HomeMy WebLinkAbout032-2163-06-000 %sconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
429911 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:
Jansen, Justin I Somerset Township 032 "
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No:
() 0 4 2 i' V G ✓� , 14.31.19.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1 A o ^ �� Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
-3 a v3. l
Holding St/Ht Inlet
TANK SETBACK INFORMATION SUHt Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
7
Dt Bottom
Septic y !
Dosing Hea r /Man. �e� 6 3S �d �'S
Aeration Dist. Piped
1b 1v r
g Bot. System ( �`
Final Grade
PUMP /SIPHON INFORMATION O 3
Manufacturer Demand St ��
GPM G��Gf�+. OY� Z . l� 102—
Model Nu er
77 Loss System Head TDH Ft
--- T
Forcemain Length Dia. Dist. to e
SOIL ABSORPTION SYSTEM lqe 4 -e,,, a--
BED/TRENCH Width / Ii Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 T - 7 S � D-- I
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM CHING anuf e it
INFORMATION AMBER OR
Type Of System: / -7 0 , `/ r / UNIT odel Number:
DISTRIBUTION
NN SS Y S TT , M 7
Header/Manifold Distribution �� x Hole Size x Hole Spacing Vent to Air Intake
//lfit Pipe(s) 6i
Length V Dia Length �� • Dia
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 4 4 Bed/Trench Edges Topsoil
3 Pf Yes [] No 0 Yes g No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: – 7 / / 63 Inspection #2: / /
Location: 2136 62nd Street Somerset, WI 54025 (NW 1/4 SW 1/4 14 T31 IN R1 9W) Gavin's Acres Lot 6 Parcel No: 14.31.19. 4
1.) Alt BM Description = � /,,, - , G �(p ,rl,,� did 4 &i_k
2.) Bldg sewer length
- amount of cover
- - -- - -- -
Plan revision Required? Yes o �� �
Use other side for additional information. L _1�_dJ _ __.._
SBD -6710 (R.3/97) Date Insepctor's Signat re Cert. No.
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Sanitary Permit Application Safety & Buildings Dive,
In accord with Comm 83,2 1, Wis. Adm. Code 201 W Washington <
Nv or co il See reverse side for instructions for completing this application PO Boy 7
mmerce Person al information you provide may be used 1or secondary purposes Madison. WI 53707.7
[Privacy Law, s. 15.04(1)(m)] (Submit completed form w counn r Attach com lete lans (to the count co onl ) for the s stem, on a er not less than 8 -1/2 x I
I inches in size. state u��n
L ' rl�t x State Sanity Permit Number ❑ Check ifrevision to previous application State Plan I. D. Number
I. A lication Information - lease Print all Information Location:
Property Ownrr Name
'r p�tf1 Property Location
r � t�r1 �E V V Nt,� �U)
Property Owner's Mailing Address
l /4S /4, S T N, R
P � 6� 1 X003 Lot Number Block ,Numb
Ciry State
Lip Code Ph rte Number
O�N(� Subdivision Name or CSM Number
�5 ,tea ( G7�V i f'�rS
11 Type of Building: (check one) O City
I or 2 Family Dwelling – No. of Bedrooms: ❑ village
O Public /Commercial (describe use): P Town of
J State -owned 56np �
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne rest Rgak -- +�._[�
A) I. New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) l
S stem Tank Onl Existin
B) System t7 .dam ❑ A Sanitary Permit was reviousl issued Permit Number Date Issued
r Type of POWT System: (Check all that a pp y) I 2
X
on - pressurized In- ground S
❑ Mound C3 Sand Filter ❑ Constructed Wetland
ressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
t•grad e n 100 Aerobic T 4`npent nit ❑Recirculating ❑Other:
V Dis ersal/Treatment Area Information: ( L(Gals to
I Design Flow (gpd) 2. DispersalArea 3. Dis rsal ea 4. on 5. Percolation Rate 6. System Elevation 7 Final Gradr
Required Proposed Raq. ft.) (Min. /inch) T I q 17/ Elevation
z q cp
VI Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete structed
Tanks Tanks
sewer IZ IZ5D 1 14- r K ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VI1 Responsibility Statement
I, the undersigned, assume res onsibilit fo installation of the POWTS shown on the attached plans.
Plumber's Name (print) Plum e s r Signat a (no st ps /MPRS No.
Business Phone Number �
Plumber's Address (S t, City, State, Zip C de)
1 5) k -TLK)
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination 2�_ Z 24D
IX. Conditions of Approval /Reasons for Di approval; _
�vlt - 'r ` SY� y — �
D a° Per
Yc A-tl MA jAAA 'At
1118
Wisconsin Department of Commerce SOIL EVALUATION REPORT P age 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
'
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference pant (BM), direction and Parcel I.D.
percent slope, scale or dimemsans, north arrow, and location and distance to nearest road,
Please print a G -,- p- Rev' wed By ate
Personal information u
yo provide may 6e used l�r•tarr, s. 15. (t) (m )).
Property Owner Pr arty Location
Grand Properties, LP JUN 1 a Z(J Go . Lot NW 1/4 SW 114 S 14 T 31 NR 19 W
Property Owner's Mailing Address Lo # Block # Subd. Name or CSM#
712 Rivard Streeet, Suite 300 ST. CROIX COUNTY 6 I Gavin's Acres
City State Zip City Village ✓ Town Nearest Road
Somerset WI 1 54025 1 715 247 - 5900 Somerset 1 60Th St.
✓ New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement Public or commercial - Describe:
Parent material Outwash Plain Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system witha 0.7gpd /sgft rating. Possible system elevation for Area I
is (step trenches high 96, low 95). Slope is 12 %.
Boring # Boring
If Pit Ground Surface elev. 99.56 ft. Depth to limiting factor >96 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD
in. Murrell Qu. Sz. Cont. Color Gr. Sz. Sh. " Efr#1 "Eff#2
1 0 -7 1Oyr3/3 none I 2msbk mfr as 2f .5 .8
2 7 -18 10yr3 /4 none Nic 2msbk mfr cw - -- .9.
3 18 -32 7.5yr5/4 none is Osg ml gw ---- -- .7 1.2
4 32 -96 1Oyr5 /4 none ms Osg ml ---- - - -- .7 1.2
I
❑ Boring # Boring
✓ Pit Ground Surface elev. 99.56 ft. Depth to limiting factor > in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 `Eff#2
1 0 -7 10yr3 /2 none sl 2msbk mfr as 2f .5 .9
2 7 -13 1Oyr4 /4 none sl 2msbk mfr cw -- .5 .9
3 13-20 7.5yr4/6 none Is Osg ml gw - - - - -- -7 1.2
4 20 -97 10yr5 /4 none ms Osg ml --- --- .7 1.2
95./
Z W Z
" Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD <_30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt i or�s.A , 227429
Address Tom Schmitt f Date Evaluation Conducted Telephone Number
586 Valley View Trail, Somerset, W154025 6/12/02 715- 549 -6651
Property Owner Grand Properties, LP Parcel ID # Page 2 of 3
• � Boring # Boring
✓ Pit Ground Surface elev. 94.56 ft. Depth to limiting factor >94 in. Soll Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-8 10yr3/3 none sl 2fsbk mfr as 2f .5 .9
2 8 -19 10yr5/3 none sl 2msbk mfr gw - - - -- .5 .9
3 19-29 7.5yr4/6 none Is 1 msbk mvfr di - - -- .7 1.2
4 29 -94 10yr5/4 none ms Osg ml - -- - - --- .7 1.2
F-1 Boring # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # Poring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz, Cont. Color Gr, Sz. Sh. Eff#1 *Eff#2
* Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD S 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
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner �-'� '� Septic Tank Capacity a l ❑ NA
Permit # Septic Tank Manufacturer �� 13 NA
DESIGN PARAMETERS Effluent Filter Manufacturer Z 13 NA
Number of Bedrooms ❑ NA Effluent Filter Model UQ ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l IXNA
Estimated flow (average) do al/day Pump Tank Manufacturer PDNA
Design flow (peak), (Estimated x 1.5) 600 al /day Pump Manufacturer [XNA
Soil Application Rate r gal/day/ft' Pump Model &NA
Standard Influent/Effluent Quality Monthly average` Pretreatment Unit �LNA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODJ _ :220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids ITSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quali Monthly average Dispersal Cell(s)
❑ NA
Biochemical Oxygen Demand (BOD <_30 mg /L i in- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Oar: ❑ NA Other: ❑ NA
"Values typical for domestic wastewater and septic tank effluent. Other: 13 NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: pZ ❑ ea I(s) (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
year(g)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
$ year(s)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) ❑ NA
At least once every: ❑ year(s)
Other: ❑ 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. 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 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 (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.
mechanical or pressurized components, pretreatment
All other services including ut not limited
to the servicing P
9 9 of effluent filters,
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.
Page of `
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). 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 cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior 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 be 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 sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing 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 must
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.
Al � ❑ T he site has seil and s ite
e ` rpa If nn ra ni tip hnIri t ank
❑ 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
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone 4 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name S7`,
Phone Phone �S _ 6 _ O
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411►, (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
,
Owner/Buyer
Mailing Address
,O , aX 30
Property Address �� �, • ^ '�
(Verification required from Planning Department for new construction)
City /State s W- - ' c-- Parcel Identification Number b -3 a — /o Y O - Pa _ 6
L EGAL DESCRIPTION
Property Location A-1 V v., 5W v., Sec. 1 y, T . 1 f N -RZ±W, Town of s 0�--�
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty eed # 6 Page # 3
ty 7l � a 7 , Volume
Spec house ❑ yes no Lot lines identifiable JJ yes ❑ no
SYSTEM MAINTENANCE
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 -
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on site wastewaterdisposal 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 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 of the three year expiration date.
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
S ATURE OF APPLICANT DATE
Any information that is mis- represented 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
l9 tI w L LOT 7 6ti pay ;
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— 7 1 6267
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
This Deed, made between Grand Properties, LP, RECEIVED FOR RECORD
- - — -- 04/07/2003 01:45PH
— WARRANTY DEED
EYEMPT #
Grantor, and _Just L. Jansen REC FEE: 11.00
TRANS FEE: 149.70
COPY FEE:
CC FEE:
_ PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 6 G_avin's Acres, Somerset Township, St. Croix County, Wisconsin. Name and Returq Address
Retum to:
Pioneer Phisti t M
825 US Hwy 8
L St. Croix Falls, WI 54024
Part of 032-1040-80-000 _
Parcel Identification Number (PIN)
This is not homestead property.
CK) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of April 2003
Grand Proper tes, LP,
* * By: MMG Ma agement, LLC by Michael J. Germain
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
— County )
authenticated this day of Personally came before me this day of
April 2003 the above named
CD Z D Grand Properties, LP, MMG Management, LLC, by Michael J.
* Z
Germain
TITLE: MEMBER STATE BAR OF WISCONSI ° M x
(If not, �0 o nown to be the person )who exec to the re going
_._ .._-- - - - -.- . - � t a jA r I dg e ame.
authorized by § 706.06, Wis. Stats.) W p t
� C 7D
THIS INSTRUMENT WAS DRAFTED BY 3 n m * ��
Att orney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 My Commission i ermanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are n n essary. _ __— _v��s Q )
* Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Company, Fond du W'- wn
STATE BAR OF WISCONSIN eooess -:_ozi
WARRANTY DEED FORM No. 2 - 1999
4