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HomeMy WebLinkAbout032-2055-50-025 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisipn INSPECTION REPORT sanitary Permit No: 463229 0 GENERAL INFORMATION (ATTACH TO PERMIT) 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: City Village X Township Parcel Tax No: Baillar eon, Daniel I Somerset Township 032 - 2055 -50 -025 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /0 Gpv\, ft 16.30.19.711 A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic AM 2 - 3 C1,- Benchmark Mob 1�3 q , t � !O-3 1 60 Dent+ IaAX� Alt. BM ( 7 . 1i ) /a 'q 3� Aeration Bldg. Sewer Holding SUHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic - 7 -7 Dt Bottom �\ Dosing Header /Man. , Aeration Dist. Pipe q rj O l�•Ce Holding Bot. System Tg Od— 3 . 1� PUMP /SIPHON INFORMATION Final Grade la ,lo �/Y X153 Manufacturer Pernand St Cover GPM S -ZS 319 Model Numb TDH Lift Friction Loss em Head TD Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Cz l 1 1 � \ SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR 1 Type Of System: JL 7 - 7 ' ' V UNIT Model Number: DISTRIBUTION SYSTEM Z3 eG ( Header/Manifold / Distribution \ x Hole Size x Hole Spacing Vent to Air Intake Length t Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only b Depth Over / Depth Over xx Depth f xx Seeded /Sodded xx Mulched Bed/Trench Center 1 5. b� Bed/Trench Edges \ Topsoil Yes No Yes No COMMENTS: (Inclu code discrepencies, persons present, etc.) inspection #1: / / Inspection #2: / / Location: 588 155th Avenue Somerset, WI 1 54025 (SE 1/4 NE 1/4 16 T30N R19W) NA Lot I - Parcel No: 16.30.19.711A 1.) Alt BM Description = � `�`, � r�5i;� b l� 6e Vjey... t\es , ►E7J r t� ` ^� 2.) Bldg sewer length = 1Z.0 - amount of cover E Z Plan revision Required. Yes ></No j 0 34 7 f - 05 - -- -- - - - -- 5 Use other side for additional informati on. `-" - Date Insepctors ignatur Cert. No. SBD -6710 (R.3/97) lV iS P Safety and Buildings Division County 4 20 1 W. Washington Ave., P.O. Box 7162 onsin Madison, WI 53707 - 7162 itary Pen Num r (to be filled in by Co.) Department of Commerce (60 IVED 4(oo S 22_9 Sanitary��� �p lica DII fl S e Plan I.D. Number In accord with Comm 83.21 e„ o form on you p�rjje 200 may may be used for secondary�puoses Pri c s15. (i)(m) Pro ct Address (if different than mailing address) I. Application Information - Please Print All Information I S ZONING OFFICE Property Owner's Name Parcel # d - Izt Property Owner's Mailing Address '/,, ,&_%<, Section City, fate Zip Code Phone Number ' T N; R E o II. Type of Building (check all that apply) rar 5 .+tip 1 1 or 2 Family Dwelling - Number of Bedrooms tt AA_ , Subdivision Name CSM Number ❑ Public /Commercial - Describe Use -J- ❑StateOwned - DescribeUse ❑City ❑Village$Townshipof III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl X Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Grou Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit El Recirculating Sand Filter El Recirculatin Synthetic Media Filter I eachin�Chamber ❑ Drip Line Recirculating Y p ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ` I C 7 ` VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Talcs Septic or Holding Tank �L Aerobic Treatment Unit Dosing Chamber VII. Respqnsibility Statement- I, the undersigned, asjume responsibility for installation of the POWTS shown on the attached plans. Plum r' 7eMl MP/MPRS Number Business Phone Number l — Plumber' Address (Street, Ci , State, Zi Cod e) VIII. Coun /De artment Use Onl Approved El Sanitary Permit Fee includes Groundwater Date I 1 uing gent Signature o Stamps) Surcharge Fee) ❑ iven Rea' for Denial IX. Conditions of Approval/Reasons for Disapproval 3� 5� � r SYSTEM OWNER: * 1 Septic tank, effluent filter and Nw,u to ' dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) z w 'k ` � I , � l tl O p Iq � V 4- 3 VI r w J h \ 1 , 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 Parma I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. R Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). [L Property Owner Property Location j Govt. Lot 1/4 l 1/4 S T N R (o Property Owner's Mailing Address Lot # Blo # Subd. Name or CSW f — m City Sta Zip Code Phone Number E] City ❑Village f Town Nearest Road L ZZ-,A,92 ( f I 10 New Construction User Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material „4�,j l Flood Plain elevation if applicable ft. General comments 4J � 1 9/ ',, and recommendations: — 's' ti-. F-/1 Boring # E] Boring ® pit Ground surface elev. 9� , ft. Depth to limiting factor � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture StructureConsistence Boundary Roots GPD/ff' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efrr#1 *Eff#2 l� / 4 Boring # a Poring � y�l Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. *Eff#1 *Eif#2 1 Ad a $ Ai 3 * ffluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L * Effluent #2 = BOD 5 30 mg/L and TSS < 30 mg/L CST N P ' Signatu CST Number / 3 Address Date Evaluation Conducted Telephone Number Property Owner Parcel ID # �/SS� i� -.T� Page,;? of Boring # 0 Boring M M Pit Ground surface elev. f� /,�5� ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 //'V� 4 4 Sd ccu otxr— F-1 Boring # Boring ❑ Y ❑ Pit Ground surface elev. ft. De th to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 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/fP 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 (8.07/00) I I 1 iq Ib z y i w 0 POWTS OWNER'S MANUAL & MANAGEMENT PLAN,, .. Page�„ FILE INFORMATION SYSTEM SPECIFICATIONS j Owner Septic Tank Capacity al Ni, Permit # - 32 2 Septic Tank Manufacturer �' ❑ N DESIGN PARAMETERS Effluent Filter Manufacturer ❑ Nn i Number of Bedrooms O NA Effluent Filter Model ❑ NA Number of Public Facility Units NA Pump Tank Capacity al NA Estimated flow (average) al /da Pump Tank Manufacturer N<, Design flow (peak), (Estimated x 1.5) al /da Pump Manufacturer NA I Soil Application Rate al /da /ft2 Pump Model` ` Standard Influent /Effluent Quality Monthly average* Pretreatment Unit � Fats, Oil & Grease (FOG) 530 mg /L 13 Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(0 ❑ N!, Biochemical Oxygen Demand (BOD 530 mg /L id In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) S30 mg /L �YNA 17 At -Grade © Mound Fecal Coliform (geometric mean) 510 cfu /1001111 ❑ Drip -Lino 0 Other. T Maximum Effluent Particle Size Y, in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA 1 *values typical for domestic wastewater and septic tank effluent. Other: [3 NA I MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: earls) Pump out contents of tank(s) When combined sludge and scum equals one -third .(Y of tank volume 13 NA At least once every; (Maximum 3 years) O NA Inspect dispersal cell(s) f3 year(s) month($) . ❑ N�, Clean effluent filter At least once every: year(s) ❑ month(s) Inspect pump, pump controls alarm At least once every: Q year(s) N< (a month(s) ,.. ANA Flush laterals and pressure test At least once every: O ear(s) Other: ❑ month($) ,${ NA A least once every: At s o ry Q ear ( s) Other: O NA 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. Tanis inspections must inciude a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surfact;. The dispersal cell(s) shall be visually 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 failing condition and requires thu immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical 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 authority within 10 days of completion of any service event. OMW (4/011 Pape � of START UP AND OPERATION ' For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products op other chemicals that may impede the treatment process and /or damage the dispersal collie). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative. surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(&) In one large dose, overloading the collie) and may result In•tho beokup of surfelco discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator poor -to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually - operating the pump' controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells, Do not 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 stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental,floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall fie taken to insure that the system is properly and safely 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 aealed,, • The contents of all tanks and pits shall be removed and properly disposed of by a Septage .$ervioing Operator. • 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 following 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. and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines 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 rnust comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS.-7-- -,,- - ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil 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 following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time, < < WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT, RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS - , - - .. ,;..,. t�4`td etSi ?t$.��a.` •a' c���+tr .r POWTS INSTALLER POWTS MAINTAINER . Name - Name I Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name - �: r Phone Phone •' , ;'his document was drafted In compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. , ST CROIX COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer :tiiailing ,- address �, iroperty Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number Property Locution_ I /., _ I / Sec, ,�, T _N -R_Z W, Town of -- -- , Lot # Certified Survey Niap # , Volume , Page # N'arrattty Deed Volume s��.�s`i... Page # S Spec house 0 yes t% no Lot lines identifiable Xyes ❑ no SYSTEM M.- 1NTIsNANCE 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 thr systcm can affect the function of the septic tank as a treatment stage in the waste disposal system, The propert owner agrees to suimiit to st, l':roix Zuning Department a certilwittion form, signed by (tic owner ;.,.d L:, a Illastel' I)IUlllt >cr, juuntc,vnlan pl umber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewa terdisposu, system is in proper uperatini; cundition 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 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 Zoning Office within 30 days f' the three y are piration date, Il /may SIGNATURE OF A "Ll DATE QWNER CERTIFI ATION 1 (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owncr(s) of the p erty described a e, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF AP ]CANT DATE~ * ++++* Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department, *+ Include: with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed �s U p 2 S 8 6 P -7 s4 -+ aS-7 t l �. ., S STATE BAR OF WISCONSIN FORM 2 - 1 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX Co., WI This Deed, made between Sam E. Miller, a single Person RECEIVED FOR RECORD Grantor, 06/01/2004 03:15PI1 and Daniel S. Baillargeon and Jennifer Bail-IMeon, husband and wife WARRANTY DEED Grantee. EXE11aT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin TRANS FEE : 11.00 (if more space is needed, please attach addendum): COPFEE: szi. SE 1 /4 of NE t /•of Section 16, Township 30 North, Range 19 West, St. CC FEE: Croix County, Wisconsin EXCEPT Lot 1 of Certified Survey Map filed PAGES: 1 August 6, 2003 in Vol. 17, Page 4581, Doc. No. 734168. Together with the driveway easement as reserved on Certified Survey Map in Vol. 17, page 4581, Doc. No. 734168. Recording Area Name and Return Address WESTCONSIN CREDIT UNION ATTN RANAE DAVIS 3� P.O. BOX 269 NEW RICEiMOND WI 54017 Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of llil y '' 2004 * * Sam E. Miller AUTHENTICATION ACKNOWLEDGMENT Signature(s) Sam E. Miller, a single person STATE OF ) - - ) ss. County ) authenticated this day of 2004 Personally came before me this day of the above named * Kristin Ogland — -- — TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland * - -- - -- — -- Hudson, WI 54016 Notary Public, State of _ My Commission is permanent. (If trot, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) L I * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac. WI STATE BAR OF WISCONSIN 800 -655-2021 WARRANTY DEED FORM No. 2 -1999