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HomeMy WebLinkAbout042-1004-50-500 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420578 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID WQ. 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: Stout, Richard I Warren Township 042 - 1004 -50 -500 CST BM Elev: I Insp. BM Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark too 'D Dosing � l.� „ Alt. BM Aeration Bldg. Sewer / l o .os q%sl Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic t 5b, l Dt Bottom / •2� 90 • �� I Dosing . u y , Header /Man. / �� • 1 , qv Aeration Dist. Pipe Holding Bot. System Z a • sz. z' PUMP /SIPHON INFORMATION Final Grade -o `� t7b.0 Manufacturer Demand i St Cover GPM l7 (7D Model Number TDH Lift Friction Loss System Head TDH Ft Force main Length ( Dia. Dist. to Well SOIL ABSORPTI SYSTEM MM(GRENCH_ Width Lengt No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME � r d /-7 SETBACK SYSTEM TO ,7 P/L B WELL LAKE /STREAM LEACHING Manuf ct • r — INFORMATION CHAMBER OR Type Of Syst t UNIT Model Number:, -I t DISTRIBUTION SYSTEM Header /Ma�ifo � c, Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s �b/ Length_ Dia Lengt 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 F No Yes ❑ No CO WENTS: (Include code discrepencies, persons present, etc.) Inspection #1: t / L r Q3 Inspection #2: 7 L " r ti Location: 1227 County Road E Ro-be_rt ,,JWII, 54023 (NW 1/4 NE 1/4 3 T29N R18W) NA Lot 5 Parcel No: 03.29.18.37A50 1.) Alt BM Description = S•�"�""�"� Cam• 2.) Bldg sewer length = �` amount of cover = �� oc 1 ` ` 1 3) �•�o� � —r G T` - - -- Plan revision Required? Ye N No i Use other side for additional ormatttio''n SBD - 6710 (R.3/97) ,w�• -y C D to I , Insepc t igna ure �-- _ i (? Cert. No. ision Canty Safety and Buildings Div 201 W. Washington Ave., P.O. Box 7162 G re visconsirn Madison, WI 53707 - 7162 Site Address n �I Department of Commerce 7 -6 Z- Sanitary Permit Application Sanita Permit Number i 4 s In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision May be used for secondary ses Privacy Law, s15. 1 m I. Application Information - Please Print All Information Stare P lan I.D. N umber Property Owner's Name ` °' Parcel Number /` pG/� -00- 42 — 5 O Property Owner's Mailing Address � t'j a Property Location Z 41 (G�'►G' e l Yat / -A g",q T N, R/9 City, State Zip Code hOtu? r Lot Number Block Number Subdivision Name CSM Number ,4"4 d S a zd II. Type of Building (check all that apply) , s ter q AA. t a uS. ❑City X1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ownship t .0 ❑ State Owned Nearest Road t Q r a) C� III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete lint B if applicable) A. 1 XNew 1 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use stem Tank Only Existing stem K B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued la 14 " ' IV. Type of Permit: (Check all that apply)( numbering scheme is for internal use) 4c ' � .., 44A'J.,��Non - Pressurized In -Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 'Set- 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line p�J 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other � j✓"" V. DispemaltTreatment Area Information: 1 Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation 7 OD'd �I r a�J qb f p,S ��— 9 7,4,' 9 VI. Tank Info Capacity in Total Number MNOUetarar fab Site teel Fiber Plastic Gallons Gallons of Tanks Co to Cons Glass New Existing Tasks Tanks Septic or Holding Tank f�Od �✓ e� S G r Dosing Chamber VII. Responsibility Statement - I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) , P Signature RS Number Business Phone Number J`:n4a/,ti0A sY Plumber's Address (Street, City, State, Zip Cod la2 �1 VIII. County /De artment Use Onl X Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing em Signs (No Stamps) Surcharge ❑ Owner Given Initial Adverse ���_ Determination ` IX. Conditions of ApprqvayRepsonsgor Disappro_va� -% L4 MARC a,,E --�� As 3. o ompi (to the County only) for em on pow not less than 8W z 11 Inches In size �-"— SBD -6398 (R. 05101) J INA 4 Sao ejt b �D AJ,4';JiV ✓ i i ✓ ton G G rJ c Y Go� I Al 11 I L I , AbY I t �7' � r r rwiscatisin Department of Cc,!}4merce SOIL AND SITE EVALUATION Division of Safety and Buildings C Page of Bureau of Integrated Services in accordance with Q0m h 8109, Wit. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM)j direction and C'k Y - I percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D! # or APPLICANT INFORMATION - Please print all informaltioq. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, S., t5.04'(t {rh)) ; Property Owner Property Location {?1 che, rJ S46L)4 Govt. Lot - '1/4 1 /4,S y ,N,R/ E (or)(9 Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# - �. 5 ,1��'? q1' ;t City State Zip Code Phone Number a ❑City El village ® Nearest Road Town {�] New Construction use: [Residential / Number of bedrooms 3— y Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow A gpd Recommended design loading rate • .' bed, gpd/ft • (° trench, gpd /ft Absorption area required /VcJ bed, trench, ft Maximum design loading rate 4 f bed, gpd/ft 6 trench, gpd/ft Recommended infiltration surface elevation(s) 7 yJ ft (as referred to site plan benchmark) Additional design /site considerations Parent material U c ry Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In d Pressure AT -Grade System in Fill Holding Tank u= unsuitable for system ❑ s u �7 s❑ u I� A ❑ u ❑ S W u ❑ S / R1 u SOIL DESCRIPTION REPORT Borin g # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench I ; , o /0 '- 312 SI ( abk mfr G5 2 3 Z 9 -33 lU y r H1 4 5, I 2mabk M-C" L - 5 Ground 3 33 -iv9 10 y r `l 11n L l rnS m v-�r C 5 $ elev. 9 �fft u4- tU r J01 / C21:) Depth to limiting factor &Y in. ZZ-0 5V l Remarks: Boring # 1 01 ICS r 3) Z S I I rnCkbk M f- cS l v 2'. 3 s .vTN 2 2 ll I r`I�'I — Si I 2r�i10 m4► C 4f j 3 3 L5 1rnS 1nV - Pr CS • -7 •$ Ground T ( -&1 I() YC 16 1 C2P (-`-( Vi S Om vt( CS . J� elev. Z'� ft. r .Z L 0' Depth to limiting V►� two. factow in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number -�-- 3 �� s� SG �� �Y�2a'" �k--U as 3.3c) S SOIL DESCRIPTION REPORT Z PROPERTY OWNER ��` Wage of 3 r PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench si I I b C Z' 2 c.bk Ground / 3/'S /!� r�l Ap LS � n m ✓ -P,.- elev. _ lO doll U _P1•S r`!1 ✓j'5 0 117 Depth to limiting f S (� �, 41 CA factor « in. Z Remarks: S� a I� „S Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. . ft. Depth to limiting factor in. Remarks: Boring # 13 Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) .1 PAGE Z OF NAME .S i LOT# LEGAL DESCRIPTIONA Its!' /4XW /4,S1STZq,N,R 19 E (or)6) SCALE: 1 "= go t 111L.44 BM 1 ELEVATION 100. BM 1 DESCRIPTION - Jopo.. 1,44h w/ Fos BM 2 ELEVATION IOU• BM 2 DESCRIPTION lath � SYSTEM ELEVATION __ ALTERNATE ELEVATION ,ulr- CONTOUR ELEVATION ,(/A- ' I t � 6t a 1 o b 107. t �1 l I SIGNATURE DATE 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 Nu mber Number of Bedrooms Design Flow - Peak pd) —O Estimated Flow - Average ( d) Septic Tank Capacity (al) Soil Absorption Component Size (ft') Type of Wastewater Dom tic Table 2: Soil Absor tion Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Compone Design Flow - Peak pd is ab % . Maximum Influent Particle Size (in) 118 Maximum BODa (m /L ) 220 Maximum TSS (m /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 nd outlet filter shall be assessed at least once every 3 years by inspection, he outlet ii shall be cleaned as necessary to ensure proper operatin The filter cartridge ou d not be remove unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the I Management Pjan to, a Septic Tee ^K are S&: bosorption COmp©nVit filter Is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent flfttr elVM may indicate surge flows or an Impending continuous alarm. The septic tank shall have Its cpntants removed when the vdume of NUM and sludge In the tank exceeds 113 the ilquld 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 r4A service needs to be performed to maintain less then maximum scum and sludge accumulation In the tank. Menhole risers, access risers and covers should be inspected for water tightness and soundness. ACMU openings used for service and assessment shelf be sealed wetartight upon the Completion of service. Any opening deemed unsound, dofective, Of subJeat to fillin must be replaced. , Sxposed access openings greater than 8. 1nches in dlemeter shall be secured by an efhrotive locking device to prevent acddentel or unauthorized entry into the tank. No one should enter s sq#1a or other tbwtment or holding tank for any reason without being► In !full ooenpllsnos with 0" stendon i ilror onaff # a CoAliftd *#tee, the #Lgx0ph" trt*hin the sop* or other trgMwit of NNW to* May imfoln hAN pm end naew of a perm Brost .lnarter of dH"May be dMUN or lmp0881114 Tank abandonment shut be in a000rdanes with Conan 83.33, Wes. Adm. Code when thG tank Is no Ionger used as a POWYS caomponam Sell Aftoton Coffilentent The soil absorption component serving this structure is designed to accept domestio wastewater from a residential facility. The limits of operation of thin► component are shown in Table g. The longevity of a soil absorption component depends greatly on proper and timely maintensnoe, and system use within or below the limits of reliable operation, Good water conservation practices by all occupants and the installation of water Canserving plumbing fixtures are key factors in ex%nding the useful life of this component. The soil absorption component's oAersbon met be assessed by Inspection at least once every three years. The Inspection shalt Include recording the leveie of ponding, if any, in the observation pipes, and a visual Inspection for any evidence of surface sospaage or discharge from #ire component. On steeply sloping sites, areas of erosion should be Id*MM*d and reported to the owner for repair. The surface dlscharp of domestic wastewater or sewage i from the system Is prohibited and considered a human health hazard. Traftic around or over the soil absorption component should be avoided particularly during winter months, The compaction or removal of utow cover oust the component may i ®ad to hydraullo failure by fre rft. This type of failure is usually ternporary, but is dOcult or Irnposalble to repair until weather conditions Improve. In general, soil compaction over this awnpo it will reduce diffusion of oxygen Into the soil and dispersal all, which may leasd to more Intense, and earlier, orgartic clogging of the Boll. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep-rooted trees and shrubs directly over of within ten feet of the component should be avoided since root intrusion Into the component may obstruct wastewater flow. Contingency Plan In the event of system failure, a new system could be Installed in on alternate area. With the Installation of a diverter valve, the existing system could also be reused after a period of three to four years, it is the property owners responsibility to maintain the alternate area free from any planting of trees, shrubs, etc. In case of failure of the original system, the alternate area will be needed. If any trees, shrubs, etc. have been planted on the alternate area, they will have to be removed at property owners expense. If alternate area is destroyed, there are other alternative systems that can be used, in which, could result in added expense to the property owner, Any tank abandonment shall be done in accordance with Wise. Code 83.33. Any questions regarding this code, please contact your Iocai Zoning Offlos or contact the Installing plumber. 'at rn 0 IS) ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGMEMENT AND OWNERSHIP CERTIFI4CATION FORM Owner/Buyer " +" Mailing Address / Property Address -,.1 7 C O (Verification required from Planning Departrner�t for new aonstructton) _ job City /State Parcel Identification Number C. 3 _ 5 .9 LEG Property Location ! -v' /4, GL)' /,, Sec. 3 , T,��' N -R 1 � W, Town of Lot # Subdivision certified Survey Miap # �� �4'� �' Volume _.���' — . - � Page # 45' Warranty Deed # to � S . Volume J , Page # Z Spec house kyeS C3 no Lot lines identifiable Yes El no �ve�rr Ma.TN'I'ENANCE oiler use and suaintenaaceof your septic system could result in its prema $ ed ailur phandWW you put the system ce consists d pumping out the septic tank every three years or sooner, if needed by can affect the function of the septic tank as a treatment stage in the waste disposal system. orm , signed ed by the owner and by a at a certificattott . The property owner agrees to submit to St. Crone Zoning Dep ararte pumper verifying that (1) the on -site wastewaterdisposal system. wasterplumbery journeyman plumber, re or a lioensedpurrtp neces8ary), the Septic tank is less than 1/3 full of sludge. is in proper opermis� condition and/or (2) after Inspection and pumping (' have read the above requirements and agree to maintain the private sewage disposal system with the standards Uwe, the und ersi g n ed Office within 3{} set forth, herein, as set by the Department of Commerce and the Departtue of St, Croix County Z'as�$ �. Certiticatsoe stating that your septic system has baea maintained meat be completed an days of the three year expiration date. / / /i d D� IONATURE OF AFPLYCANT GERTIFIICA111 D (! to the best of my (our) knowledge. I (we) Stn (are) the owner(s) of I (we) certify that all statements oa this form are true the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. HATE PPIYCANT * ** s OF A * * * * ** Any iraformation that is rtes- represented may result in the sanitary permit being revoked by the zoning Department.'` ** ion: a stamp warranty deed from the Register of Deeds office deed * intlwd� with this appucr►t p if reference is made in the warranty a copy of the certified Stitl�ay map a L !o 1454RG 424 • 6o9S7F. KATHLEEN H. WALSH REGISTER Document Number WARRANTY DEED ST. CROIXOCO., WI RECEIVED FOR RECORD Richard W, Hopkins, Shirley L. Wickline, John M. Hopkins, Susan J. 09 -03 -1999 2:00 PM Anderson, Jane M. Held and Gerald M. Hopkins, conveys and warrants to Richard O. Stout and Janet P. Stout, husband and wife, as WARRANTY DEED survivorship marital property, the following described real estate in St. EXEMPT N CERT COPY FEE: Croix County, State of Wisconsin: COPY FEE: TRANSFER FEE: 916.00 RECORDING FEE: 10.00 PAGES: 1 Recordin Area Name and Return Address Richard O. Stout 1353 Awatukee Trail Hudson, WI 54016 642 1004-59 WO 042 - 1004 -70 -000 (Parcel Identification Number) The North Half of the Northwest Quarter (N' /z of NW' /4) of Section Three (3), Township Twenty -nine (29) North, Range Eighteen (18) West, St. Croix County, Wisconsin, EXCEPT the following parcel of land: Certified Survey Map filed April 30, 1975 in Vol. 1 of Certified Survey Maps, page 121, as Document No. 326689. AND ALSO EXCEPTING Certified Survey Map filed August 3, 1983 in Vol. 5 of Certified Survey Maps, page 1330, as Document No. 386986. AND ALSO EXCEPTING Certified Survey Map filed May 1.6, 1990 in Vol. 8 of Certified Survey Maps, page 2208, as Document No. 458642. Exception to warranties: all easements and restrictions of record. Covenants, restrictions and easements of record. This is not homestead property. Dated this day of 1999. n ' *Richard W. Hopkins "R ichard W Hopkins, a A r ey -In -Fact, for Shirley L. Wickline, John M. Hopkins, Susan J. Anderson, Jane M Held and Gerald M Hopkins AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ST CROIX COUNTY Personally came before me this _�_ day of June, 1999, the above named Richard .Hopkins to me known to be the authenticated this _ day of peon w o execute rs the foregoing instrument and acknowl ge the sam s +gnature /�� signal e �(� r �y1 c�C c cc type or print name type or lnl name _ 6 TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public St Croix County. (If not, My commission is e_rm4hent. (If not, state expiration date: authorized by §706.06, Wis. Slats.) / ( Id C� Zp THIS INSTRUMENT WAS DRAFTED BY Names of persons signing in any capacity should be typed or ROBERT F. WALL printed below their signatures pouitn l�otiuy public IHopklnstostoutWDi sta1e of �Ui:onstn niormanon Pwfe -onais company Fond d, Lac. Wisconsin 800 - 6551021 }15 ME QT. AFTED BY ED FLANUM JOB NO. 00 -U 1 UA I L I -JU -uU n �/ r li i l 00 O C� �' ] IT wARE REFERENCED TO THE 0 U) m t� z m o NC ?RTH LINE OF THE NW1(4 OF SECTION � � � ,2- N 3, ASSUMED TO BEAR N88 °24'51 "E r Z U N P LATTE D LA S _ [� BY P LATEE Ft c �° - - - - -- - -- C" W m N01 °06'26 'W 468.62' m £38.69' 3.00 a m 435.62' IS co EAST LINE OF THE _ --1 -�" " -1� O NW1 /4 OF THE NWI /4 ki Ii iaj_ - - o —__- z O WEST LINE_ OF THE n ' O °' P w > w z �• 0 O $ o = NEI /4 OF THENWI /4'o Do ��n "'� a ➢� �� m mD l u C/) Q I 0 33.00 277.71' 435.62' ca 157.91 O n N I A m� O0 Im ➢ _ x-n D v o No 33' S0' ! O T m pQo ' r m *QN Z © IA ITl 8 W �G. I Z o ➢ W x • N O ` a DD D ? 11 I© Cm - Crn r- c V Z m — m Cn m U) ° -j m I P OZ v NNE Z T go 3 �A - S Dj n v, m - % Cn K 04z ^ ^ Fa ,xu N01 0626 "W x+66 62 iii �- m -� n m� A p "a M o 3C °`:435. co C O II �C) co �✓ o ��� -; ° I I 0 ;< N V� N W -v Q Toy p i z z Q m -u i� �Zi I II 8, 3' i 7�