HomeMy WebLinkAbout038-1210-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Divisio,
INSPECTION REPORT sanitary Permit No:
420733 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:
S mmes - Benson, Jessica I Star Prairie Township 038 - 1210 -80 -000
CST BM Elev: Insp. BM Elev: BM Description: t Section/Town /Range/Map No:
10 1 �' tm- 13.31.18.1146
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic h
16 6 0 B c �r d� / _ / OO. O
Dosing � ! D Alt lI BM O
Aeration Bldg. Sewer
-�S 9
Holding St/Ht Inlet �7 a S
TANK SETBACK INFORMATION St/Ht outlet G
a• ZS q �
TANK TO p P /L WELL BLDG. Vent o Air Intake ROAD Dt Inlet
Septic � � � � Dt Bottom � y
1
Dosing He e a / D •
Tx j — o d 7
Aeration Dist. e
Holding Bot. System C
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover CO
GPM /TOT Dr l
Model Number
TDH Lift Fri • n Los System Head TDH Ft
Forcemain L!riwr Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lenth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 / I &W b q SET BACK SYSTEM TO P /L BLDG WELL LAKE /STREAM ING nuf r
INFORMATION H MBER OR
Typ f System: de
�v
� l Number:
DISTRIBUTION SYSTEMS II1 g u4 4xcl _ Z / -)a / c 2 i t 1-e j
�r /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
',, / Pipe(s) y ��a. ' �d —_ �I
Lengt Dia / Length Dia cing
OIL COVER AV s e S s em y o ystems Only
Depth Over De th Over / S / w xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center (�l / Bed/Trench Edges 0 q& Topsoil
Yes No Yes I,J No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: S / Py/ 03 Inspection #2:
Location: 1375 212th Ave New Richmond, WI 54017 (NW 1/4 SE 1/4 13 T31N R18W) No gate II Lot 56 Parcel No: 13.31.18.1146
1. Alt BM Descrip
n
2.) Bldg sewer length ;R A a o
- amount of cover ✓L6 l3 �� _ ry�p�f VW � 5;-44t4 W V, V� �
Plan revision Required? Yes L No $
Q � 3 S
Use other side for additional information. � ____._j ___ _________ ___ _ _ �•I:Z/I/YL+ �__�_
Date nse ct r' Signature Cert . o.
e p o s g
SBD -6710 (R.3/97) 4 ��� p' / S�� /D��_ ���/�(�V�{2 /16 Qcca "
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352 140" STREET
AMERY, WI 54001
PRONE: (715) 268 -6637
Fax: (715) 268 -7080
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To: From:
Fax: Date:
Phone: Pagers (Includes cover):
Re: CC:
❑ urgent C] For Review ❑ Pismo Commont 17 Please Reply ❑ Pismo Recycle
- Comments:
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Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7082 T,
Vcon Sin S Madison, WI 53707 - 7082 ite Address
Department of Commerce
Sanitary Permit Application sanitary Pe o 1 33
In a ccord with Comm 83.21, Wis. Adm. Code, personal information you provide z42,
Check if Revision
may be used for secondary purposes Privacy Law, sl5.04(1)(m)
I. Application Information - Please Print All Information State Plan I.D. Number
_. n ..
Property Owner's Name Parcel Number
0 3 /0 Fo- 00d
Prffr Owner's Mailing A ess ', Property
ly Location l p
Z 2 3 SO 5 S -1. AS S4; S 1 3 T / N, R/ ! E II
City, State Zip Code one NUD*WNG OFFICc Number Block Number
��JJ Subdivision Name CSM Number
�,n m C W_ I � e/o 1' LZ
II. Type of Building (Check all that apply.) Su 1 ❑ City
❑ 1 or 2 Family Dwelling - Number of Bedrooms 3 -tna �2oQ,v .s ❑ Village
❑ Public /Commercial - Describe Use 13 Townshi
❑ State Owned
/ Near&a Road
III. Type of Permit: (Che& only one box on line A. Numbering is for internal use.) (CompIJte line B, if applicable.)
A. New 3 ❑ Replacement of 6 ❑ Addition to
System 2 ❑ Replacement System Tank Only Existing System For County use
B ' ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of POWT System: (Check all that apply. Numbering is for internal use.)
4A- Non - Pressurized In- Ground 21 ❑ Mound 47 ❑ Sand Filter 50 ❑ Constructed Welland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑Aerobic Treatment Unit 49 ❑ Recirculating 30 El Other
V. Dispersal/Treatment Area Information: A- ioD
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min. /Inch) Elevation
s - 0 y 3 4G /• Is q7. /0 /0 2.
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
pti or Holding Tank /oaO /000 �!
Dosing Chamber I f ✓ �
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP /MPRS Number Business Phone Number
1 - 22141>1 >,r -.24V G 6,T
7
Plumber's Address (Street, City, State, Zip Code)
Z / Vo .5 m-ee tt - voo
VIII. County /De artment Use Onl
Disapproved Sanitary ate Issued I�suing gent Signa a (No Stamps)
X Approved ❑ Owner Given Initial Adverse mtazy Permit Fee includes Groundwater
Determination Surcharge Fee)
IX Conditions of Approval/Reasons for Disapproval m
r StcAitu`eKs
A-U s '
Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size
SBD -6398 (R. 05101)
13L 11413
y
Wiscony of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
r , ,Ndi Human Relations
s ivision of Saf ' ety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 038 - 1055 -95
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION y9f.
D BY DATE
(ti,...
PROPERTY OWNER: PROPERTY LOCATION
Greenwood Enterprises, Inc. GOVT. LOT NW 1/4 SE 1/4,S 13T 31 N,R 18 Wor) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1416 Third St. 56 na NorthGate
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
Hudson, WI. 54016 (715) 386 -3674 Star Prairie 214th Ave.
[ New Construction Use [ ] Residential / Number of bedrooms 4 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft trench, gpd /ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft trench, gpd /ft
Recommended infiltration surface elevation(s) 99.10 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for sy stem ®S ❑U ®S ❑U ®S ❑U LA ❑U LA S ❑U EIS g7
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary oots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
1 0 -14 10 r 3Z3 none 1 2msbk mfr QW if .5 .6
2 14 -25 10 r 4/4 none sicl 2msbk mfr gw if .4 .5
Ground 3 25 -84 7.5yr 4/6 none cos osg ml na na .7 .8
elev.
10 ft.
Depth to
limiting
factor
+84
b• a
Remarks:
Boring #
1 0 -12 10 r 3/3 none 1 2msbk mfr qW if .5 .6
w if .4 2 12 - 10 r 4/4 none sicl 2msbk mfr .5
2 y 9
3 24 -84 7.5yr 4/6 none cos osg ml tea` 5 .7 .8
Ground ,....,. ,
elev.
10 ft. ,
Depth to
limiting NOV
4 I
factor','
S7 ROIX
+84 �� K CCXJ
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. AAe New Richrywnd, WI 54017
Signature: Date: 11 -7 -98 CST Number: m02298
t 1Z
PROPERTYOWNER Greenwood Enterpri DESCRIPTION REPORT Page
PARCEL I.D. # 038- 1055 -95
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barry Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmnch
Li 1 0 -12 10 r 1 2msbk mfr QW
2 12 -26 10 r 4/4 none sicl 2msbk mfr gw if .4 .5
Ground 3 26 -32 10 r 5/4 none sil lcsbk mfr C1w na .2 .3
elev.
102j 4 32 -84 7.5 r 4/6 none cos osci ml na na .7 .8
Depth to
limiting
factor
+ 8 4 ' 1
t{�i •L
Remarks:
Boring #
1 0 -10 10 r 3/3 none 1 2msbk mfr Qw if .5 .6
4 2 10 - l0yr 4/4 none sicl 2msbk mfr gw if .4 .5
Ground 3 24 -84 7.5 r 4/6 none cos OSQ ml na na .7 .8
elev.
103.1 ft. —
Depth to —
limiting
factor
+84
Remarks:
Boring #
1 0 -9 10 r 3/3 none 1 2msbk mfr w if .5 .6
.... ...5 . 2 9 -22 10yr 4/4 none sici 2msbk mfr gw if .4 .5
..................
Ground
3 22 -30 10 r 5/4 none sil icsbk mfr 9w na .2: .3
el 4 30 -84 7.5 r 4/6 none cos os ml na na .7 .8
1 O ft.
Z
Depth to
limiting
factor
+84
Remarks:
Boring #
.................
Ground
elev. i
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Greenwood Enterprises, Inc: 1554 200th Ave.
CSTM2298 NW4SEq S13- T31N -R18W New Richmond, WI 54017
MPRSW -3254 town of Star Prarie (715) 246 -6200
lot #56- NorthGate
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
1
BM.= top of 1" pvc pipe C el. 100
Alt. Bm.= top of 1 pvc pipe C el. 99.55
5 8 r ' 1 0 �� r ,� p4
1
so
p
Gary L. steel
11 -7 -98
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1 of ?/
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tank Capacity /Opp ga l C3 NA
Perm' -f to -t-g Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 2 ❑ NA
Number of Bedrooms ,3 ❑ NA Effluent Filter Model X00 ❑ NA
Number of Public Facility Units .XNA Pump Tank Capacity a l WNA
Estimated flow (average) Sao gal/day Pump Tank Manufacturer 0 NA
Design flow (peak), (Estimated x 1.5) 47p al /day Pump Manufacturer 8 NA
Soil Application Rate gal/day/ft' Pump Model IZ' NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit [] NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODd 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 F 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) ❑ NA
ear(s)
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: 0 year(s) (s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: - month(s) ❑ NA
.18! year(s)
Inspect pump, pump controls & alarm At least once ever ❑ month(s) year(s)
❑ NA
Ins
P P Y' ❑ year(s)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
❑ month(s)
Other: At least once every: ❑ year(s) ❑ NA
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.
GMW (4/01)
Page of
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 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:
13 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.
❑ 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 -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 INS LER POWTS MAINTAINER
Name Name
Phone 7f S G g-_ G 37 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name s T Qq /n
Phone Phone
This document was drafted in compliance with chapter Comm 83.220(b)(1)(d )&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address C , a
Property Address _.�- �S '/"?
(Verification required from Planning Department for new construction)
City /State I �m� Parcel Identification Number
LEGAL DESCRIPTION
Property Location W v,� L i / a, Sec. / T / N -R , L W, Town o
I
Subdivision d Y- Lot # _ .
Certified Survey Map # , Volume 2 Page # 02
Warranty Deed # i i 2 q n , Volume Page #
Spec house ❑ yes 2 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
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.
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. C County Zoning Office within 30
days. f the three year expiration date.
3 lb
SlokATURE OF AAPPCANT a&w 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 owners) of
the ropcdy described above, by virtu of a warranty deed recorded in Register of Deeds Office. y
A] mi Abilyma 15 / NATURE OF LICANT DATE
S
* * * ** 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
? 1) 0 2 It I - 7 1 e121
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