HomeMy WebLinkAbout038-1195-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 420429 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:
Voeltz, Aaron Star Prairie Township 038 - 1195 -10 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / r� 7 v Benchmark
I/ � 11 1
Dosing Alt. BM
- (�� S-7. � 2.1 /09.,S
Aeration Bldg. Sewer • 4 S
Holding St/Ht Inlet • / 3
TANK SETBACK INFORMATION St/Ht Outlet !)
TANK TO P/L WELL BLDG. Vent t it Intake ROAD Dt Inlet
T
Septic , 5� / / t ottom S /
0
Dosing Header /Man. r qq
Aeration Dist. Pie
p
Holding Bot. Sy tem
PUMP /SIPHON INFORMATION Final Grade O
/ • r7
Manufacturer Pernand St Cover . ` 9
6� S
Model Number
TDH Lift F ' ion Loss System Head T Ft
Forcemain ength
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Lenatb No. Of r es PIT DIMENS S No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WEL LAKE /STREAM LEACHING M rer:
INFORMATION Ty Of System: CHAMBER O
UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifol Distributioon f f x Hole Size x Hole Sg�ci — Ven it Intake
f,
Pipe(s) 8� °t Ic S t
L Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only "Ak" / /'til jA_&r_l-
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center / _ / Bed/Trench Edges Topsoil L Yes [A No ', Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ( / / Inspection #2:
Location: 2178 134th Street New Richmond, WI 54017 (SE 1/4 NW 1/413 T31 N R1 8W) Pine Acres Let 21 Parcel No: 13..31.18.1016
1.) Alt BM Description = ST• C.OVL-� - ° 6rX 7'L 740 (:'-If 7 -
2.) Bldg sewer length
- amount of cover
Plan revision Required 0 %, Yes VNo
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor'S gnature Cart. No.
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
,��Onsl� Madison, WI 53707 - 7162 Site Address
Department of Commerce /0— Z-vt- 3 fGp ,
Sanitary Permit Application Sanitary Permit Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ � o � /
Check if Revision
may be used for secondary purposes Privacy Law, sl5. 1 m
I. Application Information - Please Print All Information State Plan I.D. N A
try Owner's Name Parcel Number
Petty t)w ner's Mailing Address Property Location
WW mss/ S4; S N. R
City, State Zip Code hone umber r Block N ber
1
ubdivis' t Name CSttber
xx
II. Type of Building (check all that apply) ❑City
1 or 2 Family Dwelling - Number of Bedrooms a-t? ❑Village
❑ Public/Commercial - Describe Use t
❑ State Owned G✓/ / Y li�'CG� � �K^ GG-C� 3 �� 0 Neatest Road
X
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete Iine B if applicable)
A. =to County use
I A New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Adstem Tank ON Exis '
B. ❑Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
44 J2 Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 3((y-,
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line1%4� ��
45 13 At-Grade 46 ❑ Aerobic Treatment Unit 49 [1 Recirculating 30 11 Other
V. D' tment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required
Proposed Rate(Gals./Days/Sq.Ft.) (Min.fl -h) Elevation
✓ ✓ d s
P�
VI. Tank Info
C in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Dosing Cha w
VII. Rtxponsibility Statement- I, the undersigned, Wume responsibility for installation of the POWTS shown on the attached plans.
Vdd ame tint) Plu mbe 's Si WIMPRS Number Business Phone Number
ress (Street, City, S Zip Code) 1 Of
J
VIII. Count /De artment Use Onl
Sanitary Permit Fee (includes Groundwater Date Issued I h►g A Signature (No Stamps)
PProved ❑ Disapproved Surchar a Fee)
❑ Owner Given Initial Adverse
Determination v � _
Conditions f Approval/Reasons for Disapproval �� 0 h y/ ��,� Sit
� t ark
es in size
( 9 7q 0 /
SBD -6398 (R. 0 S /01)
cP�
t
3�
i I Z
�7BaSE
4v COO
oltb
i
i
O/'
. S Pi�i�S;� � G�1 � •- s jCJ�S
i
- 16 a SAE
-
W isconsin Department of Commerce ATI ON Page 1 of s
w p SOIL AND SITE EVALU
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8'/ 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, a gfi�l"8nd-distance to nearest road. parcel I.D.#
�` D �1� din IO- OCX)
APPLICANT INFORMATION - P/ iorint all informa'Wn. ev' By pate q
Personal information you provide may be used fy ndary pur bees Law, s \15.04 (1) (m)). 6 ? O-
Prop" Owner LGvt. erty Location
Lakes & Hil ls De t - _ _ —_ 1 NW 1 / 4, s 13 T 31 N,R 18 Property Ow s Mailing Address I^ ' 'Bloc�# Subd. Name or CSM#
7 'Z ' 21 Pine Acres
City State 45p Code Pho „ ;� "'` City lase ®Town Nearest Road
L✓�1 i F fly EdL �C ,,� J Y -v Y y 134 TH. ST.
New Construction Z Resl*dai ! Number drooms
Use: ,� 3 j jAddition to existing building- - - - ----
[] Replacement L-1 Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpoltF .8 trench, gpdff
Absorption area required 643 bed, ft 562 tren Maximum design loading rate .7 bed, gpd/ft .8 tr ench, gpd/f?
Recommended infiltration surface elevations) 9.7 ft (as referred to site plan benchmark) e,9 = Ctti't-��-
Additional design / site considerations C -S to GGcA'ox; dL , ;., - e, = 61
t Parent material - -- - -- Flood plain elevation, if applicable - ------ ft
ble for system Conventional Mound In -Ground Pressure AT -Grade System in Pill Holding Tank
itable for system ®s ❑ u s ❑ U s ❑ u ❑ s El u El ®u ❑ S ® u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 1 0 -10 10 YR3/3 ------------------ 1 imsbk mvfr as if .4 .5
2 10--22 10YR4/4 ------------ - - - - -- 1 I l msbk mvfr gw lvf 4 .5
Ground 3 22 -51 7.5Y R4/4 ------------ - - - - -- cs osg ml gw - - -- 7 8
elev - -- - - --
104.2 ft. 4 51 - 93 10YR5 /6 -------- - - - - -- cs o ml - - -- - --- 7 8
Depth to
limiti - - s� --1--
g S
� y lot
factor
>93"
Remarks: - - - - -- -- - - - -- - -- - -- - -- - - - -- -- -- —
2 1 0 -9 10YR3 /3 -- - - - - -- 1 1 m sbk mvfr as if .4 .5
2 9 -23 10YR4 /4 ----------- - - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground 3 23 -52 7 .5YR4/4 ------------ - - - - -- cs osg ml gw - - -- 7 .8
elev
104.2 ft. 4 52 -96 10YR4 /6 ------------ - - - - -- cs osg ml - - -- 7 .8
Depth to
l im it i n g
i,
ti
s
factor
>96"
Remarks:
CST Name (Please Print) Signature: Telephone No.
Jacque Hawk Date — CST Number Ref #
Address -f 4/9/00 7- Zz_aF7 393
-PROPERTY OWNER: Lakes & Hills Devekmlent SOIL DESCRIPTION REPORT Page 2 of ,3
PARCEL I.D.# Pending
Depth Dominant Color Mottles Structure GPD/fF
Horizon in MunseH Qu. Sz. Cant Color Texture Gr. Sz. Sh. onsistence Boundary Roots
Bed :Trench
1 0 -11 10YR3/3 - - - - -- I lmsbk mvfr as if .4 .5
2 11 -22 l 0YR4 /4 ------------ - - - - -- I 1 msbk mvfr gw lvf .4 .5
Ground 7 s
elev
3 22 -49 7.5YR4/4 ------------ - - - - -- cs osg ml gw - - --
102.8 4 49 -79 10YR5 /6 cs osg ml - - -- 7 8
------------ - - - - -- - - --
Depth to
limiting
factor 3 ? • 2 `� - 7 a —
>7911 --
Remarks: -
4 1 0 -12 10YR3/3 ---- -------- - - - - -- 1 lmsbk mv fr as if 4 .5
2 12 -24 10YR4/3 - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground 7 g
3 24-50 7.5YR4/4 ----------- - - - - -- Cs osg ml gw -- --
elev _ -_ _ _ --
102.O 4 50 -73 10YR4 /6 - - - - -- s osg ml - - -- - - -- 7 .8
Depth to
limiting — —
factor
>73"
Remarks:
5 1 0 -13 10YR3 /3 - ----------- - - - - -- 1 lms mvfr as if 4 .5
---- - - - - -- I Ims mvfr lvf 4 .5
2 13 -24 10YR4 /3 -- - - - - -- b'�'
Ground
elev 3 2449 7.5Y ----------- - - - - -- cs osg ml gw - - -- .7 . 8
- - - --
102.O 4 49 -71 10YR5/6 ------------ - - - - -- s osg ml - - -- - - -- 7 8
Depth to
limiting - - -- - -- - - -- - -- ---- - - - - -- - -- --
factor
>71"
Remarks:
Ground -- - - -- - - -- - - - - - -- - --
elev -� -- -
ft.
Depth to
limiting - - -- - - -- - - - -- - -
factor
Remarks:
r
u
� r
s
c�
2
Do 4)6
Ilk
Y �U
oI
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ,ZQr�� -�
Mailing Address
,
Property Address 3 S M ew ('w
� (Verification required from Planning Department for new construction)
City /State /" JJ &-) r W) I Parcel Identification Number
LE GAL DESCRIPTION
Property Location ' N� ' /
P rty _.�_ /4, /4, Sec. 3 , T 3 / N-R U Q
W Town of r
Subdivision •.� /jr , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume 1, , Page #
Spec house ❑ yes, no Lot lines identifiable [yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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 b the owner a
g p g y ndbya
master plumber, 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 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 yeaZp ex tion date.
Q
SIGNATURE OF APPLI T 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,
SIGNATURE OF APPLI NT 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
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pago luf e;?
FILE INFORMATION SYSTEM SPECIFICATI
Owner - Septic Tank Capacity al o NA
Permit # Septic Tank Manufacturer o NA
Effluent Filter Manufacturer 41 o NA
DESIGN PARAMETERS Effluent Filter Model o NA
Number of bedrooms o NA Pump Tank Ca ac ty gal A NA
Number of Commercial Unit dNA - Pump Tank Manufacturer ANA
Estimated flow (average) gal/day Pump Manufacturer A NA
Design flow (peak), Estimated x 1.5 gal/day Pump Model ,ANA
Soil Application Rate gal /da /ft Pretreated Unit i
III fluent /F.,1'11uunt Quality Mun ► y / \vvnlge* uj Sand /Gravel filter la Peat Filter
Fats, Oils & Grouse (1'OG) <30 nrg /L n Mechanical Aeration U Welland
Biochemical Oxygen Demand (BODs) <22U mg/L o Disinfection o Other:
Total Suspended Solids (TSS) <150 m L Manufacturer
Monthly Average ** Dispersal Cell(s)
Pretreated Effluent Quality o NA o In- ground (gravity) o In- ground (pressurized)
Biochemical Oxygen Demand (BODs) <30 mg/l, o At -grade o Mound
Total Suspended Solids (TSS) <30 mg /L o Drip-line o Other:
Fecal Coliform (geometric mean ) <10 cfu /100mL
Maximum Effluent Particle Si '/e in ch diameter + Values typical for domestic (non - commercial)
wastewater and septic tank effluent.
** Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequenc
Inspect condition of tanks At least once ever o months ears Maximum 3 rs)
Pump out contents of tanks When combined sludge and scum equals one third 'h of tank volume
Inspect dispersal cells At least once every o months jir ears Maximum 3 rs
Clean effluent filter At least once every o month eur(s
Inspect p ump, n►m controls & alarm At least once every u months o ours NA
Flush laterals and pressure test At least once every o months o yea ZNA
Other: At least once every o months o ears ,"A
Other: I At least once every o months o ears A
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 (%) or more of the tank volume, the entire
contents of the tank shall be removed by a Septuge Servicing Operator and disposed of in accordance with ch. NR 113,
Wisconsin Administrative Code.
The servicing of effluent filters, mechunicul or pressurized POWTS components, pretreatment components, and any other
maintenance or monitoring t intervals of 12 months or less shall be performed b a certified POWTS Maintainer.
g P Y
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
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 my impede the treatment process and/or damage the dispersal cell(s), If high concentrations are detected have
the contents of the tanks(s) removed by a septage servicing operator prior to use.
Owners , / °
System start up shall not occur when soil conditions are frozen at the infiltrative surface;
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 P ark 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 soft absorption are.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of
diapers; disinfectants;
ton swabs; degreasers; dental floss; dia ,
butts; condoms; cot Pe
wipes; cigarette b g
the POWTS: antibiotics; baby pe , g ,
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.
ABANDONEMENT
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 ch. 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:
X 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.
C) 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.
allure ' of the POWTS a soil and site
• The site has not been evaluated to identify a suitable replacement area. Upon f
holding
to locate a suitable replacement area. If no replacement area is available a h g
evaluation must be performed
Pe
tank may be installed as a last resort to replace the failed POWTS.
• 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 the tine.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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 INSTALLId POWTS MAINTAINER
Name ZZ Name
Phone 1 - - Phone
SEPTAGE SERVICING OPERATOR PUMPER) LOCAL REGULATORY AUTHORI
Name / "-.
Name
Phone Phone
U 1979P 307
690064
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., MI
This Deed, made between Lakes and Hills, Inc., a Minnesota RECEIVED FOR RECORD
_C orporation 09 -12 -2002 9:45 AN
_ WARRANTY DEED
_ EXEMPT tt
Grantor, and Aaron L. Voeltz, a single person REC FEE: 11.00
TRANS FEE: 83.70
COPY FEE:
CERT COPY 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
Name and Return Address
Lot 21 Plat of Pine Acres in the Town of Star Prairie, St. Croix County,
Wisc nsin. First National Bank of New Richmond
I'0 Box 89
New Richmond, WI 54017
038 - 1195 -10 -000 _
Parcel Identification Number (PIN)
This is not homestead property.
at) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this 5� day of September 2002
Lakes and Hills, Inc.
" s
"
" AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
County )
authenticated this day of Personally came before me this ��= day of
September - - ' 2002 the above named
Lakes and Hills, Inc., a Minnesota Corporation by
s 6
TITLE: MEMBER STATE BAR OF WISCONSIN ro to m -
e known to be the persons) who executed the foregoing
(If not, __ instrument and ackno edge same.
i t
6 i . 5 ts.
' 706.0 W s to
authorized by § )
THIS INSTRUMENT WAS DRAFTED BY -
Attorney Kristina Oglan Notary Public, State of Wisconsin
Hu W1 44016 JULIft baVQLmton is permanent. (If not, state expiration date:
(Signatures may be authcnticated or acknowledged. Both are noYrf!Jllbll � e- -)
" pe rsons signing in an c must be typ ed or p rinted below their sig nature. iMOm anon Frdeas onalc comp.ny, rand au tae, �
Names of
Pe 8 g Y P Y tYP P B e00- 655-2021
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 1999
99S
1 P ,0l "�
Ln N
cr
cy
�co N
CQ
CQ 00
r
2 2 2 Yr Q cl �c y 0
4 / 00 q?9:
�,�'� � J v _� 2:-3 11«
tK � � 40 V 03Spd0�f 1 ,-031
582 o
o__ rn
,
IK � 8 SOS
9S
4�
N N N �d • M 00
v �L N h M,
/ M
\ °lj`�l�d Obi � �� �ti � •9y S ti
co
/G
15
a \, ll� \ 0 \6 4 \ G `Q N o tip
ON
� S
12 \ 'm4
ol
N
l � C\2
'�- y O Q - � X •� ! ^ � M,.�'S.9S °885.
co
t0 0 R_k V
Y �i M N O Q y�Q. ��r