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Home My WebLink About020-1489-00-110Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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 Holder's Name �__,I City Village Township Kernon BM TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic /� C111a Itl-�}O _ Q.Q.Wg Holding TANK SETBACK INFORMATION I erl.4_Jd PUMP/SIPHON INFORMATION Dia OFHUDSON ELEVATION DATA STATION BS HI FS ELEV Benchmark 106 BM 1310D Sewer 3. $ /o SUHt Inlet s.Z /oo St/Ht Outlet J 97 Dt Inlet tB om Hea,gl /n Dist Pipe 17. Bot System Final Grade y• 06 - XL/ BED/TRENCH DIMENSIONS Width ^ '[J Lenc WI No Of Trenches (�J/ PIT DIMENSIONS No Or Pits Inside Dia Liquid Depth SETBACK INFORMATION SYSTEM TO JPIL BLDG WELL LAKEISTREAM LEACHING CHAMBER OR UNIT Manufacturer TylanJul �251 Z7 Madel M. Header/Manifold Distribution x Hole Sze x le Spacing Vent to Air Intake P pe(s) Length Dia Length Dia pacing _ _ SOIL COVER Id'—. , c.,_ _ Depth Over Bed/Trench Center I i t Depth Over Bed/Trench Edges I �rl xx Depth f Topsoil xx S tletl/Saddetl IJ Yes L No xx Mulchetl Yes No = COMMENTS: (Include toile discrepancies, persons present. etc) Inspection #1 ( Inspection #2 Location: 1069 HOPKINS DR rn� +II " r 2,"l"' 'AA5 �d�• �I OI.L d t 5 Vp (1yC 1) Alt BM Description=�1�'{�" 2 ) Bldg sewer length -amount of cover = 7 �slt ��/L� } ld 5 �S YL(!l Oui St"lii� L�Q� 1 ` Iri•7 50 �] Plan revision Required? ] Yes No Use other side for additional information. SBD-6710 (R 3/97) LL -41 pat in k,-cature Cart No SY 1. 2. 51Jry aPa1— O?Y'r joa"'aa"rWD Safety and Buildings Division County— 5'f = L7" / R 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Cc ) ` Sse UG 16 2021 Madison, WI 53707-7162 69338`�3 7� St. er0rSr�ti)= rmit AppliC.a.t .. 9 �, State Transaction Number In actor�R in. Code, submission of this tors to the appropn unR erclect Address (if different than mailing address) is require laming a sanitary peamt Note Application forms for state-owned PO WTS are submitted to the Department of Safety and Professional Servies Personal information you provide may be used for secondary mumoles in accordance with the Privacy Law, s. 15.04(1)(rn), Stall. q 11�� O p / \ Kulds h Application Information- Please Print All information L A Property owner's Name i� Parcel N Proper Owner's /Mailing Address r Y �r- Property Location � r % X V �r Govt. Lot L iA, �, Secti� rate ne) C' Staa Lip Code Phone Number T Z� N; R E of W II. Type of Building (check all that pply) Lot H i Sub h n Name 2 Family Dwelling -Number of �cdtmonis t -�!� r1A5 Block ❑PublidCommercial- Describe l's 11 City of ❑ State Owned - Describe Use CSM ❑ village of Number own of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. a tam ❑ Replacement System ❑ Treatirent/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Pcnnrt Revision ❑Change of Plumber ❑ Permit Transfer to New, List Previous Permit Number and Date Issued Before Expiration Oemer fV. Type of POWTS System/Component/Device: (Check all that apply) *ton -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound 124 in of suitable sod ❑ Mound 124 in ooffssu�itable soil COTO ❑ Iiolding Tank ❑ Other Dispersal Component (e plain) ❑ Prehe tit evice (exp am) / f [� V. Diapers - a - reat ent Area Information: Design Flow (gpd) Design Soil Application Ra sf) Dispersal Area Required (sf) Dispersal a Pro osed (st) S cm Eleva on . Vl. Tank Info Capacity is Gallons Total Gallons M of Units Manufaetu r / t i� Fv Jy o - New Tacks Fxaong Tacks te.m a3 sU y y i7 a Sepac m Holding Talc O J Dnsmg Chamber VII. Responsibility Statement- 1, Ike undersigned, ass r ponsibihty for installation of thePOR'TS shown on the attached plans. Plumber' Name (Prim Plum acme MPRYIPRS Number Business Phone Nunnmba .l 4 Plumber's Address (Street City, State, -Lip / < L � y. —:� - l -- C VIII. County/De artment Use Onl ✓ AApproved ❑ D Pe mit Fee $ ��i- /a/g �lyue r' ut Agent<s'pature ❑ O en Reas r Denisl 1 IX. Conditions o pproyaeirmt for lixryrrew 3)LOL 0. �~ TEM OWNER �L t n eptic tank, effluent filter and C� Ctrfr2 K" e ispersal cell must be serviced / maintained �)�1 (�� s per management plan provided by plumber. . sp - PP --"-o-"-o cnces, pl'ete yT86s T6r the system as s mil to (I�Co ty wly 4p paper oat less�Rrrzzll as per hcable code/or lnances, SBD-6398(R. 11111) to) � LU1�tK lN�lli+�• System PLOT PLAN PROJECT Kennon Bast ADDRESS 948 LaBarge Road Hudson Wi 54016 SW 1/4 NE 1/4S 10 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 97.8/97.6 4' below qrade 8/15/21 4 DATE BEDROOM CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. Top of 3/4" pvc pipe ASSUME ELEVATION too' Filter Lifetime Filter ❑ BOREI;OLE O WELL *H.R.P. same as benchmark Vent 102' r Quick4 Standard Cover of CLeaching Chamber 01' with 20.0 ft2 of Area B=2 Property 6.6ft^2/pair of end caps 4' Long 12 1167 Line Grade at System Elevation 34" Vents /� _ B.M.* 2-3' X 90' cells with >3' spacing Pro 4 Bedroom House R -f 20 10'I ST B-3 116' 2% Slope COPY .1 184' Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 8/5/21 Owner:Kernon Bast Location: SW1/4 NE1/4 S 10 T29 N,R 19W Lot 11 Hopkins Praire Hudson Manuals Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cros Section 4-6. Maintance Contige�cy Plan 7. Filter Cross ection--- / Signature License,, Amber #226900 ( System PLOT PLAN PROJECT Kernon Bast ADDRESS 948 LaBarae Road Hudson Wi 54016 SW 1/4 NE 1/4S 10 /T 29 N/R 19 w TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 97.8/97.6 4' below cradle 8/15/21 BEDROOM 4 DATE — CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK 1255 gallons LIFT 'TANK SIZE DOSE TANK SIZE MOUND SEPTIC TANK SIZE _ HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 kkBENCIIMARK V.R.P. Top of 3/4" pvc pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *II.R.P. same as benchmark Vent 102' ALon Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 6.6ft^2/pair of end caps 12" 34" Grade at System Ele 2-3' X 90' cells with >3' spacing Pro 4 Bedroom House 10'I ST Road B-2 C 116' Vents B-3 I l 6' 2%Slope 71' 184' Property Line Property Line All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 6.6ft^2 pair of end plates Typical Installation Vent Grade ,A/30/34 Septic Tank 5' Lon4 5' Grade at System Elevation Spacing 5' 5' To be >1' above grade Finish grade 101-E Vent Ovation 0JJ,21 � at System Elevation 2-3' X 90' Cells Same on other end Observation tube/Vent At end of cell A B 22 chambers per cell System elevations: A 97.8' POWTS OWNER'$ MANUAL, & MANAGEMENT PLAN Page _of- -1LE INFORMATION Owner N� ��"'xF� — —j r»9 _ 1 Permit # 17ESIGN PARAMETERS Number of Bedrooms ❑ NA i Number of Public Facility Units 'JNA j Estimated flow (average) q IS(7 tilde I Design flow (peak), (Estimated x 1.5)JII/da I Soil Application Rate / aUda Iftz i Standard Influent(Effluent Quality Monthly average" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODs) A220 mg/L D NA Total Suspended Solids (TSS) 5150 mglL !Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) 530 mg/L Total Suspended Solids (fSS) 53o mg/L74 _ Fecal Colifonn (geometric mean) 510' cfu/100ml !Maximum Effluent Particle Size Is in dia, ❑ NA {Other A 'Vaiues typicai for domestic wastewater and septic tank efliuenL NIAINTENANCE SCHEDULE SYSTEM Septic Tank Capacity ^�� aI O-NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer l_,0 NA Effluent Filter Model 11,,9 ❑ NA Pump Tank Capacity al NA Pump Tank Manufacturer NA Pump Manufacturer Pump Model rNA Pretreatment Unit • Sand/Gravel Filter D Peat Filter D Mechanical Aeration ❑ Wetland ❑ Disinfection D Other. Dispersal Cell(s) _ D NA D In -Ground (gravity) O In -Ground (pressurized) D At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other. D NA Other: Ef NA Other ❑ NA Service Event Service Frequency IInspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) �•f3 Year(s) D NA Pump out contents of tank(s) When combined sludge and scum equals one-third O of tank volume D NA Inspect dispersal cell At least once every: D month(s)s) �S ear(s) (Maximum 3 years) DNA (Clean effluent filter At least once every 9ear(a)onth(s) DNA inspect pump, pump controls & alarm At least once every: yea�(s)s) NA :lush laterals and pressure test (7ther. At least once every : _ At least once every: ❑ month(s) D year s) ( D month(s) ❑ year(s) NA NA IMher - .— D _ i iA MAINTENANCE INSTRUCTIONS linspections of tanks and dispersal cells shall be made by an individuat carrying one of the following licenses or certifications: ater Plumber; Master Plumber Restricted Sewer; POWTS Inspector: POWTS Maintainer, Septage Servicing Operator. Tank inspections must Gnclude a visual inspection of the tank(s) to identify any missing or broker; hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or pending of afflueni on the ground surface. The dispersal cell(s) shall be ivisually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. 'The ponGing of effluent on the ground surface may indicate a failing conditjo,i and requires the immediate notification of the local regulatory authority. I✓Vhen the combined accumulation of sludge and scum in any tank equals une-third (Yu) or more of the tank volume, the entire contents of I:he tank shah 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 filter, mechanical or pressurized components, pretreatment units, land 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 authoiAt whhin 1C uays of completion of any service event.