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HomeMy WebLinkAbout026-1020-95-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ` INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 538749 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. Permit Holder's Name: City Village X Township Parcel Tax No: Newham, Timothy & Julianne I Richmond, Town of 026- 1020 -95 -100 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: d� 06.30.18.73A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER n 5 CAPACITY STATION BS HI FS ELEV. Septic K Benchmark Dosing // Alt. BM Pceratiow � / � /D Bldg. Sewer Holding v St /Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet '57- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet W et. 5 Z / Z, S. �� 9 •Sl Z Sep tic 7 166 6-1 ZL 7 ZZ —` Zito d Dosing Header/ an. f- C,: 7 Aeration Dist. Pipe C $ 7 Holding Bot. System Final Grade a Q A j I PUMP /SIPHON INFORMATION 1 7 c, 7 Manufacturer Demand St Cover GPM G.l o ICJ el Number i T (1 2 Lift Friction Loss System d TDH Ft Iz 7. Forcemain Dist. to Well 9• C l� . SOIL ABSORPTION SYSTEM BED /TRENCH Width / Lew / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z /_ �1 , — me.., A es SETBACK SYSTEM TO iP � P / BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR p, Type f System: � � UNIT affi e-de �/� S Model Numbed V :C k q P / DISTRIBUTION SYSTEM ZI Z (� / 9 J Z l f- - 7 GC. -ft Header /Manifold /� Distribution x Hole Size it Hole Spacing Vent to jnta ke Lengt Length Dia / P ngth \ Dia Spacing ` 6, _S SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only u,, - 6/ - i�a.Od Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Centerti ' S Bed/Trench Edges Topsoil J N ✓ No o COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1765 95th Street New Richmond, WI 54017 (SW 1/4 NE 1/4 6 T30N R 8W) NA Lot 1 Parcel No: 06.30.18.73A10 1.) Alt BM Description =Z- ' r^�� 2.) Bldg sewer length = - amount of cover J l -- Plan revision Required? � Yes No Use other side for additional informa ion. __ Z I� SBD -6710 (R.3/97) Date Insepctor' Vignat a Cert . No Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: , 538749 0 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: Newham, Timothy & Julianne Richmond, Town of 026- 1020 -95 -100 CST BM Elev: Insp. BM Elev: T Description: Section /Town /Range /Map No: CST BM Elev: Insp. BM Elev: 06.30.18.73A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ruid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx M©und Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx i Mulched Bed/Trench Center Bed /Trench Edges Topsoil Yes E] No � Yes [ ? No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1765 95th Street New Richmond, WI 54017 (SW 1/4 NE 1/4 6 T30N R1 8W) NA Lot 1 Parcel No: 06.30.18.73A10 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? 0 Yes 0 No i ! ' Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert No t commerceml.gov Safety and i i i County 201 W. Washin o�71 i Madison, WI 7 -7162 Sanitary Permit Number mberr (tto be filled in by Co.) s c o n s i n Department of Commerce 5 3 0 Sanitary Permit Appl State Transaction Number ' at' AM In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of is form to t overnmental unit is required prior to obtaining a sanitary permit. Note: Applic ion forms for sta are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal informatio ou pmay be use secon I �� -5 p5 r 1 purp oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. Al. / 7 ! I. Application Information - Please Print Informatio Property Owner's Name p / L7�n Parcel # Property Owner 73 4- �o �'s Mailing Address y.' R /�,� Property Location / 1 L J 9 5 7 H ' S 1 Govt. Lot C . City, State Zip Code Phone Number T 5 /, /e, Section �� f2 e i Vh 01 'U'V i 5 y0 r t v r ` / �- 01 3n N; R j �circlEone II. Type of Building (check all that apply) Lot '1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name 9 ❑ Public /Commercial - Describe Use Block ❑ City of ❑State Owned - Describe Use CSM Number ❑ Village of i nk' W .Town of to III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A ' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) El Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued B. ❑ Change of Plumber El Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that appl .,Non- Pressurized In- G round ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank El Other Dispersal Component (explain) El Pretreatment Device (explain) V. Dis ersaVrreatment Area Information: S7 Design Flow (gpd) Design Soil application e(gpdsf) Dispersal a Required Dispersal Area Propos sf) System Elevation uu 11 S ll�� , L1f > N Z5 ., VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ;? v R V V y i7 New Tanks Existing Tanks n /` /Q o Cn n �°. Cd L fi w U v� c Septic or Holding Tank � t� ' �) a Q� Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for i tallation of the POWTS shown on the attached plans. Plumber's Name (Print) tier's ature MP S tuber Business Phone Number .-EFL I � z.�2'1 Z - �I 5s ASS- •Z 1 Plumber's Address (Street, City, State, Zip Code) (s >`' f oC 6c S(IS �� _ -7 � VIII. Cnun /De artment Use Onl Permit Fee Date Issued Issuing a Signatur pproved �,o, ial $ 4 7 d � �" Of IX. Condit' p� off easons for Disapproval L ( �"U ,� 14� :1or��J[N1 =R: / T ✓I'�.cL�t�A'��✓� :56 1.. Septic tank, effluent filter and 3, dispersal Celt must all be services / maintained I a �(� 6P— as per management plan provided by plumber. 5 2. AN "Iback requirements Must -be maintained Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 CONVENTIONAL COMPONENT DESIGN Residential Application 1� INDEX AND TITLE PAGE Project Name: ' I•� I��ti�r - ,� f �� Owner's Name: SIti� 4 Owner's Address: Legal Description: �l°L� /��� C Township: �iC�, 11 I it 1 County: �Gy' 0 Subdivision Name: Lot Number. Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans • J Designer /Plumber: ( -Tr License Number: Date: 3 Phone Number Signat re �, /,x, Designed pursuant t6 the fn-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01 /01). Page 1 r Jim i 7 Io5 RS7 14 6IeI66, Ea. X Alk i�XtST1 rib ( - N t,) �y. z 7r t�r,�i Nii�RiC 4 �L iD iP aF VOC K RL7A I IJlb WAIL "L = M2, in SO IL 3081 N r'�S - TI N1 'A 1 - 7 165 gSIA S`r pEkJ ( to v moLm w I S�IVr7 C:� 6WA6C EEO & U.SE' y rl A IA�Z Alk �b /oW - Nw\(- Oe� \ o f Q L0 COAL - rA Q k Q 2L00,0 MlNR -- i� �L - MP aIF RloC K R.CTA I IJ 1b WALL. 1:5,L = 10 SOIL 'Eup- c t I Soil Absorption System Cross Section q -Cl 6 ft � ft 4' Schedule 40 Final Grade PVC Vent Pipe With Vent Cap ft Leaching —► Chamber Ct RZ ft System Elevation ✓ ft y ft ft Soil Absorption System Plan View ft 3 ft { �3 ft Leaching Trench 1 Chambers 4° Dia. Vent Or Observation Pipe Trench 2 Header Trench 3 Leaching Chamber Specifications Manufacturer And Model 0 )VIL`rkAT0(Z QU 1 Li k 11 EISA Rating 20 sq ft per chamber Soil Application Rate r gpd/sq ft q56 gpd Design Flow 1 Soil Application Rate = EISA = Chambers 3 rows of chambers each. Page of z W O Q F LL � � O U LLLL Z co N Q oo�ch O W o 0 6 UcnLL LL L Z U CD CD C� 2 U cr- C-li W W Q z O U) 1L I U LL W J LL O 1..{. 1\ t0 d (O d Ix LL O rn ti 0 N All N H _J g LL � c r °w� LL � LL F- c0 LL N O O N r F 0 2 a Y U Y U U O O ¢ U) o � o v °O v rn o a= O ® o F w � g gg� a O aLLw w p LL �t:a O I O O OO t 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 Des i n Specifications Sanitary Permit Number Number of Bedrooms Design Flow - Peak d b Estimated Flow - Average d Septic Tank Capacity al / Z l O Soil Absorption Component Size 15 Type of Wastewater Domestic Table 2: Soil Absor tion Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak d 0 1 Maximum Influent Particle Size in NA 1/8 Maximum BOD (mg/L NA 220 Maximum TSS (mg/L NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Should inspect once a year and clean 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 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 vs. •i. vv rva. ♦a. vv nano , a.v vvv :vvv WE uVl ST. CAOIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r(Ivl U6 V O4Mk Mailing Address 65 1'5-t' 44 J`- Property Address e-V k 1611( Q () , (Verification requited hom Planning & Zoning Department for new construction.) City/State Parcel Identification Number cuo - iozo -RS' /D06 LgGAT. DESCRIPTION Property Location 1 5 , 6 7 V., U60 '/ , Sec. , T :S l b NR J W, Town of PICfhnD(06 Subdivision , Lot # Certified Surrey Map # , Volume , Page # Warranty Deed # , Volumc , Page # Spec louse 0 yes U no l.ot lines identifiable I.) yes 0 no SYSTEM MAINTENANCE AND QW.NER CERTMCATiON Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the sapdo 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 syysstem. Owner maintenance nsponsrbilities are specified in Comm. 83.52(!) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 7aning 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. t /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards wA forth, herein, as set by the Depat unit of Commerce and the Department ofNatural Resources, Statc of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. i/we certify that all statements on this form arse true to the beat of my /our knowledge. 1/we am/am the ownm(s) of the property described above, by virtue of a warranty deed recorded in Register of Decdsh Office. Number of bedrooms SIGNATURE O APPLICANTS) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Wlude with this application a recorded warranty deed from the Registoa of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. 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LOS ' P��L 3NI V/L Hinos - H-UtJON �."o T�-S-m vo SOM09 66 vRr..1445 / STATE BAR OF WISCONSIN FORM 2 - 1998 607E'sS5 D DE KATHLEEN H. WALSH REGISTER OF DEEDS This Deed, made between ]David E. Holmberg, a single person, ST. CROIX CO., WI Grantor, and Timothy J. Newham, Jr. and Julianne M. Newham, husband RECEIVED FOR RECORD and wife, as survivorship marital property, Grantee. 07-29 -1999 9:30 AN Grantor, for a valuable consideration, conveys and warrants to Grantee the following described veal estate in St. Croix County, State of Wisconsin (The WARRANTY DEED "Property "): EXEWT N CERT COPY FEE: COPY FEE: Part of SW 1/4 of NE 1/4 of Section 6 -30 -18 described as follows: Lot 1 of TRANSFER FEE: 450.00 Certified Survey Map filed May 27, 1999 in Vol. "13 ", page 3652, #603908. RECORDING FEE: 10.00 PAGES: 1 Recording Area Name and Return Address First National Bank of New Richmond PO Box C New Richmond, WI 54017 026- 1020_95 Parcel Identification Number (PIN) This is homestead property. Exceptions to warranties: Subject to all easements, restrictions and covenants of record. Dated this day of 1999. David E. Holmberg * AUTHENTICATION ACKNOWLEDGMENT Signature(s) IQ VA E. tiOrL.�� STATE OF WISCONSIN ) ) ss. ,'1 County ) authent ated this ?delay of Jk ( ' 1999. Personally came before me this day of 1999 the above named to �J me known to be the person(s) who executed the foregoing * D ona !d t - • s +��' instrument and acknowledge the same. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Slats.) * THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin Ronald L. Siler My Commission is permanent. (If not, state expiration date: VAN DYK, O'BOYLE & SILER, S.C. Post Office Box 127 New Ricbmond. I (Signatures may be authenticated or acknowledged. Both are not necessary.) Wisconsin Department of Commerce S ATION REPORT "'-�- --- �•.,..,. Division of Safety and Buildings ((^�� Paya in accordance with omm s*< Attach complete site plan on paper not less than 8 1/2 x 11 1 ches in size. Plan must ounry / x Include, but not limited to: vertical and horizontal reference Int (8h �l� r n percent slope, scale or dimensions, north arrow, and locatio and di t n . n r� d. arcel 1. D. PlOase print all Informatlo P ST. CRojX COUNTY evia d `by Date ry purP Personal Informallon you provide may be used for seconda CANNING $ 2 PM ° PICI 3 z5 �/ Property Owner Property location e W% ' Govt. Lot W 1/4 tN� y/4 T_30 Property Owner's Mailing Address N R` V E (o w Lot # Block # Subd,- Narrts,'r CSM# Clh' State Zip Code Phone Number C I S .1, . •, R� ❑ Ci ❑Village S D f �ToWn Nearest Road ❑ New Construction Use:'[ Resldenuai / Number of bedrooms _ ~ Code derived design flow rate Y 5 0 _ -, bPD Replacement ❑ Public or!commercial - Describe: Parent material _ �L t . IF!t Flood Plain e!evation if applicable General comments — ft. and recommendations '= 5 v.5 f t- e- F,0 e - -r t., ; $ r^ G •• - 1• 1 13.17' T. 7 T" 3 9 x. 29 • a Boring # 11 Boring .. F Pit Ground surface elev. q n� , _i Q ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description • - Texture Structure Consistence Boundary Roots Soli GP n Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff #1 'F1fiY2 1. YV 5`b -# V • w w. tr --- ( 1 a 7 Boring #' ❑ Boring i.. Pit Ground surface elev. f 1 ft. Depth to limiting (actor —120_ In. Horizon Depth Dominant Color Redox Texture Structure Consistence Er Descri P tion - Soil Application Rate In. Munse!! Qu. Sz. Cont. Color indary Roots GFG /tP Gr. Sz. Sh. 'Etf#1 •E11#2 fir S/ ' Effluent #1 = BOD > 30 5 220 mg/L and TSS 30 < 150 mg/L Effluent rig = 00D ,. f 30 mg& and TSS < 3 mg/L CST Name (Please p nature CST Number ss _ a7 0 a0 a'd""{r+ Da valuation Conductc� aleT phone Aur7r.rer Yo �.,• Property Owner Parcel Id q lJ Boring a e, -:1 -- of — Boring # +� 'psi. Pit C9�G3�tt+� sUr#se9 elev. • Depth (o limiting tailor t; 't ' h. Horizon Depth Dorninant C A" " p Soil licalion Rata R edox Descrl loon Texture Structure Consistence Boundary Roots GPD/ff in. Munsell ° °, -� Qu. Sz. Cant. color Sz. Sh. 'Eff #1 'Eft#2 to r [„/ Boring # ❑ Boring L___[ � � pit Ground surface elev. i - zs ry• Depth to limiting factor ___� __� tn. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soto ;/ n Rate in. Munsell Ou. Sz. Cant. Color Gr. Sz. Sh. 'E01 •Eff#2 I i Boring # t-1 Boring L �J ❑ pi Ground surface elev. _ ft, Depth to limiting factor In. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Soil A f n Rate In. Munsell Qu. Sz. Cont. Color Roots GPD/t Gr, Sz. Sh. •E`::Y1 'EHia2 ' Effluent #1 = BOD > 30 mgL and TSS >30 150 m - < 220 / < _ g/L 'Effluent #2 = BOD < 30 mg/L and TSS < 30 rng/L The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to --ccess services of need material in an alternate format, please contact the depariment at 608 - 266 -3151 or TTY 608 -264 -8777. SBD•IJJD(R.&W) , N.' �I ,y) - i ; ah a s ec., b� ( -r„ i w G �'1' r x.17 `f t o W 4 or Nt.d. 1 5C4 G _ { V 1 GDSM 2, 7 LS ` V s 0 E Gov. t3 6vrelgp( s4; "S l \ �' �OV56 1 � r 10 % k a 88.) 7 ' 9 � 7,5