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HomeMy WebLinkAbout040-1298-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisioh ft INSPECTION REPORT Sanitary Permit No: 430563 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: McAllister, Michael I Troy Township 040 - 1298 -50 -000 CST BM Elev ,c1 Insp. BM Elev: BM D ' t' on: Section/Town /Range /Map No: 14p V,o � � � � o I re r"' 09.28.19.1723 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic u I , , 1 / v Benchma -,, Dosing dL Alt. BM Aeration ,' / Bldg. Sewer O 9 Z Holding Ht inlet r St/Ht Outlet TANK SETBACK INFORMATION J /l] �D(. 7 .� p TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic P Dt Bottom �-- -- Dosing u H er Man. Aeration Dist. Pipe / rJ ls'1 Holding Bot. System V v p 7 f Final Grade PUMP /SIPHON INFORMATION J D/. Manufacturer a Mand St Cover r Model Numbe TDH Lift Frictio System Head Ft Forcemain Len Dia. Dist. to Well SOIL ABSORPTION SYSTEM # BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L I BLDG W L uf LAKE /STREAM LEACHING Man r INFORMATION CHAMBER OR ���r Type System: \1 �! \ � _, ✓ UNIT / v C. Model Number: T IBUTION SYSTEM rzf OZ4c�e4. Header/ Distribution Hole Size x Hole Spacing Vent to Air Intake h p ipe(s) / 0 / / o _ 1 h Dia Length 1 1-ength _y I Dia x Spacin "� � � to SOIL CO R x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched Bed/Trench C ter" Bed/Trench Edges Topsoil 11J Yes [] No ,; Yes J No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Ab,/ 3 Inspection #2: Location: 414 Glen Court Hudson, WI 54 (SW 1/4 SE I/ P9 T28N R19W) Glover Glen Lot 5 Parcel No: 09.28.19.1723 1.) Alt BM Description = Lj�GO V -6 _ _ feT (- 4'y,V..Lj Ci_� 2.) Bldg sewer length = 1 U� ►$- o'..d_�a)1 -ors - amount of cover If r Plan revision Required ?j Yes o S— Use other side for additional information. &gnature _� SBD - 6710 (R.3/97) Date Insepcto Cert. No. Safety a d BuiE=E1VZD County 201 W. Washi gton Ave., P.O. Box 7162 jT isconsin Madiso , WI 1 7162 200 Sanitary Permit Number (to a filled in by Co.) Department of Commerce ( 8) 2 1 � 30's Sanitary Permit Applic d CROIX COUNTY" State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal info ONINC� OFFICE may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information 19 1 ELI CT Property Owner's Na me Parcel # C5 , k rt,lZ -r II, 7 Y 50-e- ) Property Owner's M ailing Address Property Location 1 I Zo Ch a - , ) To kJ 5 S 4) %, 5)E tk,Section Q City,' 5� State q L Zip Code Phone Number �3 W. PA.,. YU 65/1 f - 4 ,5_1 Z! 0 2, T �� N; R (circle e) II. Type of Building (check all that apply) � P,e� �i ��.c �1 or 2 Family Dwelling - Number of Bedrooms fvir.a aQ _ �_ E or(w Subdivision Name CSM Number ❑ Public /Commercial - Describe Use 0 Ut & g h ❑ State Owned - Describe Use ❑City_ ❑Village ATownship of O II1. Type of Permit: (Che only one box on line A. Complete lin B if applicable) j 0 4 o — Z98'- 3Z- ovo • 1 . 7 23 A * i$ New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner ® 4 IV. Type of POWTS System: (Check all that apply) Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade El Sin Fite El Constructed Wetland El Pressurized In- Ground El Holding Tank ❑ Peat Filter El Aerobic Treatment Unit Recirculating Sand titer B ar El Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel -less Pipe ❑Other ( plain) a V. Dispersal/Treatment Area Information: --- Design Flow (gpd) Design Soil Application Rate( sf) Dispersal Area Required (sf) Dispersal Area Pro sed (sf) Ays Elev on r AP3 , IVY¢ 45a 97 rte VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel fiber Plastic Gallons Gallons of Units Concrete Construe Glass New Existing Tanks Tanks Septic — 4lol trtg -+_ o© ) 0 00 D y l v Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature MP /MPRS Number Business Phone Number Ca�1 �: fjelse a 0554 l - S — al9 1 Plumber's Addre ss (Street, City, State, Zip Code) ,} / 04 '1 S l �t Wig S 7 !" `t C.- . 5 o Z �- VIII. Count !De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issu" Agent Signature (No Stamps) ` ❑ Surcharge Fee) 20 Owner Given Reason for Denial IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: 1 1 Septic tank, effluent filter and�,�. � ( `` dispersal cell must all b serviced 1 maintained tt , a- as per management plan provided by plumber. sops 2. All setback requirements must be maintained ( O as per applicable codelordinances. — t +�t� a �, W t G� „/) .� � 11 Nacre_ 3G � Attach complete plans (to the County only) for the system�n pa not less thay181f2 x inches vq size / + j SBD -6398 (R. 01 /03) k u &"\ a -947� / Y1n, i < e VY�� X111; yTe, �L a PL I� YU �cS ►� n c,) La`s 5 Sc,a t ��= 3 d� (Wj P .� a aa55q o w F Ll- , h r T To o Q Be, - 1 OOV Sad P 1 is o i o F. ► Tay 3 O o cop o - r W o _ �f I T,47, be v.; Ci n► �I To 3', P�� PAP' 10, 3 1 ► 1 o� 0 W CL L h 3 Olt 8" T p � p�p- ,o o ' To p� 0 �o W1ES Q �aov c S a t oo Ter 3 I d1 S ct.Lt4✓l °� o j r 5 7e. a c,c.�1s 1 ,• f,7 Tv,,T, n, 6,e Go 7rOr+ C L 1 �u � c �� .�l C e •, 1 P 00 YU Ga� ag 7 'Elf 31 'Nlsconsin Department of Commerce SOIL EVALUATION REPORT Page of -3 livision of Safely and Buildings In accordance with Comm 85, Wis, Adm. Code /Mach complete site plan on paper not less than 8 1/2 x t t Inches in size. Plan must County include, but not Ilmtled to: vertical and horizontal reference point (BM), direction and parcel I.D. o, , /Q (o percent slope, scale or dimensions, north arrow, and location and distance to nearest road. �� v v Please pri►rl all Information, ev wed by Date Personal Information you provide may he used lot secondary purposes (Privacy Law, s. 15.04 (1) (m)), . 'W 2CV4 Property Owner .�/ Property Location s p - XP Y ����• "1 S Govt. Lot .sue 1/4 s v 114 S I T N R , / Q ft (or) W Property Owner's Mailing ddress Lot # Block 11 Subd. Name oi- 6SAAq_ 3 q, 9 9 N- /o� �' �� • S Cr G/o DER /�.v A&cs Il C Y Slate Zip Code Phone Number /� ❑ City ❑Village ®Town Nearest Road lU/ y r� ( his , y�(� • � Y3 �,e � s �• �/• G /ov�� � New Construction Use: KI Residential / Number of bedrooms 3 " Code derived design flow rate Y 322 GPO ❑ Replacement ❑ Public or commercial - Describe: Parent material _ 6-55 D� �/¢,(7(,y daf�f>�fl Flood Plain elevation if applicable n, General comments and recommendations: S,ee MAY 15 2002 ST. CROIX COUNTY ZONING OFFICE 1 Boring # Boring Pit Ground surface elev. �/ • d7 II. Depth to limiting factor � in. Soli Application Rate Horizon Depth Dominant Color Redox Descripllon Texture Structure Consistence Boundary Roots GPD /fP . In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. WWI 'Eff#2 o• 1,0 2-1 37Z 2- 7 Au 411�? w 3 / S/ Z f s /),e 2,,, f e w 3 ii - 3o ?•s le v6 sc Lfsh �^f2 Qs . s o• o; . c ' { Boring # U Boring III - -- III /O /• pit Ground surface elev. fl. Depth to limiting factor in. Soil Application Rate 4,97 S — ��� �S o 1 /0 D • /0 J� rrroperty Owner ' • Parcel ID 0 � • Page 2 of 3 Boring N ❑ Boring �� Ul V Pit Ground surface elev. �'' 11. Depth to limiting factor 4° in. Shc Application Rale Iforfzon Depth bominanl Color Redox Description Texture Structure Consistence Boundary Roots GPD/flt in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff0i `E"2 l o /ayl? 2 -13 SL L t. v�� fsh/< �4s 4� if s • 9 2- L3 s S D, S noting 4 ❑ Boring ❑ Pit Ground surface elev. _ It. Depth to limiting factor In. SoN Application Rate 1 Depth bominanl Color Redox Description Texture Structure Consistence Boundary Roots GPD /4: In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •EO#i 'Ef #2 r f noting # ❑ Boring U ❑ Pit Ground surface elev. N. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox bescrlption Texture - Structure Consistence Boundary Roots GP III In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EH #1 'Eff#2 ` Effluent #1 =1300 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent !12 = BOD < 30 mg/L and TSS < 30 mgll. The Department of Commerce is an equal opportunity service provider qnd employer. If you need assistance to access services of need.material in an altemale format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. G o ,� l 7 V_ AA S = 1311 « 1-2,'T5 fq,6 f3M- 5 E7- ID INV 103, op ► y$ , �o . "3 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner I c&7 MC A- 1 Septic Tank Capacity 10 g al ❑ NA Permit # - Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer f✓l_ 13 NA Number of Bedrooms ❑ NA Effluent Filter Model — (a p ❑ NA Number of Public Facility Units A Pump Tank Capacity g al NA Estimated flow (average) UU al /da Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) 4so al /da Pump Manufacturer A Soil Application Rate Q - q- gal/day/ft' Pump Model �ENA Standard Influent/Effluent Quality Monthly average" Pretreatment Unit �"A Fats, Oil & Grease (FOG) s30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD s220 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 <_30 mg /L - Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ 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 ❑ month(s) Maximum 3 ears) ❑ NA Inspect condition of tanks) At least once every: 3 earls) ( Maximum 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 years) Clean effluent filter At least once every: ❑ month(s) [I NA �' P year(s) Inspect pump, pump controls &alarm At least once every: ❑ monthls) �01A 0 year(s) Flush laterals and pressure test At least once eve ❑ month(s) A P every: ❑ year(s) Other: ❑ month(s) A At least once every: ❑ year(s) Other. �LNA 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 2 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 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 a discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the back 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 v 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 fj o / �' - it flu leplavenient atea a o ing ank atuai . ?RUl-118 rR� OR- lJ6b✓ a&1S n1V be � e ai e ❑ 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 E me A L� S L Name ne - Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S T'. C ( bU 20d1�1 Phone Phone 7 (5`— 3 ( _ (p This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &If) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address / �Oy r OwA) S 1 rRt) erification required from Planning Department for new construction) \ City/State w 1.5 Lo A-) b j rl Parcel Identification Number oq LE GAL DESCRIPTION Property Location 5 1 , J '/4, _V,, Sec. , T N -R a—W, Town of Subdivision Lot # Certified Survey Map # �- . Volume . Page # Warranty Deed # 7 6 g . Volume �y Page # S Spec house ❑ yes ❑ no Lot lines identifiable ❑ 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 licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating 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 7Z7 1ru I MMATUPJE J & APPLICANT DATE OWNER CERTIFICATION meats on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of I (we) certify that all statements the grope des 'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. / / U IGNATURE & 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 U 2 4 5 3 P 5 5 1 - 74aa9s KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 11/10/2003 02:00PK THIS DEED, made between Terry E. Pirius, a married person, WARRANTY DEED Grantor, and M ichael J. McAllister and Janeen E. McAlliste husband and EXEMPT # wife, d/b /a McAllister Construction, Grantee. REC FEE: 11.00 Grantor, for a valuable consideration, conveys and warrants to Grantee TRANS FEE: 270.00 the following described real estate in St. Croix County, State of Wisconsin: COPY FEE: CC FEE: Lot Plat of Glover Glen, Town of Troy, St. Croix County, Wisconsin. PAGES: 1 Recording Area Name and Return Address: Edina Realty Title, Inc. 400 S. 2" St. —Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights -of -way of record, if any. 409783 040- 1298 -50 -000 Parcel Identification Number (PIN) This is not homestead property. Dated this 5th day of November, 2003. Berry s * Terry E. Pirius * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) 1 ST. CROIX COUNTY. ) ss. authenticated this 5th day f Nov Personally came before me this November 5, 2003 the * above named Terry E. Pirius, a married person to me known to be the person(s) who executed the foregoing instrument and TITLE: MEMBER STATE BAR OF WISCONSIN acknowledged the same. (If not, - authorized by § 706.06, Wis. Stats.) EIL THIS INSTRUMENT WAS DRAFTED BY *Cheri Brown Edina Realty — Doug Berg Doug Berg Notary Public, State of Wisconsin 400 South Second Street #115, Hudson, WI 54016 My commission is permanent. (If not, state expiration date: 3/11/2007 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000 /Soo r # , 2A M r i A •' ............................ . 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