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HomeMy WebLinkAbout042-1086-20-300 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary,P�rnOo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 33 3S 11 Permit Holder's Name: ❑ City ❑ Vil a e E] T l owriship State Plan ID No.: Johnson, Mike W CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T�x QI oT086 -20 -300 4l TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � Benchmark 9 ®O Dos. Aft. BM O Aeration Bldg. Sewer Z r6 O L I Holdi t Ht Inlet 3 TANK SETBACK INFORMATION 1$nHt Outlet J py TANK TO P/ L WELL BLDG. Ventto ROAD e Air Intake Septic NA Do ' NA Header / Man. Z Aeratio Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade anu er Demand St cover x Model Number F� M TDH Friction em TDH F L oss M Forcemain Length Dia. Dist. ell SOIL ABSORPTION SYSTEM C rS BED/1Q1 Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM N N Z I I DIMENSION SYSTEM TO P/ L BLDG WELL LAKE /STREAM LE ZING Manufacturer: SETBACK HA �- INFORMATION Type O U C� ? o e N er: System: > � l DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. _n Length V- 3 S Dia. 6�ft Spacing 'V4 A/ 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 I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1•1z / / /Ob Inspection #2• Location: 903 Alex Lane, Roberts, WI 54023 (SW 1/4 NW 1/4 31 T29N R18W) - 312918482A30 -Lot 4 . 1. Alt BM Description= = o&r s," S� obs�• ✓,c1�b.� P ,joss r p sr p � l w� lkaw� 2.) Bldg sewer length = 2 z' - amount of cover = >14a O" eAe_ � e`'� kell 4, Ghri; SySle'.­ tuQS Plan revision required? ❑ Yes [0 No l Use other side for additional information. 1 1 7, V 00 SBD -6710 (R.3/97) DtT Inspector's nature Cert. No. X I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: q a f t i ¢ e i S G - , ?, t M D 3 f} L r--X pa," Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. AR See reverse side for instructions for completing this application PO Box 7302 isconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. Coun State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number l S I. Application Informati - Please Print all Informati Location: Property er Name Property Location 114 1/4, ,N, E ( r) Pt i operty OWnees Marlin A dress Lot Number Block Number City , S Zip Code Phone Number Subdivision a SM Num ber , , II. Type of Building: (check one) ❑ City S ( ❑ 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Vr11a � t�,n ❑ Public /Commercial (describe use):_ )2�Tow of �T Z Yeti. ❑ State -Owned / Nea—resk n , Parc ( N um III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) a A) 1. PP 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) ' 4 —10D 1P Non- pressurized In- ground ❑ Mound Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At - grade I ❑ eropic reatme t Unit ❑ Recirculating ❑ Other: 3 x 6 V. Dispersal/Treatment Area Infor mation: 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 /sq. ft.) (Min. /inch) Elevation VI . Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the un ersigned, assume responsibility for jnstaliodfon of the POWTS shown on the attached plans. Plumber's ame prin Lumbe Si re slam MP/MPRS No. Business Phone Number _ )c Plumber's Address (Street City, tate, Zi CoodA IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) ® Approved ❑ Owner Given Initial Adverse S�charge Fee) Determination O'?.Z5; cro 10 —Y_ Zeft X. Conditions of Approval /Reasons for Disapproval: �- ,� -,ter ,,,�- ,n�:,,���„ s�►�. �-e� -� .�P.tit -� �:�,. � p.�.� s re.��.�.��.�,,�,��, S. SBD -6398 (R 07/00) j /, %� iL ����J Sul � - J✓�.�/ -- �s�°� 3 / - ��/�- � /�!� 33 A 3X fob, �S" d 3 pia lie wlle 1 1 d es ,A = 16*I---? 6 / ®o J I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings -•• -- Page of Bureau of Integrated Services in accordance with s ma $,r.Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in si�e Plan mu County include, but not limited to: vertical and horizontal reference point (BM)11 irection ant, ) C I'Ol X percent slope, scale or dimensions, north arrow, and location and dis ancg to nearest road. Parcel 1. Q. If )._.. APPLICANT INFORMATION - Please print all informati +f , Reviewed Date Personal information you provide may be used for secondary purposes (Privacy L �w; s. a 5.Qkj;1)1O�- f'�q Property Owner Property Location j �l Char J U 7 `' . Govt. Lot �. �/4 vk/ 1 /4,S T�c� ,N,R E (ore Property Owner's Mailing Address Lot ' -BIT 6# Subd. Name or CSM# 1 3 3 A wa4u K ee- Tr - � I es s11 ZZ (/ r, . � City State Zip Code Phone Number ❑ City El Village 0–Town Nearest Road cA - n I Lkj l L40 t to ( '1t 1' )5 -41S I CX f f Cc,+4& W "ck 0 - flew Construction Use: [Residential / Number of bedrooms 3 - q Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily low (v O V d , 7 y gp Recommended design loading rate bed, gpd /ft • 8 trench, gpd /ftz Absorption area required 25-7 bed, ft 7SU trench, ft Maximum design loading rate • '? bed, gpd /fl - S' trench, gpd /ft Recommended infiltration surface elevation(s) ST • 6 ft (as referred to site plan benchmark) Additional design /site considerations kL -s-lcv• Parent material C­I(CtC4 L/ QG! &Zq's1 Flood plain elevation, if applicable -V v4 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U I El s ❑ u [5-S ❑ U I LAL S ❑ U ❑ S Q- U EIS Wl u SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench l oaz w 3lZ -- 11rnG mF�- L t F 4 . 2_ . 2. 2, l U `f —_ �� `I s i l 1 r na bk t4r c . 2- 3 Ground 3l. -7 14) yr . q 3 — LS M LS ? • �'' elev. y1Z4 lD r �Il�- rns &SCII m t c - 7 Depth to limiting factor 121 in. Remarks: Boring # Z Z 1 3 - 3fr 40 3 ta- lu /0 Vr m L Ground elev. g3•l0 ft. ' Depth to av 6 limiting factor —!Z4— Remarks: CST Name (Please Print) Signature Telephone No. Ociam 30t Address Date CST Number 4 JOR Ceder St #`f U25 2-53 309 PROPERTY OWNER S7bc> 1 SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench it C 1�' L i Z- 14 -y0 IU lr 14 Si I 1 Mabk r L5 ;. 3 Ground 3 'I0- I✓0 4 - -1 elev. gy.f9� 1 4 -I l0 - /hp M5 MI C,5 - 1 $ Depth to limiting factor JZj_in. Remarks: Boring # 0- r 312. 5 L I ✓nablc. rJ4r C. I -P `{ - 5 y Z- )Z 0 r'1 14 Si I lma +rY C.5 3 4Z -1 3 C 5 _ 8 Ground elev. 95.0 ft. Depth to limiting factor 13 6 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 # I p -I Z- !a r 3 1 Z ty LS l �' ``I • `j 5 Z 1 Z- I - 5• n4c C • 2 3 3 1_S Ground g_IZ, 16 r y/Ic '— ry) S U 1 L$ elev. 9 7,ro ft. Depth to limiting factor IZlc in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) E Gvf y �Iarrer� �awnsh ' S (-e am d-C Wo .nZ U. IU .o CJ1.00 Cot �pn wood i-r. 4 C, v 3 d A 6�z , w ` b slil - � Ate. C s 4) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County /7 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must C– include, but not limited to: vertical and horizontal reference point (BM), direction and Pam I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1/4 S T N R Ig E (or)(0 Pr6perty Owner's Mailing Address Lot # FBo # ubd. Name or Q.W City S e 'p Code ❑ Phone Number ❑City Village Town Nearest Road ( ) JN New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement // ❑ :745 Public or commercial - Describe: Parent material x642 Flood Plain elevation if applicable ft. General comments and recommendations: 7 Boring # ❑ Boring F [� Pit Ground surface elev. &Z 2Z 7 9 7 ft. Depth to limiting factor - >I&Q 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 _ ,3 _ ❑ Boring # Ej Boring ® Pit Ground surface elev. /6-�/7 ft. Depth to limiting factor / /S� in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 AJ 3 s 3 -5. Z* Zo .zY " E uent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 30 mg/L and TSS < 30 mg/L CST Na a � lease P ' t ,�, Signat CST Number Address � Date Evaluation Conducted Telephone Number Property Owner Parcel ID # Page of F? -1 Boring # Boring ®pit Ground surface elev. !4L-r-7 ft. Depth to limiting factor � /� .5� 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 J E Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor 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 Boring # F] Boring F El Pit Ground surface elev. 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 • 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) w G�k � �SE 3 x %19 3� 01 //D 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 perm its forsystem 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 3 3t5 Number of Bedrooms 3 Design Flow - Peak (gpd) "O Estimated Flow - Average (gpd) u'v Septic Tank Capacity (gal) Soil Absorption Component Size (ft Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation S n Septic Tank Component Soil Absorption Component a Q Design Flow - Peak (gpd) ouo C 3 �` Maximum Influent Particle Size (in) 1 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 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 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 proper operation. 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 i 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 components 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. 3 09/2612000 10:40 7152473036 BELISLE EXCAVATItIb I rraut nl ST CROIX COUNTY SEIPTIC 1 ANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Michael R. & C onnie M J o n on Mailing Address 1146 Partridge Lane N. Hudson, WI 54016 q D 3 j i .a La ki e Property Address new cons c (verification required from Planning Department for new construction) — City/State Roberts r WI Parcel Identification Number LE AI DESCRIPTION Property Location SW NW ' /•, Sec, 3j___ T 9 N -R 18 W, Town of Subdivision __ Lot A Certified Survey Map ti S _ __ Volume / i Page # Warranty Deed H Volume , page q �. Spec house CJ yes Rkno Lot lines idcntifiablexQ yes ❑ no SYSTEM MAINTF.NANCF 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, restrictc(1 plumber or a licensed pumper verifying that (1) the on - site wastewaterdisposat system is in proper operating condition anWor (2) after inspection and pumping (if necessary). the septic tank is less than 1/3 full of sludge. l>we, 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 Mating that your septic system has been maini.1w ed unist he completed and returned to the St. Croits County Zoning Office within 30 days f the thre t x aeon dart. # 1 4111 A A A &M lOr /f G ATURE OF rIFICATION NT DATE OWNER CE i (we) certify that all statements on itus form are true to the best of my (our) knowledge 1 (we) am (are) the owrier(s) of the pert dvsCribo;B vcrb Virtue of a a,irraniy deed recorded in Register of Deeds Office. 1 ATURE OF AP CANT DATE y g •••••• Any info ion that is mis- represented may result m the sanita p bein revoked b the Zonin Dep artment. '• "" •• 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 STATE BAR OF WISCONSIN FORM 2 - 1998 629324 WARRANTY DEED KATHLEEN He WALSH 15 A O 1 ST. REG ISTER OF DEEDS Document Number V.I. t `t 4AGE 1O ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between —RICHARD n RT WIT and 0 10:15 AM JANET P STnfiT, hnchand and wi fe WARRANTY DEED Grantor, EXEMPT 1 nd Mr[ -HAFT. R JpHNCnN anA rn[ararc M CERT COPY FEE: -pN COPY FEE: husband and wi far TRANSFER FEE: 170.70 RECORDING FEE: 10.00 - - -- Grantee. PAGES: I Grantor, for a valuable conslderation, conveys and warrants to Grantee the following described real estate in St. C;r'O].X County, State of Wisconsin: He.cuniing Ala Located in part of SW 1/4 of NW 1/4, Sec. 31, Name and Return Address T29N, R18W, Town of Warren, St. Croix County, more fully described as I.nt 4 nf rSM recorded EAGLE VALLEY BANK, N.A. Ju9e�30, 1999, in Vol _1 3 of Certified Survey 1301 Coulee Rd., Unit 2 Maps, pages as Document No. 05977 -7$.. Hudson, .,Uni Dya- ro$e -ao -3oo 3-"8t fre- P I denti a io N This homestead ro er[ . 1S -AOt— P P Y (is) (is not) =4 Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 31 5 day of August 2000 cQ (SEAL) (SEAL) ' Richard 0_ Rtnn .Tan P_ Stout — (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of Personally came before me this 8 f i t day of , 2 0 0 0 , the above named Richard 0 Rtnnt and Janpt' P Stout TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be thil!*QTdr1I�OY PLQLIQcuted the foregoing authorized by §706.06, Wis. Stats.) instrument and &Tt figPllEellta+tSCONSIN KERNON J. BAST THIS INSTRUMENT WAS DRAFTED BY Janet P Stout 1353 Awatukee Tr. H udson, WI Notary P bhc, State of W co sin My co misslgp J,s� enl. (If not. state expiration date: (Signatures may be authenticated or acknowledged. Both are not �/�/ _) necessary) ' Names or persons signing In any capacity must be typed or printed below their sigrunire. WARRANTY DEED STATE BAR OF WISCONSIN Witcorttin Leo Black Co., Inc. FORM No. 2 - 1998 Milwaukee. wit, FILES 4 _ 7 Ll JUN 3 0 1999 ► _ Li L KATHLEEN H. 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