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HomeMy WebLinkAbout038-1214-20-000 Wisconsin De of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Bu ision . INSPECTION REPORT Sanitary Permit No: 463283 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: Happe,Dan I Star Prairie, Town of 038 - 1214 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 11.31.18.1173 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �� �}- Benchmark rs Alt. BM 54, Ccvu. 3 . A,7 .$Z F ► P�� �6cjc F �- Aeration Bldg. Sewer g Holding St/Ht Inlet _ 9. 9' 7.62. TANK SETBACK INFORMATION St/Ht Outlet 9 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 9,6 / 0 i Z9 i Z19 / Dt Bottom VPJ Dosing Header /Man. 96 . Z Aeration Dist. Pipe Holding Bot. System .377 PUMP /SIPHON INFORMATION Final Grade �o 4_0 1 77- Manufacturer De nand St Cover 3 Model Number TDH Lift !Fc on Lojs Sys7Dell TDH Ft Forcemain Leng SOIL ABSORPTION SYSTEM BED/TRENCH Width Length s No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid epth DIMENSIONS - 11-k 7— �'F$�`�� SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer.. i�,4, INFORMATION CHAMBER OR Type Of System: 39 1 56 , ma I f� UNIT Model Number J y `L 4 4 DISTRIBUTION SYSTEM /4q 2, d— ZZ = 4$ ia+&Si , Header /Manifold ,� Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) N___ Length Z Dia L 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 L t� Bed /Trench Edges` Topsoil vPs No Yes ] No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 2236 124th Street Star Prairie, WI 54026 (NE 1/4 SW 1/4 11 T31 IN R1 8W) River Place Lot 12 Parcel No: 11.31.18.1173 1.) Alt BM Description = �t 2.) Bldg sewer length = 7_9 - amount of cover = / Z!i Plan revision Required? Yes No d5 5 ✓ G Use other side for additional information. — Date Insep is Si Lure Cert. No. SBD -6710 (R.3/97) �SYST R:' ep ., effluent filter and dispersal cell must all be serviced 1 maintained ned RECEIVED as per management plan provided by plumber. 2. All setback requirements. must be maintained as per applicable code /ordinances. ,� (' rt (l 004 / ST. CROiA "u,,i \, Y ZONING OFFICE ut Safety and B in Division Cam n W a 201 W. Washington Ave., P.O. Box 7082 ,scOnS,n Madison, WI 53707 — 7082 Sanitary Permit Number (to be tilled is by Co.) Department of Commerce (608) 261 -6546 2�r 3 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Atim. Code, personal information you provide may be used for secondary purposes Privacy Law, s 15.04(1 xm) Proj A ' ess different than mailing ad ) I. cation I fo tnaUoa — Pl a Print All Information r I Property Owner's Name Parcel N Lot N Block N � - 7 - 7(� (C't_C IC��� 9 I Property Owner's Mail' —� P Location r_1 � ` City, Stale _ Zip Code Phone umber �� �` Section 1 r� c' It one ) 'l T R t� E rW • IL Type of Building (check all that apply) � ' I or 2 Family Dwelling — Number of Bedrooms Subdivision N CSM Number ❑ Pub&Xommercial — Describe Use y • c ❑ State Owned — Describe Use ❑Ci ❑Vii wnoip of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) - - — ,.j _� 3 A ew System ❑Replacement System ❑ Treatment/Holding ank Replacement Only ❑ Other 8 eP Y Modification to Existing System Ya't em 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 app 1 Non — Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil b At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wedand ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter Recirculating Synthetic Media Filter thing Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ ex sin � tT✓ 1 V. Dis ersanreatment Area Io rmation: Z ., g 3 Design Flow (gpd) Design Soil Application Rate(gpdsl) Dispersal Area s a uired Dis Area APQ P Q (Q ((so Syst Elevate - .� 1 i I t Tank Info Capacity in g Total Number Manufacturer a Site Steel Fiber Plastic Gallons Gallons of Units l� / ncrete Constructed Glass New Existin i t Teaks Tanks Septic or Holding Tank h ` �K �e Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. l ILme (Prrrin 1 I/ Plu s Si azure MP/MPRS Number Business Phone Number L l` Plum s Address (Street. T State, LIC� � : 5 L+ UI VIII. Coun /De artment Use Onl J K Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is uin gent Signature Stamps) Surcharge Fee) 1 T en for Denial 2 2' IX. Co'�dlt$� ' disp must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances Pj N6- Of M5-0 7, iley co� �L J a -a C OPY -7 A d o 7 T 6) 1 C q /A) W 130 - as t /5- 7 7 tfd 7 -0 1 Wisconsin DepartmentofCommerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must St Mni 3c include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. pendin Please print all information. wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location • LaCasse DevelO ent Govt. Lot NE 1/4 SW 1/4 S T N R 1 8 K(or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 573 Cty., Rd "A" 12 City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road Hudson, WI. 54016 ( 719381-5405 ill [a New Construction Use: I2 Residential / Number of bedrooms 4 Code derive 600 GPD El Replacement ❑ Public or commercial - Describe: Parent material OUtWdSh Flood Plain eleva ft. General comments 'S SE- • �p/ and recommendations: @ el. 96.90' N0 F- rt ❑ Boring # ® Pit Ground surface elev. 1 00.50 C15 1 F] Boring .50 ft. Depth to limiting factor 12 ' �1 . i 05r Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0 -10 10 4/2 none sil 2msbk mfr cs if .5 .8 �o 2 10 -38 10 4 4 none < sil 1c b mf ClW if .2 3 •� .�- Boring # E] Boring [72 ® pit Ground surface elev. 100.90 ft. Depth to limiting factor 120 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 1 -1 1 42 rione 1f '`P .2 .3 �® 9 1111-19 1 OI&CA 4A 13013e Ulf r- --9W f 3 36-120 7.5 4/4 none cos ml na na .7 1.2 Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg /L uent #2 = BOD < mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Gar L. Steel 02298 Address ate Eval ation Con fu Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -23 -2001 715 - 246 -6200 Property Owner LaCasse Dev. , In c. Parcel ID # - pending Page 2 of 3 Boring ❑ Boring _ 3 g ® Pit Ground surface elev. 1 00. 2 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 1 0 -10 10 4/2 none sil 2msbk mfr cs 1f .5 .8 .b A, 3 38-12C 7.5 4/4 none cos Osq ml na na .7 1.2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 F-1 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 5 150 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. SBD4330 (R.6100) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. LaCasse DEv., I nc. New Richmond, WI 54017 CSTM2298 NE' SW4 S11 - T31 N - R18W MPRSW -3254 town of . Star Prairie (715) 246 -6200 lot #12 - River Place This soil evaluation was conducted to satisfy a zoning requixesmnt, it may or may nmot be suitable for your use. The location of the test may or may not be as shown as percent lot lines were not eastablisbed at the time the test was Cmducted. 'N - " =40' -BM. = top of NW lot stake @ el. 100.00' 'alt. BM = p ofSW lot stake @ el.1 � v k Gary L. steel 6 -23 -2001 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 14 Septic Tank Capacity 15_0 a l ❑ NA Permit # 3 Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) QD al /da Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) lo U r C/ g al/day Pump Manufacturer ❑ NA Soil Application Rate gal/day/ft' Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) S30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other' ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other' ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) 13 NA earls) 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(s) Clean effluent filter At least once every: ❑ month() [3 NA 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: 13 month ❑ 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. All other services, including 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 provided to the local regulatory authority within 10 days of completion of any service event. Page Z of ?/ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) 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 tankls) 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 cell(s) 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. T W/ o ing ank ai e �� A/ L'pNS'772d�T1 ON b e '�fZDld181'i� ❑ 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 u Name Phone /5 — G ys Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name s5', G kb ( b 20r�1l�tJ Phone Phone — 7/S — 3g40- (0 Z) This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. -- 7 2, ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C;;RTIFICA T ION FORM Owner/Buyer ��1 ►��1�� ( �G , �� - 1� Mailing Address �� � (� t �Lk i �����1 1�W ( # . -� Property Address 2 2 Z GJ �� ✓` (Verification required from Planning Department for new constriction) Cit y /State ,.� J� tY Parcel Identification Number d3 9- / a?/ 9 11 d C- p . LEGAL DESCRIPTION Property Location E- J 14, s� -K '/,, Sec. j , T W Town of 1.52 , z Subdivision EU :��- Lot # t Z Certified Survey Map # Volume _ Page # Warranty Deed # 7 00 :3 Volume 2 7 Page # � Spec house (ryes ❑ no Lot lines identifiable 9 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, joumeymanplumber, restrictedplumber or a licensed pumper vcrif that (1) the on-site wastewatezdisposaI 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. 27/ Oq 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ` 4-1-1 12 /72/011 SIGNATURE 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 T -d 00LS- 91FZ -STL 7 - 10N)i NNH dSI d16:90 b0 is oaa U, 2719 P 042 -7 4B 3tZ148 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number Document Name 12/21/2004 10:00AN WARRANTY DEED EXOPT t THIS DEED, made between LaCasse Development, Inc., a Wisconsin Corporation REC FEE: 11.00 TRANS FEE: 120.30 ("Grantor," whether one or more), COPY FEE: and Dan Happe Construction Inc. CC FEE: PAGES: 1 ("Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate together with the rents, profits, fixtures and other appurtenant Name and Return Address > 8 F pP interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is ase attach addendum): 1' f�isconsin. 12 lat of River Place in the Town of Star Prairie, St. Croix County, 03 8-121420 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties; Easements, restrictions and rights -of -way of record, if any. Dated (SEAL) . ti lt_) (SEAL) * *LaCasse Development, Inc. (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF ( ) �-( CO j ss. TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me (If not, the above -named LaCasse Development, Inc..a Wisconsin authorized by Wis. Stat. § 706.06) Corporation to me know to be the person(s) executed the foregoing THIS INSTRUMENT DRAFTED BY: instrument ac owledge a am Attorney Kristina OF-land Hudson WI 54016 Notary Publ , State o My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 • Type name below signatures. INFO -PRO"' Legal Form 84�. ¢5,7I1?.�• www.infoproforms.com Tracy Notary PUb StaLe o ; Wisconsin N#39*3 2fe. P 1 -OW « .LOT FT 1 .818 A CRES �� I 70 * 328 80 FT ! # T i . 4 4 309 ! i uw. nWl. wrw.. C LACAe1/EDEVELOPMaw INC. •, ,� $73 CTY. ROAD A :• ti ; ' HUDSON. m ,,,, '•/ •e -•� ��� e ....... r . _.- _ ... �.. i ' wt.aTOLD MILL ROAD ... 1 . 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