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HomeMy WebLinkAbout040-1263-70-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County - ' Safety and Buildings Division St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarx Urm it No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 370361 Permit Holder's Name: ❑ City ❑ Village.UWwrtor State Plan ID No.: Miller, Sam I Troy Township CST 811 E eZ Insp. BM Elev.: BM Description: Parcel Tax Nn uc� IlS.2( l� ! S •?.lo B CST w►r g 1 040- 1263 -70 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ,105 10 (..%s - 1 D Dosing Alt. BM Aeration Bldg. Sewer Holding St /Ht Inlet l4,`�I 8.10 111 -31, TANK SETBACK INFORMATION St /Ht Outlet ) Q .SZ )(o. f TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet "— Septic 1 r top f Sfo r NA Dt Bottom `"-- Dosing NA Header / Man. 9� q4• ems' Aeration NA Dist. Pipe `j. ' V- 9 Holdin Bot. System �D.� 9� •0 f PUMP / SIPHON INFORMATION Final Grade o+rti M ufacturer Dem nd St cover L) q go' 1I` -Io Mode umber M w�'L • (� S` TOH Friction System TDH Ft orcemain Length H ead Dist.T SOIL ABS RPTION SYSTEM 3 NC Width a L th f No O Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSIONS 3 • Z� DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE/ STREAM LEACHING Manufacturer: INFORMATION Type r Zr� r CHAMBER Moe Nu r: System: 2 0 > Lw OR UNIT DISTRIBUTION SYSTEM 1 ai 01 Header / panifolcl Distribution Pipes) x Hole Size x Vent To Air Intake Length Q.Q/ Dia. u Le in 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 C] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 04// Inspection #2: `7 1 Location: 417 New Century Drive, Hudson, WI 54016 (NW 1/4 SW 1/4 5 T28N R19W) - 0528191425 Frontier -Lot 17 1.) Alt BM Description= 5'T oA w 2.) Bldg sewer length = r- 5 ' - amount of cover = ? cr,~CJ 3 ) 2-46t k-(NM Plan revision required? ❑ Yes 10 No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature CQ'' * ISCOnSln } AjjE(J QQ Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number 5i c ao ty I 3 =to 36 l I. Application Informat - Please Print all Informa Location: Property Owner Name Property Prroperty Location �/ 514 o i I r� ( 1 1011Z 1/4, S T 2 N, 11 rE (or Property Owner's Mailing Address Lot Number Block Number DSO -�c %r I s / / 7 City, State Zip Code Phone Number Subdivision Name or CSM Number M �IDS ID S W I a o f c,, ( )" 7 II. Type of Building: (check one) ✓ ❑ city 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village Public /Commercial (describe use):_ Town of ❑ State -Owned 2 - q Y H'f4 ftAZF . , rA E Nearest Road C t ea 6' 1 � g. P, ! O�` t;" C,, Q 7,1 $ Q'F Parcel Tax Number(s)O - 1 3 -7Q - - + III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 5. 2-g, tj , 14 Z5 A) 1. Wew 2. ❑ Replacement 3. Q Replacement of 4. 5. 6. ❑ Addition to S ystem System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) 't N on - pressurized In ground �Ej�.c ❑ Mound ❑ Sand Filter ❑ Constructed Wetland Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -gr!o� 3 i ❑ Aerobic TVtment Unit ❑ Recirculating ❑ Other: �, ZS Z T L AM A P iUr V. Dispersa reatment Area I 1. Design Flow (gpd) 2. Dispersal Area 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 ,4. 6 (P (.,-,79 ®. S Co 9 Z q 4 , oo /oa. ao , VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks 0 0 0 � �- ❑ ❑ ❑ [1 11 VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (n tamps): MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip C de) 14 T IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) ,Approved ❑ Owner Given Initial Adverse SW Fee) \ Determination o -25' 266D X. Conditions of Approval /Rea for Disapproval: lk i � NA! r tAx V�.M ^ f T ` ( Gt S rv� bA�tt�tc ✓er �S V 2 Ce utiwawn�et�S t SBD -6398 (R. 07/00) (Za I�JTI,E2 Lo 7 r , } S CALE All 1 (40 CA Air 9 h1o�S E -L 3 -2 �9 - BIB ���j /.S t'� T rC N i�'t F -� 13 - E �4 m Tie irkC o I WC f 5 73 r r• - y I Misconsir, Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 and Buildings Division of Safety n9 in accord with Comm 83.05, Wis. Adm. Cod e A.C.E. sou 8c Stte Evaluations Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must County include, tut not limited to: vertic l an tal d horizon reference point (BM), direction and St. Croix percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.# - Prt of 040 - 1022 -10 APPLICANT INFORMATION - Pleas italpl ihformation. y h B Date Personal information you pro 'de may used for \ d8rt? purpos es (Privacy law, s. 15.04 (1) (m)). a ed 3 — (*' Z DtTQ Property Owner e, v Property Location Miller, Sam ` 'r Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P.O. Box 151 i 4 . , 17 Plat Of Frontier City State 00 Code PboneReWber 0 City El Village ®Town Nearest Road Hudson WI 54616 _ "'586 -2769 Troy Tower Road ® New Construction ❑ Use: ' idential / Number of bedrooms 4 [:]Addition to existing building ❑ Replacement ❑ Pu6'tc- r commercial describe _�... _. Code Derived daily flow 600 gpd Recommended design loading rate 5 bed, gpd/ft •6 trench, gpd/ft Absorption area required 1200 bed, ftz 1000 trench, ft- Maximum design loading rate •5 bed, gpdr .6 trench, gpd/ft Recommended infiltration surface elevation(s) 4 96.0 ft (as referred to site plan benchmark) Additional design /site Considerations Install trenches usin h' infiltrators Maintain system location as far west as possible. Parent material Glacial outwash Flood plai n elevation, if applicable NA ft S--Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system ® S ❑ u ® S ❑ u ® S ❑ u ® S ❑ u EIS ®U ❑ S ® u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consisten Boundary Roots — GPD/ft2 oots GPD/ftz Boring# Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -10 10yr3 /3 None sl 2msbk mvfr cs 2f 0.5 i 0.6 .� 2 10 - 7.5yr4/4 None A 2msbk mvfr cw if 0.5 0.6 , 5 Ground 3 19 -30 7.5yr4/6 None Is Osg m1 cw - 0.7 0.8 � elev 103.17 ft 4 30 -81 10yr5/4 None s Osg dl gs - 0.7 0.8 Depth to 5 81 -123 10yr6 /4 None s Osg dl - - 0.7 0.8 , limiting factor 6 0 >123" l�,,oct' t 2t• oy Remarks: 2 1 0 -18 1Oyr2 /1 None sill 2fcr mvfr as 2fm,lc 0.5 0.6 .7 2 18 -40 10yr4 /2 None sil 1 in 1 mfr aw 2fm,lc NP 0.3 P' Ground 3 40 -54 10yr5 /4 None gr. sl 2msbk dsh gw if &m 0.5 0.6 5� elev 100.05 ft 4 54 -91 10yr5 /4 None gr. s Osg dl gs - 0.7 0.8 Depth to 5 91 -124 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >124" Remarks: CST Name (Please Print) Signature: Telephone No. James K Thompson ( 715- 248 -7767 Address AC.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 54020 12/31/1999 3602 1166 Pgopwry o"ER: Miller. Sam SOIL DESCRIPTION REPORT 118e Page 2 of 3 PARCEL LDS Prt of040- 1022 -10 AC.E. Soil & Site Evaluations Depth Dominant Color Mottles Structure GPD Horizon in. sistence Boundary Roots Bed ; Trench in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 1 0 -8 10yr3 /2 None sl 2fsbk mvfr as 2f &m 0.5 0.6 S� 3 2 8 -24 1Oyr4 /4 None is Osg ml aw if &m 0.7 0.8 Ground elev 3 24 -75 1Oyr5/4 None S Osg ml gs if &m 0.7 0 102.06 ft 4 75 -121 1 Oyr6 /4 None S Osg ml - - 0.7 0.8 - '} Depth to limiting factor >126• 77.�Z .ZL Remarks: 4 1 0 -10 10yr2 /1 None A 2fcr mvfr cs 2f &m 0.5 0.6 2 10 -19 10yr4/4 None sil 2msbk mfr gw 2fin,lc 0.5 j 0.6 Ground elev 3 19 -30 10yr5 /4 None sil 2msbk mfr aw 2fin,lc 0.5 0.6 96.75 ft 4 30 -59 10yr5/4 None ISM lmsbk mfr aw - 0.4 0.5 Depth to - 59 -109 10yr5/4 None s &gr Osg dl - 0.7 0.8 limiting factor >109' Rem! H #4 consists of an undiferentiated mixture of osg is & 1 msbk sl. Horizon loading rate adjusted to reflect most restrictive soil condition. 5 1 0 -15 10yr2 /1 None A Her mvfr as 2f &m 0.5 0.6 2 15 -27 10yr3/3 None A lthinpl mfr aw 2f &m NP 0.3 Ground elev 3 27 -49 7.5yr5/4 None gr.Is Osg dl gw if &m 0.7 0.8 98.50 ft 4 49 -87 10yr5 /4 None gr. s Osg dI gs - 0.7 0.8 Depth to 5 87 -116 1Oyr6/4 None s Osg dl - - 0.7 0.8 limiting factor >116' Remarks: Ground elev Depth to limiting factor Remarks: �`c�&✓� foam road �. 3 or,3 R.� /of 5 e A E /of Ste, lot /7 �dP pig 55 0/G l�ujOV6 l'S; 6e .5, T. ?B/1� Q /q�. `� C�. J3./►f.: 1(a I i r) T. off' Tiny, 5 wit' eo cJ /. Elrn �iee• 8� ■ 85 J t IL ■ 81 ■ y s y ea. -r, ■ Bz io n L9 ■ �� s /o� Iz t 5 � { " ^eg v 51oec es! Q � /799 fe �6 CQdR.r &CG. /QSS 4rriC el�it = /GYM. co. T.- /nr Lot Ae ,Lod 7 r � 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 36 Number of Bedrooms Design Flow - Peak (gpd) 6 et Estimated Flow - Average (gpd) qcin Septic Tank Capacity (gal) 2.I Soil Absorption Component Size (ft Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 1 2-60Q Maximum Influent Particle Size (in) 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 septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain 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 1/3 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 4 ` 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 /j'l I L,L D F 0 tz BioDiff Specuications s o 3 76 " ► , __ =3r C�G= �� C� �� °�G� ©© C�C—� Chamber OD pp Dp p© � C� Height ©� D p D ©O © p 0 Q p i C =3 O p pp p p po a © cp© cep D a p o oo Dp o c° p �o 00 ©i °po pp Chamber Height End View 34' 4" Knockout Universal End Cap i Available Sizes a, ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 44 ( L. 1- L Mailing Address O V rS Property Address 4 1 / - 7 N � LL) C °` �� L) ( y � �-E (Verification required from Planning Department for new construction) City /State U L)OS0 N / Parcel Identification Number 0 7 b 17- 4 3 ' 7 ' 00 0 LEGAL DESCRIPTION Property Location N UL) V.,; � ' /., Sec. , T �-� N -R W, own of k (D Subdivision � iZ y NT 1 2 . Lot # 7 Certified Survey Map # Volume Page # y Warranty Deed # l D. 4% Y , Volume y Z- , Page # Z Spec house yes ❑ no Lot lines identifiable 9 yes ❑ no SYSTEM NANCE 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, restricted plumber or a licensedpumper 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, 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 Q the three e e n date. TURE F APPLICANT DATE i OWNER CERTIFICATION I (we) certify that all statements on this force are true to the best of my (our) knowledge. I (we) am (are) the owners) of th perty escribed abo e, by virtue of a warranty deed recorded in Register of Deeds Office. ATURE O APPLI 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 Vni.1442PAGE 42 • STATE BAR OF WISCONSIN FORM 2. 1998 It304B841 WARRANTY D KATHLEEN H. WALSH REGISTER OF DEEDS This Deed, made between Kathryn B. Tuleren, and Ferris ST. CROI X CO., WI — _ R I)A gri-n wife a n d husband - RECEIVED FOR RECORD Grantor, conveys and warrants to 07 -14 -1999 11:00 gM Sam F Miller_ a s(nale nrrxnn. WARRaMtY DEED E)D:IpT N Grantee. CERT COPY FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee COPY 2229,10 the following described real estate in St. Croix County, State of PAWS: DING FEE: 12.00 Wisconsin (The "Property "): Recording Area Name and Return Address I i 040 - 1022.10: 040.1022-30: 040 - 1021 -90: 040-1029- 70:040- 1028 -70 Parcel Identification Number (PIN) This is not homestead property. (See Attached Exhibit "A ") ti Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any Dated this 13th day of July, 1999. " Kathryn B. ulgren Ferris R. Tulgren AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. authenticated this _ day of St. Croix County ) Personally came before me this 13 day of July, 1999, the above named Kathryn B, Tularett. and Ferris R. Tagren, ffe mid so TITLE: MEMBER STATE BAR OF WISCONSIN (If not, me nown o the per s) who executed the foregoing authorized by § 706.06, Wis. Stars.) instru and ackno ge rite same. THIS INSTRUMENT WAS DRAFCED BY fit/ yv ` Attorney Kristin Ogland Hudson, WI 54016 N blic, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commissio iSC anent. If not, state expiration date: 1ec Breaida Poulin it f' d 0 Notary Public State of Wisconsin *Names of persons signing in any capacity should be typed or printed below their signatures WARRAMT DORD STATE BAR OF WISCOMM FORM Na 2 - IM MFORMIA7 M PROFESINOtMO COWANY FOND DV LAC. wt 800-0S MI t _ 1442 43 1 VPL PAGE EXHIBIT "A" That certain parcel of land located in the NE 'A of SE' /. of Section 6 and in the NW' /. of SW' /, and the NE' /. of SW 1 /4 of Section 5, ALL in Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin more fully described as follows: Beginning at the West quarter comer of seld Section 5; thence N87 0 51'08 "E (recorded bearing on the East -West quarter line of said Section 5) a distance of 2342.24 feet; thence S00 °13'24 "E, 854.00 feet; thence N87 0 51'08 "E, 288.00 feet to a point on the East line of said NE % of SW '/.; thence along said East line, S00 °1 3'24 "E, 466.08 feet to the SE corner of said NE % of SW' /.; thence along the South line of said NE % of SW' /, and the South line of said NW % of SW %, S87 0 54'54 "W, 2372.41 feet; thence N00 0 30'28 °E, 170.48 feet; thence 687 0 54'54 "W, 273.91 feet to the monumented West line of said NW' /, of SW %; thence along said West line, N00 11 30'28 "E (recorded as N01 032'36 "E), 941.26 feet; thence N64 0 57'47 "W (recorded as N63 0 54'50 "W), 458.40 feet to the North line of said NE 1 A of SE' /. of Section 6; thence along said North line, N88 °20'13 "E (recorded as S88 WE and N89 0 24'42 "E), 416.69 feet (recorded as 25 ' 1 /. rods) to the Point of Beginning. f � � - .h.. ` ✓� � I 1 0 IY+ lh .Y .41.0 w rr13t �` lE .06KY 7. /L[I.7 Ih ~ re N r 1 w ZI N 1 1 I p we �r ft I 4: O Ch g Oyu, ,� I •f 1 M � ' .' 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