HomeMy WebLinkAbout032-2100-20-000 r
Wisconsin Depa"tmer'tolCommerce PRIVATE SEWAGE SYSTEM ounty:
Croix
Safety and D ivision St.
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 384150
Permit H er s Name: City ❑ Village own o : State Plan 10 No.:
a rtman, Mike Somerset Township
T BM E ev.r Insp. BM Elev.: 8 Description: Parcel Tax No.:
0 U s4k 032- 2100 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S Z Benchmark 3 / /0 0
sing Alt. BM 9
Aer on Bldg. Sewer 4 9S ..
Holding St Ht Inlet 7, 0 '/ 9
TANK SETBACK INFORMATION Ht Outlet
TANK TO P / L WELL BLDG. Air I ntake to take ROAD
Air
Septic 100' (2 _S' NA
D NA Header/ Man.
1 , f2 - • 9 ?.Z
lion A Dist. Pipe z Z
Holding Bot. System 3 fI2
PUMP / SIPHON INFORMATION Final Grade y 3�
MWwfacl Demand St cover
Model Number PM
TDH I Lift riction System TDH t
FForcema
I Length J Dia. To well
SOIL ABSORPTION SYSTEM
BED a Width Leng�tj No.OfTrenches IT No. Of Pits Inside Dia. Liquid Depth
DI EJUST SYSTEM TO t P /L BLDG WELL LAKE /STREAM G Manu
SETBACK T MBE INFORMATION Type O Num r:
System: Zs / G /OO r NIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length �.S Dia. Y �� Length 22L Dia. y ~ Spacing y / Z 9 Z � L Q '> $� 1
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 1 Trench Center Bed /Trench Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: G l b /0/ Inspection #2:
Location: 1956 62nd Street, Somerset, WI 54025 (SW 1/4 NW 114 26 T31 R1 9W) - 263119957 Pinecliff -
Lot t12
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover = &,k5� 4e > /J'"
3) ho Lue�� ' ' �`i,* -(
Plan revision required? ❑ Yes � No
Use other side for additional information.
Cert. No.
SBO.6710 {R(R.3/97) Oat inspector's S96ture
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19 S( ( 2` Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
t
N*Is See reverse side for instructions for completing this application PO Box 7302
Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce [Privacy Law, s. 15.04(i)(m)) (Submit completed form to county if not
state owned.
Attach complete plans to the county copy only) for the system, on paper not less than 8 -1/2 x I 1 inches in size.
VAA State Sani Permit Number ❑ Check if revision to previous application State P lan I. D. N umber
n Information - Please Print all In ti Location:
Property Location
1 l 11/4 I/4, T31 N, or
r perty Owner's Mailing Address Lot Number Block Number
City, State Zip Code NutUet Subdivision Name or CSM Number
ST CR +� ' j ' P _
II. Type of Building: (check one) �NGoFr -ivi ❑ Vili ge
pa I or 2 Family Dwelling - No. of Bedro ms :
o l�
❑ Public /Commercial (describe use) Town of
� � --T " `
ZU State- Owned �'�
3 Q�tx V� 03 ° - te a 10 0 - 0 -00 0
2 _FrP,� Cl .ltSLS /111 - Parcel Tax Number(s)
6 .914-7. 4s
III. Type of Permit: Check only one box on line A. Check box on line B if applicable
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. S. 6. ❑Addition to
System System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) Ar
It j Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
4 O!
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required i Proposed Rate (GalsJday /sq. ft.) (Min. /inc Elevation
r
` a s7 y. 1
i- VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- I Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks I Tanks ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
t VIII. Responsibility Statement
I, the undersigned, assume responsibility for install tion of the POWTS shown on the attached plans.
Plumber' ame (print) Plum s Si (no slam )„ =NT/NPRS No. Business Phone Number
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j - S�
Plumb s Address (Street, City, State, Zip Code)
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IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued I ing Agent Signature (No stamps)
) Approved ❑ Owner Given Initial Adverse Surch�ge F�
Determination . R - .G�
X. Conditions of A pe roval /Rea ns f or is r val:_ a ,,�
r A - R -6 a^-f p Soi cave `w.,�►�a oucr ` w.� _
sY yte"„ ln.ow. ,
p�l,t s s -dam " Q
s UAC&N fr> t &*V1
✓` —�—_
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30-
Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page of
Labor and Relations
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
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 information. R viewed y ` . I 8.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Z�
Property Owner Property Location _-- ���1�s
t Govt. Lot 1/4 S� 5 rT ' N,R (or) W
Property Owner's Mailing Address Lot # Block# Subd. Na e'or. tSW " Y
Ci Stat Zip Code Phone Number ❑ /Neer sA
W Town
( ) r
ID New Construction Use: - Residential/ Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 1aA11 gpd Recommended design loading rate 7 bed, gpd/ft trench, gpd/ft
Absorption area required gl�_.? ed, ft ft Maximum design loading rate / bed, gpd/ft �g trench, gpd/ft
Recommended infiltration surface elevation(s) U2 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material , to 'e' d 1k Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In -Gro nd Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable forsystem El S ED U CDs El U ® S El U (0 S❑ U EIS VI U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
0_9 Al
-
` u ` is
Ground
elev.
YZ
Depth to "' 7: T
limiting e a,S' S 8 —
factor
1�1 0 -in. '
Remarks:
Boring #
s
s°t .�
7 sWIV
1
Ground
Depth to
limiting
factor
Remarks:
CST Name (Please ri Signature Telephone No.
�h - y
Address Date CST Number
PROPERTY OWNER SOIL DESCRIPTION REPORT Pag g Z °f
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. 9ont. Color Gr. Sz. Sh. Bed , Trench
a ,
Ground T s _
elev. - o S
Depth to
limiting
factor
;min. i3 y`f `fg -� — Sy s T
l
Remarks:
Boring # 7{
i
7 to
Ground
elev.
Depth to • o S3
limiting
factor
Ss' 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 #
Ground
N
elev.
Imo. o`( S3• o ,
Depth to
limiting
factor
-192Jn' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
SBDW -8330 (R. 08/95)
�. loo ����y� � � ,,�<-�;,� -� . .
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 4 ; - D
Number of Bedrooms
Design Flow - Peak (gpd) acso
Estimated Flow - Average (gpd) &D
Septic Tank Capacity (gal)
Soil Absorption Component Size (ftZ) z _
Type of Wastewater D mestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) I Zlom Z as RgL .MS
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 filte shall be cleaned as necessary to ensure
Droner ononeratin The filter cartridge should not be removed unless provisions are ma e o
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
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ST CRO1x COUNTY
SEPTIC TANK MAINTENANCE AQRBf 42NTM :; ,► . N
AND
019NERSMIP CERTIFICATION FORM
owner /Buyer IV % i k�
�. Mailing Address �" a • � k .3� Cjrvi`''`:'r� -*� �.v - - S` "6 � S
.Proncrty Address
tvenrieatton tequ'�re,l from Planning Dep.Mrtnicnt for now eo111111 on)
City /State `� Parcel Idontification Numbsr
LF CAT QFSCBI Tt N
'A, I� l'.' -A, Scc. � C_, T � � N.R�, Town of
Prcperty Location _,,,,_ ._.._
Subdivision Lot
Certified Survey Map f1 , Volume , Page M
Page M °
Wxrrnnty Oced q
Spec house �Kes O no Lot lines identiflable ( yes O no
SYSTEM MAINIENANCE h
Improper use and maintenanec or yew wnt,: system :ould in its premsturc rallure to handle wastes. Proper mainteranCt.
CO lsists of ruT r ptna ow :he septic tank eery t;rcc years cr sooner, needed by a licensed purnptr. What you put into cite systems;,
cat affect the fu.100n of the sap i. tank as a "atm'lit stage in the waste daposal system..
The property owner agrees to sOmit to St. Croix Zoning Depertment a certification form, signed by the owner and by.
rcsir,ctc
master plumber, jol:e,tieytran p.umber, d p!umbe.- or a I ;consed pumper verifying that (t) the on•site wastewater disposal sy114
,a in proper operating condwon anctror (2) s'tc! oupection and pump Mg (if necessary), the septic tank is )as thsr. )I] N11 of sludge:. ,c
:h in :crs,gncd ha�c fad ;ho abovc requ c iwws and it,tcc to r+ta;.�tain the private sowa`c disposal systen with -,he sur.dards i
set icnh, herein, as set by the Dcpaa-ncnt or Cumnurce and the f)cp�rtment of Natural Resources, Su:e of Wisconr.n. Certtfcss�an•
stanng that your sep:i: system has bier rra.nta mast 5e co ohtc:cd and returned to the St. Croix County zoning Oftice within �4 '`
daXor ha troo y or exp,r ten dots. �,
DATE `
SIG.AT RF I' APrOlCAST ? t
OWNER CERTIFICATION
I (we) verify statements ify that all sta on :113 form art tree to the best of my (our) knowledge. ((we) am (are) the owners)
the prop y sV�bg abo e, by value or u %v;,rranty deal recorded in Register of Deeds Orflce.
S1C14ATURG' 1 APPLICANT p^'* !
0 00000 Any infonnatnon that is nt;s•reptesentcd n:ay result in .he Unitary permit being revoked by the Zptsift$ Depart11rlent. •••'r•
i
•• Include with this applteatlon a scam of the eertilled ssurvey t
a P Reg ister eference i s mad in the wationty deed I t a copy r
V
ta•d •aab>i�rzzri ntioxa 2IS9138 wa 1.11:41 46 -211-4311
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• State Bar of Wi.wonsin Form 2 1982 �..,,�„�,
TV DEED �EGISTER'Sr�F i
00 NO. " ST. QAX
- - - - -- - -- - -- — -- Floc a t,N ..,. _. .
MAY 9 1995
George T. Pennock Georgik _Ip ock
at
11:0� A
cocvevs anJwarn:.ts to _ Pir).eeliff Partnership
- - -- - -
THIS S PACE RESERVED FOR RECORDING DATA
_ '--- - -- - - ^ -- NAME AND RE'URN ADDRESS
1 the following describeG real estate in St, X 2,
County, State of Wiscomin:
I �
4 (Parcel Identification Number)
I)
I W1 /2 of NW1 /4; SEl /4 of NW1 /4; NEl /4 of SW1 /4; all that part of NW1 /4 of SW1 /4
lying Ely of Apple River and that part of SE1/4 of SW1 /4 lying Ely of Apple River;
all in Section 26- and all that part of NE1 /4 of SE1 /4 lying Ely of the Apple
River of Section 17; All in Township 31 North, Range 19 West, St. Croix County,
Wisconsin. 'i
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This is n homestead property. ,
}t, (is n(t)
i
Exception to warranties: Ea sements, restrictions and rights -of -way of record,
if any. ,I
Dated this _� _
_ day or I
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(SEAL) (SEAL) II
• _ . George._. Y L Geor �pennock �I
(SEAL) (SEAL) ; I
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AUTHENTICATION ACKNOWLEDGMENT
T. Pennock, a/k/a STATE OF WISCONSIN
s=.
�+ County. k i4
w
0. � + day of _ May , 19 95 Personally came before me this day of ;I
19_ the above named �I
_ _
TI IABLR STATE BAR OF WISCONSIN
(If no, --
authorized by §706.06, Wis. Stats.) to me known to be the person __. _ __ who executed the
foregoing instrument and acknowledge the same. �I
ii
THIS INSTRUMENT WAS DRAFTED BY �I
Kri.stina — gO land
Attorne at Law
i - - - -- Y-- __ _.. - -___ _— Notary Public — County. Wis.
(Signatures may be authenticated or acknowledged. Both are no, My commission is permanent. (If not, state expiration date:
necessary.) .)
II ---
*Names d rierwms agn u ,w
ins in any pacily shW tK grwd or printed hetow (heir .ignawc,
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WARRANTY DEED STATE 8.%R OF w7SCONSIN W Legal Blank Co In
FORM N...2— 1"2 Mdw +u \ ?e. W
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