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HomeMy WebLinkAbout040-1288-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420696 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)]. Permd Holder's Name: City Village x Township Parcel Tax No: Bartizal, Joel & Annette Troy Township 040- 1288 -40 -000 CST„BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: OD, 0 , p' �dE' 4i = ti•en� � =�uw ( 31.28.19.1639 TANK INFORMATION ELEVATION DAT TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z�aO Benchmar l.J Dosing Alt. BM Aeration Bldg. Sewer 2 fl i Holding St/Ht Inlet O. TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 5� 1 55 Dt Bottom Dosing Header /Man. IO.z �oy.l� Aeration Dist. Pipe Ip,L2, 104- ljxo) 11• o .I 1 Holding Bot. System li. 2 S Jos, I S 11 .3 0 o • o' Final Grade � PUMP IPHON INFORMATION 4'30 Manufacturer Demand St Cover a l �. f 2 •9 GPM G `7*vt o Model Number TDH Lift 1fric Loss System Head T Ft Forcemain Length Dia. Dist. to well SOIL ORPTION SYSTEM RENCH Width Length No. Of Tre Chas PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/ BLDG IWELL I LAKE /STREAM LEACHING Manuf INFORMATION ti CHAMBER OR �. Type Of S stem: ( J• 3 UNIT Model Number: Z �r DISTRIBUTION SYSTEM 4•4- ^n pL a .,E�- Header /Manifold u Distribution J x Hole Size x Hole Spaci g Vent to Air Intake 1 Pipe(s) 1 Length Dia 1 Length Dia Spacing 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 discrepencies persons present, etc.) Inspection #1 ,Ao3 Inspection #2: / f Location: 374 Indigo Trl Hudson, WI 54016 (NW 1/4 NE 1/4 31 T28N R19W) East Meadows Lot 4 Parcel No: 31.28.19.1639 1.) Alt BM Description = uS'a- 5' X. v " • �`� �"' 2.) Bldg sewer length = ( 2 -/ - amount of cover = > liz Plan revision Required? Yes No �— i q _ ,e other side for additional information. 6710 (R.3/97) Date Insepctor's Signature Cart. No Safety and Buildings Division County � ,rte _ � 201 W. Washington Ave., P.O. Box 7162 �o ,SCOnSIn Madison, WI 53707 - 7162 Site Address Department of Commerce 3 7 / i, Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide l zo 6% ❑ may be used for second purposes Privacy Law, s15.04(1)(m) Check if Revision I. Application Information - Please Print All Information State Plan I.D. Number Property Owner's Name Parcel Number Property Owner's Mailing Address . Property Location 0 7 6 DV1/ AI UJ A .1v6-' ,A; s 3 T 2 S & R /q City, State Zip Code Phone Number Lot Number if Block Number Subdivision Name CSM Number 11 j o Al W1 � Ut 6A5t H. Type of Building (check all that apply) ❑City It 1 or 2 Family Dwelling - Number of Bedrooms 1 4 2003 ❑Village ❑ Public /Commercial - Describe Use ®Township 41z 0 El State Owned ST. C RUI^ N1Sy OFFICE Nearest Road (�-- III. Type of Permit: (Check only one box online A (nfimbering scheme for internal use). Complete line B if applicable) A. 1 *New 2 ❑ Replacement System 3 ❑ Replacement of 6 El Addition to For County use System Tank Onl Existin S stem 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) ' 'A ,1 44'� Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed We nd �C" � 22 El Pressurized In- Ground 41 El Holding Tank 48 El Single Pass 51 ❑ Drip Line 45 El At-Grade 46 El Aerobic Treatment Unit 49 El Recirculating 30 11 Other Q � V. Dispersal/Treatment Area Information 2 k _Sv Design Flow (gpd) V Area ispersal Area Soil Application Percolation Rate System Fqevation Final Grade Required Pro po 5E ` d Rate(Gals. /Days /Sq.Ft.) (Min. /Inch) Elevation 16V VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank /� ,� 6 � Dosin Chamber vV )4'I00 V II. Resp onsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signature MP /MPR9-Number Business Phone Number Ro eK, ,IJ 7 Z ; 4� Plumber's Address (Street, City, State, Zip C �SW - t w( .6; VIII. County /De artment Use Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse Determination3 IX. Conditions of App A ro�UR� o Disap�pra ^ _ (} E G ft/r Uw+K- r.+ A ctd� '.sec r 4 4;pecl S. ;PeM Attach compl a tans (to the ou y only) For thg sys m on pa r not less than 8112 x 11 inches In size SBD -6398 (R. 05101 J41 s� +� r \ C 6z LL L lZ� JA- f�GL 7 a v J- f d 7 6 z L �-- N'� mnsin Department of Commerce 5UIL LVALUA I IUN KLFUK I Page of vision of Safety and Buildings in priywelmm with C' &R, Vft. Aft_ rxeip - - - 1 County St Croix Attach complete site plan on paper not less; than 8 1/2 x 11 inches in size. Plan must M i Ass N* runt Kyritad fn- va r-a h re nri IRLAII A n arm clu— Mecfie.. -- I Paco, -L,- percent slope, scale or dimensions, north arrow. and location and distance to nearest road. py"Se R by Date Pefumal information you pfovide may uiwd for secondary puipows (PdVd;.-.y Law, s- 15-04 (1 .) (In' )). 1"A Property Owl I r I LqM q We-aborl, F] I 1VA us Govt. Lot YJ W 1/4 hi-1/4 S5 I T N R i 1 fl I Property Owners Mailing Address k * I Subd. Name -m CSM# 14 Dry Run Road • City State Zip Code Phone Number i LJCity FJNANage LfjTown Nearest Road ruver raus I W1 I -I4U22 I i Troy I Ik JW New Construction UseEj Residential ed design flow rate S O GPD T 10 Replacement Lj Pubic or commercial - Yesoi 4: Parent material 12 C2 Lut 6t in e - ' l ' s" i f applicable 1 7 General comments and recommendations COW T GPQX Boring # U Boring Pit Ground stmt3ce eiev. -/-// — in. 1 sal Annksdinn Rafe Horizon Depth I Dominant Color l Redox l3escnptim Texiti 1 Consistence. Boundary Roots CPniw in. I Munseli Ou. Sz- Cont. Color Gr. Sz. Sh. .81111f1l *EfM2 Ld LO - 3 W39 I z//(, 0,, r j .1 10 7, G /O 3 I C) L Boring # rl I_J 2 Pit Gi v-td:&W'I6C* e;eV-AQ"-5: - IL rpupae W lo I'auhn" [RI Application Pate Horizon I Depth Dominant C Redox Description Texture 1 Structure C imsistence Boundary Roots I . 'f# in. Munsell Ou. Sz- Cont. Q Gr. Sz. Sh. I I — EfWI Ef 2 0-10 joye- 5 m c 1 2 10 - V 4A I Uns6l( I r I rj 1 1 , 5 1 1 t 8 10 7, S 0' 09 1 ()C�C� M Effluent #1 = BOD > 305 VO mg& and MS >'-V < 150 r%& = -tiftnt #2 = M:5 30 mg& and TW:5 30 mg& M Name P" --- CST Nurnber C �511 2.273 7 Address Date Evaluation Conducted Telephone Number ���� 1 2��� S� �� �2i ,��,�ti 0_ ?15.2q - 0 ) ?15.2q 0 , Prope . Owner Pace! m # P ry* r ---- I I ( Boring # V owiIiy r zt Pit Grou sv, ela:. boS 35 f" Depth to i, ng facto 1 a S ,n. Horizon Depth I Dominant Color Redox Description Texture ! Stnrcture Consistence ! Boundary Rods SW GPDA R_ ! in. Munse!! Qu. Sz. Cont. Color Gr. Sz 1 `EfWI I `Eff#2 joyr 2. r© - 3 iW 4 r . so m I( m r 1 r s, ,1 r6 S ! bs i I I r� n RM a ! Boring # U - -- -� - -1- AC - L — Pit �a�w�ni3iiiiauesemsv. i� iresNui w mw�� iauW its. Sdi �� Redox Description { Horizon Depth Do Mu sell Q r Texture Strexture Consistence BouMa ! Rook `E ( II 1 I 4i I I ! I i Boring Ground surface elev. ft. Depth to limiting factor in. Sal Apomtion Rate ! Horizon ! Depth I Dominant Color Redox Description Texture I Structure Consistence Rods GPD/ff ` in- MunseN Qw Sz. Cont- Color Gr- Sz- Sh- - Effile1 'E02 I ! ! I 1 I ! r I ' .W ;M a BOD � 30 c M .�iy'L a!A TS-S ='tr! c !SO tttn.R * Elkz A 42 _ WOV c M Mrt!! and TCR c 'N! -R need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. a ssr'- s�ar�rx- m.^eae L of y 100 ,o ed2n �► 13� L o Q rk C- r-) 0 o �, Pe �fn 'L , op Ic P o IVV,1-7 QZ lot • LS Z Z- - Tj 7 0 c cz co U j - c t ', LLL �' € coo N a r , L .L � � t LL x ^ C5 r (� c CLI D Q c Z c 0 d E N D z o t y G W f 8 j a o 0 N I( J p.+ c Private Onsite Wastewater Treatment System Management Plan I Y 9 Septic Tank And Gravity In- Ground Soil Absorption Component p Y p p 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 q(, Number of Bedrooms Design Flow - Peak (gpd) 11 lofo Estimated Flow - Average (gpd) Wo Septic Tank Capacity (gal) 2so p p Soil Absor tion Com onent Size ft 2 Type of Wastewater Oomestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 290 i"x Maximum Influent Particle Size (in) 5. 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once eve 3 p ev ears Y Outlet Filter Inspect once a y ear and clean at least once eve 3 P Y every ears Y 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 tic or Holding Pumping Tanks, Pum in Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se tic tarlh and outlet filter shall be assessed at least once every 3 years by inspection. Th outlet filter hall be cleaned as necessary to ensure proper operatio 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 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. I P � f j .— Go /s C 2 C k C- 715 6`x Co 108 4 �� S-f c c� 2,��✓ r n> �� z 73 6 7 4�(7 3 02/07/03 FRI 09:49 FAX 715 386 4686 ST CRX CO ZONING Qb001 ST Mom COMM SSMC TANK MAIInMKANC13 AGIR WMT AND OWN PJM P CERTIFICATION FORM OwtrslBus►ar /,v - A �14,� pwparty Ads (VMfi mpmd 6 AN aaw roc oa Ck k I tl Co F ACS U✓ Paecel Identification N Z- C' 7 LEGAi. OESCPJY-MON_ property Eocene j �! ya 1/LC y4. Sm L_. T j , 5 N -R_L7—W, Town of Subdi,ision s C ' �� °� Lot # Cwdfied Survey Map Vol.. =,_. .pop # w mtmty Deal # _ 6 7 & Volume Page # 26 Spec house O yes Ed no Lot Um i&mdfable yes 0 no SYSTEM rfAII�11�iANt� asasadm .�mE�a4eof]ra�rsa�r�m�d�tiu �e&s�ro h�dlawasees. Piopere aoosips of pmmplag oat dss septic tack evexY tb�ee ]►� � aoaoe� �' aeededby a lieeoa�d pampas wit � Pd Ito fire � ast ailed a fmW= of ire septic lsnk as a tnodsamt ataeo in the wee disposd syatam. The p qmw owocr agrees to mbmit t St. C aft Zauwg D s oat WWKfor sip ped by die owm sad by a � is prope�c Opeeatiag aonditim (Z ) wor =d ared pmq bog (if aeoenwA ibe `l sepdo Oak isis lm n of do4p• Vw. the =AoWg od have and *a abtwa reqph�ts ad ag m to mda%k dd pdirale eon P + whh 1be sdadads sd ford~ boaft ar set by no Deput mw of Cammapae and do Dqm m W of Nat tral Resoarak BUM of vwooadis. that MRAk symm has bom ma mad be eompidod smd mtomed to the SL C olz Ck mtY Zoait� OtAae 30 off do" of el W AM MANT f DATE OWNER CERTIFICATION I (wee) ct)► that aU uaseaxmb oa this Aram are CM to the bast of my (our) lm�owledge. I ( am (arc) ac oaraac(s) of die dawxibad r vietsa of a vmzm ty deed recorded is Register of Deeds OMM 7 RB O DATE Any b0conatim that is mis -rap edmay ras* in ti►a ambW PaniA bda8 wwW by do moat' • « «••« «' bdWe with ob spoodm a ibasped wmmxoy deed $am the Register Of Deeds Off m a OW Of ire cartm d wK ay msp if tIfew P 0- t#0 is aaad0 bt the waataty deed i U 1855P 268 6 7 3 7 6 5 STATE BAR OF WISCONSIN FOttM 2. 1999 RE T REGISTER OF DEEDS riG�rmntze. mber WARRANTY DEED ST. CROIR Co., MI RECEIVED FOR RECORD made between Mean Valley Contracting, Inc 03 - 18 - 2002 10:15 AM WARWPP DEED E%DPPT t nnette A. Hagen - Bartizal a marr a pereo REC FEE: 11.00 TRANS FEE: 239.70 COPY FEE: CERT COPY FEE; PAGES: 1 Grantor, for a valuable consideration, conveys to Orange, the foDowiog described real estate in SL Croix Courtly, State of Wisconsin (if more space Is needed, please attach addendum): Raomd4 Ana Lot 4 East Meadow, SL Croix County, Wisconsin. Name snQ i chim Address Edina Realty Title 400 S. 2nd St., #115 Hudson, WI 54016 #3 as 040-12 .40.0m Parcel Identification Number (PIN) This boot }aatateadpr�nY� Exceptions to Wuranties: Easement, restrictions and r hts -of- (is Jot) IB vray of rw4rd, if any. Dated this 3 Y — ' day of March 2002 `t Ma Va ontraetine, Inc f • AUTHENTICATION ACKNOWLEDGMENT Signaturc(s) STATE OF WISCONSIN ) _ Q � 1 County x ) authenticated this day of Personally pane before me this 1 3!!n:- day of rian Scott Eckholm March 2002 the ab named 0 a O IC Mann Val Coa traetfa , Inc. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the persoa(s) who executed the foregoing authorized by § 706.06, Wis. Slats,) SinXnad �� INSTRUMENT WAS DRAFTED BY t Attora!!z Kristine Opc fland Hudson, W1 54016 Notary Public, State of Wisconsin My Commisslon is emanent. Of not, state expiration date: (Sil;naNrw may be authenticated or acknowledged, B are nog necetsuy.) 1 - �/ GO .) • Names of penotu signing in Jay ppactty must be typed Or printed below their signmee. aremn� •n �w..:•rv4 COMPM,r,. 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