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HomeMy WebLinkAbout030-2120-40-000 wisoonsin Department of Comrnerce PRIVATE SEWAGE SYSTEM Co nty: Safety and Buildings Division INSPECTION REPORT fit. Croix GENERAL INFORMATION (ATTACH TO PERMIT) S 384y247 it Personal information you provice may be used for secondary purposes (Privacy Law, x.15.04 (1)(m)). Per�ryt Ho r s Name: City ❑❑ Vi lag ❑ Town o .- State Plan ID No.: ae 11 ling, Sohn 5t. Joseph Township CST BM Elev.; Insp. BM Elev.- SM Description: Parcel Tax 2 ? j • ZZ i q 3 . Z, r y CS-1- 63 iu 030- 2120 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2,(o v Benchmar g, I l� I. Z 3 9 3.2 2. Dosing It. BM 2 . G $ CIE3. 6S' Aeration Bldg. Sewer y, l a q1. l s ' Holding St / Ht Inlet sr (OD 1 RS 73 TANK SETBACK INFORMATION St/ Ht Outlet b �S q(r, TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > uo 2 NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe RO .St Holding Bot. System PUMP / SIPHON INFORMATION Final Grade , 30 .03 / Manuf urer Demand S over Model Nu GPM TD o lift Friction System DH Ft rcemain Length Fi ist. To Well SOIL ABSORPTION SYSTEM ),l ) % BED / TRENCH Width i Length , No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth D IMENSIONS 3. DIM N I N Man ur r: LEACHING SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM CHAMBER s1 �� INFORMATION Type O A _ r OR UNIT M e Number* System: l�e > It�4 1 0 DISTRIBUTION SYSTEM Header /Mani of Distribution Pipe(s) x Hole Size �HoIeZpacin g Vent To Air Intake Length �F.� Dia. Lengti SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over Lxx D epth Of Lxx Seeded /Sodded xx Mulched enter Bed / Trench Edges psoil ] Yes 11 No ❑Yes C] No COMMENTS: (Include code discrepancies, persons present, ection #1: ltd /J9 /a( Inspection #2: ' - 7 -- ' Location: 805134th Avenue, Hudson, WI 54016 (NW 1/4 SW 1/4 25 T30N R19W) -253019977 Bass Ridge Pines -Lot 4 1.) Alt BM Description 2.) Bldg sewer length = :201.a' - amount of cover = >itz " s a;l �,,•,� 4-11 6pr C-0 4) No w� - + . v sect � Plan revision required? []Yes `qNo . O 1 Use other side for additional information_ ff SBD -6710 (R.3/97) Date inspector's Signature Cert No p� 30� 8 09 ? � 6 . 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 you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1 } (Submit completed form to county if not i state owned.) Attach complete plans (to the county copy only) for th tq pape not l s an 8 -1/2 x 11 inches in size. County State Sani Permit Number ❑ Ch i ision v' us ap i i State Plan I. D. Num ber I. Application Information - Please Print all Information Location: Property net Name Property Location C G 1/ I/4 N, ( Property Owner's Mailing Add ss Lot Number Bloc ber City, to Zip Code Pho ! Suhdh&io&Name or CSM Number ( z& ES II. Type of Building: (check one) ✓ 1�.,�� ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: ( 4 0 Town of ❑ Public /Commercial (describe use):_ ❑ State -Owned / 2 3 K '3 . 47 ' S Nearest Road Q Parcel Tax Number(s)O 0 y - 0 M. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. ANew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) 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 Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation Off' 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 / 'J X425' ./ ❑ ❑ ❑ ' ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installa ' n of the POWTS shown on the attached plans. Plumber's ame (print Plumber' Sig r (n s� MP/MPRS No. Business Phone Number A _ �� Plumber's Ad Tess (Street, City, State, ip ode) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ss ' g Agent Si a (No stamps) Approved 11 Owner Given Initial Adverse Su r z�' Fee) A Determination t -Z1 M X. Conditions of Approval /Reasons for Di sapproval: G'�' T� fS CJC�D IMQI��I'C4.{C l / ps fS re f SBD -6398 (R. 07/00) L I : E.0 o - �' l's F. 19 � Ile Ile - - - - -- -- � y �tJd? .. SCi� l�1c,I O I I I I I I I i A -- -- : : r i i O� i i ��,iySr O s 0 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division 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 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 3 Please print all information. R iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 'L� I Property Owner Property Location "L/ Govt. Lot ) 1/4r 1/4 T D N R E (o Property Owner Address Lot # Bloc Sub g. N ame or CSM# City State Zip Code Phone Number ❑ City Village 10 Town Nearest Road New Construction Use: Residential / Number of bedrooms e derived design w rate GPD ❑ Replacement ❑ Public or commercial - Describe: °► Parent material lood Plain a jiflapplicabl'0 ft. General comments ' '1 / E and recommendations: /x Boring # ❑Boring �t jai Pit Ground surface elev. X97 ft. Depth toh 'itingfactor //D in. Soil Application 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 3 ❑ Boring # ❑ Boring Pit Ground surface elev. 2 ft. Depth to limiting factor > / //� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Co t. Color Gr. Sz Sh. *Eff#1 *Eff#2 " Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name lease rint � S' nat CST Number ZZ Address Date Eva uation Conducted Telephone Number �)T f2:4� SBD -8330 (R07 /00) f Property Owner Parcel ID # Page of M Boring # ❑ Boring Pit Ground surface elev. , 5:,f7 ft. Depth to limiting factor in. Soil Application 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 r F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application 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 F-1 Boring # El Pit ❑ Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application 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 Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 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. SBD -8330 (R.07 100) sW, 41 - n°i9�1 /Gf.e d ,aye a y3 , T ss\ { Wisconsin Department of Commerce SOIL AND SITE EVALUATION Divi,� of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm ode god- NA4� 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 r ,� C D) k percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes u oses (Privacy Law, s. 15.04 (1) (m)). a . _ 2 Property Owner Property Location C _., ` 6 Govt. Lot Al 1/4 < 1 /4,S �T 30 ,N,R q E (or)©V Property Own e s Mailing Address Lot # I Block# I Subd. Name or CSM# City to Zip Code Phone Number City ❑ Village EL Town Nearest Road ems l SYU/ ( ?/ �y�3/ -� . �D s �C. 33 J -24 X New Construction Use: 5Z Residential /Number of bedrooms — Addition to existing building ❑ Replacement�,'� l ❑ Public or commercial - Describe: Code derived daily flow. gpd Recommended design loading rate . 7 bed, gpd /ft gPd/ft Absorption area required n/3 bed, ft2 . roi�3 trench, ft Maximum design loading rate - - bed, gpd/ft2 Y trench, gpd/ft Recommended infiltration surface elevation(s) eeex .7r =4 ft (as referred to site plan benchmark) Additional design /site considerations Parent material 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 XIS ❑ U Jos 1:1 U .� S El U S ❑ U El S ,� U E03 S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 inn. Munsell / Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ULL -a. Ground v. 0. Depth to q � 1 _ _ Remarks: Boring # j 104 Ground ft. Depth to limiting im F in. Remarks: CST Name (Please Print) nature ` Telephone No. Address / Date CST Number SOIL DESCRIPTION REPORT PROPf.RTYT OWNM Page of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ✓/h �� Ground Depth to 2 4 16 Z limiting fac_WI/ Remarks: Boring # �' I M 2 1 6 i Ground le �� ttt. Depth to -- limiting i i t 1 4 � in Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ! L �, �� � •S'� Ground Depth to limiting tr in. Remarks: Boring # Ground elev. , ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) ' r Soil Test Plot Plan Project Name Dave and Aria Railsback Sha d Address 845 133rd Ave ft, , N R i c hm o nd Wi 54017 CSTM #226900 Lot 4 Subdivision Date 6/ 4/99 NW 1 /4 1/4S T 3 0 N/R 19 W TownshipSt. Joseph ❑ Boring ()Well PL Property Line County S T. C ROIX ,r VRP Assume Elevation 100 ft. Top of Steel Fe nce Post with Orange Ribbon System Elevation 93.0 /90.6 * H R p Sa a s Benchmark Alt. BM Top of Nail in Tree with Orange Ribbon @ 99.6 od 514' Property Line 40' Turn around for pro town road Soil Test done to satisfy zoning requirements, may not be suitable for buyers desired building site. 100' 6 342' r Line Property 60' Pri A lt. 30 , .M. Rep A 115' 350' _4 Property B-5 60' Line Slope 428' Property Line i 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 a Number of Bedrooms Design Flow - Peak (gpd) Estimated Flow - Average (gpd) Septic Tank Capacity (gal) } Soil Absorption Component Size (W) < < Type of Wastewater Do estic r Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absor 'on Component Design Flow - Peak (gpd) 2( ( as `� 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 the septi and outlet filter shall be assessed at least once every 3 years by inspection. The tlet filte s hall be cleaned as necessanUa. proper operation. The filter cartridge should not be removed unless provisions are made to re1WffT67iU§­ilTthe 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 May- 29.01 12:OOP adp hollander 612 -551 -5778 P.05 ST CROIX COU NTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWN[! If' CERTIFICATION FORM Jwner/Buyer —.b 1 ra. � + t'� 9 Mailing Address 4 7 81 VI' l l L. L. WMI 'M 2 - L V ®� A A i.. f a $ !'rC?(?Crty Address 8 05- ».,.._..... ..t 7`�! � d � (Vcrrlt:Jtitin rcgLjrcd fro i'larnurt Uepartnrent for:)"IN consttu.'ictn)_ City /State Parcel Identification Number _ — ° 3 6- ;2 / ,PCo - Do c-> I.,FGA DE ` Property Loccit�n -41L !', !' +, Se , '1� N -R Div', T�twn of _�"r�.J �''1 Subdivision � � a � 5 R ' c)_q� P "'j LS_ » ,Lai # 1 4 C:ertirted Survey Map # , Volume , Page # Warranty Deed-.# 6 5 0 4, � V O'tlrrti _ ,Page Spec house 0 yes R no Lot lines identiF bie X yes L no S YSTEM NIAINTENA T Improper use and mat :vvn;anceof y our scptic s ystem cUiitd resuit al its prrmanuc Iatlure t4 handic waslt5. !'roper m sintcnuttc :c consists of pumping out the ripe, tank every tn;cr yeurs or suontr, if rrredcw t;y a iiccmcd purnher, What you put into the syste:r: can aflev the fununo, of the wpt c tank as a ireutmrnt singe in the waste Disposal system The property owner agrees to submit to St. Croix Zoning 0cpattment a cenificadon form, signed by the owner and b; a mastcrplurnber, iounteytnan piurnber, restu plumhcr or a liucrised;;arnper verifying that i.l i the on-site wavewaterdispusai sysrctn is in proper cper;tting condit v .,wll or (2) a'tcr i7,pcction and pumping (tf ciecessary), the scptic tank is less than 1/3 full of s!ud, 1,'we, the undersigned have rsa,l J! above requ and agree to mai;rutirt the pnYaic srwge disposal system %kith the stam]at is set forth, herein, as set by the (.)apartment of' '1 a nmerce at.id the 0epar!ment of Natural Resources, SUN of Wrsconsrn Cer-I i -O"Q0 stating that your septic system has been maintuined must be eompleted and rctvmed to the St Croix Counry Zoning Office Within 50 days of the three • year j expiration date. SI ATURE OF APPLICANN 17A ATE OWNER CERTIF i (we) certify that all statements on this torn are true to the best of my (our) knowledge. 1 (we) am (are) the owric"W of the property described above, by % irtue of a warranty deed recorded to Register of Decds Office. SI TURF OF APPLICAN f' i N CATF, 0000 *0 Any information that •.s mrs•reprr.sented tray result in the sutntary pemlit being revoked by the Zoning Departm 00000 f Include with this applicatium a stamped Warranty decd from the Register of Deeds office a copy of tha certified survey map if refetmnce is made to the warranty decd allay X29 -01 11 :59A adp hol lander- 612 -551- -5778 P.02 i oyO�vcsv sTA i & W,le ur xsscawstx FC atM 2 199 r KaINLEL4 M. Wµ,SH 1 9a►ARIIAN II RV REGISTER CW DEEDS tMittmM N YM iKr .M -- _ T. ROIX CD., GT -- --- rirWdllJ.i�Yt�fck+•Ll, X06 Arh J. RfCEI" MR RCCM =}�1ii �r.�ei enaileirolwaYn - µiiu►s[wck_MwAand Yad,+d!c, _ ��— _._�_. —_ . -- 05i�4 -ZCOl 4:20 W) —_ _ -- — — car r — ,rrntor, a+ 1 J4ho D. KXSt7TY C F EE; I{E _ __ . � .007T F EE; Grantee..... .._. sAnveys fu GI entev the Cvtrnfet'. *1(iA W-bk ci "— t ti>til[tu'ioR +I scriDe+t n> &j vmurc in 1 5,#Iv of Wisconsin if nwrc Spa" is needed, ptease atmch addcndum): StsAt'Qitlg ArcF }9Ttf tTFiEI' / . Ss ••/ Lot y, E}:rss Ridge Pines, Torn: of St. JLSepn .. }�ppt WI 54016 S�TH 6, ©.3o�aia.o Yxnr+ )detnificnan Numb (NN) na, is Aol .. hatYis:sa� WYpirtY a �� 04) olr4nt) LkcY iQl%s I0 wett8rI.ies: Easements, r"- IrMd0Rs and "ighsi svYy oT record, if any'. 1 tlay of _'May 2001 — AUTIfLNT1CATION ACKNOWLEDGMENT ST Or WISCONSIN 3 sigm�vrcty +�Yr:aK x .;�bY�,•u� prL.t FYisse Yak. — ),s. 8ulh.rq. rlrc this ° dY of !4d -.. �. Pau+�Y11y curve before me th'.a _ —. day of t TI17.1.: MENVI.li STA'SF. MR. CH; WISCl7NSIN emu Rtwvrn tr be the prrso�(a/ wlrn unccvlt� tlr< furegoinC ilE rw +� _.... — -- -- ---- -. i:lurmnca! rrsfi alknttwleAged 1115 TNSTNI3'viif'f�' nS71R7tftirU fly blowy NWX-Sisu of Uyit4ettairP owmaerfirisr+irta')R Yludson, Wt3W +e — — _.__ Mr C•dmn+isstur+ i■ perrnallc. ttr not. etale cxp �Mttn•'nutta +uan p nr ecknnwicdl{cJ. both arc not n.`i et,5'i 7.1 M r „ a „ytY a e tivYy city meat be cy9cd or prihmj trclwr thta signatum. waa+ato 3yA"f E OAA OF W I6cs)N,ra t �YARRANP DtJ tl .'ORhI No. 3 - 1999 ` GI • a � r r Ile wl 4p iy. OT • `✓ cy �- is r a c R � -t UUt E t ,� '� •c+e- tea+ Qi 2` i Q Qi Ya St Nab � wati`•dw )'d ELLS- 199 -Z19 - AE)pueLLOy dp» d69:Tl TO- 62 -XPW