HomeMy WebLinkAbout032-2192-09-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 624833
GENERAL INFORMATION state Plan ID No
Personal information you provide may be used for secondary purposes [Privacy Law, s 15 04 (1)(m))
Permit Holder's Name I City Village Township Parcel Tax No
Wittstock Builders TOWN OF SOMERSET 032-2192-09-000
CST BM Elev. map BM Elev BM Description. J� Section/Town/Range/Map No
E)o Z .t T'UL t C 33.31.19.1620
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
H`Lgc1
.-14
l "Z50
pis
IC�+� 5
------------
g
TANK SETBACK INFORMATION Laid .}—CVLGvkG !
�.
MAM,
�A
�A
AM
M11FAR�_,V-MA&VAM
®m
_M�-
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Mo el N er
TD
lift
F ction Lo
lam He d
T H t
For main
a gth
Dia.
Dist to Vitiv
SOIL ABSORPTION SYSTEM
ON DATA
STATION
BS
HI
FS
ELEV.
Benchmark
� � 2
I d1,
tt90
AVM
(CUvcr
8.I
3.
Bldg Sewer
It.)
q0, 1
SUHt Inlet
IIJ
61.5
St/Ht Outlet
Iz.o
e4. 2
Dt Inlet
Of Bottom
Header/Man
Dist. Pipe
Bot. System
Z
I L4 .0
'
62. Z
Final Grade
S"° er
8.1
43.
2 Z. a- Z-a G v�htcS
BED/TRENCH
DIMENSIONS
Width x
Length
'
D
No Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
P/L J
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufact Yn' vfa ,6
Type Of�im O��
ll.O_.�.� 'm
2�
3W
Nq
-
Model Number OQ\
DISTRIBUTION SYSTEM
Header/Manifold t
!� t
Length Dia
Dismbution
Pipes)
Length Dia Spacing
x Hole size
x Hole Spacing
Vent to Air Intake
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over I
Bedrrrench Center _ 3. L
lDepthOver `
Bed/Trench Edges > ''Z
xx Depth of
Topsoil
xx Seeded/Sodded
Yes No
xx Mulched
No
COMMENTS: (Include code discrepancies, persons present, etc.) ,.,Inspection #1,
Location: 439188TH AVE
G r — 5 Siii"'GGGrH C}S j CCCJJJCCC...
1.) Alt BM Description = ' r !
2.) Bldg sewer length - is t -& Sv�s
- amount of cover = %j ptx
v 7'-es �-eo�a� . �'1„ 16,
Plan revision RequireV Yes I— No (-7 Z J 2 ZO
Use other side for additional information.
SBD-6710 (R W97)
Date Insepclo
Inspection #2:
�rat,.l�c �s-e,Ma,�•9—
-' 0.0UC�•�l'�" vas r �—! � So r
5ys� t 'tLJ3td gd'C4.
s5 ure Cart No
nl44,
P1V10%)."CPrw1a4d nhiew P
5f --dodo-1�
--. (�; (`� I11\Ili t� tlJ)
''—" d and Buildings OAris'wn
} -" 201 W: Wa hington Ave., P.O. Box 7162
1..4)IItty 4
� ✓'"`�% 4-••-
�y y amn N,mtba (to be filled in by Cc,)
p-i Ma sari, Wi 53707-71
' JUN 03 ZGZa c
102�833
'tme Trans* tionNumber
''.. S
In accordance with SPS 383.21(2 , is. Adm Code, sub.'nission of this fowl ♦ the appry� goveovam
is required parr to eblauting a sanitary permit None Application forms for starc-Owwd KMrTftftQQaDd to i
Pm)ett .Address ([f d0civat than mailing address)
the Depatiment of Safety and Professional $envies. Personal information you provide may be used
is aocordanee with the Privacy Law, s. 15.0441)(m„ Spats.
�purposes;
L Application Information -- Please mt All laforma
Property Cs 's Name V&I i i%.1 ,e 'Lrei- D
- 8�
Pasxl
�-d'19) cal -0c1 - 00 C7
Oana` Address
�
Property Location P_3
q I gernov
br
City, State I Zip Code ne Number
/ ll
"L Ty of Building (check all that apply)
r2Famdy lla.•elling-Number ofBTamt s�
Itlf/ Bic+ck #
Subdrvt2. saw
/',_-••—r-
✓ ~�
�PublidCnmmanial-Describe Use �.�
r t� Cszti of
❑ Stan Owned-17es¢ibe Use_ CSMN •,,,umber
I
D villllaage of _,
-1714
_
Ill. Type of Permit: (Cbeck only one box on line A. Complete line Rif appiiubk)
A. ew System Replaccwen[ System Lam. 7naopenvF•Ioldmg Tank Replacanmt Duly l) Other Modtfirat:on to Frosting System(=plam)
T
Perna Renewal 'Ll persistRe -Unit r) Change of Plombe Pemut i raasfer to Ne» tit Previous Pama Num`xr mid Date Issued
Before Expiration j I Owner
I IV Type o£POW'i'S SYstem/ComponenyDeviee: (Check all that apply) , __
. - -Press raed In-Cxound ❑ Presszmzed In -Ground 11 .it -Grade C Moumd � 24 W. suitable soi n Mound <24 m. of sustaok sod
E7 Holding Titok ❑ Odra Dtspersal Compcnem (explain) __ L Raremntt Deice av(=palm) _
• V. Dis rsal/Treatment Area Information: 1 L42 / I R
Des Fl ) TDoogt Soi] ApPticanoo dsf) 1 D ptrsallacea Rrquircd (sf) ispa�l Area oposed (sf) S Eltvatron
'SOT
j VL Tank info I
GG?/.JE y�9 �C'/ yry j/p�
W _ u 1 /
Capanity m 1 Tout l a of tm v
Gallons Gaibns, Units
New Tadet
Sepx Holding 7mk
; c" �.� T wz 4
w
�
Dosing Camber
a d`s- -T
( �.
I VIL Responsibility Statemt - I, the me responsibility for installation of the POINTS shown oa the attached plans.
Plum 's Name (Print)
�nadersigne
's Stpranoe tviPMII+RS Nttmba Busmass Phone--_
.,_
! /.
G'
Ad
Plumber's dress (Street, City,
p Code
!VM County/Departmeat Use Only
}q Approv0d 0 .
_
Permit Fe -ye Da�t`c &suJed issu Agent Sipsawe
Sa�'
I GivenR for Denial /s/'40jap�r+-�j-•^-�`-"
�J.°.4�
,�
IX. (:oaditions of Approval/Reaaoas
OWNER:
for Disapproval Q.y �pt.ytc.--
�1 STEM
Septic tank, effluent filter and
_-=••y-0`-^-I^'�--' �„p.4Mrpt
dispersal cell must be ser%%,ed / maintained
i as per management plan provided by plumber.
L`P IFS tt98el fePtdlfemenlwmlen�oalp orlamf the s}•saem ands�mn fheC ovlym pc vat less—�tnxll uKLesmitt
as perapCrlicableCode�or utana.T--r�4r�etu•f.¢r-,(
SBD-6398 (R 11/11)
I
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page— cfi
FILE INFORMATION _
# �i
! Permit
13ESIGH PARAMETERS
Number of Bedrooms
i
❑ NA
I Number of Public Facility Unitsyp
Estimated flow (average)
160
aalilday
I Design ftoW (peak), (Estimated x 1.5)
�I ff
adda
Soil Application Rate
aUda /ftz
Standard InfluentlEffluent Quality
Monthly average*
Fats, Oil & Grease (FOG)
s30 mg/L
Biochemical Oxygen Demand (BODs)
15220 mg/L
CI NA
total Suspended Solids (TSS)
<150 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand (BODs)
,= mgfL
Total Suspended Solids (TSS)
s30 mg/L
0 NA
Fecal Cordann (geometric mean)
s10" cUl oomi
Maximum Effluent Particle Sus
Ya in dia.
0 NA
(Other.
0 NA
'Values typical for domesdc wastewater and septic tank effluent -
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity
al ❑ NA
Septic Tank Manufacturer
Effluent Filter Manufacturer
Effluent Fitter Model
Pump Tank Capacity
Pump Tank ManufacturerPump
ManufacturerPump
ModelPretreatment
Unit
❑ Sand/Gravel Filter
0 Peat Filter
0 Mechanical Aeration
D Wetland
0 Disinfection
D Other.
Dispersal Cells)
p NA
0 In -Ground (gravity)
0 In -Ground (pressurized)
❑ At -Grade
❑ Mound
❑ Drip -Line
0 Other:
Other.
0 NA
Other:
0 NA
Other.
0 NA
Service Event
Service Frequency
Inspect condition of tank(s)
At least once every:
=(a) (Maximum S years) 0 NA
a
Pump out contents of tank(s)
i When combined sludge
and scum equals one-third (Ya) of tank volume ❑ NA
Inspect dispersal oelts)
i At least once every;
> _ 0 month(s) (Maximum 3 years) ❑ NA
Glean effluent filter
At least once oncef every:
j 0 month(s) 0 NA
! nspect pump, pump controls & alarm
At least once every:
0 year(s)s) ❑ NA
1-lush laterals and pressure test
At least once every.
0 month($)
0 year(s) ❑ NA
IJdrer.
At least once every:
0 month(s)
0 year(s}
NA
xher.
rf'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
�:ombfnad sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal call(s) shag bs
misually 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 falling condition and requires the immediate notification of the local
regulatory authority.
Alhen the combined accumulation of sludge and scum in any tank equals one-third (X) or more of the tank volume, the entire contents of
the tank shag be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
1N1 other services, including but not limited to the servicing of e'tli:ent filters, meawical or pressurized components, pretreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authoritywithin. 10 days of completion of any service event.
Pegs _, of _,
START UP AND OPERATION or may
chemicals that
For new construction, prior to use of the POWrS check treatment tank(s) for the prewce of painting etected hers the contents of fire
may impede the hem. ant process and/or damage the dispersal cell(s). If high ooncenhadans
tank(s) removed by a septsge servicing operator prior to use.
System start up shall not occur when sol conditions are frozen at the infiltrative sudace.
DurbV power outages pump tanks may ill above normal highwater levels. When power is restored the access wastewater will by
discharged to the dispersal cell(s) in she large dose, ovarWM9 the call(s) artd May re UK in the beci f or aurfaw discharge of dfiuerd.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prig to restodrg power to the
effluent pump or contact a Plumber or POWTS Mairdairer to assist In misaidy operating the pump conttrole to reaiore normal levels
within the pump tank. disturb or the area within
Do not drive or park vehicles over tanks and dispersal cats. Do not drive or park over, or altarwise
iS feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the pertkirms and Proms the ilfe of the pOWr$:
ardibiotiw: baby wipes: golfs butts; condoms: cotton swabs; degreasers; dental floes; diapars; disinfectants. fet foundation drain
(eump pump) water: fruit and vegetable peelings; gasdkw, greasy herbicides; meat soaps; medioalora; all; points producils;
pesticides: sanitary napkins: tampons; and water softener brine.
ABANDONMENT
When the POWiS fails and/or is permanently taken out of service the following steps shall betaken to insure that the system is prope(ly
and as" abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be enmevataij and removed or their covers removed and the void space filed with soil,
gravel or anotiher inert solid material.
CONTINGENCY PLAN
ff the POWTS fats and cannot be repaired the foliowdng measures have been, or must be taken, to proNde a Code cornprlBM
replacement aysten:
��-,+—�•+ suhoble replacement area has bean evaluated and may be utilized for the location of a replacemed soil absorption system.
The replacement area should be proms from dfshabence and compaction and should not be infringed upon by remd'bd
setbacks from a dsting and proposed structure, lot Ines and wale. Failure to protect the replacei " in the neW
r
for a new adl and aft evaluation to establish a suitable replacement urea. Rapboamerd systemsmust ile$ in
effect at that time.
O A suitable replacement area is not available due to setback and/or soil limitations. BanTV advances in POWTS tachnology a
holding tank may bd installed as a last resort to replace the failed POWiS.
O The site has not been evaluated to identify a suitable replacement area. Upon faiure of the POWTS a sol and aft evalua$on
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be instilled as
a lest resort to replace the failed POWTS.
0 Mound and at -grade sdl absorption systems may be reconstructed in plow fdbwing removal of the biomat at the Infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
«vvARNING»
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANWOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANW UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSn3LE.
ADDITIONAL COMMENTS
povvrSINSTALLER n
Name
7,
Phoa
( 5-_ �4 -
.4
SEPTAGE SERVICING OPERATOR P MPER LOCAL REGULATORY UTHORITY
Noma Name
Phone Phone ih/) ' ' C
The doaanerkwas dralsd in compliance wiM chapter SPS 38322")(1)(d)&(f) and 3e3.54(t), (2) & (3). Wisconsin Ad inistrathre Code.
2� 1 4i�048A
00
e
SECTION A -A ,
�1
POU D CONC FOUNDATION
W CEIUNG ®MNN if L
.uv�xr�.��ve awme w+ �sw�
FOR BIDDING ONLY
NOT FOR CON5TRUCTION 8 6�
m
0
6
0
J
S
J
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i
JUN 13 2020
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
FRAN101
—=— — ()WNERSHIP CERTIFICATION FORM L L L
Owner/Buyer V A , V t r �%
Mailing Address —P.C. 1 n
Property Address 439
(Verification
-i''
from Plannine &
for new
City/State , }�VR✓S�� Parcel Identification Number
LEGAL DESCRIPTION Property Location Yk,'/a ''/a , Sec. , T __�j cN RAW, Town of Jo (/�G+
Subdivision Plat: n (5 e A ✓ /� CSvk V. I I/e. "YO Lot # �.
Certified Survey Map # , Volume , Page #
Warranty Deed # __�o T90 3- (before 2007)Volurne age # —
Spec house Dyes❑ro Lot lines identifiable ❑yesFIno
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 cat) 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 113 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 faith, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification slating 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 lurowledge, I/we am/are tlne owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office,
Number bedrooms i
IG A 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. 04/12)
�X- S0�wi� z
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
ANTI
Owner/Buyer
Mailing Address
Property
City/State
LEGAL DESCRIPTION Property Location Y-11'A , 4.)'/a yt�Q , Sec. , T _ N R�W, Town of So64
Subdivision Plat: Ip l S C A �et4 , Lot # _z.
Certified Survey Map # , Volume Page #
Warranty Deed #
(before 2007)Volume , Page #
Spec house Dyes Dio Lot lines identifiable ❑ yes ❑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 maintenaucc
responsibilities are specified in §SPS. 383.52(I) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Platming & Zoning Department a certification forrn, 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 retuned 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 lmowledge. I/we anm/are the owner(s) of the
property described above, by virtue of a wartanty deed recorded in Register of Deeds Office.
N;WRE
s
7-0
OF APPLICANTS) 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)
Sr; vwl z
SST aGi�-H I
Wisconsin De a`p����(ices ) Page of
Division of Indus
SOIL EVALUATION REPORT
Fn
JUL 01 24h actor ncewith SPS 385, Wis. Am. Code County 7
Attach complete site pl non paper not less thanv1/2 x 11 nches in size. Plan must include,
but not limited tc verti 1 and hclA�o it rBf NEE' f(B ), direction and percent slope, Parcel I.D. �Gt•�" t 03'2— 109q— 0-02.!
scale or dimenswns, no h arrotw.ROA)* G0M to nearest road.
Please print all information. Red by / Date
"< 7 _ / ! 1 a 1/G 1/
Prop e Owner
/_
_
Property Location I%
Govt. Lot 2Allb7,1
._
S T 3
❑ C9
N R E (or) W
Property O ner's MaihCAddd ess
Lot # Block #
SubQName or CSM# ea.;' S�
a
City Zip Coe
Phone Number
❑ City El Village
Town
Nearest Road
/Sta)e
t� -
—
a New Construction Use 0Residential/ NumberofbedroomsE--/Code dedveddesignflow rate GPD�;O-�G0
❑ Replacement ❑Public or commercial — Describe:
Parent material r. ,� Flood Plan elevation if applicable,44 ft. Z-6 C�C
General 1comme1ntcr a(�nd recommendations: [y� Q
-0.,f111AA =l 11'{,�/ �IYid� J/a,'1^Jtt�.S ri/ cJ/ /
cloning
Boring # Pit Ground surface elev. �zft. Depth to limiting factor %(, in.
Soil ADolioation Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont Color
Texture
Structure
Gr. Sz. S/h.
Consistence
Boundary
Roots
GPD/Ft2
'Eff#1
•Eff#2
_
/i
/C
5
c
s/
/�
T
9
/
R
fi
..�
GZ 8
7
aBoring #
❑ Boring
[ Pit Ground surface elev. 21L2ft. Depth to limiting factor �[r in.
Soil Aooll ication Rate
Horizon
Depth
In.Qu.
Redox Description
Az. C nt. Color
Texture
Structure
Gr. Sz. Sh
Consistence
Boundary
Roots
GPD/Fe
-Eff#1
`Eff#2
jDominant
$�
/
?
9
h
nn
7 8Y
i Ffflnant tt1 - Rnn > 3n <??n mnll and TSS > 3n <,1 Sn mnY ' FM font 92 = Rnn > vn 5 JWl mnll and I SS > 30 5 1 hn mnn.
CST (Plea Pr
Signature j
CST Number
r
Address
d/'
Date Evalua ion Conducted
Telephone Number
'2
Z
_
-
bbIJ-833IJ (MIJ4/1b)
�—b
EROSIONCONMOLNOTES
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LOCATED IN PART OF THE NEI/4 OF THE N WI/4 OF SECTION 33, TOWNSHIP 31 NORTH, RANGE 19 WEST, TOWN OF
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SOMERSET, ST. CROIX COUNTY, WISCONSIN; BEING LOT 2 OF CERTIFIED SURVEY MAP, VOLUME 17, PAGE 4496.
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