimension (reserve A (alarnn B Inches �22, W 2 Valume Gal. ��- (dose C � � dead D . S � Total Ctl $ottoctt of Tank Elev. C � Is1 L?7 O£f Elev. �, Ft Ft D �� D19QOilI19Ct Means � 4 1 ;< Outlet �� s CENEILA.L YN'STALLATION: The dose tank is bedded anal back idled in accordance with the manufacturer's product approval specifications, Ma�timum depth of bury as speei�ed by the manufacturer may net be exceeded without prior approval. Manhole covers exposed to grade have an effective lockJng device (padlock) installed. Piping at the Inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. 'The force main is sleeved with 4" Sch. 40 1�VC to bridge the excavation and is sealed � watertight. Electrical service complies with NEC 300 and Comm 16,28 Wis. Adm. Code. 03/O5 Igj ��A„ Weep Kola 1/ 2 Site Search -Zoeller Pump Company (g' ..S^ httn://www.zoellernumns.com/en-na/distribntor/sitesearch?search=152 bf2/: Owner/Buyer Mailing Address Property Address ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Verification required fi•om Planning & �IaI St. cro�x Community t far new construction.) City/State NAQ I QVI VYI nt12 Parcel Identification Number VOV 1p07_ 1 V "VVQ ent LEGAL DESCRIPTION ovt 10 i ` Property Location `/ , Sec. °j_, T &LN R .W, Town of�- Subdivision Certified Survey Map # Volume Warranty Deed # I OAP � � � 2— (before 2007)Volume Spec house ❑yes�no Lot lines identifiable 1$J yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Page #. Lot # Improper use and maintenance of your septic system could result in its premattu•e failure to handle wastes. Proper maintenance consists of pumping out the septic tank every tluee 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 §SPS. 383.52(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 Safety And Professional Services and the Deparhnent of Natural Resowees, 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 forth are true to the best of my/our knowledge, property described above, by virtue of a watrant� deed recorded in Register of Deeds Office. Numb�t• of b I/we am/are the owner(s) of the V SIGI ' "�'`URF/OF A PLICANT(S) �- DATE • *** n that is mi sented may result in the sanitary permit Planning & Zon4 eparement. * * Any information h y c y p t being revoked by the g 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. 04/12) WARRANTY DEED ,This Deed, made between George E Belisle, by his Attorney in fact, Bruce A Tobin under Power of Attorney, a copy of which is attached hereto and incorporated herein Grantor, and Brandon Searle Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum). The South 22 rods of the East 28 rads of the SEl/4 SElJ4 , also described as Government Lot 1, Sec. 29-TMN-R19W, except the East 2 rods reserved for highway purposes. Dated this i g day V IVIAIII,NII111111111NI I 1068112 BETH PABST REGISTER OF DEEDS ST. CROIX CO.r WI 07/ L6/2018 11:01 AM EXEMPT#: REC FEE TRANS FEE Recording Area 30.00 660. )0 PAGES: 7 Attorney Kristina Ogland Estreen & 0gland 304 Locust Street Hudson, WI 54016 030-1084-10-000 Parcel Identification Number (PIN) This is homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of --way of record, if any. * AUTHENTICATION Signature_____ * Bruce .Tobin. _A,ttor y-in-f c . for George E. Belisle ACKNOWLEDGMENT STATE 1 SC &N 5 i 7 Q\\ e»n %!a (�\ 8 ■ \ �( 2 2 Uodm&rmk�ym+ w- .,_wing PoosLLCma { § , a3 \ � e /2 0 CN � � � ��s � aUwvxeroz � ° lain's Drawing Room o d P�rancion & KimberlyJearle � � •• • � o ;off � 488 Perch Lake Road, Hudson, Wi 54016 � � «; � a ( \ \/ a3 sm Q /\ Wisconsin Division of Attach complete site but not limited to: vex scale or dimensions, Personal information MPS ®� �®2® �y 0IL EVALUATION'0' Cto CoU'op ance with Sr 385, Ms. Adm. Code In per J 8 1/2 x 11 inches in size. Plan must include, 3YFi n reference point (BM), direction and percent slope, v, and location and distance to nearest road. Please print all information. ❑ Boring Pit Ground surface elev.r /� ft. Page I of 3 Sol it Annlication Rate 1 Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 0 r a r �� 2 ro` 7 M !ct Nor) r a Boring # ❑ Boring ® Pit Ground surface elev.�dl.'{��"ft0 Depth to limiting factor�� in. Soil Aonlication Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/FtZ *Eff#1 *Eff#2 CS s Effluent #1 = BOD. > 30 s 220 ma/L and TSS > 30 _< 150 mq/L *Effluent #2 = BOD. > 3075 220 mo/L and TSS > 30 _< 150 mo/L CST Name (Please Print) Sign e CST Number a � >an� � 2 222 Address Date Evalu IM Conducted Telephone Number " SBD-8330 (R04/15) L3j Boring # Horizon Depth In. ❑ Boring pc� ® Pit Ground surface elev: Y� 3J` ft. r �1 Depth to limiting lVqin. �- Soil Application Rate Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 d q je% 7 s 3r ❑ Boring . ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr, Sz. Sh.. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 ❑ Boring # ❑Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2 In. Munsell Qu. Az. Cont. Color Gr, Sz. Sh. *Eff#1 *Eff#2 luent #1 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L * EfFluent #2 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L r IAW I tt 1 � L I --' r _ i_C�I L I I � �T - OLL L 12 i I I L 14 L_.-_�____ _. �---;- ---- - i Wisconsin I Division of I Attach complete site but not limited to: vei scale or dimensions, Personal information f�fy'and Professioi APR 06 ti00 Co��ty �` T Ooao CJ38' 1 � � Page I of SOIL EVALUATION REPORT with SPS 385, Ms. Mm. Code 8 1/2 x 11 inches in size. an must include, p reference point (BM), direction and percent slope, and location and distance to nearest road. Please print all information. ❑ Boring Pit Ground surface elev�� ft. =tLtn to umiung tactori � �+--yin. Snil Annliratinn Rata Horizon FPTI Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 C' 0V i 24 -12P Yt1 Boring # El Boring ® Pit Ground surface elev.'�� `15 ft. Depth to limiting factor,�16`� in. Cnil Annlir�finn R�to Horizon Depth Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Consistence Boundary Roots GPD/Ft2 Eff#2 ,/�f lGr. /14 " tTTlUent iFl = ttUU, > :iU 5 22U mq/L ano 155 > MS 1b0 ma/L 'Effluent #2 = BOD. > 30 <_ 220 ma/L anri TSS > 3(1 < 15(1 mn/I CST Name (Please Print) Sign e CST Number wet av�e 222. �f Address 12a FI;Gi�Gh S arc �� ref uA Date Evalu tiConducted J' ZU2 6 Telephone Number lS - �} /C� - 051 SBD-8330 (R04/15) 1 v 7 j+ i e f INN y .�- i, irmpw OF Irk r ML ,1 Wool 0 04:p