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HomeMy WebLinkAbout032-2167-35-000 (2) r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 453151 0 GENERAL INFORMATION (ATTACH TO,DERMIT) State Plan ID No: Personal information you provide may be used for secWdary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: r City Village X Township Parcel Tax No: Hartman, Mike Mvie C 1 14 4 Somerset Township 032 - 2167 -35 -000 CST BM Elev: Insp. BM lev: BM Description: Section/Town /Range /Map No: 26.31.19.1415 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark j Dosing Alt. BM n , , Aeration BI g. S er Holding St/ t Inlet TANK SETBACK INFORMATION St/Ht utlet TANK TO P/L WELL BLDG. Vent to A Intake R D IDt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pi Holding B 0 System PUMP /SIPHON INFORMATION Final Grade Manufacturer Deman St Cover GP Model Number TDH Lift Friction Loss System Head DH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold 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 xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes I No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: 1 / Location: 622 196th Ave Unknown (SW 1/4 NE 1/4 26 T31 R1 9W) Pinecliff Lot 35 Parcel No: 26.31.19.1415 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety :urd Buildings Division County 1 *hsconsin 201 W. Washington Ave., P.O. Box 7162 Madison, Wl 537117-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce y(608)266 - 3151 State Plan I.D. Number Sanitary Permit App uitiia ; =E, In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes rivacy Law, sl 5.04(1)(m) Project Address (if different than mailing address) I. Application Information — Please Print All Info ation Block # _;ll of # � B ck Property is Name _ OFFI CEr Parcel # a p it r n -t? G V c5 Z - 2 - 35'- crab C• 1 15 Property O "er's Mai I Address t�2_ Property Location 7 3 _'/'/., Section — City, Zip Code Phone Number (circle gge�e) N; R��ort'1Y' ,,. Type of Building (check all that apply) ' v or 2 Family Dwelling — Number of Bedrooms L S, ubdivision Name r C ❑ Public/Commercial —Describe Use 1 r / ❑ State Owned — Describe Use 2 X ❑City❑ illage ®Township of t III. Type of Permit: (Check only one box on line A. o lete line B if applicable) ` New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl on – Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter eaching C er rip Line ❑ avel -less Pipe, Other (explain) 1 V. Dispersal/Treatment Area In rmation: -0 42 i Design Flow (gpd) Design Soil Application f) Dispersal Area Re ire so Dispersal Area Proposed (so S stem Elevation VI. Tank In C Gallons rn Gallons of Units � Ivniifacturer refali "" Site - ' Steel Fiber Plastid _J C70 oncrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank - S Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement -'I, the undersigned ssume responsibility for installation of the POWTS shown on the a ttached plans. Plumber' Nam (Print) ;..„ ' ,Plum is Z nat MP /MPRS Number Business Phone Number PI tuber' Address (Street, City, S te, Zip C VIII. Coen /De artment Use Onl pproved ❑Disapproved Sanitary Permit Feecludes Groundwater Daty ssue Is ing ent Signature (N Stamps) Surcharge Fee) ❑ er Given Reason for Denial 2 S D IX. Conditions o Approve 1 sa"nr- fmro+ SYSTEM O R: 3 ) �p I e-t�iT QA� l S °� 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained 5 -AAA as per management plan provided by plumber. c�] 2. All setback reO Cements must be maintained o w •� � as pe'f code /ordinances. 0.t l9✓ �- S! it eu vordotft` plow (to tht County onky) for the system on or net leas than 81/2 x 11 inches in size SBD -6398 (R. 01/03)-- o IN ��� 41 IK Q - Nqll 7 �1 10 IQ o Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of J Division of Safety and Buildings in accordance with Comm 85, 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 Parcel 1. . percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. R vi ed by Date Personal information you provide may be used f rc co endar purposes (Privacy Law, s. 15.04 (1) (m)). Y , p Prope Owner , p� roperty Location ' ' ovt. Lot �W 1/4� 1/4 S 2 6 T 3 J N R ! (or)�N 4 eC l Ff (P � ncPry Pro erty Owner's Mailing Address ,�:/ of # Block # Subd. Name or CSM# !�?� 71 a d;- C U J r_ �J �l�✓t e C l 8 r City State Zip Code Phaffe Nufter € ❑ City C3 Village [g Town Nearest Ro J ad l f I 0 L�.L Y /6 ° - y 1' _, S'O� ems e� 6 2 [}� New Construction Use: Residential / Number of bedrooms �_ Code derived design flow rate 6 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material 5 e C / f d PS ' Flood Plain elevation if applicable 1 l+ ft. General comments y� f C� _ (, G� 9, S and recommendations: F 11 Boring # ❑ Boring ® Pit Ground surface elev. OZ ' d s ft. Depth to limiting facto 17 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 'E Z l2- /'P l o X/A Si L 2r s�� /L a S Z pS 0-E 3 / , P- Yv 7 5 X SL 2 -2s,4 A C w �� O, S ©. ? ' T5i�% k // -7s�, 4 c 1L-,d 0, /t-2 > 5 7S % fIV' C01, 6 YL7 4. — 0,7 1, 2- a Z C2.`f Boring # ❑Boring /0 1-p ` y ©p;t Ground surface elev. ' f ft. Depth to limiting factor 0O in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color / Gr. Sz. Sh. 'Eff#1 'Eff#2 2 q-,71 7, S)W Yi I N - 5'L :2.PJa- 4, s 0, Y ) 6 - y 8 7 r ' ( 6 � ! / � ¢ I S dt O.7 2 VF-10 7,S 0,,/ J-h S%, ®s — 1 ije- 0,7 z RCLX ' 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 g '�1 �'��,el� z3 13- 1 y Address Date Evaluation Conducted Telephone Number 3 l9 2 c�, e Io.�,�. ri g- (,�-Z 6 - 2 - ©-Z Ifs = Z W- 32-0, SBD -8330 (R07 /00) L - -7S Property Owner j, e C 14 Parcel ID # Page Z of 3 F31 Boring # Boring ® pit Ground surface elev. b� 6 Sft. Depth to limiting factor - I - J in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Mun sell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 •Eff#2 p - 1 0. V 0'. 6 Z 12- 23 / y A l ,2 �f� k Ces 2 O S� O_ 8 .3 23 -.?.7 7rlfY ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E1ff#1 'Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 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 need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) Z)WNER Page 3 of 3 Name P1111 C 6 Brian Parnell Address -47 CST 231314 Date / wBenchmark I �z. A '` eiichmark 2 - )ETSoil Boring L _j' Suitable Area 1 40' Scale A 7 fp i 6 T 1 IVA -- T ---------- t - ----- T . .... ..... T 7 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page —L of FILE INFORMATIO14 SYSTEM SPECIFICATIONS E Septic Tank Capacity a l ❑ NA # c) 5 Septic Tank Manufacturer s' ❑ NA &: & e DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model O NA Number of Public Facility Units _;E�NA Pump Tank Capacity a l k1-NA Estimated flow (average) g al/day Pump Tank Manufacturer �* NA Design flow (peak), (Estimated x 1.5) 6 60 gal/day Pump Manufacturer .ANA Soil Application Rate gal/day/ft' Pump Model ANA Standard Influent /Effluent. Quality Monthly average* Pretreatment Unit ,6NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L O Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L 64n-Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ,ANA O At -Grade O Mound Fecal Coliform (geometric mean) 510 cfu /100m1 O Drip -Line O Other; Maximum Effluent Particle Size Y in dia. O NA Other: O NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: O NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month($) (Maximum 3 years) ❑ NA t� ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA R__- ... .��._ month ._._ ._.. .. . Inspect dispersal cells► At least once every: earls) ( Maximum 3 years) 13 NA Clean effluent filter At least onc7ov ❑ month(s) ❑ NA erY: -0 year(s) Inspect pump, pump ❑ month(s) �NA controls &alarm At least once every: ❑ earls) ❑ monthls) Flush laterals and pressure test _ __.. At least once every: ❑ year(s) MNA Other: ❑ month(s) ANA w _.. ._,, .....��.. -.,. At least once -every: O year(s) Other: 0 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.Weal regulatory authority. When the combined accumulation of sludge scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall i ber;removed by :a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative All other services, Ingluding but not limited ,to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at Intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be proMi�o�d to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of I 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 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 cells) 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 tech nob . ld q-tar*. may be4notalled as a last resort to replace the failed POWTS.� O The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound. and at gradss systems may W .reconstructed in place following removal of the biomat at the .infiltrative surface. .,FAqan¢tructions 9f. such systems must comply with the rules in effect at that time. « WARNING » Viii!_ i ,cu =_ _ :. . SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP Ok O*H�R TREATMENT TANK UNDEWANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIO0 'A TANK'MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS gyp• 11 1.q ;u , 7. 77 POWTS INSTALLE 't P OWTS MAINTAINER Nam k �. Name Phone - 'Phone SEPTAGE SERVICING OPERATOR 1PUMPER) LOCAL REGULATORY AUTHORITY Name _ c r. :.. Na ma Phone a +au ,pa; c.; Phone — This document was drafted in comp ande =with chapter Comm 83.22(2)(b)(1)(d)&M 54(1), 12) & (3), Wisconsin Administrative Code. i ST. CROI K COUNTY SEPTIC TANK MAINTAINA�WE AGREEMENT AND OWNERSHIP CERTIFICATE FORM Owner/Buyer Ake Ra- 1.4V14- - n,iting Address 7`44 !� (� Property Address 1 (Veri&catiaa rer� amffig Deportment for new �ucti City /State � J Parcel Identification Number o - 3S G I *S LEGAL DESCRIPTION Property Location K, )U K Sec b T3N -RN > Town of Subdivision �1'u �/ C/� i k� Lot# Certified Survey Map# , Volume Page Warranty Deed# Volume 2 -i `1 22 Page Spec house yes mo Lot lines identifiable �L yes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on- site wastewater disposal 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. I/we, 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 th Department of Commerce and use 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 10 days of the three year expiration date. SIG C 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds ice. S1GNA�T?rVRfb DATE •"'"' Any infonnsuan that a misrepresented may rewk m the sanitary permit bong romkedby the Zoning Department""*" " Include with this apphcaban a stamped warranty deed from the Reg*ar of Deeds office a copy of the caged survey map if rda emm ar aide in the wwrenty deed i �._ -�. r_4 U 2922P 9 741752 REGISTER OF DEEDS STATE BAR OF WISCONSIN FORM I - 1999 ST CROIX Co., Wj Document Number WARRANTY DEED RECEIVED FOR RECORD This Deed, made between Stan D. Falkenhagen and Laura L. 0 9/29/2003 12 :45PIi Falkenhagen, husband and wife WARRANTY DEED EXEMPT # REC FEE: 11.00 Grantor, and Pineeliff Partnership LLC TRANS FEE: 450.00 • 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): Part of the Northwest Quarter of the Southwest Quarter (NW 114 of SW 1/4) Recording Am and part of the Southwest Quarter of the Southwest Quarter (SW 1/4 of Name aryl Return Address SW 1/4) of Section Twenty -six (26), Township Thirty-one (3 1) North of Range Nineteen (19) West; St. Croix County, Wisconsin described as The RiverEank follows: Lot 1 of Certified Survey Map filed May 29, 2002 in Volume 16, P. O. Box 188 page 4308, Document No. 680290. Osceola, WI 54020 Together with the right of ingress and egress over Outlot 1 of said Certified Survey Map. part of 0 32 - 107340 and 042 - 1073 -60 -200 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is not homestead prosy. 40 (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and ordinances of record and will warrant and defend the same Dated this ! D th day of Sep tember 200 + •. Sta en • • ra L. Fe enhag n AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. Polk County ) authenticated this day of Personally came before me this 16h day of September 1 2003 the above named * Stan D. Falkenhagen and L aura L. Falkenhagen TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, authorized by § 706.06, W is. Stats.) i strument and dgc� th 5 1. THIS INSTRUMENT WAS DRAFTED BY • �7 Gt r i Priscilla R. Dorn Cutler. Attorneys at Law Notary Pub li of ;Visa Osceola, Wisconsin 54020 My Commiss' rr t..' , state expiration date: (Sigttauires may be authenticated or acluMedged. Both arc not nocessor) .) z, ) ' Nwnts ofpc sons signing in any capacity must be typed or printed below their signature. .son Pmhwioneds Cempmy, Fona�ctnt WARRANTY DEED STATE RAR OF WISCONSIN FORM No. 1 -1999 vi 'tot kO V W ss o I Q U v I oo ( w I t Lu 89'ISVAh6Z,Le.WS X � - . cr: 1 w w Go cq C9 g a 100, v g O� - cr� z - u. O Z_ I - ZS O Z O 3: jce'vsv "Ce . o.00s 891M M e�, so.00s T • I ' I I cc N o t= I Cg I I U LU a • N N �� �. U— I O I F. I 0 I ( se me M=s �,