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HomeMy WebLinkAbout040-1262-50-000 Wiscon3in Department ofCommerce y Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. CroiX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Pe o.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ❑ City ❑ Village ❑ T n of: State Plan ID No.: Miller, Sam Troy Township CST B v.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1 {•9 9'- 9 4 C ra* 040 - 1262 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. � Septic Benchmark 0 . )05 r `f q 9 Alt. BM I Dosing 3� ID Io2• Aeration Bldg. Sewer -_+,k . h Holding St / Ht Inlet TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/ L WELL BLDG. Aeintake ROAD Dt Inlet Septic } 5 p ` 3 D �--- NA Dt Bottom Dosing NA Header/ Man. Aeration N )k Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade u cturer and St cover Model Number GPM TDH Lift L Ion TDH Ft Force n Length Dia. Dist. To well SOIL ABSORPTION SYSTEM , 5 - / 8th NCH Width Le th �51 No.9 enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7 v� 4 0� DIMENSIONS Manufactu yy:: gg SETBACK SYSTEM ' °' ° T 5 O P/L BLDG WELL LAKE/STREAM LEACHING � INFORMATION System: u t I OR UNBT R Number: DISTRIBUTION SYSTEM Header / ManjfoId Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length �, Dia_ ngth Dia. Spacing , ►oo 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1• I I /ZI /C- Inspection #2• Location: 548 Tulgren Street, Hudson, WI 54016 (NE 1/4 SW 1/4 5 T28N R1 / 9 r W) - 0528191413 Frontier -Lot 1.) Alt BM Description = { «� S w caw�w Pa 2.) Bldg sewer length = -3 u` - amount of cover = '), 3) 4:, A A' 61A-jeA A fie/ Plan revision required? ❑ Yes J W No Use other side for additional information. 2 �� ate,,,,. _ _a 1A,`_ 11 1 1 -� k SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Iv ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: �. { s $ i P h t , p v a � t � � f C � c n 9 E § r x § � � I h � i , I Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. i See reverse side for instructions for completing this application PO Box 7302 N iseonsin Personal information you provide may be used for secondary Madison. WI 53707 -730, Department of Commerce p [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if r state owner Attach complete plans (to the county copy only) for thesysTejT-6i1= r not less than 8 -1/2 x 11 inches in size. County State Sanita Permit Number ❑ C cly v' ' r v ou.�application State Plan 1. D. N umber I. Application Information - Please Print all Information Location: Or Property Owner Name lam, Property Location q S> `L NE 1/4 �/4. S S TV,N. 9 E (otrW Property Owner's Mailing Address Lot Number Block Number U' UN� City, State Zip Code oneLl�ljµtNlFi Subdivision Name or CSM Number II Type of Building: (check one) �� _ City 1 or 2 Family Dwelling — No. of Bedrooms '` O Village X T2o ❑ Public/Commercial (describe use): Town of ❑ State -owned III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road A) 1. XNew System 1 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) System Tank Only Existin S stem 140- So 040 B) Permit Number Date Inwd ❑ A Sanitary Permit was previously issued I S. 2—Q, 9 .1 ( 3 IV. Type of POWT System: (Check all that apply) -2 A — I Qo X[Non- pressurized In- ground - LEACH/ ❑ Mound ❑ Sand Filter ❑ Constructed Wetland /❑ Pressurized In- ground ❑ Holding Tank ❑ Si le Pass ❑ Drip Line ❑ A ade ❑ Aero is Treatment U it ❑ Rect ula ing ❑ Qt er: JsL IS'EAct�t �- V Dis ersanreatment Area Information: 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation (� Od .So O 1 .7 9' �.00 1 9p, 00 VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks '���' T � L- �( � z S0 � W � 1 Est..- ❑ ❑ ❑ ❑ FIt,T� 13 r 1aa ❑ ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersig assume responsibility fer installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber'S'gnature (no � s): MP/MPRS No. Business Phone Number 10 1 kF- t=� Wjl , ( 101 �s =3�G� 69 Plumber's Address (Street, City, State, Zip C de) 10 10 14 u F/L 9 IU6i_� Q D 114)VSo W k)J J_ 3 1 4 1% VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) 4Approved ❑ Owner Given Initial Adverse Su arge Fee) Determination au Z060 IX. Conditions of Approval /Reasons for Disapproval: SBD -6398 (R. 07/00) t � NT rk G oT - It S S IVL6AC-N SZ'kEF- r Al Tpu�Q ROAD S� aZ,y 3 1_& o F lo STA x E F- (= I OD,�o r 1i5 70 l z I �n m 3 2. o �d j 2 SD 6A I. :'� _�-- i06k ficrt2 UJl ZAQE —' 110 a � DRWE W AY LL 3o- CHR,nBEfLs �'��T wr TkfArc;�_ - Z��s: ' F t �� VI A Lt. Z, m. TO cif L eT' s TAkF Wisoonsin Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code AC.E. Soil &Site Evaluations Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must F include, tit not limited to: vertical and horizontal ref direction and St. Croix percent slope, scale or dimensions, north arrow 41s to n�rest road. D.# Prt of 040 -1021 AO APPLICANT INFORMATION - P 37e print nfonn�tfit� d By Date Personal information you provide may be u fw.�}�eonda vary l au'f s. 15.04 (1) (m)). 3 Property Owner ° I roperty Location Miller, Sam (Atr f '" G vt Lot NE 1/4 SW 1/4 S 5 T 28 N,R 19 W Property Owners Mailing Address ST CRUX # Block # Subd, Name or CSM# P.O. Box 151 COUN S Plat Of Frontier City State ipC "%CrrE City E] Village ®Town Nearest Road Hudson WI 5 1;6 715 386- - Troy Tower Road ® New Construction Use: ❑ Resider bedrooms 4 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate •7 bed, gpd/ft •8 trench, gpolff Absom area required 857 bed, ft 750 trench, ft2 ✓ Maximum design loading rate •7 bed, gpd/f1 •8 trench, gld/ft Recommended infiltration surface elevation(s) 95.00' ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using high capacity infiltrators. Increase trench length if silt inclusion is found while installing Parent material Glacial outwash Hood plain elevation, if applicable NA ft S for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system I ® S❑ U M S❑ U ®S El ® S❑ U ❑ S® U ❑ S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/fl Horizon Texture C Boundary Roots Boring# in. Munsell Qu. Sz. Cont. Cob' Gr. Sz Sh. Bed ;Trench 1 1 0 -14 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6 2 14 -40 1Oyr4 /4 None sil 2msbk mfr aw if 0.5 0.6 Ground 3 40 -50 10yr4 /6 None is Osg dl cw 1 f 0.7 0.8 elev 99•x' ft 4 50 -94 10yr5 /4 None s Osg dl gs - 0.7 0.8 Depth 5 94 -123 1Oyr6 /4 None s Osg dl - - 0.7 0.8 limiting Large sift inclusion observed on east side of soil pit in ti#4. m2d7.5yr5/8 mdox features observed at outer edges of sift inclusion result from greater factor metric potential of sift to surround' sand. Redox features are not indicative of groundwater. — T >123' .srD 9Y. fL Remarks: 2 1 0 -14 10yr3 /2 None sl fill NA NA as - NA NA 2 14 -48 10yr5/4 None s 0 sg dl gw - 0.7 0.8 Ground 3 48 -75 10yr6 /4 None s & gr 0 sg d1 cw - 0.7 0.8 elev 99.43'ft 4 75 -120 10yr6 /4 None s 0 sg dl - - 0.7 0.8 Depth to limiting factor >120' S'3• (b� q r` Remarks: Site cut & filled to stonn water drainage. — CST Name (Please Print) Signature: Telephone No. James K Thompson ? 715- 248 -7767 Adder A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 54020 12/31/1999 3602 1153 pROPERTVOVVNM Miller, Sam SOIL DESCRIPTION REPORT Page 2 of 3 'PARCEL LDJ Pit of040- 1021 -90 A.C.E. Soil & Site Evaluations Horizon Depth Dominant Color Mottles Texture Structure sry Roots GPDW in. Munsell Qu. SL Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0 -4 10yr3/2 None sl 2fcr mvfr as - 0.5 0.6 2 4 -28 10yr4/3 None is 0 sg dl gw - 0.7 0.8 Ground elev 3 24 -57 10yr6/4 None s & gr 0 sg dl cw - 0.7 0.8 98.48'ft 4 57 -117 10yr6/4 None s 0 sg dl - - 0.7 0.8 Depth to limiting factor >117' Remarks: 4 1 0 -13 10yr3/2 None sl 2msbk mvfr F-cw- 2f 0.5 0.6 2 13 -28 10yr4/4 None sil 2msbk mfr If 0.5 i 0.6 Ground elev 3 28 -32 10yr4 /6 None is Osg dl if 0.7 0.8 96.03 It 4 32 -80 10yr5/4 None s & gr. Osg dl gs - 0.7 0.8 Depth to limiting 5 80 -114 1Oyr6 /4 None s Osg dl - - 0.7 0.8 factor >114' Remarks: 5 1 0 -12 10yr3/2 None sl fill NA NA as - NA NA 2 12 -16 10yr5/4 None s 0 sg dl gw - 0.7 0.8 Ground elev 3 16 -64 10yr5/4 None s & gr 0 sg dl cw - 0.7 0.8 99.34 ft 4 64 -118 10yr6/4 None s 0 sg dl - - 0.7 0.8 Depth to limiting factor >118' Remarks: Site cut to create required storm water drainage. Ground elev Depth to limiting factor Remarks: Tower eoQd sra?.513 , • le / 06�Serdc�7� ,4ssu.med elect; = /0 CV-' .�Q�» NKd.son, i. SNO l!o Zoca:&eO»: I �d /Ir`ySwAe, Sec.,, T. zg f &cAj, �l BS � 76 ■ I � w Y� w V) d ■ a v � go'.g4 ■ 82 ■ .e� ' uSer SP ifi cations Is- - , �� T�1v BioDif f ' .9 s 76" _ O D pp O D � � OD © = ©n 0� �C� �� C hambe r Clfl OD p© ©C=1 G71 DD C�C"'7 ©_G_� �© Height o0 I Chamber Height End View 34" 4" Knockout Universal End Cap Available Sizes i i 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 3 Number of Bedrooms Design Flow - Peak (gpd) Ot Estimated Flow - Average (gpd) Septic Tank Capacity (gal) Soil Absorption Component Size (ft '� 1 'L Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) S - S I �- Maximum Influent Particle Size (in) 0 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 se nd outlet filter shall be assessed at least once every 3 years by inspection. T e outlet filter gal[ be cleaned as necessary to ensure proper operation. The filter cartridges ou not be removed unless provisions are made to re am 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 113 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 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 7 ilt) 0 s Property Address S g (Verification required from Planning Department for new construction) City /State Q S D 1%( W Parcel Identification Number LEGAL DESCRIPTION Location '/4, 5 w '/4, Sed. s . T �� T N Town Town of Property Subdivision X28 a 1. . Lot #_. Certified Survey Map # t8 (4 SS . Volume Page # Warranty Deed # lao 4*r8 4 I . Volume 4 Z— , Page # Spec house )] yes ❑ no Lot lines identifiable tt 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, journeyman plumber, restricted plumber or a li cense d p verifying that (1) the on -site wastewaterdisposal 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, asl 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 exp' on date. ATURE 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 owneds) of th rty de ' d bov b virtue of a warranty deed recorded in Register of Deeds Office. ATU W AP DATE s * * * *s * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departmen t ** 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 I � V01.1442PAGE 42 ` STATE BAR OF WISCONSIN FORM I - 1998 606841 - KATHLEEN H. NALSH REGISTER OF DEEDS Tlds Deed, made between Kathryn B. Tuleren, and Ferris — ST. CROIX CO. • UI R- nil gran wi fa n"dl htliibzYLGL RECEIVED FOR RECORD Grantor, conveys and warrants to 07-14'1999 11:00 N Sam E. Miller, a single person. Grantor, Do E)07pT I ` Grantee. CERT COPY FEE: Grantor, fora valuable consideration, conveys and warrants to Grantee COPY FEE: the following described real estate in St. Croix County, State of TRIWSFER FEE: 2228.10 RECORDING FEE: 12.00 Wisconsin (The "Property"): PAGES: 2 Recorditut Area Name and Return Addreu 014«122 - 010. 1022 - 70:010- 1021.90: 010. I M9-20: 0141028.70 Parcel Identification Number (Ptll) Thu Is not htxtwtead property. (See Attached Exhibit "A ") Exceptions to warranties: Easements, restrictiona and rights -of -way of record, if any Dated this 13th day of July, 1999. • *'Ferris B. 'ulgrcn ' " Ferrren AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) $a. authenticated this _ day of St. Croix Country ) Personally came before me this 13 day • of July, 1999, the above named Kathryn B. Tuleren, TfTLE: MEMBER STATE BAR OF WISCONSIN and Ferris Rgrerr, — rife — arid � (If rot, ntu mown t the PC' s) who executed the foregoing authorized by 5 706.06, Wis. State.) ins(rV find ackno 1 ge the same. THIS INSTRUMENT WAS DRAFt ED BY Attorney Kristlala Oglond • � Iludson, WI 54016 N blic, State of Wisconsin (Slanatura may be authenticated or acknowledged. Both are not My Commiuio is none not, state expiration due: C AC7firy ) Brekda Poulin 7 r r F d Ova Notary Public State of Wisconsin •Names of persons signing In any opacity should be typed or painted below their signaitues w,WAM DUD firAflt a" OF WISCONLN row N.. I - urn NFORW MW PROF ES&OPM 1 COMPANY FOND tx1 LAC. v41 8004MWIMI i __ Y 1442 43 EXHIBIT "A" in p arcel of land located in the NE' /+ Of S 1/4 That carte i n�Town hip 28 North , Range 9 P , Wisconsn more fully described as follows: of SW '/• and the NE St. O f Countyectlon � i on 5, 87 051'08 "E , thence N West Tower Troy, at the West quarter comer of said Section , Beginning uarter line of said Section 5) a d 288 00 feet to a (recorded bearing on the East - West q 24 feet; thence S00 °13'24 "E. 854.00 feet; thence N87 E, E 2342 thence along the point the East line of said NE' /+ of SWr /of said NE '/+ of SW �4; t line, , along Soo* 13'24 "E, 466.08 feet to the SE corner S87054'54 \N. South line of said NE 'A of SW ' /+ and the3 28 line 70 feetW /+ of on said S87 °54'5 "W 2372.41 feet, thence N00 thence a 9 s N01 °3; thence f said NE 'A 54 273,91 feet to the monumented West tine 2'36 "E), 941.26 feet of said NW,/, of SW +, o West line, N00 °30'28 E (recorded a 458. feet to the North line N64 °57'47 "W (recorded as N63 50 N88 °20'13 "E (recorded as of SE 'A of Section said North tin 6; thence a line, S88 °40' 19 "E and N 89 °24'42 "E). 41669 feet (recorded as 2 5'/• rods) to the Point O Beginning. ! NORDIC- H_ EIGHTS_ ADD MON. r`.' ' 2"1 U -4 5 t— w• tB � 40ft- od • It" of a• k p Not J2•3°" N 0*30 *78" 1 I' ( rM , , 5 . R ♦ . MIS d _ R L 4 i i l l a f I I � f at O/ 1f� Ir iNf �.'••. ••. i �` ( � i !!QQ �� �! k� srol la� • �\ \` �k j� ��,� J � / I w i >k i a� R.usr ® ��l� 1 _ ._._._. — —• Missal► ................. K .._.......` l� y >R� g IYW� I � i c c , fo 1' iti p j N•r /• a � A � / k y � `• Q�,/'j19 8 r. t�� en t„ t Fro " !( s o -w i,..i, 141 tar j• _ O i w t I , J QH fill IN No 4 a lal C t fix' ®'. r " - kJO 9, o - i9 ti . sl a # I LA ={ ��. � I . � �^ � � r �CC{{e. ► � , � 000 I tO 26U2 f AIR �� �� �k � RCN p `��� ',a 1.r71 s +. ICIC7 i }} ,� � Ir, re am I --1 1 t 07 1 s o•L1�,• 1 ,uor.nN• _ R VNPtA�TEO -L-4NDS OWNED BY OTHERS N i AI�j� • �a �0�� �..3 QI A 1 04 Y R i �• i o � �