HomeMy WebLinkAbout018-2019-17-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)].
Permit Holders Name'. I City Village Township
W C LAND HOLDINGS
IPATPP►[eIW:1_\LI►M0191
Ga V`-I
ELEVATION DATA
TYPE
MANUFACTUR r
1
CAPACITY
Septic
W
Dosing
344— o
to
Aeration
Holding
TANK SETBACK INFORMATION. Jild eil%or Colt
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PUMP/SIPHON INFORMATION
Manufacturer
Demand
M
Model Nim
e
TDH Litj
ricti Los
stem H ad
DH Ft
Forcem
L lh
Dia.
Di to Well
SOIL ABSORPTION SYSTEM
3
STATION
BS
HI
FS
ELEV.
Benchmark
S g
J• O
I
lit ."it
."
Alt. BM
Bldg. Sewer
rD.l$
�/
9Z•K1
SVHt Inlet
1L& p
Y
i t r pn
St/Ht Outlet
'O.
9
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Spyer soli -tom
6.8
g5.07
eMtN�K. .5eW
r /;yt
2
13. %
88. Q
BEDfTRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
I No. Of Pits
Inside Dia.
Liq76ril
SETBACK
INFORMATION
SYSTEM TO
P/L
BLDG
WELL
LAKE/ST EA
LE CHIN
CH E OR
U I
Manure rec
T70»Of System .' �
,{M-
O
I
�D V-
od Number:
DISTRIBUTION SYSTEM
Header/Manifold
IDistribution
x Hole Size
Ix Hole Spacing
Vent to Air Intake
e(s
Length Dia
Length Dia Spacing
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svsterns Only,
Depth Over
Bedrrrench Center
Depth Over
B
xx Depth of
xx Seeded/Sodded
xx Mulched
es
es ■ No
COMMENTS: (Include code __discrepencies, persons present, etc.) Inspection #1:
Location: 162372ND AVEE�W 01
1.) Alt BM Description = S1&-1011t r W L �l h f r✓1Si-c� e�
2.) Bldg sewer length =Z 1 - -\-
- amount of cover = L Z 11
Inspection #2:
eh -o pY� �I I'nsretAw
Z-01-
1 Mr,,,K1a
Plan revision Required? 0 Yes I;YI No �.. I ( �f� 74, —1 � '� O
Use other side for additional informatio 1 ram/
SBD-6710 (R.3197) Date Insepctor's fignEiture, Cert. No.
S 40 )b a4 —6Z2
�a
County
Safely and Buildings Division
St -Croix
APR '06 2020
201 W. Washington Ave., P.O. Box 7162
r
Sanitary PermitNumber(lo be filled in by Co.)
Mad 7 71
St. Croix County
N 4S t
eve o en
t A plication
State Transaction Number
In accordance with SPS 383 21(2), Wis Adm Code, submission of this form to the appropriate govemmenml unit
O. q
f a"-,� TICle)I I b 2--c-, v wa
Project Address (if different than mailing address)
is required prior to obtaining a sanitary permit Note Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Servies. Personal information you provide may be used fro secondary
purposes in accordance with the Privacy law, s. 15. 1 m , Slats.
1623 72nd Ave
L Application Information -Please Print Ali Information
Property Owner's Name 37 , �r�
7
Parcel #
W C Land Holdings coos le
018-2019-17-000
Property Owner's Mauling Address
Property Location
626 Tremont Lane
Govt. Lot
SE /, SW y., Section 29
City, State
Zip Code Phone
Number
River Falls Wi. 54015
zs (e°clCO1e)
T N; R 17 E m W
IL Type of Building (check all that apply) Lot
#
Subdivision Name
Rolling Hills Farm
JR I m2 Family Dvvelling- Numberof fledCms 4 17
Block
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned- Describe Use CSM
❑ Village of
Number
56 Town of Hammond
III. T of Permit. (Check only one box on line A. Complete line B if applicable)
A.
System
❑Replacement System
❑ Treatment/Holding Tank Replacement Only
❑Other Modification to Existing System (explain)
B. ❑Permit Rrnewal
❑Permit Revision
❑ Change of Plumber
❑Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration
Owner
IV. Type ofPOWTS System/Component/Device: Check all that apply)
❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade® Mound> 24 f amiable anal ❑ Mound <24 in. ofstritable it
❑ Holding Tank ❑pillar Dispersal Component (explain) , ` R treatment Device(explain) Hoot 600
V. Dispersalffirealment Area Information: 11
Design Flow (spin
Design Soil Application Rate(gpdsf)
Dispersal Area Required (at)
Dispersal Area Proposed Is
ystem Elevation
Existing
1 1
103.30
VL Tank Info
Capacity in
Total
# of
Manufacturer
Gallons
Gallons
Units
v
a
New Tanks
Existing Tacks
6 U
rn m
no
Septic or Holding Tank
4W/921
Hoot 600/ Wieser
X
Dosing Chamber
2500
Wieser
Viz. Responsibility Statement- 1, the andersigned, asaame res afb' - fo intall 'oa of the POWTS shown on the attached plans.
Plumber's Name (Prim)
pl Si --
-MWIAPRS Nunnber
Business Phone Number
Keith Knudtson
648443
651 470 1737
Plumber's Address (Sheet, City, State, Zip Code)
927 150th St. Roberts WL 54023
Coun !Department Use Only
.�VUL
qQ Approved
(
❑Disapproved
Penn) Fce
$
DIssued
Agent Signs
❑ Owner Given Reason for Denial
ZO!
%19?ftQMtApprovaUReasons for Disapproval 3 Alu 'tca 294 t/Cdis,
1. Septic tank, effluent filter and p•ww+a- sarvt ii 04w�
dispersal cell must be serviced / maintained D �� `ly i 4 vAq;.A�MtCe
as per management plan provided by
plumber. •If1[� +p I,q,y,�b pµ}-1
2. All setback requirements must be maintained
rn Pet aNFn t` uie t:wtXrhy plans for the ".I d s m to the County only on.p.p�Iper not less than 8Aa j1 inches in sus 1 -
Py(y�,,,a�,.��ir;,^}o ,��F /�t'tt w•tl L4nn.ec.� ��✓
SBAe398 (R. 11/l>
G ov'i
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KNUDTSON PLU W:;:
CONTRACTING, LL
927150TH ST. 648447MPiP .5
ROBERTS, WI 54023-85'_3
CELL 651-470-1737
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KNUDTSOM PLL
CONTRACTIN,'
927 150TH ST.6439'T.-
ROBERTS, Wl 54023
�✓� CELL651-4704737
DIVISION OF INDUSTRY SERVICES
Plumbiry Product ReAew
P.D. Box 7302
McAson, W*wr sa153701 2658
TTY- Confaot Through Relay
Rp—, Ommpilim SEWAGE TREATMENT APPARATUS
der HOOT SYSTEMS, LLC
Pe■Yd 11111IN (trans id 3097849) H-SERIES HOOT
bbft t inbBr(s): H-500-A (MAX. DWF 600 GPD)
Po ixt cibe W. 20180134
The snecicahons and/or plans for this plumbing product have been reviewed and determined to be in compliance
w1h ors SPS 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin
Stabiles
The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative
Code. This approval is valid until the end of May 2023.
This approval supersedes the approval issued on March 12. 2013 under product file number 20120398.
This approval is contingent upon compliance with the following stipulation(s):
• This tank must be designed to withstand the pressures to which it will be subjected.
The manufacturer must keep at the manufacturing plant a set of plans and specifications bearing the
department's stamp of approval. The plans and specifications must be open to inspection by an authorized
representative of the department.
+ This product may not receive backwash discharge from a water softener. Water softener backwash
discharge must be discharged in another method acceptable to chs. SPS 382 and 383 (formerly Gomm 82
and 83), Wis. Admin. Code.
+ The maximum daily wastewater flow, which may discharge through this product, is 600 gallons per day.
When this product receives wastewater from dwellings, it Will produce an effluent !quality with a maximum
monthly average value for BOD5 of less than or equal to 30 mg/L TSS of less than or equal to 30 mg/L TSS
and F,O.G. of less than 30 m9/L and fecal coliform of less than or equal to 10,000.cWl00mi.
Plan review for the installation of this product must be obtained from the department in acoordanoe with SPS
382.20 (1) of the Wis. Adm. Code.
This product must have installed a department -approved effluent filter capable of filtering particles of 118
inch in size or larger.
SBD-10564E (N.10197)
File Rat. 18013403.000
Systems LLC APR 16 2020
ay 10, 2018
Page of St. Croix county
Product Fite No.: 201M34 rnmmumty Dever
Table 1 Maintenance. Insnectien. Pumninn Reauirements
PRODUCT/ els
H-500 600 aUda
Initial/Startup Inspection/ Maintenance
2-yr. service agreement wlmanufactraer
Ongoing Pumping Cycle And/Or Requirements
2-yr. pumping (trash tank only), unless more restrictive
by local or state regulation; for samilm chamber, see
inspection nesult§ ...
Back -Wash Cycle
N/A
Effluent Performance Levels
NSF-40 Class 1.
BODS Credit For DownsiziM Distribution
Area
YES
Fecal Credit For Reduction Of Vertical Separation
YES
Addifional Comments
none
• These tanks shall be fitted with locking manhole covers in accordance with s. SPS 384.25 (7) (h) Wis. Adm.
Code. The manhole cover must be secured to the riser using screws which are not standard or Philips head
to be considered an effective locking device.
a These tanks shall bear warning labels, that are visible after installation, that conform to s. SPS 384.25 (8).
• The tank Is not recommended to be installed where saturated soil or seasonal high ground water tables are
Indicated between the bottom of the tank and the ground surface.
• BEDDING: 3-41nches of compacted bedding shall be provided. The bedding material shall be dry, sandy
loam material, or coarser: 'Y2 diameter in the largest dimension.
BACKFILLING: must be compacted ats 6-inch intervals. Backfill material shag be free -flowing soil or gravel
s 4 inches in diameter in the largest dimension.
The department is in noway endorsing this product or any advertising and is not responsible for any situation which
may result from its use.
S
incerely,
4
dueter
ct Reviewer
Department of Safety and Professional Services
Division of Industry Services
Bureau of Technical Services
(608) 267-1401 Phone
(608) 267-9723 Fax
glen.schlueter@wi.gov E-mail
4" OAS
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sm.. Z,w
4" OA4
FOolm it Arxr..A9 LID (TYP)
Y. 4E'R RISER (TYP)
AAF I.D. PLASTIC RISER
F 0,13,
TLTi
INLETT CAST-A-SIAL (CAI) DDOT OR EQUAL
TTAANKi MIXli xDEVON RY (�MALLAFIDIA)
CLITOMIUD TANK9t
►OR HISTON TANKS CONTACT WESER CONCRETE
FOR APPROVAL
APPROV40 AV[ ____
WINK& RATAI
PNZUCTA NCIAlU AYI �
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- v
St. Croix County
N�
o0
EROBIC TREATMENT UNIT (ATU)
U C
SERVICING AGREEMENT
N E
[state Plan Transaction Number - D D
_ C L..WD NouArArcts
IuC
Name — (Owner) Typed or printed
Being duly sworn, states, under oath, that:
1. He/she is the owner/part owner of the following parcel of land
located in St. Croix County, Wisconsin, recorded in Volume, Page,
Document Number 109y419dated oz St. Croix County
Register of Deeds Office:
A parcel of land located in the SW '/4 of thew'/4 of Section 299, T 29
N — R J+ W, Town of 13 NO , St. Croix County,
Wisconsin, being duly described as follows (include lot no. and
subdivision/CSM or detailed legal description):
�f/l�/�azo l� e� R�pll
Agreement Date: 1p.Go r trtm 4Cd' $�-•arW)}�C�iaN,W
tots pi-+. K
I I8lll5lll5lll0lu4ll9 6111
Tx:4563346
1100663
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
04/17/2020 12:39 PM
EXEMPT
REC FEE 30.00
COPY FEE 2.00
PAGES: 1
rvnme r.nv -tdDD ��'t- �° L-CC.
As an inducement to the county to issue a sanitary permit for a POWTS equipped with an Aerobic Treatment Unit on the above -described property,
we agree to do the following:
1. Owner agrees to conform to all applicable requirements of SPS 383, Wis. Adm. Code relating to Aerobic Treatment Units (ATU) and the
maintenance requirements for the proposed POWtechnology-
POWTS (Private Onsite Wastewater Treatment System) tenology. If the owner fails to have
the POWTS and ATU properly serviced in response to orders issued by the govemmemal unit or the Department of Safety and Professional
Services (DSPS) to prevent or abate a human health hazard as described in s. 254.59, Slats., the governmental unit (Town) may enter upon
the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill a$ a
special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Slats.
2. The owner agrees to maintain a contract with a licensed POWTS maintainer for the life of the system. The POWTS maintainer wig perform
periodic Inspections and maintenance as required by the manufacturer and the Department, including, but not limited to: the blower, electrical
controls, and treatment unit operation and sludge depth. These inspections are to be scheduled every 6 months for the first two years of
operation and yearly thereafter.
3. The owner agrees to contact the POWTS maintainer immediately upon any malfunction of the treatment unit and to maintain the unit so as to
not create a human health hazard as described in s 254.59, Slats.
4. The owner recognizes that the county, DSPS, or POWTS maintainer may make periodic inspections of the components to complete
performance monitoring of the unit.
5. The owner or the owner's agent agrees to report to the department or designated agent at the completion of each Inspection, maintenance or
servicing event In a manner specified by the department or designated agent within 10 business days from the date of inspection,
maintenance or servicing.
6. This agreement will remain in effect only until the county office responsible for the regulation of POWTS certifies that the aerobic treatment
unit no longer serves the property. In addition, this agreement may be cancelled by executing and recording said certification with reference
to this agreement In such manner which will permit the existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement
to the Register of Deeds, and the agreement shall be recorded in a manner that will permit the existence of the agreement to be determined
by reference to the property where the Aerobic Treatment Unit is installed.
Owner(s) Name(s) - Please Print
Subscribed and sworn to before me on this date:
A10'1
G L
Note raed ignatuhe
Note ••
� •••
/t j
b :
Q,
Governmental Unit Official Name, Title - Please Print
My Commission Expires
Ilt1-
Govegnmental Unit Official Signature
Drafted by:
.....,......
ST. cR.crx CoIaNTY %unw111dlTY'
Personal information you provide may be used for secondary purposes [Privacy Law a. 15.04(t)(m)]
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT— DO NOT REMOVE"
This information must be completed by submitter. document title. name & return address. and PIN (if required). Other information such as the
granting clauses, legal descdption, etc. may be placed on this first page of the document or may be placed on additional pages of the
tg y,t4dy„ttor .y 0"fig "itijavp"age adds one page to your document and $2. 00 to the recorcilm fee. LYrsconsm Statutes, 59.43.
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DISCLAIMER: Thee map Ie not guaranteed m be
accurate, caned, current, or complete and
concluvionf dmen am Ne teapowbirry of Ota
beer.
ST. CROIX COUNTY
SEPTIC TANK MAI14T NANCE AGREEMENT
. Vr)
OWNERSHIP CERTIFICATION FORM
OwnerMuyer Gil C. % •c,&
Mailing Address (o Z � / /2 /V1, 0 "f I
(Verification requucdirimt Planning & Zoning D tment for naw cconstr) om ey City/State s r Parcel Identification Number -/7 — Cop
LEGAL DESCRIPTION 1
Property Location rV4 , Y4 , Sec. . T N R W, Town of
Subdivision
Certified Survey Map #
Volume , Page #
Warranty Deed # O % `(3 f Volume Page #
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Lot # —a.
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 yeas 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 fort, signed by the
owner and by a master plumber, journeyman plumber, restricted phrmber 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 (ifnecessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herem, 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 in= to the best of my/our knowledge_ I/we am/are the ownet(s) of the
property described above, by virtue offaa warranty deed recorded in Register of Deeds Office.
Nttmber ors
SIGNATURE OF APPLICANTS) DATE
:"Any information that is misrepresented may result in the sanitary permit being revoked by the Phoning & 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. OWS)
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PRIVATE SEWAGE SYSTEM
St. Croix
INSPECTION REPORT
SAMMY PemM No.
GENERAL INFORMATION
(ATTACH TO PERMIT)
615459
Sure pan M No
Pe•sc^amforrreton yc. p,voo may be uudto• e,c,,dary Furoosee (PrIvulY law. a •5.04 t )(m)'
m; .I N Name
city Vma•Ta a^.nit.
Para' Tax No
T'
Tyme Properties LLC
Tr1VVIJ nr: HAMU(TNI]
018-2019-78-000
/oo
TANK INFORMA
I G5T
ELEVATION DATA
I YPE
MANUFACTURER
CAPACITY
Sepllc
Dosing
•bit
I {'
w
.y
G7
Aeration
Holding
TANK SETBACK INFORMATION
STATKJN
HI
/�•
FS
ELEV.
Eiencl+m,rk
5, S
/dS.
/41
91dg. SeveA
SVM Wel
SUH1 OtAlet
Ot Inkl
Ol "«n
T3 5
Header M.lan.
L h
Dist Ploe
/d
eot
-vial Graft
S10
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EWRENCN
'vn
leng-A"
.
inrd
DIN
X
J
rffDE`N
_
SETBACK
SYST MTO
PA- BLDG
WELL
LW(EtSTREAM
LEACNW.
Mantfact.w `1
INFORMATION
"ypa ahem
CNAHUX OR
Model NumM/. `
S �a
SYV
�
UNIT
DISTRIBUTION SYSTEM - �• S..U_
HeacaNsJu" 1 110
Lergn� pa�
s'rn n 5
Vim, ', I • S Soar. ^F_
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3
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3
V Air Into
SOIL COVER / a Pmsuro Svslalns OnN as Mound Or Atdlrsde 8vatarru Only L K..915 �
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Dew N
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v MWUM
aea''renc. Cant+ / . '1 Q
6ed'T ercn Capne _�
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`„�� No
`!ee D No
COMMENTS: {Inrdude code elscrepem es, persona pnescnl. ex.)
Loudon: No Address Ava a,0�4u
1.) All BM Oescriptem • V1,0 u ,p 66J&l
2.) Bldg sever length -
amaax or cover .
Plan review ReQuaed9 i : Yes No
Use other side for awfhionaH ahlgmallen. 1 V
5513-071c (R.O.•gT) Dak
Irtspectlonol- �/� 9 Infpedon 02:
Cut. No,
_ rv-aat - at
�„- r. , .CAMMY
;•'
/ j' � ; _.',.,'1 . -, �_,
safety and BldWings Dirkltm
St. Crab(
�° • � ..
201 W. washlrgton Ave., P.O. Bw 7162
S.MWy Pia Numb. le. be lid in by Cal
`_�! ¢% JuUL 29 2 119
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f�+aason,wl 53707-7162
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l
. it Applicat' n I
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071901182-C
it rayuun) prie k. aanalnnlp u a. Wy pemril Fkae. Appl.atam fem<(i» .tee-nM1C.i FYIWTN oR wbgined W
1'n+jacl Addrea (if diRertM ilia mulmg addlsa)
dK mp+rt.neat Of Slfc1Y mid Pwfcuixv l %Cffm. PQ Y I .nkemalnm yMl tllMI& umy be law RR
.»ee m umedence wrh Ik 14i.av - 1 wa�. a I5 I q Stra
72nd Ave.
1. Applies lam leforwail _�.1Rt AM Informamim
parcel0
Pnparty(hner'a Name 1
ate' o:S �
018-2019-78-000
Pnrpafy fMner'. MrL..s AdAeq Ds.MaA
n _ . I .
IJG�v,
Ph)p". L..ma+.00,
3435 Labore Rd.
ctml I,a
SE SW 29
Y., 'H, 4atum
fig•. SY1c
%p lhWc
Phe.e Number
Vadnais Heights Mn
T N: R
11. Tlpe of Buildiog (ebwk all that apply)
Ld v
bV
❑1ar21'umihUwellulp Nunl,n .•I llcdr..m.a 12 too
15-17
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If app ble)
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❑Iron. ,Ikadm0'fank Rgdacemnr Only
Over MMWiiorma a. FAWN* Syr (aWiaW)
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_
V. mVf scot Area la e
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2600
12500
11
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.
Phmber'a Name (Pnni) Plum MPIMPR.S Number B1a91cYa Pllare thunder
Keith tcnudlson % 648443 a6t /To-tfs2
Plumber'. Addq ISbce1. ('ay. Stak./pl'.dc) .
927150th St. Roberts WI.54023
u"0alr
ppored ❑ i)"
Prn i1 F.
1 Iss
Iwi gaa Nignaore
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.hare 1. e»eP11e 01am be Ile g•arm aaa Meit r» Iar furry »alY w Mfr aw k.» lbaa a vt a 11 IaeW» r we
/I
SBD-6398 (R. 11!11)
Pap 2 of 9
Sanitary Site Plan
For: Tyme Properties LLC
Rolling Hills Farm Outlot 1
Part of the SE114 - SW114
Sec. 19 T29N-R17W
Hammond Tnsp. - St. Croix County
BV ELEV
.:MQ1
DM -Top ofL l Im SA' Gorr of1at 16
A8$UMtDELLV.- 10
9Mn - Top a L011%' ear Corns V' Lot'T
t1w. -16..7
OUTLOT 1
20.50 ACKS
1.2e7,e., e0. FT.
M
10/0 - M ELEV. L
_, q,7F 1047.02
L"MIan
OT
3
Jam/ LOT ' 6O0 LOT
Is Is 14
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17
p,211, I
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$ -
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