HomeMy WebLinkAbout032-2116-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buil ding Division Sanitary Permit No:
� INSPECTION REPORT 399463
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:
Hokeness, Jon I Somerset Township 032 - 2116 -10 -000
CST BM Elev: / Insp. BM Elev:, BM Descri p ion:
qR.3[� q`j - 3c7 � ,n, asfi (CST gZ ct�ed�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic Benchmark • 3S� o� �S� 99' 3 v
Dosing Alt. BM I 1
Aeration Bldg. Sewer
Holding St/Ht Inlet 4 1. 34 I oo • 3 i 1
St/HtOutlet • (pZ. �t7�•o3`
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic I / Dt Bottom
� I Ci0
Dosing Header /Man.
Aeration Dist. Pipe cj }
9 of
Holding Bot. System • b Z„ 6 p3
. 2 4 • qs
Final Grade 4 bn 1
PUMP /SIPHON INFORMATION hex/
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift rictt Loss System Head )H Ft
Forcemain Length Dia.
SOIL SORPTION SYSTEM
RENC Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIME S "2 Z
SETBACK SYSTEM TO P/L — 19LDG IWELL LAKE/STREAM LEACHING Manuf rer.
INFORMATION
CHAMBER ORHt+
Type Of System: ' 09 r UNIT Mod umber:
J.
DISTRIBUTION SYSTEM
Header /Ma if Id u Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of j 7reeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil A Yes [N No Fol Yes [ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: j7/�/ Inspection #2: 7
Location: 597 217th Avenue Somerset, WI 54025 (SE 1/4 NE 1/415 T31 N R18W) Shadow Pines L Parcel Ng., 15.3 ,1 1061
1.) Alt BM Description =
2.) Bldg sewer length
- amount of cover
Plan revision Required? raj Yes )K No S (�
Use other side for additional information. � Insepctoes D Signature
SBD -6710 (R.3/97)
C
Safety do Buildings Division
/ 201 W. Washington Ave.
NVAI Sanitary Permit Application po Box 7302
In accord with Comm 83.21, Wis. de Madison, WI $3707 -7302
Department or commerce Personal information you provide maybe f ll a urposes (Submit completed form to county if not
[Privacy Law, s. .l* state owned.
Attach com fete plans to the county copy only) fWIh uwr not n 8 -1/2 x I I inches in size.
Couny State S anitary Permit Number ❑ if r di
1b
e , ious applicatio Stale Plan I 1J
Gj L Y L u
I. Application Information - Please Print all Information Location:
Property Owner Na e Property location ) Q
�..J v N Q i� �S� v �, Sit ! 114 N C1 /4, S ~ T T N RI IE or W
Property Owner's Mailing Address tS ,. Lot Number Block Number
City, Stage Zip Code Phone r Subdivision Name or CSM Number
II Type of Building: (check one) ❑ city
1 or 2 Family Dwelling - No. of Bedrooms:��_ ❑ Village
0 Public/Commercial (describe use): fl Town of
El State -owned — -- S A g-
III Type of Pe ck only one box on line A. Check box on line B if applicable) Nearest Road /�
A) blew Syst 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s)
System Tank Only Existing System 0 // — /d •- 000
B) Permit Number Dale Issued
❑ A Sanitary Permit was previously issued J 31 q f 0 6
IV. WT em: (Check all that apply)
on- pressuri d In- ro ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
C0 tzed In- ground ❑ Ilolding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
30
V Dis ersaVrreatment Area Information: 6 3 ' a 9 3 • - 4- S
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevati 7. Final Grade
Required Proposed _S/eI.L Rate (Gals. /d /sq. ft.) (Min. /inch) 9 �.(�'' Elevation ti- I U).
VI Tank Capacity in Total # of M ufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks _
VII Responsibility Statement
1 the undersigned, assume res on ibility for installation of the POWTS shown on the attached plans.
Plumber's Nays. 'nt) Plumber's Signaturo;(no stamps): MP/MPRS No. Business Phone Number
brxi e, �- I ? ''1 �—,
���U ICJ ;� 1, �: ' Q
Plumber's Address (Street, Cily, State, Zip CIle)
�—
Q 7D C —)A k
VIII Use Only
0 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued sum Agent Signature (No stamps)
Approved 13 Owner Given Initial Adverse Surcharge Fee) - -) to lly(D ( (- •
Determination
IX. Conditions of Approval /Reasons for Disapproval;
1. Effluent filter to be installed and maintained per manufacturer's recommendations.
. F oo p am mapping = Zone
3. All setbacks to system and residential structure must meet applicable code requirements.
4. Well setbacks to be maintained per NR 811 & 812.
5. Filling and grading in the designated pond onsite is prohibited. The high water elevation of the pond is 933.18'.
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w W.tegrtWd erce SOIL AND SITE EVALUATION
Divis Page � of
Buree Services in accordance with s. ILHp 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inche ' ,size..- Plan must County
include, but not limited to: vertical and horizontal reference poi �� ' directiopA�Dd St. C r o i x
percent slope, scale or dimensions, north arrow, and location d^dlStancOraearestVad.
arcel I.D. #
r
APPLICANT INFORMATION - Please print all i �mah sr..^ti3 evi ed b Date
Personal information you provide may be used for secondary purposes nv�cy Law, s. jV.(t4m �)). 3
Property Owner
locatlon
zo�ii WE
Richard Stout j., Govt. Lot ;'` ' 1/4 NE 1/4,S 15 T 3 1 ,N,R 19 E (or) Kl
Property Owner's Mailing Address /� ;tat i # Subd. Name or CSM#
1353 Awatukee Trail .�' Shadow Pines
City State Zip Code Phone Number ❑ City ❑ village [3j Town Nearest Road
Hudson WI 54016 (715) 549 -673
60 th Street
New Construction Use: U Residential / Number of bedrooms 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate . 7 bed, gpd/ft . 8 trench, gpd/ft
Absorption area required _bed, ft2 7 5 0 rench, ft Maximum design loading rate 7 _ bed, gpd/ft trench, gpd /ft
Recommended infiltration surface elevation(s) S pio= plan ft (as referred to site plan benchmark)
Additional design /site considerations Trenr - heS
Parent material Cc)C2 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 [�S El ED S ❑ U ®S ❑ U KI S El U ❑ S ] LI U EIS ® U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD/
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Tr nch
1 1 0-10 10yr4/6 none sl 2mabk mfr cs 2f .5, .6
2 10-10 7/5yr4/6 none ms osg ml cs -- .7 .8 1.2_
Ground
elev.
9 9- fi5-ft•
Depth to
limiting �E
fcor
96 in.
Remarks:
Boring #
1 0-11 10yr4/6 none sl 2mabk mfr cs 2f .5..6
2 12-84 1 0yr4 /6 none ms osg ml c -- . 7' .8
Ground
elev. Z 60
9 9�r5
Depth to
limiting
factor
8 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
- 7
I,
1 tRORERTYOWNER Richard SOIL DESCRIPTION REPORT Strut _
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
3 1 0 -8 10 r4 6 none 31 2mabk mfr Cs 2f
2 8 -90 7.5yr4/6 none s osg ml Cs -- .7
Ground
9 3 eW ft.
Depth to
limiting
factor
9 0 in.
Remarks:
Boring #
1 -10 10 r4/6 none 1 2mabk mfr Cs 2f
4 ! 2 10-86 7.5yr4/6 none 11S osg ml Cs -- .7 tL
Ground
91 elev.
ft.
Depth to
limiting
factor
8 6 in. '
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
5 -
2 36-S6 10 r4/6 none ms 'V
Ground
elev.
92. ft.
Depth to
limiting
9 6factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R..07/96)
r -
,�''T';�
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_ ,gym a jpUc,p,� I J,` A 7A
412 o ,- ,. T 97 G S 72 - 9l S
U
a� Y
.'r Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number
Number of Bedrooms
Design Flow - Peak (gpd) (, U b
Estimated Flow - Average (gpd) a V
Septic Tank Capacity (gal)
Soil Absorption Component Size (ft OU
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) to (oo •a
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
i
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
p P Y
flow.
When system fails, we will replace with another system
at owner's expense. Alternate area must be left undisturbed.
St Croix County Zoning Office 386 -4680
Boumeester & Sons Excavating 386 -9020
Tri- County Sanitation 386 -2130
3
83/1312882 26:21 7253866473 CEO' CAF PAGE 81
ST CRO IX COjiH'!'X
SEPTIC TANK MAINTBNANCB AGRBBMEW
AND
OWNERSHIP CERMCATION FORM
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AM PACE 2 58
STATE BAR OF WISCONSIN FORM 2 - 1998 11SEE)aS11165,C> 1E31 Z
WARRANTY DEED i : a,i._E.E I -1. WAL5N
OF DEED'S
Document Number ' "I } • , :dI
RECEIVED FOR' RECORD
This Deed, made between
RICHARD O. STOUT and JANET P_ STOUT. _
hu sband and wife orARniANI'i DEED
Grantor. _ :: F' li
- - - - - -- - -- — _ CERT COPY FEE:
and -- rnm n St(IKFNFSS — UP" Fc :
TKANSrER FEE: 149.70
ECORDING FEE: 11.00
- _ -- _ Grantee. PAGES: I
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St' Croi x County, State of Wisconsin:
Lot 4, Plat of Shadow Pines, Town.of
Somerset, St. Croix County, Wisconsin. Name and Return Address
A*awo � -Auk-"
019 -000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: easements, restrictions, rights -of -way and covenants
of record.
Dated this 1 ct day of September 2001
Richard O. Stout (SEAL) Janet P. Stout _ (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
53-
- St. Croix __County.
authenticated this day of Personally came before me this 1 St day of
September , 2001 ,the above named
Ri shard O Stout and .Tani t P Stout .._
NOTARY PUBLIC
TITLE: MEMBER STATE BAR OF WISCONSIN CTATC f1 tnnonnr t�tr t -_. _ to
vn.
(If not, me known to be thNE�j_ /1
v8 STuted the f
� oregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. D
THIS INSTRUMENT WAS DRAFTED BY -'—
Janet P. Stout
1353 Awatukee Tr. - -
Hudson, WI 54016 Notar ublic,Stateof is nsin
My ommissi is pee manent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not
necessary)
' Names of persons signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
WARRANTY DEED FORM No 2 - 1998 Milwaukee, Wis.
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