Loading...
HomeMy WebLinkAbout032-2137-00-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division tt. Croix • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitagiurygNo.: Personal information you provice may be used for secondary purposes [Privacy Law .15.04 (1)(m)]. b mit olde s Name: ❑ City ❑ V la e o of: State Plan ID No.: ugler, Jim bo�nr�se�''ownshi CST BM Elev.:- r Insp. BM Elev.: BM Description: Parcel Tax N .: 032 -00 -000 L TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION HI FS ELEV. Septic Z Benchmark $.$e( Dosing Alt. BM Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet , 7 TANK TO P/ L WEL -BLDG. ventto ROAD Dt Inlet Air Intake Septic *> l ao I a r ----• NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe I �•!oS Holdin Bot. System PUMP/ SIPHON INFORMATION Final Grade 11 gY .3 1 r Ma facturer nd Model Nu r GPM jv TDH ion System TDH Ft Loss orcemain Length Dia. Ff Dist. To we SOILAPORP TION SYSTEM ENC Width Length N f renches PIT No. Of Pits Inside Dia. Liquid Depth DI M E N S IONS 3 R3•K DIMEN SETBACK STEIVI TO . P / L BLDG LEACHING Manu cZ1 . �IS' WELL LAKE /STREAM ( CHAMBER INFORMATION Type O f ) }fr 3 / ) > �� OR UNIT Mo e ' ryum System: Xtt1! DISTRIBUTION SYSTEM Header / anifold 4 Distributi n Pipe x Hole Size x Hole Spacing Vent To Air Intake r f Length Dia. ength Dia. Spacing SOIL COVER ,nt'r"" eo�x P ressure Systems Only xx Mound Or At - Grade Systems Only FBW Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched rench Center Bed /Trench Edges Topsoil ❑Yes No Yes ❑ No _A / CO MMENTS: (Include code discrepancies, persons present, etc.) OS - - Location: 1568 84th Street, Somerset, WI 54025 (SE 1/4 NW 1/4 1 T30N R19W) - 0330191212 -Lot 10 1.) Alt BM Description =4T o+� a:� WIt,r v+.r12r (SW) , 3 2.) Bldg sewer length = -L 3a a� [ - , amount of c 3 ) �-LDD W40 11 Plan revision required? Yes No Use other side for addition I Information. mac- IoI o t SBD -6710 (R.3/97) Date Inspector's Signature Cert No. � j i N ,�N � �Z ,� O �-- �`^ 1 �� b � . � ' t o y ; 1 , j y + fo i__ %{. I I + • I A .I .. .... ..__.�_ .. j _ {...... _. _..._(.. ...- +. . -.j.. ��1. "..;•I . -z. ... .'"°T'� 1 wr p l " `�- .d.' //�bfA ITT .1 ........ 1. F _' i ._._ i. , i L_ co7� i l � j i ( L p I- 1 j. , f ' f r n . C l ; f I a I • + f I �f F ' } f I I,� i 4 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. V AR 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)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. Coun State Sanitary P mut Number ❑ Check v,�ivn to prey' us application State Plan I. D. Number .�l� cr- I. Application Information - Please Print all Information Location: Property Owner Name Property Location °•.T' t� 1/414/ 1/4, S /3 T.1b ,N,R)7E (or s Pro Owner's Maili Addr s ^ Lot Number Block Number fl V Al K l4 f City , S Zip Code hone Nu I ' F- Subdivision Name or CSM Number II. Type of Building: (check one) ❑ City 0( 1 or 2 Family Dwelling - No. of Bedrooms :� _. ❑ Village ❑Public /Commercial (describe use):_ Town of ❑ State -Owned scrl,. Nearest Road D v .!s' 2 3 ' k R�- 1 �Ll L� Parcel Tax Number(s) vu III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) o , A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) — Ida . O 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/Treatmen 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 /' (p60 S 0 S Y 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 Vf ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on t ched plans. Plumber's Name (print) Plu is Signature (no stamps): MZMERS Business Phone Number c5104 C' " / /-e 2ZI Y 1 fird6 fl- 463 Plumber's Address (Street, City, State, Zip Code) ,3 ?.Z IY rX T `1'r e / WT, IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date, Issued s Signature (No stamps) lkApproved ❑ Owner Given Initial Adverse Surcharge Fee dD Determination 22-e, - �a �� X. Conditions of Approval /Reasons for Disapproval: A is le.L 5�4C�_.'1'� �KbltAt"rq 4 SBD -6398 (R. 07/00) l / G � Qx-, gz/v � 6 .SrIYAV,S a l3 7 NO w Z07' AO Z o B , Ir► j ADO �. — — — lQT,� � c,�,� / = v o' ,cc.,� :� 01 / . rK i 7 i �e�aStO u,� .SF,Nkl,S 13 T3o Ne / 7 w j ollll� 6 6A Of Lam ,/��/'� ioz. >Lr • s Rt �a L`0 p4Pos�o asp r + 7� - 'SIr Wisconsa, Department of commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrf}ted Services in accordance with Comm 83.09, Wis. Adm. Code 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please pri ar , `� R iewed by Date ;. Personal information you provide may be used for secondar pw�oses (Priva�Law zoo I Prope Owner ar Pope Location Gds, 6t 1/4 1/4,S T� N,R (or l� Prope Owner's Mailing Address Lo tar Block# Su_ bd_K ame or CSM# c—� ; T 0R0 x _ City Stalls Zip Code Phone Nu ejW4GOFF Nearest Road _tJl ity 1:1 Village ®Town s S ( ) New Construction Use: (Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow ���- gpd Recommended design loading rate _ bed, gpd/ft , .- trench, gpd/ff Absorption area required bed, ft ,Zs� trench, ft Maximum design loading rate � bed, gpd/ft _4sf_ trench, gpd/ft Recommended infiltration surface elevabon(s) -ft (as referred to site plan benchmark) Additional design /site considerations Parent material / Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Ta U = Unsuitable for system � S ❑ U 5 ❑ U LR S El ® S ❑ U ❑ S Mu ❑ S � SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD/ft g Texture Consistence Boundary Roots ...,..<_. in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench f, S Ground 3 ej elev. etaft• / Depth to limiting �4- 42 -s `( factor ?�in. Remarks: Boring # o- el Ground elev ft. , Depth to limiting factor - ([m in. Remarks: CST Name (PI as rint) Signature Telephone No. S� - Address Date CST Number -,9,; SOIL DESCRIPTION REPORT PROPERTY OWNER �+; ' �`�— / ®� Page ;,.2 of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench v , © _ Ground elev. ' /44aft. — Depth to limiting qS' factor ,-L3e in. i Remarks: Boring # I !' 4 1 111C 125 1 Ground elev. ��tt• Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP �2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # All S IS z �J S Ground , elev. Depth to � limiting ; factor ;>//_�s in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) 1 - _ i __ _ -_ _ - � __ __ _ __ _ __ ;_ - -- I - -_.} -- __ - - -- 'f __ _ - - - _ _ _ _ __ - I '� - __ _ _. -. _ ____ _ _ __ i __ __ -, i, _ __ - _ __ -- - - -- __ __ _ - _ - �', �- - -- __ i - _- I I i _- __ _ _- -- __ __' I '_ __ - -- - - _ __� 0 3/3 (r/01 FRr 14:24 FAX 715 386 4698 ST CRY co ZONING QoU1 Private Onsite Wastewater Treatment System Manage-tent Plan Septic Tank And Gravity in- Ground Sall Absorption C : im ponent Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastc -,n v ylaer Treatment System (POWTS) shall include information and procedures for maintaining tl "N r�,ystem within the parameters of Comm 83 and 84, and the conditions of approval by the dog otment, agent, or govemmental unit The approved plena and permits for system are on file a . the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, 4 1 rd the In Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatrneril; : , �,ostems SBD- 10567 -P (R.6199). Table 9 - System Des Gin Speciiticatlons _ Sanitary Permit Number Number of Bedrooms m �, Design Flow - Peak (gpd) Oo , Estimated Flow - Average (cgpd) o _ Septic Tank Capacity al) >' Soil Absorption Component Size (ype of Wastewater DomestH,-, Table 2. Sol[ Absorptlo Com ponent- Limits of R®Ilable Opa Alon Septic Tank Component Soll Abser; ion Corry anent Da sign Flow - Pear (gpd ) ° Maximum Influent Particle Size On) M /8 Ma ximum BC D, m /L L °D T Maxiimum TSS (mgAQ _ I50 Table 8: Maintenance schedule Septic Tank -- — Inspect and /or service once every 3 yea $ . u.. Outlet Filter Inspect ince a year and clean least o n � Bt every 3 years Soil Absorpt Component Inspect once every 3 years . ._ Styptic Tank The septic tank shall be maintained by an individual certified to service, septic tanks under s. 281 A8, Stats. The contents of the septic tank shall be disposed of i1:11 accordance with NR 113. Ms. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chary "d ears, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or P table Restr ooms). The operating condition of the septic tank and outlet filter shall be asp:gc reed at least once every 3 yeeis by Inspection. The outlet filter shall be cleaned as necess l y to ensure proper operation. The filter cartridge should not be removed unless provislor°i. , ire made to retain solids in the tank that may slough off the filter when removed from its :rr c:losure. if the ' X 03/310/01 FRI 14:25 FAX 715 386 4686 ST CRC Co ZONING 1002 Management Plan for a Septle Tank and Soil Absorption Come y cent fitter is equipped with an alarm, the filter shall be serviced if the alarm is act v !! :ed continuously. Intermittent filter alarms may indicate surge flows or an Impending continumii igarm. The septic tank shall have its contents removed when the volurne of scum and sit Ige in the tank exceeds 113 the liquid volume of the tank. If the contents of the tank are noik 1 moved at the time of an assessment, maintenance personnel shall advise the owner of whi ci the nod service i„ needs to be performed to maintain less than maximum scum and sludge acc . ! 'nulation in the tank. Manhole risers, access risers and covers should be inspected for watt i • tightness and soundness. Access openings used for service and assessment shall be seal ; J watertight upon the Completion of service. Any opening deemed unsound, defective, or subj e !t to failure must be replaced. Exposed access openings greater than 8- Inches In diameter sl!h ! it be secured by an effective locking device to prevent accidental or unauthorized entry into the: 'tank. No one should eater a septic or other tneatmerrf or holding trl<k for any reason without Ding in full compliance wifh OSHA sta6d ; 6-do for entering a confined space. The atmosphere within the septic,.: a other tr+ intent of holding tank may contain lethal gases, and ream' 4re of a person from the Interior of the tank may be difficrtlt or lmpo*i;l rl& Tank abandonment shall be In accordance with Comm 83.33, Wis. Ad •t. Code when the tank it no longer used as a PO'VTS component. 8911 Absorpt,ign Com000en# The soil absorption component serving this structure is designed to ac rapt domestic wastewa rom � a #er a residential fadllty. The limits of operation of this comport e t are shown in Table 2. The longevity of a soil absorption component depends greatly on proj;y IL. and timely maintenance, and system use within or below the limits of reliable operation., 0od water conservation practices by all occupants and the Installation of water consawiir l plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by insp, Aon at (east once every three years. The inspection shall Include recording the levels of p 111ding, If any, in the observation pipes, and a visual inspection for any evidence of surface sage rage or discharge from the component On steeply sloping situ, areas of erosion should be Idgh O led and reported to the owner for repair. The surface discharge of domestic wastow!!!!t it or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be svol6ii I particularly during winter months,. - rho compaction or removal of snow cover over the a, r uponent may lead to hydraulic failure by of eezing. This type of failure Is usually temporary, but : diffloult or impossible to repair until weather conditions improve. In general, soil comps c kin over Uft component will reduce diffusion of oxygen Into the soil and dispersal cell, wh Ic t may lead to rrx7re Intense, and earlier, organic Dogging of th soil. i ' . ba /3n /01 FR! 14:25 PAX 715 386 4686 ST CEM CO ZONING, 1@ 003 Managemant Plan for a Septic Tank and Soil Absorption Come vlent Plantings of deep- rooted trees and shrubs directly over or within ten ti ,, A of the component should be avoided since root intrusion into the component may of v ibvct wastewater flow. 3 03/28/2001 08:23 7152686637 GILLE TRUCKING PAGE 01/01 ST CRO[X COUNTY SEPTIC TANK ,MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Addre� Property Address t) y 7`1' S / (Vr" fi.cation required from Planning Department for new construction) .S-A) 0— City/State - Parcel Identification Number 03 t Z 43 7 - a G LEGAL DESCPJP7 , CIV Property LocationS,�_. %,,�_ y,, Sec. T- 30—N -R-D Town of S,v7le Subdivision Lot # Zo . Certified Surveyr Map Volume ,Page # Warranty Deed # �Q _`�3 3'0 3 Volume ��?-Z- , Page # S� Spec house D yes 95 £ .c' Lot lines identifiable -91 yes O no SYSTEM IVLAMEk J Improper use and m kkitenanceof 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 th , ;,,optic tank as a treatment stage in the waste disposal system. The Prop" owro.ei 1`• gmcs to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman ;lumber, restricted plumber or a licensed r veri ry} is in proper operating conditi 31:1 and/or (2) after inspection and pumping necessa the septic eptic tank is less than i/3 full e. of sludg dg Uwe, the undersigned have r.: a-J the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by tiro 1, of Commerce and the Department of Natural Resources, State of Wisconsin_ Certification stating that your septic syst +sr. t 11as been maintained must be completed and returned to the St. Croix County Zoning Office within 30 d;NATURE the three year a ua iti-A date. S OF I ki Tt' DATE OWNER CERTM C ICON I (we) certify that rd; Clate the rnents on this form, are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of roperty described above„ t y virtue of a warranty deed recorded in Register of Deeds Office. V GN g= A�OFAPPLICJr , T' 1 - 1 22t d — / DATE Any information Wo is; mis- represented may result in the sanitary permit being revoked by the Zoning Department. ••• «•. •+ Include with this applies' ion: a Stamped warranty deed from the Register of Deeds office A copy of the ccrtifred survey map if reference is made in the warranty deed I Apr 16 01 08:24a Jim Brugler 877 -871 -9291 p.4 STATE BAR OF WISCONSIN FORM I - 1998 6c(3 3o 3 WARRANTY DEED li G Z Document Number ` P G as This Deed made between Hermle Enterprises, LLC Wi—onsin. Limited Liahility Company II Grantor, c and T @mAs F Brugler and Amiee Brugler -- !j ( ���' f id Ivi a zs surv�v�rs>}i marital A � property,II Grantee. 0i Grantor, for a valuable consid b ration, conveys to Grantee the following I� described real estate in S t • ra 1X County, State of Wisconsin h (the "Property "): Necordin9 Area I: Name and Return Address _... Heywood $ Cari, S.C. Lot 10, Stonewood, Town of Somerset, St. 11 P.O. Box 12S Croix County, Wisconsin 'j Hudson, WI 54017 jl None Assigned 1 I Parcel IderaHicaligl Number (PIN) II This is n O t homestead property. ll i}CS�C (is not) I� I! I II Together with all appurtenant rights, title and interests. Grantor warrants that the tide to the Property is good, indefeasible in fee simple and free and clear of encumbrances except II easements, covenants and restrictions of record, if any; !I Dated this 13th _day of Apri _ 20 01 IIEWIE NTERPRII E LLC (SEAL) By (SEAL) g • i "ara A. Geving l i (SEAL) (SEAL) "? -- Jerome Geving AUTHENTICATION ACKNOWLEDGMENT II Signature Barbara A. Geving and State of Wisconsin, J erome Geving as. I County. � authenticated da 4f - Ap r i 1 2001 Personally came before me this day of the above reamed 1 mueI R. TITLE: E BAR OF WISCONSIN to Of not, me known to be the person who executed the foregoing authorized by §706.06, Wis. Slats.) instrument and acknowledge the same. II 1 I THIS INSTRUMENT WAS DRAFTED BY Heywood & Cari, S.C. by Samuel R. Cari P.O. Box 125, Hudson, WI 54016 Notary Public, State of Wisconsin iI _ My commission Is permanent. (If not, state expiration date: 'I (Signatures may be authenticated or acknowledged. Both are not ) ii necessary.) i! 'Names of persons signing in any capeciry muu he typed or primed below their signature. �I WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legs_ Blank Ca., i+c. FORM No. I - 1998 Mep I UKAF'HK. bL ALL I —� IN FEET: 1 inch = 100 feet ' N01 '02'29 "E 2636.26'-- ------ J -- 2603.25'--- - - - - -- ' * : .pig 199.60' AL I x . 310.59' `• AL AL l m O W V r g =Fn V Z i a W / _ y U) z to Z t0 Z ��N I 0 A C; m I O AV I C w • OD ao /v T 10 m O ' g L O T 11 L. \,/ 176,058 SO. FT• r /' 236,177 SO. FT. 4.04 ACRES o I N 5.42 A CRES m ........... O4• tip. OD ti cc • C) (n �� -tea _` - - - -- • 1 P OD �'' i� O� \ m ``St Ot 1ti •''�� p �'I �5 X4)10 / rr 9 ��� �'' i� • 9 ` i' � � � N 2 i 0 •O �o rn 0 o I �i ' .Q� �' I • � /N v m INGOT 1 I It So8!I gMW ,�� • i 137.88' I � I I I z 1 Z 132, 953 SO. FT. 00 ► co Oo Z LA ' O � w 3.05 ACRES �, _ \sr. MINIMUM F.F.E.= 942.8' I •4 4 p/ h cC A i I d r <N m to s ? ` r � N = D ,' cp O Z \ I 00 0 i Io r P S 0 I LOT4 p IN m ° W � W ! $ I� , 1 m �� i 145, 204 S0. FT. sass • z A, 0°c Z N16• I 3.33 ACRES '� `� •�� ! a MINIMUM F.F.E. =943.3' ry L O T 6 �9i �06�10 ��6j 14318, c^'n 1 j '52 170, 907 S0. FT. , m , 3.9,9 ACRES �• Io I = . .g I y,