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HomeMy WebLinkAbout032-1027-95-200 0 c J § ■ � 2 2 ■ - V § 7 � 0 { 0 ° { j - �KC § ® ° ■ P ~ ° �§�; i� f :f w § 3 ; @ k n § . � � � ■ N & ° « F e © o e w g / > t $ } CL / m � \ CL \ CO } n r CO) ® B e ( r k �- . Z / 0 0 0 rr i § § z g 0 § ■ ■ ■ a > / 77 7�v g_ � � ■ � � fA .� ] 7 , I a { .. § > o \ R 0 N z \ c6 } ` § / § E » CL @ R \ w V 2 o E § z � m o e z 7 z � r � . 0 § � k � 0 CL � � f IZ, � � & � Q. � � § � $ � $ � 2 � � ■ 0 ° t § _0 \ CL W i h V h� I co J ; CY i k n d � Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399599 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID N 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: Elliott, An elika Somerset Township 032 - 1027 -95 -200 CST BM v: / Insp. BM Elev: BM Description: &D I OD , c7 C ST 01 1' TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark D I tp I Dosing Alt. BM l , a0 Aeration Bldg. Sew - Holding SUHt Inlet R 55 02. IZ� TANK SETBACK INFORMATION St/Ht Outlet Io1.94 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic y }S f �l �- Dt Bottom Dosing Header /Man. '/'90' �•�.� r Aeration Dist. Pipe .� 6Z' Holding Bot. System e4-u I� ZZ . PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover a(iu�ut_ M Model Nu ber TDH Lift Friction Loss System Head T Ft For ain Length ell SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/L JBLDG IWELL K STREAM LEACHING Apauf�ctu/er.,.► � _ INFORMATION CHAMBER OR �e� td�! Type Of System: 1 t UNIT Mo I�Number: cap"W4 DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake t l Pipe(s) S o Length Dia Length Dia Spacing ti SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bedfrrench Edges Tops, ii Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) inspection #1 / / 2% -- Inspection #2: — Location: 2267 50th St Somerset, WI 540�2�5 (Unknown 10 T31 R19W) NA Lot �D ,,D Parcel No: 10.31.19.134C 1.) Alt BM Description = S�` '� Q "� ASS--) M -(eD � 2.) Bldg sewer length = 7 r -amount of cover= 10 "+ Plan revision Required? [] Yes X No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. ��' 1 - - -- C� -J � - � ��� l__ Safety and Buildings DlYISIUn County 201 W. Washington Ave., P.O. Box 7162 _ consr n Madison, WI 53707 - 7162 u ss Addre y )e artment of Commerce Sanitary Permit Application sanitary Permit Number se 3�� • in accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide ❑ Check if Revision may be used for secondary ses privacy Law, 05. 1 m I. Application Information - Please Print All Information State Plan I.D. Number Property wner's Name Parcel Number Property Owner's Mailing Address Property Location u / �4 ; S T N, R City, SuALC Zip Code Phone Number Lot Nurnher Block Number Subdivision Name CSM Number - II. Type of Building (check all that apply) ✓'` '' ` `'' "" ❑City I or 2 Family Dwelling - Number of Bedrooms ❑Village ws P sw ❑ Public /Conuncmial - Describe Use _OCownshiP a^ " i ❑ State Owned Nearest Road M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A ' 1 New 2 ❑Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use S stem Tank Only Exis S stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) A - IM . 44 J 9 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pus 51 ❑ Drip Litz 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. DispersaVrreat ment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate 3ystem Elevation Final Grade Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) Elevation Tank Into Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank _ / x Dosing Chamber VII. Responsibility Statement- I, the undersigned, asnpe responsibility for installation of the POWTS shown on the attached plans. Plumber's a (Print) Plumber' Si MP/MPRS Number Business Phone Number Plumber's Address (Street, City, Sta , Zip Codc) VIII. County /De artment Use Oal Approved ❑ Disapproved Sanitary Pcrmit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fu) ❑ Owner Given Initial Adverse � �S dD Determination Condi tiions of /Rea; ons for Disc 1 0oval re) D a re fj ,&CWAZAJ S 1 � L_X.e WXA t wt mt J L plane (lo We u t7 0 or We c •p SBD -6398 (R• 05101) D O et R `e Q �7 _. - - -- -- __ _ _ _; - � - -- �- { ___ - _- - - __ - _ -- i- __ _._' _ _ j ', w` s I iiVcctnsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page Z of Bureau of Integrated Services in accordance with s. ILHR 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 print all infomlation. R by Data Personal information you provide may be used for seoondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner /°f AP— Property Location L iz �} [ Govt. Lot 114 1 /4,S T 3 ,N,R(o Property es Wiling Address >j y W - � v eYY Lot # Block Subd. Name or CSM# S TILL �tT�12 tMw �5 Ur Z. City State Zip Code Phon�() mbar (O /� ❑ City ❑ Village (� Town Nearest R New Construction Use: V3 Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd* _ L trench, gpd/W Absorption area required C;�� _ bed, ft ft Maximum design loading rate _ bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site co siderations Parent material .. Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [as ❑ U ®S ❑ U 0S ❑ U (2 S❑ U E3 S 0 U ❑ S W u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground —� elev. �J_ Depth to limiting factor .&— in. Remarks: Boring # Ground l a elev. ST c x ; .- Depth to limiting .r factor �-6w—in. Remarks: CST Name (PI as rint) ° Signature Telephone No. S Address Date CST Number ���' - / SOIL DESCRIPTION REPORT PROPERMOWNER ° ' Paget of " PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench a 7 Ground elev. `• Mt' Depth to limiting factor Remarks: Boring # 1&,3 8 Ground — _ 3 AV A(Y elev. tt. Depth to limiting fact Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. � D /S'`� Depth to limiting factor ;-!O — Remarks: Boring # [3 Ground elev. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) A.- 'Q o f tip POWTS OWNER'S MANUAL 8T MANAGEMENT PLAN Page —,/— of FILE INFORMATION SYSTEM SPECIFICATIONS Owner — Septic Tank Capacity a l ❑ NA Permit Septic Tank Manufacturer - S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA, Effluent Filter Model ❑ NA Number of Commercial Units ONA Pump Tank Capacity gal JWNA Estimated flow (average) gal /day Pump Tank Manufacturer 19 NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer GYNA I /da /day/ft' NA. Soil Application Rate ga y Pump Model [� Influent/Effluent Quality Monthly average* Pretreatment Unit .t9 NA. ❑ Sand /Gravel Filter [3 Peat Filter Fats, Oil 8Z Grease (FOG) :_30 mg /L ❑Mechanical Aeration ❑Wetland Biochemical Oxygen Demand (BODs) :5220 mg /L ❑Disinfection ❑ Other: Total Susp Solids (TSS) :_150 mg /L Manufacturer Pretreated Effluent Quality ,INA Monthly average* * Dispersal Cell(s) Biochemical Oxygen Demand (BODs) _ :30 mg/L .tip In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) _ :30 mg/L ❑ At -grade ❑ Mound Ftecal Coliform (geometric mean) 1 _ :10' cFu /100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size �6 inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 3 ❑ months 12 year(s) (Maximum 3 yrs. ) Pump out contents of tank(s) When combined sludge and scum equals one -third (A) of tank volume Inspect dispersal cell(s) At least once every ❑ months ;Y year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 ❑ months ft year(s) Inspect pump, pump controls at:alarm At least once every ❑ months ❑ year(s) 14 NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) ONA Other At least once every ❑ months ❑ year(s) SZNA Other At least once every ❑ months ❑ year(s) - NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Mast( Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspection must include a visual Inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure th, volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. 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 the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one -third (lfs) 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 ch. NR 113, Wisconsi Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemica that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content: of the tank(s) removed by a sentage servicing operator prior to use. I� I • Da << � of System sun up shall not occur when soil condlt.lvm are (roaen at the InNvative surface, During power outages pump tanks may R(I above normal hlehwater levels. When power is restored the excess wastewater will br discharged to the dispersal cell(s) In one large dose, overloading the cell(s) and may result In the backup or surfxe discharge u' effluent. To ivold this situation have the contents of the pump tank removed by a $iii a Servicing Operator.prlor to restonnt power to the effluent pump or contact a Plumber or POWT5 Malntalner to assist In manually operating the pump con(rol) to restore normal levels within the pump lank. Do not drive or park vehicles over sinks and dispersal cells, Do not drNe or park over, or otherwise 4 lswrb or conipact, the are: within 15 Net down slope of any mound or at-grade soil absorpWn arts. Reductlon or elimination of the following from the wastewater steam may Improve the performance and prolong the life of trine POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental (lass; diapers; disinfectants; lit; foundation drain (sump pump) water; fait and vegetable peelings; gasoAne; grease; herbicides; meat scraps; mtdicatium; oil painting vrodticts; oesticldes; saniwn nooklns: tampons; and wetter softener brine. AAANDONEMENT When the POWTS fails and /or Is permanently taken out of service the following sups shall be taken to Insure that the system is proprr(y and safely abandoned In compliance with ch. Comm 83,33, Wlsconuln AdminImadve Coder • All piping to links and plu shall be disconnected and tht abandoned pipe openings sealed, • The contents of all tanks and plu shall be removed and properly dlspos*d of by a Septage Servicing Operator. • Aher pumping, all t.)nks and plu shall be excavatxd and removed or their covers removed and the void space IIIIed w,;r wil, gravel or another Inert solid matrrlal. CONTINGENCY PLAN If the POWTS falls ind cannot be repaired the following measures have tseen, or must be uken, W provide a code compliant replacement system: A suitable replacement area has been evaluated and may be udllred for the Iocatlon of a replacement soil absorption system, The replacement area should be prottcted from disturbance and compaction and should not be Infringed upon : required setbacks from exisdng and proposed strucwre, lot lines and wells. Fallure to protect the replacement ani will result In the need for a new soil and site evaluation w escabilsh a sulubly replacement area. Replacement systtnts rnust comply with the rules In effect at that dent, D A suitable replacement arcs Is not available due to setback and /or soil IlmltaWns. Darting advances in POWTS technuloP a holding tank may be Installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be pirrformed to locate a sultable replacement arts. If no replacement area Is available a holding tank m;: be Installed as a last resort to replace the failed POWTS. 0 Mound and it-grade soil absorption systems may be reconstructed In place following removal of the biomat at the Infllua0vt surface. kt<onswctloiu or such systems must comply with the rules In effect at that dme. < < 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 TKE INTERIVR OF A TANK MAY 6E DIFFICULT OR IMPdttlRI F. ADDITIONAL COMMENTS POWTS INSTALL R POWTS MAINTAINER Name Na me Phone — r Phone SEPTAGE SERVICING OPER ATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Agency ' Phnnt S f CROIX COUNTY SEPTIC T, MAINTENAINCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J �T / ' r Mailing Address Property Address .2 %�I—"; - T i 5 (_� ' r j r� P,� ( F_ ��if �-- (Verification required from Planning Department i_or new construction) _ City /State lrtjr s C.. Parcel Identi fic: ; uon Number 3j (D - LEGAL DESCRIPTION Property Location � "`� '/,, VIA) 'A, Sec. �= , T ..; I N -R_ � � W, Town of Subdivision , Lot # r I�" Certified Survey Map # %� t , Volume �l , Page # Warranty Deed # L ,Volume Page # Spec house ❑ yes Ono Lot lines identifiable �' yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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, it needed by a licensed pumper. What you put inio the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the r ner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site was Le waterdi:,posal 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. Uwe, 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 Commeice 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 011ice within 30 days of thq three year expira i SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements of this form are true to the best of my (our) knowledge. I (we) am (are) ti;e owner(s) of the property described above, by virtue of a wananty deed recorded in Register of Deeds Office. SIGNkrURE OF APPLICANT DA'f L * * * * ** Any information that is mis- represented may result in the sanitary pemnit being revoked by the Zoning Department. •• * * *' ** Include with this application. a stamped warranty deed f+ ,m the Resister of Deeds office a copy of the certified survey map if reference is made in the warranty deed DOCUMENT NO. I WARRANTY DEED ,' 663297 VOL 165VJ ?F9 This Deed, made be ween Patric -'a ' /a Patricia �; � a A. Reid, a. - .. '; �', r• .. x A. schachtner, a /K /a Pat A. Reid- schacht:.ijr, a sing =e S- - `- M ?, woman, Grantor, Inc j io Nwaw and Angelika rlliott, a single woman and Gary Dallek, a AUG 1 1997 single man as tenants in common, Grantees, 4 Witnesseth, That the said Grantor, for 3 valuable f � 4 M consideration conveys to Grantees the following '�•.���. 44 described real estate in St. CrOiA County, State o f Wisconsin: - --- -- -- . q W. M �' i e k �i A/ ' r y Y2- �0 TRAM �( 032- 1027 -95 -200 Parcel Identification no. A arcel of land located in the southwest Quarter of the Northwest Quarter (SWk of NWT), section Ten (10), Township Thirty -one (31) North of Range Nineteen (:9) West, described as follows: _ Commencing at the Northwest corner of said Section 10, thence south 00° 24 West, along the West line of the Northwest Quarter of said section, 1312.96 feet to the point of beginning; thence, continuing South 00 °24 west, along sa - 3 West line 446.92 feet; 4, thence South 67 27.4 East, along th�o "ff of certified survey Map recorded in volume pa a 2001 in the St. Croix County Regi3ter of Deeds office, 347.06 feet; thence North 9° 39 East 26 69 fejt; thence North 00 27 32" East, 47 - _ - feet to the North line WT( of the SWh of the N of said Section, thence NN - or�Ti 89° 15.04" hest, along the North line 571.37 feet to the point of beginning outlot o er ified Survey Map filed in Volume 9 of Certified Survey Maps on page 2565 as Document No. 491646, in St. Croix County, Township of Somerset, Wisconsin This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; f And Grantor warrants that the title is good, indefeasible in fee simple ana free and t clear of encumbrances except easements, reservations, restrictions of record and zoning ordinances and will warrant and defend the same. 199 a Dated this �_ day of (.UXAZ4 - 4 G P A. 1 4 Patricia A. schachtner AUTHENTICATION ACKNOWLEDGMENT signature (a) STaTTS OF WISCONSIN 11 County authenticated this _ day of , 1997. Pe_ sacmima ly came before ma this � day of t , 1997, the above named �p j=.& A. Schachtner _- TITLE: MEMBER STATE BAR 02 WISCONSIN to s tsown be the person(s) who executed the ppt7 f or•-aq nstrumq�it and acknowledge the e f< (If not, authorized by S 706.06, W. � // State.) j THIS INSTRUMENT WAS DRAFTED SY�� Harman A. Friess, Lawyer ;,. Rice Lake, WI 54868 t or llama) w ` F (Signatures may be authenticated or acknowledged. Nor- - y ?abjic; Co., YD M both are not necessary. ) Ply G' � +(ia6 exp tea: � -u-' KIMBERLY A. HULLETT i NOTARY PUBLIC - MINNESOTA { ANOKA COUNTY 11 My Commlaslor. - xpiras r January 31, 2000 - - 81' P94aJl4�it3 :, , . • -� :�tuodw0paouemsul 0t7!1 595 aOVa 6 SwnZOn r 'AIIoolvz 04 poonsse 'oj uot;oos I0 {AN 044 40 outj 4SOA O44 03 po0u9J942J aJU S6utJeo8 Y Y N 6 a• PJOA ll Unu eg 0 lenojddr • d k % -( Oj2P4enoidda > > o o u u • . 0 ,w. N U 4. H .-� . • O r• N r .Y ;o CARP 0£ u14:: u ■ .. e a -' "' C. a Z. '� (! v 0 (n PaplOasJ ;OU U' ° N s v L n ' �) � ■ 7 X OIL C Y N N � O C ..r O A •J . '. V X V p � Q a , � ♦� �3lt11W0'J r>ll3d C i •.•. i u. s aI' � W W o+ ,-i Pus DuluoZ a &Vueld enlSUeyex{wo^ B v° ,k1Nl100 X10110 'I 0 0 O .0 ' Po, v' (' • �aee�s� N M O1 E F [ 4r� Am +� of U0143as j0 {AN 0 44 ., o� t 4o IAS 4 44 I0 oull ;tea '1 00 . 0£S �uZ£ILZo00N Q3 J� ^�J o J OUddV bl • bLb x 0 / • a. 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