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HomeMy WebLinkAbout042-1079-40-400 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CroiX Safety and Building Division r INSPECTION REPORT sanitary Permit No: 430171 l 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: Anderson, Lacie I Warren Township 042 - 1079 -40 -400 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: O O . cvG 1" �_ rn - Q., p..c. �.� *- k-d 29.29.18.451A50 TANK INFORMA ELEVATION DATA • S /.,� /� TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing cJ LC Alt. BM Aeration Bldg. Sewer Holding SUHtInlet St/Ht Outlet TANK SETBACK INFORMATION 7.35 13 7`f TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic w 3Q n. y Dt Bottom � r � Dosing Header /Man. Aeration Dist. Pipe ` -7 ,QS . r� Bot. System v C I S . c, 5 - t-- oa. 2 Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model N er �OSti5�1 nn s w 13 -Z to 1 . �l TDH Lift tion Loss System Head TDH Ft [ 3 3,1q I i) 11 Cog Forcemain Length Dia. ist. to Well g .► / .alp/ INS•I / .c 13.2/"i SOIL ABSORPTION SYSTEM . 4 Z. BED /TRENCH Width Length (y No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO I P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR g Type Of System: UNIT 611:1" 'j 1 '�7c N© — . 6 Model Number:�fd tt DISTRIBUTION SYSTEM � <- y Header /Manifold Distribution 1 x Hole Size x Hole Spacing Vent to Air 77 „ Pipe(s) Length ^ Dia Lk 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 BedlTrench Center Bed/Trench Edges Topsoil Yes No ?: Yes :i', No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: Inspection #2: / / Location: 760 103rd St Roberts, WI 54023 (SW 1/4 NW 1/4 29 T29N R1 8W) NA Lot 7 Parcel No: 29.29.18.451A50 1.) Alt BM Description= � '-� ""'^^� � � aA- W"+ we-- lie- ~� 2.) Bldg sewer length = h� aJ b �pr e- ,- f / ✓c� L(S 3 p � P Z /L .�-R ,. 1L -/V - amount of cover I ' _ -- - � � Plan revision Required? , ;Yes No i 6 Use other side for additional informa o SBD - 6710 (R.3/97) 1 6 ' 7 — Date Inse Signature Cert. No. r N VI A Safety and Buildings Division County N w , 201 W. Washington Ave., P.O. Box 7162 5 sco SI n Madison, WI 53707 - 7162 Site Address De a tment of Commerce `#__ — +(a0 I 0 Sanitary Permit Applic Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal inf rmatiop you provR= may be used for secondary ses Privet Law, 15. 1 m ` _ ❑ Check if Revision I. Application Information - Please Print All Information State P lan I.D. Number Property Owner's Name _ 7003 Parcel Numbe r a- 6i �. ��hSO/✓'f C �.d v-d�T � t9 °L2 � tD �-� �0 � k +© . :r Property Owner's Mailing Address Property Location 7" u 'A; S T 22N, R City, State Zip Code Phone Number Lot Number Block umber � ���g �' "l S Gv�- s 4 n� 3 � 1 S'- 7 Y � ��.� S``•L � CSM Ntunber t y p. 'f zS8 32 ; n a of Building (check all that apply) a� ❑City LrJ 1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public /Commercial - Describe Use L�JTownship � ❑State Owned Nearest Road � S � III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 eNew 1 2 El Replacement System 3 11 Replacement of TExisting 6 11 Addition to For County use System Tank Only System B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. 'I)yge of Permit: (Check all that apply)(numbering scheme is for internal use) 44 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line , 45 ❑ At -Grade 46 ❑ Aerobic Treatment U0 4R ❑ Recirculating 3R ❑ Other �� 3 V. Dispersal/Treatment Area Information: ' « l Design Flow (gpd) Dispersal Area Dispersal Area it Apflication Percolation Rate System Elevation Final Grade 0 0® 7 Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) �r �B �Eley� tit 8 S 41Y 19 -� , Law rL Ltt .-r tOs'so LQ° , VI. Tank Info t6aciry in Total Number Manu�cf rer Prefab Site Steel Fiber Plastic Gallons Gallons of Ta iv� x, Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank - �S ElQ IV PIV. Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installati POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP RS Number ;Z. TO Business Phone Number Plumber's Address (Street, City, State, Zip Co 9b 7 /rev y lv S` VIII. Column / artment Use Onl ❑ Sanitary Permit Fee (includes Groundwater Date Issued Issu Agent Signature (No Stamps) Approved Disapproved Surcharge Fee) ❑ Owner Given Initial Adverse . Determination IX. Conditions of ApprovalMeasons for Disapprov n . /I Attach complete W only) for the "em on paper not less than 81/2 s 11 lathe to size ^S � SBD -6398 (R. 05101) I vi ' •t �o �O � v o d �j d ip +� 4 AQ6 j. W bib y y ` ` d . o n q QQ 3 � o L � �b � o ° vi 1 M $� 4Q6 I L f - � v w `' a g aQ 3 •� �'� niNS: , o`lx- I e7q• yg • 0 7 s /a7�• S'a' oso 0yz /a7 'Msconsin Deparlmenl of Commerce SOIL EVALUATION REPORT ii vision of Safely and Buildings Page ( of In accordance with Comm 85, Ms. Adm. Code /Attach complete site plan on paper not less than 8 112 x 11 Inches in size. Plan must County e„t, G/POi•�C Include, but not limited to: vertical and horizontal reference point (BM), direction and .D. percent slope, scale or dimensions, north avow, and location and distance to nearest road. Parcel I.D. Please print all information. R bale Personal Information you provide may used f REeEl L- L.F OF 15.04 (1) (m)). Property Owner �j roperly Location 6 ovl. Lot SE 114 AM1 /4 S Z / T 1.� N R /0 Q 9 (or) w Property Owner's Mailing Address 01 # Block # Subd. N me or CSM# 73 6 /o 7 it- sT. 7 �-,vD City Stale Zip Code Piton ' r Rom p; s �/• yO Z3 I� FF E] City ❑ Village to Town Nearest Road [� New Construction Use: Residential / Number of bedrooms Code derived design flow rate (O GPb ❑ Replacement ❑ Public or commercial - Describe: Parent material !W p V Flood Plain elevation If applicable General comments j� n and recommendations: l/ 1 Boring 0 11 Boring s Q ail Ground surface elev. " _ fL Depth to limiting factor � ��+ tn. f Sollpplication Rale Horizon Depth Dominant Color Redox description Texture Structure Consistence Boundary Roots GPD /It? In. Munsell Qu. Sz. Con[. Color Gr. Sze Sh. 'E11#1 'Etf#2 / o • /v rR 3 — ifs b AOfR J,0 3 f Z 9•17 / Z- 317-90 7.5 Y 1-5 r Boring # L] Boring /0& •, > F 111 - -- 111 H Pit Ground surface elev. ft. Depth 10 limiting factor In, Horizon Depth JY5 Redox Description Texture Structure Consistence Boundary Roots Soil SPD/` ►1 n Rate In. Qu. Sz. Coht. Color Gr. Sz. Sh. °• rZ L Shy /WIT/r (� •Eff #i "EBi12 / •/ _--- -- ,,v. S, p .� /• Z ak Effluent Ni = SOD > 30 < 220 mg /L and ISS >30 _< 150 mg/L ' Effluent 02 = SOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature _ 'ROBE R u L13R� G 17— CST Number Address 2 Z. 4 3 - 7 . • Date Evaluation Conducted Telephone Number Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL � y 3 Property Owner rr Parcel ID N Page of poring p 1 1 Boring ` r, S ' 9 ,r surface elev. n. Depth to limiting factor / � In. Pit Ground su ace � P g Soil Application Rate I orizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary RAols GPDRI' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efrift I 'Eff#Z 04 1 • io ff Y4 Ara k M-Fk C5 L t • z . 3 • z 7-5 _' . /,w 10 R V, C S i. 1,o y 5 Boring If L] Boring L7 Pit Ground surface elev. fl. Depth to limiting factor In. Soil Application Rate flotizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /(t' In. Munsell Qu. Sz. Cont. Cola Gr. Sz. Sh. 'EIfNi 'Eff#2 r F1 Boring !! � Boring Pit Ground surface elev. fl. Depth to limiting factor In. Applicalon Rate S horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda 0018 GPD /Il' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 '01112 Effluent ff 1 = SOD > 30 < 220 mgll_ and TSS >30 < 150 mg/L ' Effluent 02 = SOD 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider $nd 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. snn -w »n rR ammtf► a I , 385 N o S O o o N w ' N V \ 1 v c 0 IN o 0 i CIO fi ( \ C . , � d v sk �� 1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of y FILE INFORMATION SYSTEM SPECIFICATIONS Owner Q j r X At d F 0,A1, f a., C- e0l Septic Tank Capacity jJ L. a l ❑ NA Permit # ! } Septic Tank Manufacturer W jfz F.*_ C&/V Pro ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer a6 NA Number of Bedrooms A ❑ NA Effluent Filter Model d ❑ NA Number of Public Facility Units ®�IT Pump Tank Capacity al It< Estimated flow (average) 460 Od g al/day Pump Tank Manufacturer &l IAA Design flow (peak), (Estimated x 1.5) (0 0 o g al/day - Pump Manufacturer d<A Soil Application Rate © gal/day /ftz Pump Model d IA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit 1116A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) _ <150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Di al Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L P1NA ❑ 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 Inspect condition of tank(s) At least once every: ❑ m th(s) (Maximum 3 ears) ❑ NA ear(s) y Pump out contents of tank(s) When combined sludge and scum equal one -third (Y f tank volume ❑ NA Inspect dispersal cell(s) At least once every: r ❑ pWrorith(s) (Maximum 3 years) ❑ NA I>9'year(s) yyroo Clean effluent filter At least once every: ❑ nth(s) ❑ NA Bryear(s) ❑ month(s) A Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) B<A Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA 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 S12 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. GMW (4/01) START UP AND OPERATION Page For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products oiother 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 discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup 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 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. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • 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 Name 4 L Name Phone 7 �-- Z yf — �3 2Z Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name t .010 jr I Name 57`C P o Co cv At Phone - 7 16 - - ' A 19 ---0 / 5 3 Phone This document was drafted in compliance with chapter Comm 83.2212►(b)(1)(d) &(f) and 83.540►, (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT • AND OWNERSHIP CERTIFICATION FORM Owne uyer Mailing Address ZU 10131014 Property Address O 1 t- Q (Verification required from Planning Department for new construction) City/State , A" G O ; Parcel Identification Number © y2 -- Zp — C - 'Y 00 LEGAL DESCRIPTION Property Location : 51AJ V4, WW V4, Sec. , T -R Town of ,� Subdivision , Lot # 7 Certified Survey Map # 7 ;?- "3;L , Volume Page # _ Warranty Deed # 7 '7,73 or,-? , Volumed , Page # t a Z 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal 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 days of the three year expiration date. Z 1 f�� SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF 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 V 2 2 8 8 P 10 7 7273x2 KATHLEEN H. WALSH DOCUMENT NUMBER REGISTER OF DEEDS QUIT CLAIM DTSD ST. CROIX Co., MI RECEIVED FOR RECORD 06/25/2003 12:19PH Donald D. Anderson and Edie R. Anderson, husband and wife, quit QUIT CLAIN DEED BOW # 8 claims to Lacie D Anderson, a single person, the following described real estate in St. Croix County, State of Wisconsin: REC FEE: 11.00 TRANS FEE: Lot 7 of CSM, recorded in St. Croix County Certified Survey Maps, COPY FEE: � 7, P aa�a� , as Document No. 725832. being located in the CC FEE- Southwest Quarter of the Northwest Quarter (S of NWk) and the PAGES: 1 Southeast Quarter of the Northwest Quarter (SE;* of NWk)•,of Section 29, Township 29 North, Range 18 West, Town of Warren. NAME AND 4ETURN ADDRESS G3v��f�s A, 7 , 092 - 1079 -90 -900 Parcel Identification Number This is not homestead property. Dated this A day of June, 2003. z / (SEAL) (SEAL) Donald D. Anderson ie R. Anderson (SEAL) (SEAL) AUTSSNTICATION A CKNOWLEDGMENT iignature(s) STATE OF WISCONSIN ) ) ss. .LJ(O{X COUNTY ) authenticated this _ day of 20_ Personally came before me this - -)!!4 day of June, 2003, the above named Donald D. Anderson and Edie R. Anderson to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. CITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 5706.06, Wis. Stats.) % 1 A *' w� OBIS INSTRUIWNT WAS DRAB'TSD BY: Notafit public `. County, Wis. My ¢ mm =ssion is permanent. (If not, expiration date: ituart J. Krueger �G lodli, Beskar, Boles & Krueger, S.C. ?.O. 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