HomeMy WebLinkAbout042-1003-60-000 r
Irti�Department of Commerce PRIVATE SEWAGE SYSTEM county'
Sa; and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarv. Permit No.:
Personal Information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 370354
Permit Holder's Name: ❑ City ❑ Village jj TVwrxof State Plan ID No.:
Mickelson, John Warren Townshi
CST BM Elev.: Insp. BM Elev.: BM Description: [ Parce,Tax Nn
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic , cop Benchmark pwe (M .6
Dosing Alt. BM .` `e• 19 r
Aeration Bldg. Sewer , a� q5 `
Holding St/ Ht Inlet . 3`f 4 s• `{5
TANK SETBACK INFORMATION St /Ht Outlet �o.laO C15% Z3'
TANKTO P/L WELL BLDG. Venttake ROAD Dt Inlet
Septic S ` / �--- NA Dt Bottom —
Dosing NA Header / Man.
Aeration NA Dist. Pipe pk Ifl zo ql.� 3
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manubaurer emand St cover al
Model Number GPM
TDH Lift F* ' n stem TDH Ft
COSS —] .
Forc9mla<Length Dia. Dist. To
SOIL A PTION SYSTE ja �s
ENCH Width I Length No f renches PIT No. Of Pits Inside Dia. Liquid Depth
IMEN 8� a- DIMENSION
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM Z i _
INFORMATION Type O SO r OR UNIT CHAMBE o e Numb
System:
DISTRIBUTION SYSTEM 14 4-° 2.1
Header /Mpni of u Distribut ion Pipe ( s) x Hole Size x HoleSpacing Vey•To�Ai;lntake
Length iya, Dia. Len i . 5
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 t /30/0D Inspection #2:
Location: 1110 140th Street, New Richmond, WI 54017 (SE 1/4 SE 1/ 2 T29N R18W) - 02291832A
1.) Alt BM Description=
2.) Bldg sewer length= 2G-o'
- amount of ove� ` 1a+`'�e�� � �CAL*-'. CAL*-'. 3 3) �
r P Lt
Plan revision required? ❑Yes 1 4 No Z (v
Use other side for additional information. 67- Is •�(s �w�,
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
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►lla '' / S Sanitary Permit Application Safety &Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
lV i sconsin Personal information you provide may be used for second purposes Madison, WI 53707 -7302
[Privacy Law, s. 15.04(1)(m)]
Department of Commerce ar'Y P rP (Submit completed form to county if not
state owned.)
Attach complete plan (to the county copy only) for the system, on paper not less than 8 -1/2 x I 1 inches in size.
County State Sanitary Pe it Number ❑ Check if revision to previous application State Plan I. D. Number
`3F. C22 /)C 3 � 3
I. Application Information - Please Print all Information Location:
772er Name Property Location
1/4s 1/4, T (or
Property nee ailing Address r Lot Number Block Number
City ,/State Zip Code tone Number Subdivision Name or CSM Number
II. Type of Building: (check one) '�`� /L / ❑ City
JR I or 2 Family Dwelling -No. of Bedrooms: S�'�'+�'��"'" ❑Village
❑ Public /Commercial (describe use):_ J& Town of
❑ State -Owned -
Nearest Road
3 Parcel as N tuber s)
III. Type of Permit: (Check only on box on line A . Check box on line B if applicable) 2,. r
A) 1. JFJ New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
1Z Non - pressurized In ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade 1 Aerobic Tr atin t U it 11 Recirculating ❑ Other:
Z 3 x 118�s" __�
V. Dispersal/Treatment Area Information:
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 /sp- ) (Min. /inc Elevation
z
VII. Tank Capacity in Total # of %nufactuier Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
29 ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for install ion of the POWTS shown on the attached plans.
Plumber' ame (print) Plumb 's Si a (no.. s) : MP/MPRS No. Business Phone Number
IF L _J/
lumbe s Address (Street, City, State, Zip ode)
7' , G
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
ISApproved ❑ Owner Given Initial Adverse Sur&harge Fee)
Determination
X. Conditions of Approval /Reasons for Disapproval: -
SBD -6398 (R. 07/00)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of —3
Division of Safety and Buildings
in accordance with Comm 85, 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 not limited to: vertical and horizontal ref Ir J(BML, direction and Parcel I.D.
percent slo p, scale or dimensions, north arrow a Idn rld dls�atl to nearest road.
" i d s
Please print a ,,( 1fpFinat *n. Reviewed by Date
Personal information you provide may be used �sbgt ndarxp ivacy l-aw,� I! Q4 (1) (m)). lo.-23
Property wrier 1 �Op Location
f A 11. of 1/4s 1/4 S T_ N R E (o&
ry
Property Owner's Mailing Address Block Subd. Name or CSM#
}
city � Ste Zip Code Ph(xte Nunj City ❑ �Ilage Town Nearest Road % ` 5
1A JAI��l
[� New Construction Use: ® Residential / Number of beesoms `� Code derived design flow rate _ ��� GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material A ? i �� Flood Plain elevation if applicable ft•
General comments
and recommendations:
Boring # F] Boring
F — /1 R] Pit Ground surface elev. -i /e ft. Depth to limiting factor 7 //� in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
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Boring # ❑ Boring
Pit Ground surface elev. 51� ft. Depth to limiting factor �,��_ in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Al
i
* E uent #1 = BOD > 30 220 mg/L and TSS >30:5 150 mg/L * nt #2F BOD < 30 mg/L and TSS < 30 mg/L
CST Name lease rint) A _ na CST n'�
Adcfreii Date Evaluation Conducted Telephone Number
't°�
I
Property Owner Parcel ID # Page of
❑ Boring # ❑Boring ��
Pit Ground surface elev. _(� ft. Depth to limiting factor 7 /.� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
�. d -
,6•'f Z -Y
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in. all Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
❑ Boring # Boring
❑ Ground surface elev. ff. Depth to limiting factor in.
Pit
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.6/00)
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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
Number of Bedrooms
Design Flow - Peak (gpd) S�
Estimated Flow - Average (gpd) 3
Septic Tank Capacity (gal) aw
Soil Absorption Component Size (ft) q 3 7 "
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absor
Sep tion Component p P
Design Flow - Peak (gpd) (0 S - '_-
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 y ears
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 Servicin Septic or Holding Tanks, Pumping Chambers, Grease
Code ( Servicing
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
cartridge should not be removed unless
proper operation. The filter ca dge provisions are made to P
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
1
Management Plan for a Septic Tank and Soil Absorption Component r
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
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w 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.
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ST CROIX COUNTY
.S[ I' i'1( T,�NK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
2
Property Address
(Verification required from Planning Department for new construction) N 7 Itrf'
K
City /State G 1',1rccI IdcntI icatIon Number 0 eQ. z /P��c
LE GAI, DESCRIPTION
Property Location Sec.T -R_W, Town of
Subdivision
_ -- Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # `4k `(O 9 Volume 89 3 , Page # I36
Spec house O yes no Lot lines identifiable yes C7 no
SYSTEM MAINTENANCE,
Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper matnte.n.an_
consists of pumping out the septic lank c%'cry three years or sooner, if needed by a licensed pumper. What you put into the s src.
ran affect the function of the septic tank as n treatment stage in the waste disposal system.
The property owner agrees to submit In St. Croix Zoning Department a certification form, signed by the owner and b a
masterpiumher, journeyman plumber, restrtctcd pluniher or a licensed pumper verifying that (1) the on-site wastewater disposaI system
is in proper operating condition anti (2) ally inspection and pumping (if necessary), the septic tank is less than 1/3 full of slue' !�
I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the stance' .,
set forth, herein, as .set by the Department vl Commerce and the Department of Natural Resources, State of Wisconsin
tiIalinf that your septic svtitcm I1:1s h�.cn rn.iin�:; � _ ' usl he anti returned to the SI Croix County Zoning Offic_
clays of the three ear cx piration t
Y ( date
�v'YLJ 10 / l / 00
Si ATURE OF APPLICANT DATE
OWNER CERTIFICATION
i (we) certify that all statcmen;c on iLis form are tnic to the best of m our knowled ge, f ( we) am (are) o•tner. s �,`
the property described above, by vutue of a %, 'Irranry deed recorded in Register of Deeds Office.
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SiG ATURE OF APPLIC NT DATE
"•"" Any information that is mis-rc rescntc�l may result to the sanitary P y permit being revoked by the Zoning Department.
Include with this applications a stamped %�nrranry deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
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DOCUMENT NO WARRANTY DEED t�# SP,: f W ERVED FOR RLV M, -N9 0.,.
STATE BAR OF WISCONSIN FORM '2 -1W2
4 f f 4f 9 S93?AGE � 36
REGISTER'S OFF' :E
Wesley Frederick and Mary Frederi_g k,...huaband and ST. CROIX CO., WI
wife as_ Joint.. tenants, _..._ .._ Recd for Record
_ ..................... FEB 141991
convey:; ,ind warranta to . John. . C... Mickel . son . ........ at 8 A. M
....... .... ...........I ........ ... V h+ Q
.. ... . ... .. ..... .. .. ..... ... .. .. .... RETUPN To
the following described real estate in .... S t... Cr . ..............County
State of Wisconsin:
Tax Par cel No: ..............................
The Southeast Quarter (SE}) of Section TWo (2), 1 1bvmship TWenty -nine (29) North, of
Range Eighteen, (18) West, excepting therefran the following described tract: C uTnencing
at the Southeast corner of said Southeast Quarter (SE}); thence West, 420 feet; thence
North, 150 feet; thence East 420 feet; thence South, 150 feet to the Point of Beginning;
also excepting Lot One (1) of Certified Survey Map recorded July 22, 1977, as Document
No. 341785, in Volume "2" of Certified Survey Maps, page 415, St. Croix County Register
of Deeds office, subject to Town Road right- of-way over the Easterly 33 feet thereof.
TRAN6
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This _ 15_ 119 - ._.... homestead property.
(is) (is not)
Exception to warranties:
Dated this _ __ _ day of ...__February ' 19 91 .
(SEAL► _ (SEALS
Wesley Frederick •_Mary Frederick.
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Parcel #: 042 - 1003 -60 -100 07/27/2007 08:58 AM
PAGE 1OF1
Alt. Parcel #: 02.29.18.32A -10 042 - TOWN OF WARREN
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - HENRY, TODD A
TODD A HENRY
1110 140TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description 1110 140TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 4.264 Plat: 4216 -CSM 15/4216 042/01
SEC 2 T29N R18W PT SE SE BEING CSM Block/Condo Bldg: LOT 02
15/4216 LOT 2 4.264AC
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
02- 29N -18W SE SE
Notes: Parcel History:
Date Doc # Vol /Page Type
12/31/2001 666867 1804/360 WD
07/23/1997 893/136
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.260 44,600 165,000 209,600 NO
Totals for 2007:
General Property 4.260 44,600 165,000 209,600
Woodland 0.000 0 0
Totals for 2006:
General Property 4.260 44,600 165,000 209,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00