HomeMy WebLinkAbout032-1092-30-100Wisconsin 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)]
renda Daniel
TANK INFORMATION „-Av.
TYPE
MANUFACTUR
CAPACITY
Septic
'
Hold'
F1ijEP—
Ill
A�
TANK SETBACK INFORMATION ' C y,,6AS� L(1(kr 1
TANK TO
oW
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
"No"
I
Dosing
Ion
i
Helding
PUMP/SIPHON INFORMATION
Man uf r -
D and
PM
Mod k, Number
TDH
Friction Loss
System ad
TDH Ft
Forcemain
glh
jx�
Dist. to Well
SOIL ABSORPTION SYSTEM
DIMENSIONS
SETBACK ISYSTEM TO
2'
DISTRIBUTION SYSTEM 11.6 Ad
X
OF SOMERSET
TION DATA
STATION
BS
HI
FS
ELEV.
Benchmark
�•
D
f
(�
O�.
Alt. BM
Bldg. Sewer
St/ Inlet
4q
su t outlet
&�
117 - 0
Dt Inlet
Dt Bottom
Header/Ma
,^,
Cr
J
Dist. Pipes{ dw-
bin
Itj-
, b
Bot. System
0.113
p4•�
Final Grade
.>
l��•�
St Cover
•
L�
�'`��
Of Pits Inside Di , Liquid Dep_
LEACHING Manufacturer:
CHAMBER OR
UNIT ModeNNumbe . I
Header! d
Length Oia
Distribution
Pipe(s)
Length Dia Spacing
Is Size
x Hole Spacing
Vent to Air Intake
SOIL_COVE10 ' x Pressure Svstems Only xx Mound Or At -Grade Svstems Only
o rDepth
- Depth of
xx Seeded/Sodded-Yes
rot Mulches
Bep ,e ,.
BedfTrench Edges / lLu
Top oil
��
Yes 0 No
C9"ENTS: (Include code discrepancies, persons present, etc.)
Location: 483 184TH AVE
1.) Alt BM Description = i
2.) Bldg sewer length =
- amount of cover = 1 V 4 Cover GA
A11 ,, �i
Plan revision Required? ® Yes No
Use other side for additional information. ' --VOL
Date
SBD-6710 (R.3197)
Inspection #1: Inspectio�n�#2:
191
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I epctorsLSignare Carl. No.
cam'��nn r
50-202w- 0o
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22 2020
Industry Services Division
1400 E Washington Ave
P.O. Box 707 r�
Madison, WI 53707=7162
Courtly 7
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itNumber(tobe�`dm"yCo)
(492
Cam»lll ppllcation
Trras�rion NuotMr
In accordance with SPS 38321(2), Wis Adm. Cade, submiseian of this furor to govern mw unit
is required prior In obmllupg a summary permiL Note: Appliabon (mans for smto-o� PDAF S are submitted an
the Department of Safety ad Professional Services Personal m&mmbm you provide may be used for secondary
in accordance with the Privacy laws IS.04(lXml Stets
Peojwtt Address (if dill smat than mtligaddtess)
(" 3 p
I. ApplHicattion Imfar h atiom - Pease Print All Iaformati
san
PmP�y s Name
Parcel 0
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—30
Pmpertyownersmwling,ukkcasInch
City, State
Zip Cade
Phone Number
_ N' R'" E V
U. Type of Bald ag (Reek all that apply)
�d1 or 2 Family Dwdlmg-Number of
Lot 9T
Subdivision Name
S)
❑ PublidCommacial-Describe Use
Block IF
❑ City of
❑ Sate OwrnM- Desarbe Use
❑ Village of
mny�
p'° fi0 2S
G
l
_ 7 y
V4 Town of
UL Type of iC (Cheek only one boa on line A. Complete line B if applicable)
A
New System
❑ Re k...d System
❑ TrmmscnNH okkrng Tack Replacement Only
❑Other Modification m Enu.Vung System (explain)
B-
❑ Permit Renewal
❑ Permit Revision
❑ Change of Plumber
❑ PCOMA Transfer to New
Lim Previous Permit Washer and Dam Issued
Believe Fspinmun
Orwer
I of POWTS SysteuWarnapenentlikvicc Cheek all that apply)
YJ In-C p ❑ ftessx a I M-Gmurd ❑ At -Grade ❑ Mound a 24 m, of suimble soil ❑ Mq®d <24 0, of prfable sal
❑ Roklhg Tank ❑ Odor Diesel Chmprswnt (?[�1am❑ Device (explain
V. Disparsadfrrestfirweat Ara Isfor®tiomc
Design Plow (gpd) Design Sal Appl on
Dispersd Ara Required (at) Arm Proposed (
Sysr®an
�. 7/
c� —
VL Tank Info
Capacity in
G
Total
GGallonsUnitFlPd
$ of
Mamdecoaer
tL PL-SZ�
V
g $
trap. Tabdkas
Sryac a fldd'ec Tack
r
_
�S
VH- Respezistibillily Statame rt- L the wedvegaad, aaame l r taslatlation of the POWTS shown no the atmrhed plans.
P s ) I /
/
Flum S
MP/MPRS Number
L
Br®css Phone Number
PIMIWs Adilress (Sheet, City. Stem, Zip C
`��
VIIL Coam rtment Use Unly
Ql
jo
❑
❑ far Deoid
Pewit Fee
f 5Q% --
Dam Issued
6/ �p
Agent SipWue
OL Conditions of ApprervaMeasoas for Disapproval -�\ �� „_ _ -. n
SYSTEM OWNER: j(J
1.Septic tank, effluentfilter and PC(N+n�W� 2uwi�52 rAaaw c.e
dispersal cell must be serviced ! maintained in�v'rt�to
as per management plan provided by plumber.
a av tpa eta: I' 6�
as per applicable code or loan spmurne' me' . � 7°"L" - ,_A/)
(Y�C.. C/X.1�(VITi-[1B>,t
SBD-6398 OL 09/14)
Lot Nuffuber
CONVENTIONAL COMPONENT DESIGN
U40EX AND Tfn_E PAGE
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,JAV.-chnmft: &A Test & Hmnse Pleas
Lk:m a Nmmber
Data:PboreNunber
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Leaching
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4' Schedu a 40
PVC Vent Pipe
Y1fdh VentCap
v
Soil Absorption System Plan View
Vent Or Observation Pipe
O.Q zvOS -
9V7 ft
Leaching Chamber ee' cafioos
Manufacturer And Model
EISA Rating � sq it per chamber SoN Application Rate gpd/sq it
�A() gpd Design Fk w a _ � Sol Appfica6on Rate EISA = 7 �' Chambers
3 rows of chambers eatch.
Page , �3 of
PL-525 EFFLUENT FILTER
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters. The
PL-525 is rated for over 10,000 GPD
{gallons per day) making it one of
the largest commercial filters in its
class_ It has 525 linear feet of 7i16'
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has
an automatic shut off ball installed
with every fitter. When the filter is
removed for cleaning, the ball wilf
float up and temporarily shut off
the system so the effluent won't
leave the tank. No other titter on
the nzwfwt can make that claim►
PL-525 Maintenance:
i he PL-525 Effluent filter should
operate efficiently for several years
under normal conditions before
requiring cleaning. It is recom-
mended that the fitter 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 fitter needs
servicing. Servicing should be
done by a certified septic tank
pumper or installer.
1. Locate the outlet of the
septic tank.
Z'Remove tank cover and pump
tank if necessary.
Filers
i � a
Alarm
aaessfi8ty Accepts
6CaneWe
Cj
g�
fS 525 linear feet y
of 11101 ,
f8tration slots- Rated for over
to,9eo GM
4aepts4 & 6-
t
1
4` n
Gas door
Automatic shut
fsr s. ^+ ball when filter E
2 is removed t
l.U. PdHK Noe 6A15,428
? 5,877.640
t
PL 52-5 Installation:
3. Do not use plumbing when
filter is removed. Ideal for residential and com-
4. Pull PL-525 out of the housing. mercial waste flows up to
5. Hose off fitter over the septic 1o•000 Gallons Per Day (GPD)_
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.
f
t
1. Locate the outlet of the
septic tank
2- Remove the tank cover and
pump tank if necessary_
3. Glue the filter (rousing to the
4' or 6' outlet pipe_ If the
filter is riot centered under the
access opening use a Polylok
Extend & Lok or piece of pipe
to center filter.
4. Insert the PL-525 filter into
its housing_
& Replace the septic tank cover.
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START UP AND OPERATION
Page of—
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are
detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be discharged to the sal absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or POWTS Maintaner to assist in maritally operating the pump controls until normal effluent levels are restored within the pump tank
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do root drive or park over, or otherwise disturb or compact, the
area within 15 feet down slope of any mound or at -grade soil absorption area_
Reduction or elimination of the following from the wastewater strearn may improve the performance and prolong the fife of the treatment
tanks and soil absorption system: adds, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers. dental floss,
capes, disinfectants, W foundation drain (sump pump) discharge, fid and vegetable peelings, gasoline, greases, herbicides, meat
scraps. medications, offs, painting products, pesticides. sanitary napkins, solvents, tampons, and water softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps stall be taken to insure that the system is property
and safety abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code:
0 All piping to tanks, pits and other soil absorption systems shall be disconnected and time abandoned pipe openings sealed.
• The contents of all tanker and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper).
After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the Ulowing measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance aril compaction and should riot be infringed upon by required
setbacks from existing and proposed structure, lot Ines and wells. Failure to protect the replacement area will result in the need
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil Imitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holing tank may be installed as a last resat
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sod and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a
last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place fdbwinmg removal of the biomat at the infilhalve
surface. Reconstructions of such systems must comply with the rules in effect at that fime.
WARNING TREATMENT TANKS, PIMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE
ADDITIONAL INSTRUCTIONS:
POWfS hNST POWfS MAINTAINER
Name Name
Phone c17
I Ptxhne
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORIITY
Name
1 slr cf la., h IJQ
knoorme71 1 Phone
This doainnert was drafted by the staffs of Me Green Lake, Marquette and Washaa Camty POWTS regdalmy agaviis h wrytiarmce with secoo
Comm 8322t2PX1Xd)d n and 83.54(1), (2) d (3). vmfscwrjn ndmk*Jratoe Code
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
n OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
City/State
LEGAL DESCRIPTION
Property Location _A�_ r/4 , -Ste'/4 , Sec. 3.3 , T -3)_N R_Z_9�_W, Town of
Subdivision Plat: �� Lot # 1 .
Certified Survey Map # 111011-Flr a , Volume :;7,V Page # �.
Warranty Deed # 3 (S9g`f (before 2007)Volume " V , Page # 3 .
Spec house Dyesho Lot lines identifiable [Ayes[] no
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 §SPS. 383.52(1) and in Chapter 12 - SL 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 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 pf a warranty deed recorded in Register of Deeds Office.
APPLICANT(S)
/ 1/!o'o
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. 04/12)
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#20-117 CU 15 or
Parcel #: 032-1092-30-100 Valid as of 021271202011:09 AM
Alt. Parcel #: 33.31.19.436D-01
TOWN OF SOMERSET
ST. CROIX COUNTY,
WISCONSIN
Owner and Mailing Address:
Co-Owner(s):
HUBERT I & BRENDA DANIEL
487184TH AVE
Physical Property
SOMERSET WI 54025
Address(es):
184TH AVE
Districts:
Dist# Description
Parcel History:
Date Doc#
Vol/Page Type
5432
SCH DIST OF SOMERSET
1700
WITC
02/01/2018
11QkL62a
28/6447
CSM
05/08/1973 315984
497/349 WD
Abbreviated Description:
Acres: 5.002
,. SIsfi33T31NR19WPTNESECSM28- LOT
1
Plat
Tract (S-T•R 401/4160Ye GL)
Block/Condo Bldg
' 6447-CSM 28-6447 032-2018
33-31 N-19W NE SE
LOT 1
2019 Valuations:
Values Last Changed on
04/18/2019
Class and Description
Acres
Land Improvement Total
G1-RESIDENTIAL
1 5.0021
55,000.001
0.001 55,000.00
Totals for 2019
General Property
1 5.0021
55,000.001
0.001
55,000.00
Woodland
1 0.0001
0.001
0.001
0.00
2019 Taxes
Bill #
Fair Market Value:
Assessment Ratio:
905
64,800.00
0.8491
Aml Due Amt Paid Balance
Installments
Net Tax 683.14
683.14
0.00
End Date
Total
Special Assessments 0.00 0.00
0.00
1
01/31/2020
247.71
Special Charges 0.00 0.00
0.00
2
07/3112020
435.43
Delinquent Charges 0.00 0.00
0.00
Private Forest Crop 0.00 0.00
0.00
Net Mill Rate
0.015833841
Woodland Tax 0.00 0.00
0.00
Managed Forest Land 0.00 0.00
0.00
Gross Tax
969.68
Prop Tax Interest
0.00
0.00
School Credit
98.82
Spec Tax Interest
0.00
0.00
Total
870.86
Prop Tax Penalty
0.00
0.00
First Dollar Credit
0.00
Spec Tax Penalty
0.00
0.00
Lottery Credit
1 Claims 187.72
Other Charges 0.00 0.00
0.00
Net Tax
683.14
TOTAL 683.14
683.14
0.00
Interest Calculated For 0212712020
(Posted
Payment Payments)
Date Receipt#
Type
Amount Note
01/24/2020 310091 T 1
683.141 DANIEL CHK#7606 MK
Key Payment Type: A - Adjustment, R - Redemption, T - Tax * -
Primary
4 S, —aoi7 d36
RECEIVED 1 166
Wisconsin Department of Commerce , SnII — Page _ of
Division ofSaferyand BuildirgZ96 2 ')'.•, r Fy .
r rice wni _.....,n oa, vrns. mom. woe
Attach complete site plane '11 inches in size. Plan must
include, but not li:; I a onzontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print afl information.
Partonarm l infoation you provWe maybe used for secondary purposes (Privacy law, s. 15,04 (1) (m)).
COunN
peel l,D,
Re ' wed by Da/t/9
� v 2
Property Owner 2
�A.
Property Location
Govt. Lot � 1! f 1 /4 S 3 3T , j /N R E ( ) W
Property Owner's rs Mailing Address
Lo/
81ook #
Subd. Nan�ror CSM#
Cit�y State Zip Code Number
>69' C/ I .s -2 ( )
❑ city ❑ Village own Nearest Road
m </
PQkw Construction Use,51d Residential / Number of bedrooms Code derived design flow rate =a22_ GPD
[I Replacement ❑ Publi commerdal-Describe:
Parent material t( L 11 ft.
,ptcFlood �Plain elevati2gid a twble
ws SvN.r y
and roortmacidations:
�-
System Type O System Elevation
?e mB2 C Z ax
`
�c�'�o�
Boring #1 �it Ground surface elev. 1t. Depth to lirnifing factor in.
Sail Application Rate
Horizon
Depth
in.
Dominant Color
Musel
Redox Description
Ou. Sz. Cont. Color
Texture
I Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/ff
'Eff#1
I •E
6 —I
/
- 6
-6a
3
OS
'I
iv
k�
9 • i-o'
. L q.7-
Boring # L❑� Boring
zt, Pit Ground surface elev/� . Z ft. Depth tolimiting facto ,, in. Sad icabon Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/ff
'Eft#1
I 'Eff#2
d-
3/
S
-6
1,/,
Zif,6-
S
3
-
-s
D z—
Effluent #1 = BOD. > 30 < 220 hglL and TSS >30 < 150 • Effluent #2 - BOD, < 30 mg/L. and TSS < 30 mWL
CST Name (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Eva ation Conducted Telephone Number
1432 120th St, New Richmond, WI 54 �Q �� /2 7 715-246-4516
N
Property Owner _ Parcel ID # Page __ of
Boring # ❑ Boring
I Pit Ground surface e 2--ft. Depth to limiting factor in.
S61 Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Cola
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDRF
•Eff#1
'Eff#2
%Z
s
E' -
7p
Z
-
U s�
e
'
S
/t
Boring # El Boring
❑ Pit Ground surface elev. R. Depth to limiting factor in.
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Stricture
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDlfF
'Ef#t1
'ER#2
Boring # ❑ Boring
❑ Pit Ground surface elev. R. Depth to limiting factor In.
Horizon
')epth
in.
Dominant Color
Munsell
Redox Description.
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/fF
'Eff#1
•Eff#2
Effluent #1 = BOD, > 30 < 220 nxyrL and TSS >30 < 150 mgA. • Effluent #2 = BODE < 30 rng/L and TSS < 30 mgAL
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SB6SM ut OiM)
Soil Test Plot Plan
Project Name Hubert Daniel
Address 487 184th Ave
Somerset Wi 54025
Lot 1 Subdivision ---------
NE 1/4 SE 1/4S 33 T 31 N/R19 W
- Boring Q Well PL Property Line
BM VRP Assume Elevation 100 ft.
CVft #226900
Date 126/17
Township Somerset
County ST. CROIX
Top of 1"pipe
s em Elevation TBD *HRpSame as Benchmark