HomeMy WebLinkAbout032-2191-08-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law. s 15.04 (1)(m)I
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
11
,-1'I*: i.s
Dosing
it
Holding
1 t}}Li
(�
t-l�E.t'1JSL2.
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
?I6t
5D
IoR
Dosing
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Friction Loss
Head
7DH Fi
Forcemain ILength
Dia.
Dist to well
F7.11 �_�=f-7•l.l J � L.�. F'1-1-'1 � a i r
County. St. Croix
Sanitary Permit No:
645483
State Plan ID No
Parcel Tax No
032-2191-08-000
Section/Town/Range/Map No
26.31.19.1601
STATION
BS
HI
FS
ELEV.
Benchmark
0
IOC 03
g a3
AIL BM
F feu (adrr
Bldg. Sewer
�,tJ�
��I•I$
SUHt Inlet
SUHt Outlet
Dt Inlet
Dl Bottom
Header/Man.
%5
ctIO.53
Dist. Pipe
Bot. System
r
�.
Final Grade
St Cov
FITt'r
�}5
Ioy z.6
BEDlTRENCH
DIMENSIONS
Width
Length
No Of Trenches
P OIM IONS
. OI PKs
Ine i..
Lpuid Depth
SETBACK
INFORMATION
SYSTEM TO
P/L
JBLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacture
rZ•tS`IIRT�+
Type Of S
fllV 1
6 m:
�•011
I
47 W
Model Nu gtsr
UIQ 1 K101.11 I IUIV 0T.J I tM
Header/Manifold
x Hde Size
x Hde t p
Vent to Air Intake
j11:;e'Inbut*n
P(s)
Length Dia
Lengtri n,= Spacing -
AUIL. %,UV GK x Drw•uro Rvef•ma nnly xr U....A A. ws_a..A. C..vn•nc Aril..
Depth Over
Depth Over
xx Depth of
xx SeededrSodded
xx Mulched
Bed/Trench Center
B E s
s
/0. No
COMMENTS: (Include code discrepencies. persons present. etc.) Inspection *1:
Location: 1946 64TH ST I�
y s'}crn C, I {,.ie1T70t/1 vu I l;-eA WIA Still kkvf(v� 3
1.) Alt BM Description = (liar C•+�r
2.) Bldg sewer length = ZZ. r+
- amount of cover = 15 f
Plan revision Required? ^ . Yes g No
Use other side for additional information.
Date
SBD-6710 (R 3197)
Inspection 1k2:
j5 7i�s
Con. No.
DT9(?-Z1- � 5AN 2.ULL-3S-9
j.l` N 0 V 2 1202
+ n way
s'
M dison, 53
Madiaoq w133705 Ssissy Perat Nastier (b ba fB1ed o by Co J
P.O. Box 7162
• St. Croix Count
Madssa4w153707-7162 6,q5 qq 93
pplication
1n eorordtrree wY S M 311321M wis. Abu Cods. submissi of min ram b the appmpriaa gwernmenhl unit
is rc*ored prim to d`kii =AMY P . Note. Aqr coon fbmks for sumovmed POD TS are -d nft d no
the DVwD=a of'aeeq tad patissiaal Saviors. Penaul infatuation You peoride nay be wed for woo dary
Project Address(if dim" a tbaa rmeiirrg address)
ir.enarirea.ierae law, a1S.01(lXrnLSan
Tt0
L Appilientin Ienresaliea Prbd
—pease AN Iaftwaeodon
Property Owner's Name k
TW)�kS .Spo1sbo PaCBL TiZUST SCAN SACk
Pareet a
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T J N R
city. SLae
Solt- : hf 1
Zip Cade
5LI 615
Phone Numbs
IEL Type dRaYifng (dw& an that app y) ' L
1
Lot a
Subbddivwo°N/a�me
+ I
B1or2FamlyDwelling -NuoberofBedrooms
��
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11 i +� OlU F l 114. I
Block /
'ty of
take Owned - Describe Use
NIX
illage of
Of sot E�s� l
GSM Number
111 Type of POW1 S Part.iC (CMdc eMhar "Phw' or "Replaemaal" anal e&w appisW M Yore A. (.'Melt sae M= M Yore & CaaepMb &wC11
A.
SYMM
3yssem
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OioWmg Taek
oomeurorral MM
Okt
ound
Inilmduel Sib DesignType
(wpmC.
❑ Renewal Before ❑%rni m runsfer to New Owni Pm'^O18 Permit Number and Dale Iaarad
awer
ffl rMINKag Ana 11ai Tndt Ltenatioa: IYl 2 q
/
DesW Flow (8pd) Daipt Sad Andew. RaN(gpd/>f) Dispersal Area Required (d) MVersal Arm Pmpred (sf) Sysma Oeratiea p
3 P PLC
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"tuber's Address (Suess. City. Sale, Lp ()o
P'a Bt)x 6(os
1'%Cov
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❑
Permit Fee
Date lased
Il
Iwiog Agess Siprmm
`
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3er 20 Z
cardition. seat•fer�iaepproar
triFifM-01 (OWNER: IR-,Ie Q
I. Septic tank, effluent filter and dispersal cell )w
a� ��
must be serviced I maintained as per vc� ; cQ4 �* W
management plan provided by plumber. � Ms. a 5 WO • Qk
A
NI setback requirements must be maintained '� —S i e� � � C r
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it
9KI Z Top oryOIL vi 2/y' flpE
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94).56 = 77,85
85
Z t�Z T98,86 = T5.67
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rows at dat Tgmv sock
Paoe._ of
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The bestjust ed bens!
fk rdYneis h them61 ditlet bwdiet awnte
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tdtle dli� alrtY�++. ttds sriyrPet G�ttr use Pr,daS ta, rsma
rdd�iY 4r awua eesi@rd snpe-peee keraucadars roue a
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Heavy -Duty Outlet
tb ten;.bdY Mot das ed6har>a,& a'*,d n b Prade rdre
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ary Yutdellm a✓ aadr 0aia sN w.
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of Z
FILE INFORMATION
Owner ?fbiuAS C J f S u s No
Permit I
DESIGN PARAMETERS
Number of Bedrooms
9❑
NA
Number of Public Facility Units
At NA
Estimated flow (average)
400
a)/da
Design flow (peak), (Estimated x 1.5)
(o�
gal/day
Soil Application Rate
�� gal/dayffe
Standard Influent/Effluent Quality
Monthly average'
Fats, Oil & Grease (FOG)
530 mg/L
Biochemical Oxygen Demand (DOD.)
5220 mg/L
❑ NA
Total Suspended Solids ITSS)
5150 mg/L
Pretreated Effluent Ouality
Monthly average
Biochemical Oxygen Demand (BODE)
530 mg/L
Total Suspended Solids (TSS)
530 mg/L
❑ NA
Fecal Coliforrn (geometric mean)
510` cfu/100ml
Maximum Effluent Particle Size
Ye in dia.
❑ NA
Other:
❑ NA
`Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity
156 gal
❑ NA
Septic Tank Manufacturer
yjjF=5e
❑ NA
Effluent Fitter Manufacturer L ) reT/
❑ NA
Effluent Fitter Model
l
❑ NA
Pump Tank Capacity
al
NA
Pump Tank Manufacturer
fi�NA
Pump Manufacturer
P�NA
Pump Model
%NA
Pretreatment Unit
❑ Sand/Gravel Fitter
❑ Mechanical Aeration
❑ Disktfaction
❑ Peat Filter
❑ Wetland
❑ Other:
4NA
Dispersal Call(s)
�&In-Ground Igravityl
❑ At -Grade
❑ Drip -Line
❑ NA
❑ In -Ground (pressurized)
❑ Mound
❑ Other:
Other.
❑ NA
Other:
❑ NA
Other:
❑ NA
Service Event
Service Frequency
Inspect condition of tank(s)
At least once every:
? monthls) (Maximum 3 years)
J earls)
❑ NA
Pump out contents of tank(s)
When combined sludge and scum equals one-third (Y.) of tank volume
❑ NA
Inspect dispersal Cell(s)
At least once every:
3 ❑ month(s) (Maximum 3 yews)
011Cyearlal y
❑ NA
Clean effluent fitter
At least once every:
monUtls)
earls)
p NA
Inspect pump, pump controls & alarm
At least once every:
❑ month(s)
❑ year(s)
NA
Rush laterals and pressure test
At least once every:
❑ monthlsl
NA
❑ year(s)
Other
At least once every:❑
month(s)
❑ yearlef
A
Ether:
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 Opwator. Tank
inspections must include a visual inspection of the tankls) to idently 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 celllal 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 512 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.
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ST. CR (,NTY SANITARY SYSTEM File ik
iU<srydase1 Office Use Only
OWNERSHIP/ADDRESS FORM cmawz'202t
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of your new or replacement sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email. If you would like to view your issued sanitary permit online, you can
do so by using the Prog2eM Files Scanned weblink.
OWNER/BUYER INFORMATION
Owner/Buyer THOMAS G JACKSON RVCBL TRST, SUSAN R JACKSON RVCBL TRST
Mailing Address
1946 64th Street
City/State/Zip Somerset, Wl 54025
Phone Number (required)715-571-4627 (Thomas), 715-571-4216 (Susan)
Email Address (required) sdacks49@gmail.com (Susan)
Parcel Identification Number 032-2191-08-000
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location :5—S'A , SW '/4 , Sec. 26 . T 31 N R 19 W, Town of Somerset
Subdivision Plat: Pine Cliff Fourth Addition . Lot # 60
Certified Survey Map # Volume . Page #
Warranty Deed # I I(before 2006)Volume , Page #
Number of bedrooms 4 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no
New Property Address
(St ff Initials)
0"lakRUONLY
(o L ST
(ven tion of new address required from Community
I 1 4 ZZ,
(Date)
Department for new construction.)
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified
survey map if reference is made in the warranty deed.
Community Development Department — Land Use Division
71 S-386-4680 St. Croix County Government Center 71 S-24S-4250 Fax
cddidsccwi.aov 1101 Carmichael Road, Hudson, WI 54016 www.sccwiaov
JACKSON RESIDENCE
FOR BIDDING PURPOSES ONLY
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DOOR SCHEDULE
Rough I Rough
Type Mark I Count Width Height Width Heigh Description Comment
LOWER FLOOR
24MO.8'
14
r-r
C-8•
7-10•
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INSNNG
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1
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2
4'-0•
8'-r
4'-r
V-111
DOUBLE INSWING
FYVG8080
1
8-111M•
7'-111F
5'-113w
C-0'
wood Palo Door
PKT,74W-S'
1
7-r
?-r
z-r
6-111?
POCKET
7'4>mw•
1
Y-o'
8'-9•
3'-r
r-r
GLASS INSWING
DBL4-0-&4r
1
4'-0•
8'-e•
r-r
V-11'
DOUBLE INSWING
OKV4-xl(r4.
13
1V-0'
8'-0•
10'-r
8'-1•
JOVERHEAD
zsxsa
1
z-r
a-r
z-s'
d'-11•
INBWING
z-rw-'
4
2'-e•
a'-r
7-10•
8'-11'
INSWING
.T-0)04r
1
3- Or
a-81
3'-r
e'-11•
GLASS INSWING
3'4W-V
1
r-r
9-01
Y-r
a-3•
INSWNG
Wvlu-sloeLIGNr
DSL-1'-0"&-Cr
1
4'-0•
9-0•
4'-r
W-31
DOUBLE INSWING
FVYG8M
1
7'-111?
7'-111?
S-0•
d'-01
VkWk*ad wood Ghing Palo Door
G-2'-0'z8'-0•
1
z-8"
B'-0•
2'-10,
8'-3'
GLASS INSWING
PKT-zaxe'a
1
7-9•
8'-8-
z-7'
a-n 10
POCKET
PKT-Z-8*1&4r
1
z-e•
e'-r
iz-v
1w-nt?
IPUEKET
PKT-Y-0W-r
1
3'.cr
e'-8•
7-1-IV-
111?
1POCKET
WINDOW SCHEDULE
Type Rough Rough Head
Mark Count Width Height Width I Heigh I Height Desaipton Comment
WMN r�
AN281
2
2-71?
1'-Bill'
z-r
1'-r
8'-r
wood awnkV widow
AR281
7
z-71?
1'-5•
z-r
T-51?
T-111?
wood widow
AR451
1
V-413116'
1'-r
4'-55Mr
1'-51rz
T-111?
wood widow
ASW O15
1
4'-51?
V-5•
4'-e•
V-51?
9'-91W
vwodamw widow
ASW5715
2
V-81?
1'-5w
5'-7•
1'-51?
T-111rr
wood wYwow
CX15
2
2-71?
4'-11718'
2'-8•
6-03V
V-3'
VWWWO wood oaamwnt widow
CX18
8
2'-71rr
5'-117@•
z-8•
8'-0318'
T-11w
ywoc6d wood eaamlwt widow
CX145
3
z-71?
4'-41311(-
2-r
4'-55r18'
Mbv
VWWWWwoodcaeu mt widow
P45M
1
4'-413l1d'
4'-11M
4'-55Mr
S-031e'
V-r
VhykW wood cmanw9aw*V picture widow
Uralw Ww 30
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10I312022
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TKK
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10947H
oWMPLAT OF: PINE CLIFF FOURTH ADDITION
T,D IN PART OF THESE7/I OF THE SWl/{, SWS/{OF THE SWI/SNWl/{Oi THE I I I
hxf U,Iv
SWl/{, NEI/{ OF THE SW 1/1 AND THE SE3/{ OF THE NW3/4, ALL IN SECTION 26, FV17 1T
TOWNSHIP 31 NORTH, RANGE 19 WEST, TOWN OF SOMERSET, Si. CROIx COUNTY, I LOT ED
WISCONSIN; INCLUDING OUTLOT 1 OF CERTIFIED SURVEY MAP VOLUME 16, PAGE 4308, 0 ` 1 - JAp
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LOCATION SKETCH v�,w�Y N 37RE� I
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Wisconsin Department f Safety and Professional Services N O V 0 4 2019 Page of
Division of Industry Services
SOIL EVALUATION REPORT` °'` C00 'tY ent 19q(4 taq,4
CO n
In accordance with SPS 385, Wis. Adm. -1
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include,
but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. O32 - 2I°I I - O 000
scale or dimensions, north arrow, and location and distance to nearest road. %-
Please print all Information. Rev)&gd by / /)pI Date
�� Property Location v El' 40
-MP' Owner
C 'L � ��TART Nr�st/� ►� Govt. Lat %y. S T 3/ N R E (or) W
Property Owner's M ' g R . ; 7� l v `°t # O Block # S Name or CSLM# ,Or�
City State Zip Code Phone Number ❑City ❑ Village 2 Town Nea st R
Gdsnrt/ ws syolb �, ISonz;.Psefl ��/�' ST
It New Construction Use::Residential/Numberofbedrooms,,--',� Code derived design flow rate'r,:t�&PD
❑ Replacement ❑ Public or commercial - Describe: -Z-p (\t-
Parent material Flood Plan elevation if applicable ft.
General comments and recommendations: /
qr��-gyp. I-
Boring # ❑ Boring $ ! l• , U C/ �•&s y '7C�
,A Pit Ground surface elev. _ Depth to limiting facto/ / / in.
Rnil Amlir�finn R9ta
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft'
•Eft#1
'Eff#2
36
�-
❑ El Boring $$g.
Boring # cep .
®8 %�O Pit Ground surface elev. Depth to limiting fad In.
Anil Annlirrtinn Rntn
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft'
•Eff#1
'Eff#2
/0 - 35
711irvle
--
M b K
'" d
CIC
1.6
• 6
7,
—
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i. d
b
7st
—
s
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W
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1,4
CST,Wm (Pleas Print) � �
Signature
CST Number
Address
Date Evaluati "TV/
2Sduct Teleph e N mbe
+ aou�aw trawl io/
s�oe
❑B�ng gat. 1o8�9g,9�
Boring # - "��
QPit Ground surface elev. ft. Depth to limiting facto7!'�ln.
Anil Annliratinn Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDfFt'
6Eff#1
'Eff#2
K
;►
ZS
-.G
D
.ems,1
-78
S
C
r -
❑ Boring # Boring
❑
❑ Pit Ground surface elev. ft. Depth to limiting factor _ in.
Snil Annlir�tinn Rat.
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft'
'Eff#1
'Eff#2
❑ Boring #
❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor _ in.
•' 1
Sal A lication Rate
Horizon
Depth
In.
Dominant Color
Munsell
Redox Description
Qu. Az. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/Ft'
•Eff#1
I 'Eff#2
Effluent #1 = BOD, > 30 s 220 mg/L and TSS > 30 < 150 mg/L ' Effluent #2 = BOD, > 30 s 220 mg/L and TSS > 30 5 150 mg/L
�lr q� �Gf
�j ❑ Boring gem
�S
I Boring # �V
L�rCJ Q Pit Ground surface elev. ft. De to limiting
fact n.
===-Uwe
: • i f . F.,
❑ Boring #
❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
�C�
C
❑ Boring #
❑ Boring
❑ Pit Ground surface elev.
ft. Depth to limiting factor In.
Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L . Effluent #2 = BOD, > 30 s 220 mg/L and TSS > 30 5 150 mg/L
_ — INDEX CONTOUR LOT 60, PINE CLIFF 4TH ADDITION
INTERMEDIATE CONTOUR
CONTOUR INTERVAL IS 2 FEET
MINIIMUM BUILDING SET/ACKS:
j ROAD SO FEET
REAR ■ 25 FEET
/ SIDE a 10 FEET
y 12-FOOT VADE UTILITY EASEMENT
DRAINAGE EASEMENT
�( SOIL BORING LOCATION WITH ELEVATION
BENCHMARK LOCATION WITH ELEVATION
CHMARK
< w4uI COAC(� i+
r
( 893.73
\ 1891.58
LOT 60
90RING M1 \
BORING
WRI
C.r �C \ 1892.68 /
W \
\ CHMARK /
C4-1 \ \ \ YELLOW
� /Il
\ \ ` 891.76
NORTH
SCALE: 1"= ,W.
0 20 40 Bo
ALL ELEVATIONS ARE REFERENCED TO THE
NORTH AMERICAN VERTICAL DATUM OF 1983.
tog4711
ourmpLATOF: PINE CLIFF FOURTH ADDITION
\
I ---
XATW M ►Al1T OF THE SE7/4 Of M SlNV4. SM11/4 Of THE SWV4. NWV4 OF TIE nl.[ r I L LOB 4
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IOCONSM; wt1UOING OunOT I OF CVIT MW SUWM EM► VOLUME 1E, ►AGE 430E 4-
LOCATION SKSV#
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Af A& rs 0
couNn � NO. 64,5483
STA4pwE SANIT RY PERMIT
/?% s-r)
� L PREVIOU NO.
.J',{pw�t S ?r1c CSA� std"
OWNER
PLUMBEIUI
TOWN OF
SEC9T_
AND/OR LOT
a� Rai. qT1WCr
K LICa# 2Z3 '
N, R
r0 —Iq — mommoom
L
CHAPTER 145.13572) WISCONSIN STATUTES
(a) The purpose of the sanitary permit Is to allow installation
of the private sewage system described in the permit.
(b) The approval of the sanitary permit is based on
regulations In force on the date of approval.
(c) The sanitary permit is valid and may be renewed for a
specified period.
(d) Changed regulations will not impair the validity of a
sanitary permit.
(e) Renewal of the sanitary permit will be based on
regulations In force at the time renewal is sought, and that
changed regulations may Impede renewal
(I) The sanitary permit is transferable.
History: 1977 c.168;1979 c. 34,221; 1991 c. 314
IF Note: If you wish to renew the permit, or transfer ownership of
r SUBDIVISION �epermit please contact
-AA
1Y
W&Y—f
ZEDISSUING OFFICER - DATE 2o22a
PERMIT EXPIRES UNLESS RENEWED BEFORE THAT DATE
POST IN PLAIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (R11/20)